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Although several clinical guidelines for prostate cancer (PC) recommend extended pelvic lymph node dissection (ePLND) during radical prostatectomy for high-risk cases, there are several issues to consider, including certain technical aspects. A simplified approach to the medial internal iliac region and paravesical arteries has not been established. The uretero-hypogastric nerve fascia (UHF) envelopes the ureter, hypogastric nerve, and pelvic autonomic nerves. To preserve the UHF, it is possible to approach the medial side of the internal iliac vessels without injuring any important tissue. We analyzed technical feasibility and lymph node (LN) yields.After obtaining institutional review board approval, 265 high-risk PC patients with ePLND were identified. A da Vinci S or Xi robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used. We divided the patients into conventional (non-UHF) method and modified (UHF) groups. The numbers of LNs removed, procedure-related complications, and surgical outcomes were analyzed.The median number of LNs removed was 19.0 in the non-UHF group and 22.0 in the UHF group (p = 0.004). Significantly more LNs were removed from the internal iliac region in the UHF group (p = 0.042). There was no difference in overall operative, console, or LN dissection time, or the severe complication rate (Clavien-Dindo grade ≥ III), between the non-UHF and UHF groups.Our simplified approach using the UHF development technique is technically feasible, has no major complications, and allows for the removal of significantly more LNs compared with the conventional method.

Durable techniques that prevent postoperative inguinal hernia (IH) after robot-assisted radical prostatectomy (RARP) have not been established. This study evaluated the long-term efficacy of a postoperative IH prevention technique that uses no artificial agents to assess the characteristics of IH occurrence after introducing this technique.We retrospectively analyzed 201 consecutive patients who underwent RARP at our institution between September 2011 and February 2014. In total, 189 cases were eligible for the study. The non-IH prevention and IH prevention groups comprised 72 and 117 cases, respectively. We compared the incidence of IH between the two groups using Kaplan-Meier curves. Risk factors for IH in the prevention group were determined via multivariable logistic regression analysis.The rate of IH occurrence was 20.8% (15 cases) in the nonprevention group and 8.5% (10 cases) in the prevention group, with median follow-up periods of 99.5 and 89.9 months, respectively. The Kaplan-Meier curves indicated a significant difference between the two groups (p = 0.011). Only cutting of the vas deferens significantly contributed to reduced occurrence of IH in multivariable analysis (p = 0.047). After reviewing the intraoperative videos, insufficient separation of the vas deferens was considered the main cause of IH in the prevention group.Our simple prevention technique with no artificial agents had a durable effect on IH prevention after RARP over a median follow-up period of more than 7 years. Cutting the vas deferens effectively prevented IH after RARP.

Introduction Hem‐o‐Lok® clips are widely used in robot‐assisted radical prostatectomy because of their ease of application and secure clamping. Although there have been some reports of their migration into the urinary tract, this usually occurs a few months after robot‐assisted radical prostatectomy. Late‐onset cases of Hem‐o‐Lok® clip migration, that is, after more than 1 year, are rare. Case presentations We report three cases of delayed endourethral Hem‐o‐Lok® clip migration more than 2 years after robot‐assisted radical prostatectomy. The Hem‐o‐Lok® clips were almost completely endoluminal, and were attached at one end to the vesicourethral anastomosis. We successfully removed them via transurethral surgery using a holmium laser. Conclusion This case series describes late‐onset Hem‐o‐Lok® clip migration into the bladder more than 1 year after robot‐assisted radical prostatectomy. Transurethral holmium laser surgery was very effective for Hem‐o‐Lok® clip removal. To avoid involvement of Hem‐o‐Lok® clips in the vesicourethral anastomosis, appropriate resection at the time of bladder neck transection is important.

Introduction Large adrenal adenomas are clinically rare. We report a case of a large adrenal adenoma with a renal arteriovenous malformation, mimicking a malignant adrenal tumor in preoperative imaging. Case presentation A 66‐year‐old woman presented to a local hospital with abdominal pain. A right adrenal tumor was detected, 66 mm in diameter and surrounded by thick and tortuous vessels. Based on the imaging findings, pheochromocytoma was suspected. However, clinical symptoms and endocrine abnormalities were absent, and radionuclide accumulation in scintigraphy was negative. Laparoscopic right adrenalectomy was performed. Intraoperatively, a notable growth of vessels forming a nidus surrounding the tumor was observed. Pathologically, this was diagnosed as an adrenocortical adenoma in conjunction with a renal arteriovenous malformation. Conclusion We report a case of a large adrenal tumor surrounded with an arteriovenous malformation. To the best of our knowledge, this is the first reported case of this combination.

Objectives To investigate the incidence of and risk factors for febrile complications (FCs) in patients undergoing holmium laser enucleation of the prostate (HoLEP). Methods This retrospective study enrolled 847 consecutive patients who underwent HoLEP in our hospital from June 2006 to December 2018. FCs were defined as a body temperature ≥38.0°C within 30 days after surgery. The incidence of FCs was determined and possible risk factors assessed using multivariate logistic regression analysis. Results Overall, 87 (10.3%) patients presented with FCs, and 6 (0.7%) had urosepsis, with no fatal complications. Multivariate logistic regression analysis revealed that patients with preoperative positive urine culture and urethral catheterization had an increased risk of FCs compared with those with a negative culture who did not need catheterization (odds ratio [OR] 2.587, 95% confidence interval [CI] 1.307-5.121). A negative urine culture with catheterization and a positive culture without catheterization were not associated with the development of FCs (OR 0.320, 95% CI 0.040-2.553 and OR 1.370, 95% CI 0.662-2.365, respectively). Other significant risk factors included preoperative serum albumin levels (OR 0.382, 95% CI 0.173-0.846) and immediate postoperative body temperature (OR 2.559, 95% CI 1.549-4.230). Conclusions FCs are relatively common among patients after HoLEP despite preoperative prophylactic antibiotic administration. Surgeons may need to consider performing screening of urine cultures prior to HoLEP, especially in patients with urethral catheterization, even if asymptomatic. If the culture is positive, prophylactic antibiotics should be tailored according to bacterial susceptibility.

Objective: To evaluate the safety and efficacy of using one-surgeon basketing technique by a solo surgeon for stone extraction during flexible ureteroscopy (f-URS) for urolithiasis. Patients and methods: This retrospective study enrolled patients with urinary calculus who underwent f-URS at two institutions in Japan between September 2014 and March 2020. A total of 100 patients were operated by one experienced surgeon using the one-surgeon basketing technique. With this approach, the f-URS apparatus was manipulated with the non-dominant hand and the basket catheter was manipulated with the dominant hand. We retrospectively examined the perioperative results, complications, and stone-free rate [with ‘stone free’ defined as ≤2 mm with kidney–ureter–bladder (KUB) at 1 month after f-URS] to estimate the safety and efficacy for comparison with the results of conventional retrieval basketing technique. Results: Among our study population, the median stone size was 14 mm and median operative time was 74 min. A stone-free status was achieved in 91 patients (91%). The median stone fragmentation time was 15 min and stone retrieval time was 30 min. All included patients were treated using the one-surgeon basketing technique. Complications related to stone retrieval were identified in two patients (2%); the degree of ureteral injury was classified as Clavien–Dindo Grade IIIa. Conclusion: The one-surgeon basketing technique is safe and effective for the extraction of stone fragments during f-URS for urolithiasis. This technique does not require assistance for basketing; therefore, f-URS with active retrieval basketing can be completed by a solo surgeon. Abbreviations: BMI: body mass index; KUB: kidney–ureter–bladder; SFR: stone-free rate; UAS: ureteral access sheath; f-URS: flexible ureteroscopy

Xanthogranulomatous pyelonephritis (XGP) is one of the most common granulomatous diseases of the kidney. XGP is subdivided into diffuse, segmental, and focal subtypes. Preoperative diagnosis of focal XGP on radiological imaging can be challenging, especially without involvement of the renal pelvis. Here, we report the case of a 61 year-old male with focal xanthogranulomatous inflammation of the kidney without pyelitis. The lesion presented as a mural nodule on the left renal cortical cyst, and kidney cancer was suspected on the preoperative image. The patient underwent a successful partial nephrectomy. Pathological examination revealed that the mural nodule displayed xanthogranulomatous inflammation and was clearly distinct from the renal pelvis. Thus, it should be considered that a mural nodule in a renal cortical cyst could be xanthogranulomatous inflammation.

Objective To determine the safety and efficacy of the one-surgeon basketing technique for stone extraction during flexible ureteroscopy when carried out by novice surgeons under instructor guidance. Methods We retrospectively compared perioperative results, complications and the "stone-free" rate (defined as ≤2 mm fragments on kidney-ureter-bladder imaging 1 month after flexible ureteroscopy) between experienced (group A, n = 50) and novice (group B, n = 50) surgeons using the one-surgeon basketing technique. Results Baseline patients' characteristics were similar between the two groups. There were no significant differences between groups A and B in operative time (mean 76 min vs 85 min, P = 0.46), stone-free rate (98% vs 92%, P = 0.36), postoperative fever events (4% vs 4%, P = 1.00) and postoperative hospital stay (24 h vs 24 h, P = 1.00). Clavien-Dindo grade IIIa complications (ureter injury) were only observed in two cases (4%) in group B. Conclusions The one-surgeon basketing technique for the extraction of stone fragments during flexible ureteroscopy might be safely and effectively carried out by surgeons with no prior experience under proper guidance.

OBJECTIVE. IgG4-related disease is characterized by extensive infiltration of IgG4-positive plasma cells and fibrosis in various organs. The objective of this study is to investigate CT findings of IgG4-related lesions involving the upper urinary tract and compare them with those of urothelial carcinomas. MATERIALS AND METHODS. This study reviewed pretreatment CT images of 13 consecutive patients with IgG4-related disease with upper urinary tract lesions and 80 consecutive patients with urothelial carcinomas. The findings assessed were laterality, location, growth pattern, margins, internal structure, presence of calcification and lipid component, enhancement pattern, and extraurinary findings. RESULTS. Bilaterality (p < 0.0001), an extramural growth pattern (p < 0.0001), a greater number of affected segments (p = 0.04), and a gradual dynamic enhancement pattern (p < 0.001) were significantly more frequent in patients with IgG4-related disease. With regard to extraurinary findings, paraaortic fat stranding (p = 0.03), presacral fat stranding (p < 0.001), fat stranding of the pelvic walls (p < 0.001), and aortic involvement (p < 0.001) were seen more frequently in patients with IgG4-related disease; on the other hand, there was no statistically significant difference in terms of frequency of pancreatic involvement. Hydronephrosis and renal involvement were seen more frequently in patients with urothelial carcinoma, although the difference was not statistically significant. CONCLUSION. CT findings suggestive of IgG4-related upper urinary tract lesions in comparison with urothelial carcinoma are bilateral and have a longer urinary tract involvement and exhibit an extramural growth pattern, ill-defined margins, a gradual enhancement pattern, aortic involvement, and fat stranding in the paraaortic, presacral, or pelvic wall areas.

Objectives To evaluate the effectiveness of indocyanine green-guided extended pelvic lymph node dissection during robot-assisted radical prostatectomy for intermediate- to high-risk prostate cancer. Materials and methods After institutional review board approval, between July 2017 and December 2018, we carried out 100 indocyanine green-guided extended pelvic lymph node dissections in patients with localized intermediate- and high-risk prostate cancer, using the Firefly (Novadaq Technologies, Mississauga, ON, Canada) and da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Indocyanine green was injected transrectally using ultrasound sonography before each surgery. Then, lymphatic drainage patterns and pathological findings were recorded. Results Lymphatic drainage routes were successfully determined in 91 right-sided and 90 left-sided cases. Five main lymphatic pathways and sites were identified: (i) an internal route (57%); (ii) a lateral route (50%); (iii) a presacral route (20%); (iv) a paravesical artery site (20%); and (v) a pre-prostatic site (5%). Lymph node metastasis was positive in 15 patients, with 44 pathologically confirmed metastatic lymph nodes. Metastatic fluorescent lymph nodes were found in 15 out of 44 lymph nodes (34.1%). For sentinel lymph node identification, the 34% sensitivity and 64.8% specificity rates were detected in regard to identification of lymph node metastasis. Conclusions Lymphatic drainage patterns from the prostate can be identified and classified using indocyanine green-guided extended pelvic lymph node dissections. Although the direct role of fluorescent lymph nodes in sentinel lymph node identification appears to be limited, the identification of lymphatic pathways could contribute to high-quality extended pelvic lymph node dissection during robot-assisted radical prostatectomy.

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.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.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.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.

We report a case of dialysis kidney with multiple renal carcinomas in three locations. A 74-year-old man who had a 20-year history of dialysis, was admitted to our hospital complaining of sudden right lateral area pain. Computed tomography (CT) scan revealed hemorrhage from the right dialyzed renal subcapsule. He underwent immediate transcatheter arterial embolization (TAE), but after 6 days the CT scan showed new active bleeding. A second TAE was performed, but, the CT scan several days later showed hemorrhage from the same site. So we decided to perform a right radical nephrectomy. Pathological results revealed three different renal carcinomas at sites different from the bleeding site. The presence of triple carcinomas in the same organ of the kidney is quite rare. Because of the high incidence of renal carcinoma associated with polycystic kidney disease in long-term hemodialysis patients and the possibility of multiple carcinomas as in this case, radical nephrectomy is recommended even in the case of spontaneous rupture.

Introduction Diagnosis of renal cell carcinoma during pregnancy is rare. We report a case of renal cell carcinoma during pregnancy with rapid growth. Case presentation A 39-year-old woman presented to our hospital for treatment of renal tumor at 22 weeks gestation. The tumor had a cystic lesion with a partition and showed rapid growth from 28 mm to 32 mm over a period of 4 weeks. The tumor was diagnosed as renal cell carcinoma and an open partial nephrectomy was scheduled at 26 weeks gestation. The operation and perioperative course were successful. Pathological findings confirmed the tumor to be clear cell renal cell carcinoma with G2 > G3, Fuhrman grade 2, pT1a, negative surgical margin, and positive detection of progesterone receptor. Conclusion We reported the successful management of a patient who was diagnosed with renal cell carcinoma during pregnancy. We also had a suggested association between rapid growth tumor and progesterone based on histopathological analysis of the tumor.

OBJECTIVES A pre-equipped metal trocar is required to use as a camera trocar due to a specification change in the da Vinci X/Xi system (Intuitive Surgical). We observed slight slippage of a trocar placed by the open method. With optical trocar access (OTA), the initial trocar is viewed directly with a laparoscope during placement. Reports regarding OTA for robotic surgery are limited, particularly for robot-assisted radical prostatectomy (RARP). We modified the OTA procedure such that it was appropriate for RARP. PATIENTS AND METHODS A total of 158 patients were enrolled in this study. The first trocar placement time (FTPT) was compared between the open and OTA groups. In the OTA group, the trocar was mainly placed through the upper abdominal quadrant. We also analyzed the differences between the conventional and modified OTA procedures using the Kii Fios First Entry trocar (Applied Medical). We examined the factors affecting the FTPT using linear regression models. A P value

Purpose: The cumulative sum (CUSUM) approach has been adopted to evaluate surgical competence in various contexts. The CUSUM method comprises sequential monitoring of cumulative differences from a ...

Background To assess the safety and effectiveness of using the self-retrieval basketing technique by solo surgeon as a method for stone extraction during flexible ureteroscopy (f-URS) for urolithiasis. Methods This retrospective study enrolled patients with urinary calculus who underwent f-URS at two institutions in Japan between September 2014 and November 2019. A total of 100 cases were performed by one experienced surgeon using the self-retrieval basketing technique. With this approach, the f-URS apparatus was manipulated with the nondominant hand and the basket catheter was manipulated with the dominant hand. The self-retrieval basketing technique employed two parts—specifically, a “front catch” and “side catch” to gather fragmented stones visible in the front and side of the ureteroscopic view, respectively. We retrospectively examined perioperative results, complications, and the stone free rate (with “stone-free” defined as ≤ 2 mm with kidney ureter bladder (KUB) 1 month after f-URS) to estimate the safety and effectiveness for comparison with results of the conventional retrieval basketing technique. Results Among our study population, the median stone size was 14 mm and the median operative time was 80 minutes. A stone free status was achieved in 87 patients (87%). The median stone fragmentation time was 16 minutes and the stone retrieval time was 32 minutes. All included cases were completed with the self-retrieval basketing technique. Complications related to stone retrieval were identified in two cases (2%); the degree of ureter injury being Clavien grade IIIa. There were no intraoperative complications such as heavy hematuria not to detect ureteral mucosa. Conclusions The self-retrieval basketing technique is safe and effective for the extraction of stone fragments during f-URS for urolithiasis. The self-retrieval basketing technique does not require assistance for basketing; therefore, f-URS with active retrieval basketing could be completed by solo surgeon.

Congenital external iliac vein defects are extremely rare. A 56-year-old man underwent robotic prostatectomy (RARP) without pelvic lymph node dissection (PLND) for localized low-risk prostate cancer. Intraoperative findings revealed a markedly dilated vein on the dorsal side of the pubic bone,which was difficult to preserve and was therefore clipped. Sudden swelling and pain appeared in the right leg on day 2 after successful RARP. A contrast-enhanced computed tomography (CT) scan showed a deep vein thrombus (DVT) and lack of a right external iliac vein. Immediate heparinization improved the symptoms, and no other postoperative complications occurred. In the retrospective review,a large dilated vein lying transversely on the prostate surface was observed with a robotic scope,but no manipulation of the pelvic vessels was performed because PLND was not performed. Therefore,the dilated vein was not recognized as a shunt from the right femoral vein to the left external iliac vein. A preoperative staging CT scan,which faintly revealed the right external iliac vein,could be useful to identify this extremely rare deformity in advance of surgery. Although preoperative imaging examinations are often difficult to diagnose preoperatively,as in this case,we consider it important to use appropriate approaches and treatment when dealing with symptoms that arise during pelvic surgery in patients with many anatomical variations.

OBJECTIVE To evaluate the relationship between the lengths of 2 regions of the intraprostatic urethral sphincter, the distal region (from the apex to the adenoma [AA]) and the proximal region (from the adenoma to the verumontanum [AV]) and prostate volume (PV) in patients with clinical benign prostate hyperplasia. MATERIALS AND METHODS A total of 110 patients who underwent magnetic resonance imaging before holmium laser enucleation of the prostate were enrolled. The lengths of 2 distinct intraprostatic urethral regions were measured on magnetic resonance imaging, and we used multiple regression analysis to explore the association between these lengths and PV. RESULTS The median age was 69 years. The median AV and AA lengths were 6.0 and 5.7 mm, respectively. Multiple regression analysis to predict PV revealed that the interaction between age and AV length was significant (P = .012), whereas that between age and AA length was not (P = .819). In patients aged ≥69 years, the AV length was significantly positively associated with the PV (P = .005); in patients aged ≤69 years, a nonsignificant positive association was observed (P = .130). The AA length was not associated with the PV in either subgroup (P = .621 in those aged

To investigate the relationship between the upper urinary stone distribution and the "crossing point," an area of relative fixation within the upper ureter at approximately the level where the ureter crosses the gonadal vein.We reviewed 298 consecutive patients presenting with acute renal colic, identified upper ureteral stones in computed tomography. For stones located at the "renal pelvis and upper ureter," we measured the vertebral level of each renal pelvis, crossing point, and stone. The distance between the crossing point and the stones (designated as positive if the stone was located above it) and the distance between the renal pelvis and the crossing point were measured.The average stone size at the "renal pelvis and upper ureter" was 6.0 ± 3.2 mm, at "middle ureter" 5.2 ± 1.9 mm, and at "lower ureter" 3.7 ± 1.8 mm. Lower location was significantly correlated with smaller size (P .001). The level of the crossing point and stone location were significantly lower on the right (P = .019, P = .033, respectively), whereas the vertebral level of the renal pelvis was not significantly different on both sides (P = .225). The mean distance between the crossing point and the stones was -5.6 ± 18.4 mm (median: 0 mm) on the right and -4.7 ± 19.3 mm (median: 0 mm) on the left. The mean distance between the renal pelvis and the stones was significantly longer on the right (57.2 ± 18.5 mm and 48.2 ± 19.1 mm) (P = .038).The crossing point is the peak site of stone distribution in the upper ureter and likely different from the traditionally identified obstruction site at the ureteropelvic junction.

In recent years, the shortage of experienced welder has become a problem. Therefore, we are developing online welder support system so that we can demonstrate the performance of experienced welder by providing in-formation to non-skilled welder during welding. This system can be applied to the actual work of welding as well as training only. In this system, the pre-diction and optimization for welding condition is provided to the welder as acoustic, visual and haptic information during actual work by analyzing the measurement results of welder’s behavior and welding condition with molten pool shape, etc. For data analysis, the prediction of penetration shape and optimization of torch movement can be also carried out using numerical simulation by mol-ten pool model. In this paper, in order to develop the on-line support system for welder, a basic investigation was carried out. As a result of the welder gaze measurement test using the smart glass with the proper filtering, it was confirmed that the eye tracking of the skilled welder was more stable than the non-skilled welder. Also, in the TIG manual welding, based on the measurement results of the torch movement by the camera for skilled welder and beginner, the situation of the backbead by numerical simulation was compared. The simulation results agree with the trend of actual welding. It was shown that the application of numerical simulation based molten pool model to simulation manual welding is effective.

In addition to breast, ovarian, and pancreatic cancers, BRCA1/2 genes have been associated with prostate cancer (PC). However, the role of BRCA1/2-associated family cancer history (FCH) has remained unexplored in treating these four cancer types as a homogenous pathophysiological group. We aimed to clarify the relationship between BRCA1/2-associated FCH and PC, and to assess its relationship with cancer aggressiveness. Patient characteristics, positive family history of BRCA1/2-associated cancer, and cancer characteristics (Gleason score, prostate specific antigen level at diagnosis, and clinical tumor stage) were analyzed. Among the 1,985 eligible candidates, 473 (23.83%) patients had adequately detailed FCH, obtained via questionnaire, and were thus included in the study. BRCA1/2-associated FCH was observed in 135 (28.54%) patients with PC (68, 14.38%), breast (44, 9.30%), pancreatic (31, 6.55%), or ovarian (8, 1.69%) cancers. BRCA1/2-associated FCH was not significantly associated with high Gleason score (≥ 8). Patients with BRCA-associated FCH were less likely to present with high clinical tumor stage, and no difference was observed in prostate-specific antigen level, presence of metastatic lesions at diagnosis, or likelihood of high-risk classification between patients with and without BRCA-associated FCH. This is the first report of BRCA1/2-associated FCH in Japanese men, indicating that family history did not affect the severity or aggressiveness of PC.

We conducted a retrospective study to compare the perioperative course and lymph node (LN) counts of patients undergoing limited pelvic lymphadenectomy (lPLND) or extended pelvic lymphadenectomy (ePLND) during robot-assisted radical prostatectomy in an initial Japanese series. The cohort included 1333 patients who underwent either lPLND (n = 902) or ePLND (n = 431) during robot-assisted radical prostatectomy at five institutions in Japan. All complications within 28 days of surgery were recorded, and clinical data were collected retrospectively. The outcomes and complications were compared relative to the extent of lymphadenectomy, and we conducted univariate and multivariate logistic regression analyses to assess the predictors of the major complications. On multivariate analysis for evaluating the associations between major complications and perioperative characteristics, console time (p = 0.001) was significantly associated with major complications, although the extent of lymphadenectomy (p = 0.272) was not significantly associated with major complications. In the distribution of positive LNs removed in the extended pelvic lymphadenectomy cohort, 60.4% of patients had positive LNs only in the obturator/internal iliac region. However, 22.6% of the patients with positive LNs had no positive LNs in the obturator/internal iliac region, but only in the external/common iliac region. ePLND, which significantly increased the console time and blood loss but nearly quadrupled the lymph node yield, is considered a relatively safe and acceptable procedure. Moreover, the results of this study suggest that ePLND improves staging and removes a greater number of metastatic nodes.

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 m2 (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.

Mucinous tubular and spindle cell carcinoma (MTSCC) is a relatively rare renal epithelial neoplasm. Although MTSCC is considered to be a low-grade and indolent neoplasm, aggressive cases have been recently reported. The present study discussed two additional cases of high-grade MTSCC causing multiple distant metastases with a fatal course. In case 1, a 71-year-old patient presented with hematuria and pyuria. Computed tomography (CT) scan of the right kidney revealed a mass lesion, for which partial nephrectomy was performed. However, a follow-up CT imaging revealed distant metastases in the liver, the paraaortic lymph nodes and the bone. Despite molecular targeted therapy and irradiation, the patient succumbed due to tumor progression. In case 2, a 64-year-old patient presented with an incidentally identified mass lesion in the right kidney. A laparoscopic nephrectomy was performed, and a follow-up CT imaging revealed metastases in the skin and lungs. The cytology of pleural effusion revealed pleuritis carcinomatosa. Histologically, both cases were diagnosed as mucin-poor MTSCC with high-grade transformation, which comprised uniform tumor cells primarily forming slender tubules. The tumors contained low- and high-grade regions. In addition, venous invasion and necrosis were observed. The tumor cells also demonstrated increased Ki-67 labeling indices and cellular tumor antigen p53 (p53) nuclear accumulation. High-grade transformation, large tumor size, necrosis, venous invasion, high Ki-67 labeling index and p53 nuclear accumulation are generally predictive findings for aggressive behavior of malignant tumors. In the current report, it was emphasized that MTSCC possesses a wide spectrum of clinicopathological features. Thus, careful postoperative investigation is required for MTSCC with high-grade elements due to its aggressive nature.

Prostate cancer can be diagnosed as an incidental finding during the pathological examination of benign prostatic hyperplasia (BPH) specimens by Holmium laser enucleation of the prostate (HoLEP). BPH and comorbidities such as hypertension, diabetes, and dyslipidemia often coexist in elderly people. We identified which comorbidities can be used to predict the presence of incidental prostate cancer, particularly high-risk cancer, in men who had undergone HoLEP. On the basis of pathological findings of HoLEP specimens, patients with incidental cancer were categorized as low-risk (Gleason ≤6 and T1a) or high-risk (all others). Of the 654 patients who underwent HoLEP, 41 patients (6.3%) were identified as having incidental cancer (25 low-risk and 16 high-risk). There were no significant factors for overall prostate cancers. However, a significantly higher frequency of diabetes was observed in patients with high-risk cancer compared to those with BPH (31% vs. 13%; p = .033). Logistic regression analysis using prostate-specific antigen (PSA) and prostate volume (PV), and smoking showed that diabetes was an independent predictor of high-risk cancer (odds ratio, 3.15; 95% confidence interval, 1.06-9.43). Diabetes may be an important predictor of the presence of high-risk prostate cancer in men with BPH who have undergone HoLEP.

Introduction: Epidemiological data regarding complications after holmium laser enucleation of the prostate (HoLEP) are scarce in Japan. We examined the associations of the 24-hour pad test results immediately after HoLEP with continence acquisition at 3 months postoperatively. Materials and Methods: In this hospital-based case-series study, we reviewed medical charts of 341 patients without catheterization and 150 patients with catheterization at the time of surgery. The 24-hour pad test was conducted immediately after catheter removal to measure the leakage weight. Subjects were divided into 2 groups: leakage weight = 0 g (negative) and >0 g (positive). Urinary incontinence (UI) at 3 months postoperatively was self-reported by patients. Results: Significant relationships were observed between pad test positivity and UI at 3 months postoperatively and between the pad test weight and the timing of continence acquisition in patients with and without catheterization. In multivariate analyses, the pad test positivity was associated significantly with the Overactive Bladder Symptom Score and enucleated tissue weight in patients without perioperative catheterization and with age in patients with catheterization. Conclusions: The 24-hour pad test immediately after catheter removal could indicate the need for early and active intervention to prevent continuous postoperative UI. Patients' symptoms and clinical items predictive of test positivity should be carefully assessed.

Introduction: To evaluate the incidence and risk factors for postoperative inguinal hernia (IH) after robot-assisted radical prostatectomy (RARP) and to assess whether a newly developed prevention technique reduces the incidence of IH after RARP. Methods: We included 161 consecutive patients (322 groins) who underwent RARP between September 2011 and October 2013. The prevention technique was as follows: (1) sufficient incision of peritoneum around the internal inguinal ring; (2) separation of spermatic vessels; (3) dissection of vas deferens. Results: Postoperative IH occurred in 14 cases (19.4%) occurring in the observation group compared to 2 cases (2.2%) in the prevention group. Patent processus vaginalis (PPV) was the only risk factor. Time-to-event analysis demonstrated a significant decrease in IH incidence in the IH prevention group (p = 0.005). Conclusion: Our data reveal a higher incidence of IH after RARP, with the existence of PPV as the only identified risk factor. Our simple IH-prevention technique, which does not involve the use of artificial materials, appears safe and effective.

The weld defect of the welded beam-to-column joint in steel structure causes the brittle fracture and has possibilities to reduce the deformation capacity. It is considered that the effect of the weld defect on the deformation capacity from the difference of between shop and site welding beam-to-column joints is different. Therefore it is important to understand this difference. In this paper, full-scale welding test was done it were shop and site welding beam-to-column joints. Then, the effect of the deformation capacity of test specimens caused by the difference of the position of welding defects between two joint methods was studied. As the results, the deterioration of deformation capacity caused by the welding defect was low using shop welding beam-to-column joints, and high using site welding beam-to-column joints.

To evaluate the feasibility and reproducibility of a simple technique for identifying the initial cutting point of the bladder neck during robot-assisted radical prostatectomy. To precisely identify the prostatovesical junction, we first pulled the anterior bladder wall in an upward direction with the second arm to identify the precise location of the prostatovesical junction where anterior bladder neck dissection is initiated. After one experienced surgeon had established this technique, three surgeons who were less experienced in robot-assisted radical prostatectomy utilized this method for 50 consecutive robot-assisted radical prostatectomy cases. The pathological results and the time required to transect the anterior bladder wall were evaluated. There were no cases of positive resection margin on the site of bladder neck. The mean resection time was not significantly different when comparing less experienced surgeons with the experienced surgeon (P = 0.29). In conclusion, this method is a simple and reproducible way to identify the bladder neck during robot-assisted radical prostatectomy. This technique is also useful (for laparoscopic or open radical prostatectomy) even in difficult scenarios, such as post-transurethral resection of prostate cases.

Objectives The prevalence of transient stress urinary incontinence (SUI) after HoLEP has been reported to be as high as 44%. Anteroposterior dissection HoLEP was newly developed to protect the urethral sphincter and therefore lower the incidence rate of SUI. This study was conducted to determine the SUI incidence rate after anteroposterior dissection HoLEP. Methods Sixty-eight consecutive patients with benign prostatic hyperplasia underwent HoLEP from January to December 2008. The first 31 cases (Surgery 1) underwent HoLEP according to Gilling's method. The next 37 cases (Surgery 2) underwent anteroposterior dissection HoLEP, where adenoma was dissected antegradely. This antegrade movement of the cystoscope allows the apical gland to be removed from the sphincter without causing damage. Surgical quality indexes (hemoglobin change, operating time, resected prostate volume) between the 2 groups were compared. All patients were assessed at 2 weeks postoperatively for clinical SUI, international prostate symptom score (IPSS), quality of life (QoL), and peak flow rates (Q max) . Results Patient characteristics and surgical quality indexes did not differ between the 2 groups. Clinical SUI was found in 25.2% of cases in the Surgery 1 group, but only 2.7% in the Surgery 2 group. IPSS, QoL and Q max. were significantly improved postoperatively in both groups. At 2 weeks, the QoL of the Surgery 2 group was significantly improved compared with that observed for Surgery 1 (1.5 ± 1.1 vs 2.4 ± 1.0, P = .02). The Q max. of Surgery 2 was significantly higher compared with Surgery 1 (19.8 ± 8.4 vs 13.0 ± 4.7 ml/s, P = .02). Conclusions These results indicate that our anteroposterior dissection HoLEP is a promising procedure to avoid postoperative SUI and also to substantially improve QoL.

Objective: We present our experience with a novel bladder reconstruction model using a collagen sponge pre-embedded within the omentum. The aim of the study is to evaluate tissue regeneration of the reconstructed bladder and the effect of prefabricating the collagen patch within the omentum. Materials and methods: Twenty pigs were divided into three groups. For the prefabricated patch group (PFP; n = 10), collagen sponge was inserted into the omentum. After 1 week, the pigs underwent a hemicystectomy and the sponge with an attached omental flap was brought to close the defect. For the non-prefabricated patch group (NPFP; n = 6), pigs received hemicystectomy and closure with a collagen sponge without prefabricating in the omentum. Four other pigs received hemicystectomy alone as a control (C; n = 4). All animals in the NPFP and C groups, and 7 of 10 in the PFP group were sacrificed at 4 or 8 weeks. Three other pigs in the PFP group were sacrificed at 12 weeks. Resected bladders were submitted to hematoxylin–eosin, and immunohistochemical staining. Results: All animals except for two in the NPFP group survived. At the time of grafting, the collagen sponge was covered with thick omental methothelial layers, and neo-vascularization from the omentum was observed. At each time point, only slight adhesion was observed around the patch in the PFP group, while severe adhesion between the patch and the bowel was observed in the NPFP group, suggesting that prefabricated collagen sponge within the omentum prevented urine leakage from the bladder. Histologically, the patch was well vascularized, and the luminal surface was covered with urothelium at 4 weeks in both groups. However, in the PFP group, there was mild inflammation in the submucosa and in-growth of smooth muscle derived from the adjacent muscle layers was observed with time, whereas severe inflammation was observed and in-growth of smooth muscle was limited in the NPF group. Conclusions: Prefabricating of a collagen patch within the omentum stimulated early neo-vascularization before grafting, and this procedure appears to offer an advantage for bladder reconstruction over a non-prefabricated procedure in terms of prevention of urine leakage and inflammation, and favorable tissue regeneration.

OBJECTIVE To examine the chemopreventive effects of a selective cyclooxygenase (COX)-2 inhibitor, meloxicam, and a selective epidermal growth factor (EGF)-receptor tyrosine kinase inhibitor, gefitinib (as a single agent) on a carcinogen-induced rodent bladder carcinogenesis model. MATERIALS AND METHODS The study comprised 103 male Fisher-344 rats (8 weeks old); after initial carcinogen treatment for 8 weeks with 0.05%N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN) in drinking water, the rats were divided into five groups, i.e. group 1, control (vehicle only); group 2, gefitinib high-dose (15 mg/kg by gavage once daily); group 3, gefitinib low-dose (5 mg/kg); group 4, meloxicam high-dose (1.8 mg/kg by gavage once daily); and group 5, meloxicam low-dose (0.6 mg/kg). Twelve weeks later the rats were killed; after fixing the bladder in 10% formalin, the number and size of hyperplasia and carcinoma foci were recorded microscopically in sections stained with haematoxylin and eosin, submitted entirely as multiple strips. RESULTS The incidence of carcinoma, confirmed microscopically, was: control 14/20 (70%); high-dose gefitinib, 7/20 (35%); low-dose gefitinib, 7/20 (35%); high-dose meloxicam 7/21 (33%); and low-dose meloxicam, 12/20 (60%). The mean numbers of carcinomas per bladder in groups 1–5 were 1.2, 0.5, 0.4, 0.5 and 1.1, respectively. The incidence and the mean number of carcinomas per bladder were significantly lower in the treatment groups (P