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This study aims to evaluate the influence of myosteatosis on survival of patients after radical cystectomy (RC) for bladder cancer. We retrospectively identified 230 patients who underwent RC for bladder cancer at our three institutions between 2009 and 2018. Digitized free-hand outlines of the left and right psoas muscles were made on axial non-contrast computed tomography images at level L3. To assess myosteatosis, average total psoas density (ATPD) in Hounsfield Units (HU) was also calculated as an average of bilateral psoas muscle density. We compared cancer-specific survival (CSS) between high ATPD and low ATPD groups and performed cox regression hazard analyses to identify the predictors of CSS. Median ATPD was 44 HU (quartile: 39–47 Hounsfield Units). Two-year CSS rate in overall patients was 76.6%. Patients with low ATPD (P = 0.01) than patients with high ATPD (≥ 44 HU). According to multivariate analysis, significant independent predictors of poor CSS were: Eastern Cooperative Oncology Group performance status ≥ 1 (P = 0.03), decreasing ATPD (P = 0.03), non-urothelial carcinoma (P = 0.01), pT ≥ 3 (P P

Introduction Prostate sarcoma is an extremely rare disease with a poor prognosis. Undifferentiated pleomorphic sarcoma has never been described in the prostate.Case presentation: A 27-year-old man complained of frequent urination and dysuria for several years. Various examinations were suggestive of prostate sarcoma. The pathological diagnosis was confirmed as prostate sarcoma via ultrasound-guided transrectal needle biopsy. Because the location of the tumor in the prostate was confirmed by magnetic resonance imaging, we performed robot-assisted radical prostatectomy. The final pathological diagnosis was undifferentiated pleomorphic sarcoma. Local recurrence occurred at the front of the rectum 2 months after surgery. Although chemotherapy and radiotherapy were initially effective, he died 18 months after surgery. Conclusion Undifferentiated pleomorphic sarcoma of the prostate is believed to have a poor prognosis. When selecting the surgical procedure, functionality should be considered for individual cases with complete resection.

Evidence of the prognostic value of pretreatment systemic immune-inflammation index (SII) after radical cystectomy (RC) for bladder cancer is limited. This study aims to assess the association between preoperative SII and prognosis after RC for bladder cancer. In this multicenter retrospective study, we calculated preoperative SII as well as the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) in 237 patients who underwent RC for bladder cancer between March 2009 and March 2018. Patients were classified into high SII and low SII groups by using the optimal cutoff value (438 × 109/L) based on receiver operating characteristic curve analysis for cancer-specific death. We compared cancer-specific survival (CSS) and overall survival (OS) between the two groups. To evaluate the prognostic impact of preoperative SII, we also performed Cox proportional regression analyses for CSS and OS. Of 237 patients, 127 patients were classified into the high SII group and 110 patients into the low SII group. During the follow-up period, 70 patients died of bladder cancer (30%) and 21 patients died from other causes (9%). Patients with high SII had significantly lower rates of CSS and OS than those with low SII (p < 0.01 and p < 0.01, respectively). Multivariable Cox proportional hazard analysis showed that high SII was independently associated with poor CSS (p = 0.01) and poor OS (p < 0.01). In conclusion, high SII could be an independent significant predictor of poor prognosis after RC in patients with bladder cancer.

A modified 5-item frailty index was recently developed as a predictor of patient comorbidity-based mortality and morbidity. We evaluate the association between preoperative modified 5-item frailty index score and prognosis after radical cystectomy for bladder cancer.In this multicenter retrospective study, we calculated modified 5-item frailty index scores of the 238 patients that underwent radical cystectomy for bladder cancer between March 2009, and March 2018. The patients were classified into high frailty index score (≥ 2) or low frailty index score (≤ 1) groups for comparison of overall and cancer-specific survival between them. To evaluate the prognostic impact of the preoperative frailty index, we also performed Cox proportional regression analyses for overall, and cancer-specific survival.Of 238 patients, 53 patients were classified into the high frailty index score group and 185 patients into the low frailty index score group. Overall, 70 patients died of bladder cancer (29%), and 21 patients died of other causes (9%). The patients with high frailty index score had significantly lower rate of overall survival than those with low frailty index score (P.01). On the other hand, there was no significant difference in cancer-specific survival rate between the 2 groups (P = .07). Multivariable Cox proportional hazard analysis revealed that high modified 5-item frailty index score was independently associated with poor overall survival (P = .01), but not with poor cancer-specific survival (P = .15).High preoperative modified 5-item frailty index score could be a significant independent predictor of poor prognosis after radical cystectomy in patients with bladder cancer.

Objectives To determine the significance of molecular diagnosis of lymph node metastasis using quantitative reverse transcription polymerase chain reaction in patients with upper urinary tract urothelial cancer. Methods A total of 51 patients with upper urinary tract urothelial cancer who underwent extended lymphadenectomy were included in the present study. Retrieved lymph nodes from each patient were divided into two parts. One part was assessed by quantitative reverse transcription polymerase chain reaction assay for molecular staging, whereas the other one was assessed by routine histopathological examination. Four kinds of molecules (FXYD3, KRT19, KRT20 and UPK2) were selected as markers to detect urothelial cancer cells. Results The average number of retrieved lymph nodes was 18.3. As UPK2 showed the best discrimination ability among four markers, the patients were classified in three categories according to UPK2 expression: N(+)PCR(+) for patients who had lymph node metastasis by routine pathological diagnosis as well as quantitative reverse transcription polymerase chain reaction (n = 4); N(−)PCR(+) for patients who had lymph node metastasis by polymerase chain reaction but not by routine pathological diagnosis (n = 7); and N(−)PCR(−) for patients who showed no lymph node metastasis not only by routine pathological diagnosis but also by polymerase chain reaction (n = 40). The prognosis of the N(−)PCR(+) group was better than that of the N(+)PCR(+) group, and similar to that of the N(−)PCR(−) group. Conclusions Quantitative reverse transcription polymerase chain reaction could detect micrometastasis in patients with upper urinary tract urothelial cancer. However, the prognosis of patients with micrometastasis is better than patients with pathologically metastasized lymph nodes, and similar to patients without micrometastasis.

The objective of this study is to compare the quality of life (QOL) outcomes between laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP). Between July 2007 and July 2013, 229 patients with localized prostate cancer underwent LRP while 105 patients with localized prostate cancer underwent RARP between December 2012 and August 2014. We evaluated their QOL using the 8-item Short-Form Health Survey (SF-8) and Expanded Prostate Cancer Index of Prostate (EPIC) questionnaires at preoperative and at postoperative 3, 6 and 12 months. In the LRP and RARP groups, over 80 and 90% of patients answered questionnaires at each follow-up time, respectively. At baseline QOL of EPIC and SF-8, there was no significant difference between LRP and RARP groups. At postoperative 3 months, Physical and Mental Components of SF-8 and Urinary Summary (U), all Urinary Subscales, Sexual Function and Bowel Function of EPIC showed significantly better scores in RARP group than in LRP group. At postoperative 6 and 12 months, there were no differences between LRP and RARP groups in terms of all QOL scores. RARP group showed better scores in SF-8 as well as urinary and sexual function of EPIC at postoperative-3 months. These differences disappeared at postoperative 6 and 12 months.

Objectives To identify biomarkers predicting prognosis in bladder cancer patients undergoing the gemcitabine and cisplatin regimen. Methods We studied 52 patients with metastatic bladder cancer treated with the gemcitabine and cisplatin regimen by evaluating the relationship between the expression of two biomarkers, ribonucleotide reductase subunit M1 and excision repair cross complementing 1, by immunohistochemistry and clinical outcomes. Results The patients with low expression of ribonucleotide reductase subunit M1 showed a higher objective response rate by the gemcitabine and cisplatin regimen than those with high expression of ribonucleotide reductase subunit M1 (80.0% and 45.5%, respectively). No differences were observed according to the expression level of excision repair cross complementing 1. Low expression of ribonucleotide reductase subunit M1 significantly prolonged overall survival and progression-free survival compared with the high expression group. Low expression of excision repair cross complementing 1 tended to prolong overall survival and progression-free survival, but there were no significant differences (P = 0.07 and 0.10, respectively). Multivariate analysis showed that the expression of ribonucleotide reductase subunit M1 was the only independent prognostic factor (P = 0.012). Conclusions The expressions of ribonucleotide reductase subunit M1 seem to be associated with clinical response and survival in patients with metastatic bladder cancer treated with gemcitabine and cisplatin-based chemotherapy.

To retrospectively determine whether recovery of urinary continence after radical prostatectomy is associated with the preoperative length of membranous urethra (MU), the amount of rhabdosphincter and the length of MU removed with the prostate.The study cohort comprised 179 consecutive patients who underwent laparoscopic radical prostatectomy (LRP: n = 98) and robot-assisted radical prostatectomy (RARP: n = 81) at Wakayama Medical University between July 2010 and May 2014. The length of MU was measured by preoperative MRI. The amount of resected rhabdosphincter and the length of resected MU were assessed in hematoxylin and eosin sections at the apical margin of prostate specimens. Patient-reported urinary continence status was determined at 3, 6, 12 and 24 months postoperatively, with urinary continence considered as 0-1 pads/day. Kaplan-Meier analysis and the log-rank test were used to compare time to urinary continence recovery. Multivariate Cox regression analyses were performed to determine the predictors of urinary continence.RARP vs LRP (p = 0.02) and shorter length of resected MU (p = 0.01) showed significantly better postoperative continence recovery by log-rank test. Nerve-sparing, preoperative length of MU, and amount of resected rhabdosphincter did not significantly correlate with continence recovery. Only the length of resected MU was the independent factor for predicting postoperative urinary continence by multivariate Cox regression analysis (hazard ratio 0.84, p = 0.01).These results demonstrated that the length of resected MU measured by specimen was an independent predictor of urinary incontinence after radical prostatectomy. Care should be taken to preserve maximal length of MU for optimal continence outcomes.

A 78-year-old woman presented with macroscopic hematuria. We diagnosed giant hydronephrosis with a left ureteral stone and multiple renal pelvic carcinoma cT3N0M0 tumors.Open nephroureterectomy proceeded via a peritoneal approach, and 8,600 mL of urine were collected from the renal pelvis. The pelvic carcinoma was histologically confirmed as a rare giant cell variant with high malignant potential. The same variant was found in the upper ureter where a 15-mm stone had lodged. We considered that this was due to rapid progression of the renal pelvic giant cell carcinoma and hydronephrosis during the month before surgery.Multiple lung and bone metastases occurred after three courses of gemcitabine/cisplatin combination chemotherapy as postoperative adjuvant therapy. Therefore, radiotherapy for bone metastasis and gemcitabine/paclitaxel combination chemotherapy were performed concurrently.

A multicenter, double-blind, randomized, controlled trial was conducted to determine the efficacy of naftopidil as medical expulsive therapy (MET) for patients with distal ureteral stones. Ninety-two patients presenting with a single distal ureteral stone ≤10 mm were randomly assigned to receive either naftopidil (75 mg of naftopidil once in the morning and placebo twice a day) or flopropione (80 mg three times a day). The primary end point was time to stone expulsion calculated by the Kaplan–Meier method. Secondary end points were the percentages of patients who required analgesics, hospital admission, and surgery, the number of working days lost to the disease, and treatment safety. Overall, three patients were excluded from the final analysis. No significant differences were noted in age, stone size, and stone side between the treatment arms. The median time to stone expulsion was 8 days [95 % confidence interval (CI), 3–16] for the naftopidil group, and this was significantly less than the 18 days (95 % CI, 11 to not reached) for the flopropione group (p = 0.03). On multivariate Cox regression analysis, the hazard of expulsion was 1.8-fold higher for the naftopidil group than for the flopropione group after adjustment for age, sex, stone side, and stone size. No significant differences were noted in the secondary end points. The administration of naftopidil significantly improved time to stone expulsion in patients with distal ureteral stones ≤10 mm. We believe that this is the first multicenter, double-blind, randomized, controlled trial demonstrating the efficacy of naftopidil for MET.

Objectives To investigate the effect of weight loss intervention on the urinary stone risk parameters in a rat model of metabolic syndrome. Methods In a prevention study, 4-week-old male Otsuka Long-Evans Tokushima “Fatty” rats were randomly assigned to three groups: control, food-restricted and food-restricted + exercise-trained groups. In a treatment study, 24-week-old male Otsuka Long-Evans Tokushima “Fatty” rats that had already developed type 2 diabetes were randomly assigned to the same three groups. Blood and 24-h urine chemistry were measured after 16 weeks. Results In both studies, food-restricted and food-restricted + exercise-trained rats showed significantly higher urinary pH and higher excretion of urinary citrate than control rats. In the prevention study, ion-activity products of calcium oxalate in the food-restricted and food-restricted + exercise-trained groups were significantly lower than that of control rats. In the treatment study, ion-activity products of calcium oxalate index in food-restricted + exercise-trained rats was significantly lower than that of control rats. Conclusions Weight loss intervention seems to reduce the risk of uric acid stone formation by improving low urine pH and calcium oxalate stone formation by increasing urinary citrate excretion. The present study provides the first theoretical evidence to support weight loss intervention programs for nephrolithiasis patients with metabolic syndrome.

We report a case of renal transplantation using a horseshoe kidney from a living, genetically unrelated donor. The recipient was a 60-year-old man with diabetic nephropathy, and the donor was the 63-year-old wife of the recipient with a horseshoe kidney free of complications. Computed tomography showed two renal arteries and one renal vein on the left side, and the isthmus was perfused by several accessory arteries and veins. To demarcate the boundary of the isthmus, the left renal artery was ligated and cannulated for in situ perfusion. Furthermore, the isthmus was clamped, and the boundary of the isthmus was confirmed. The kidney was divided at the left margin of the perfused boundary. The cut ends of the isthmus were closed by sutures. The left kidney was transplanted into the right iliac fossa of the recipient. Asymptomatic fluid collection occurred on the cut surface at the isthmus of the donor, and this fluid decreased in due course. On the other hand, the recipient experienced no surgical complication or rejection, while maintaining serum creatinine levels of 2.00–2.20 mg/dL over a 22-month follow-up period. Horseshoe kidneys may be used for transplantation in selected cases after a detailed preoperative evaluation.

Objective To validate two prediction models (European Organization for Research and Treatment of Cancer and Spanish Urological Club for Oncological Treatment) for recurrence and progression of non-muscle invasive bladder cancer in Japanese patients who underwent bacillus Calmette–Guerin instillation therapy. Methods From March 1985 to April 2007, data were analyzed from 366 patients who underwent transurethral resection of bladder tumor followed by bacillus Calmette–Guerin instillation therapy. The ability of two scoring models to predict recurrence and progression was assessed by concordance index. Results For recurrence probability, the concordance index of the European Organization for Research and Treatment of Cancer and Spanish Urological Club for Oncological Treatment models was 0.514 and 0.576, respectively, which was lower than that (0.604) of a selected single prognostic factor (age) by our multivariate analysis. For progression probability, the concordance index of European Organization for Research and Treatment of Cancer and Spanish Urological Club for Oncological Treatment models was 0.693 and 0.764, respectively, which was higher than that (0.633) of a selected single factor (T stage) by our multivariate analysis. The Spanish Urological Club for Oncological Treatment scoring system resulted in better stratification of tumor recurrence and progression when compared with the European Organization for Research and Treatment of Cancer model, probably because more patients underwent bacillus Calmette–Guerin treatment in the Spanish Urological Club for Oncological Treatment cohort than in the European Organization for Research and Treatment of Cancer cohort. Conclusions The Spanish Urological Club for Oncological Treatment scoring system is a good predictor of tumor recurrence and progression in Japanese patients who underwent bacillus Calmette–Guerin immunotherapy. A large prospective study is warranted to confirm the efficacy of this system.

Although metabolic syndrome and its individual components have been associated with kidney stone disease, whether the clustering of metabolic syndrome traits increases the severity of kidney stone disease has not been examined in a large-scale study.Cross-sectional analysis.Data were obtained from 30,448 patients enrolled in the 6th Nationwide Survey on Urolithiasis in Japan conducted in 2005. Patients with lower urinary tract stones, struvite stones, cystine stones, or hyperparathyroidism and those younger than 15 years were excluded.Number of metabolic syndrome traits (obesity [body mass index ≥25 kg/m(2)], diabetes, hypertension, and dyslipidemia).Severe form of kidney stone disease, defined as recurrent and/or multiple stones, and abnormalities in urine constituents (hypercalciuria, hyperuricosuria, hyperoxaluria, and hypocitraturia).11,555 patients were included in the final analyses. Proportions of patients with recurrent and/or multiple stones were 57.7%, 61.7%, 65.2%, 69.3%, and 73.3% with 0, 1, 2, 3, and 4 metabolic syndrome traits, respectively (P0.001). There was a significant and stepwise increase in the odds of recurrent and/or multiple stones after adjustment for age and sex. In patients with 4 metabolic syndrome traits, the odds was 1.8-fold greater compared with patients with 0 traits (OR, 1.78; 95% CI, 1.22-2.66). In addition, the presence of metabolic syndrome traits was associated with significantly increased odds of having hypercalciuria, hyperuricosuria, hyperoxaluria, and hypocitraturia after adjustment for age and sex.Cross-sectional design, absence of dietary data, ill-defined diagnostic criteria for metabolic syndrome traits, and missing data for the majority of participants.Metabolic syndrome trait clustering is associated with greater severity of kidney stone disease; increased urinary calcium, uric acid, and oxalate excretion; and decreased urinary citrate excretion. These results suggest that kidney stone disease should be regarded as a systemic disorder linked to metabolic syndrome.

INTRODUCTION AND OBJECTIVES: Length of membranous urethra (MU) and the amount of striated muscle (SM) removed with the apical aspect of the prostate can be predictive of urinary incontinence after radial prostatectomy. The aim of the present study was to assess whether these histological measurements correlate with urinary incontinence after laparoscopic radical prostatectomy (LRP) and robotassisted radical prostatectomy (RARP). METHODS: We retrospectively reviewed the charts of 179 patients who underwent LRP (n1⁄498) and RARP (n1⁄481) from July 2010 to May 2014. Two uropathologists reviewed the hematoxylin and eosin sections of the apical margin to measure the length of MU (distance from the resection margin of the urethra to the prostate apex) and semiquantitatively assess the amount of SM, which was expressed as the percentage of total apical margin surface area occupied by SM. Patient-reported continence status was determined at 3, 6 and 24 months postoperatively, with urinary continence considered as 0 1 pads. The histological measurements were compared between continent and incontinent patients using Student’s t test. Multivariable logistic regression analyses were also performed to determine adjusted odds ratios (OR). RESULTS: Patients had a median age of 67 years at surgery. Urinary incontinence was observed in 55% of the patients after 3 months, 22% after 6 months and 10% after 24 months. The length of MU was significantly longer in patients with incontinence compared to those with continence at 3, 6 and 24 months, Fig. 1). While, no significant differences were observed in the amount of SM between the groups at any time point. Multivariable analyses revealed that the length of MU was associated with significantly increased odds of incontinence at 3 months (OR, 1.46; 95% CI, 1.09-2.00), 6 months (OR, 1.58; 95% CI, 1.14-2.23) and 24 months (OR, 2.43, 95%CI 1.44-4.49) after adjustment for age, length of membranous urethra measured on preoperative MRI, preservation of the neurovascular bundle and type of surgery. CONCLUSIONS: These results demonstrated that the length of MU in the pathology specimen was an independent predictor of urinary incontinence after radical prostatectomy. Care should be taken to preserve maximal length of MU for optimal continence outcomes.

Background While novel drugs have been developed, docetaxel remains one of the standard initial systemic therapies for castration-resistant prostate cancer (CRPC) patients. Despite the excellent anti-tumor effect of docetaxel, its severe adverse effects sometimes distress patients. Therefore, it would be very helpful to predict the efficacy of docetaxel before treatment. The aims of this study were to evaluate the potential value of patient characteristics in predicting overall survival (OS) and to develop a risk classification for CRPC patients treated with docetaxel-based chemotherapy. Methods This study included 79 patients with CRPC treated with docetaxel. The variables, including patient characteristics at diagnosis and at the start of chemotherapy, were retrospectively collected. Prognostic factors predicting OS were analyzed using the Cox proportional hazard model. Risk stratification for overall survival was determined based on the results of multivariate analysis. Results PSA response ≥50 % was observed in 55 (69.6 %) of all patients, and the median OS was 22.5 months. The multivariate analysis showed that age, serum PSA level at the start of chemotherapy, and Hb were independent prognostic factors for OS. In addition, ECOG performance status (PS) and the CRP-to-albumin ratio were not significant but were considered possible predictors for OS. Risk stratification according to the number of these risk factors could effectively stratify CRPC patients treated with docetaxel in terms of OS. Conclusions Age, serum PSA level at the start of chemotherapy, and Hb were identified as independent prognostic factors of OS. ECOG PS and the CRP-to-albumin ratio were not significant, but were considered possible predictors for OS in Japanese CRPC patients treated with docetaxel. Risk stratification based on these factors could be helpful for estimating overall survival.

What’s known on the subject? and What does the study add? The expression of hENT1 was significantly associated with prolonged survival in advanced bladder cancer treated with gemcitabine–cisplatin-based combination chemotherapy. The mechanism-based approach to the chemotherapeutic agents may be helpful to personalize medicine for the individual advanced bladder cancer patient. OBJECTIVE To evaluate the expression of the human equilibrative nucleoside transporter 1 (hENT1) and excision repair cross complementing 1 (ERCC1) as possible prognostic factors for patients with metastatic bladder cancer treated with gemcitabine–cisplatin-based combination chemotherapy. PATIENTS AND METHODS The present study retrospectively evaluated the expression of hENT1 and ERCC1 by immunostaining in chemo-naive primary bladder tumour specimens from 40 patients with metastatic bladder cancer who received treatment with gemcitabine–cisplatin-based combination chemotherapy at Wakayama Medical University Hospital and affiliated hospitals from May 2002 to July 2009. Immunohistochemistry on formalin-fixed, paraffin-embedded tissues was performed with specific hENT1 and ERCC1 antibodies scored by two pathologists who were blinded to clinical outcomes. The clinical and histopathological variables were analyzed to evaluate predictive values for survival. RESULTS The median survival time in patients with high and low hENT1 expression was 17.3 and 11.6 months, respectively (log-rank test, P= 0.003). This contrasted with the median survival in patients with high and low ERCC1 expressions, which did not differ significantly (high ERCC1, 13.6 months; low ERCC1, 17.1 months; P= 0.178). In univariate Cox regression analyses for pretreatment clinicopathological variables, performance status (P= 0.02) and hENT1 expression (P= 0.004), but not ERCC1 expression (P= 0.182), were associated with overall survival. Multivariate analysis using a Cox proportional hazards model showed that hENT1 expression was an independent prognostic factor (P= 0.008). CONCLUSION The data obtained in the present study show that high expression of hENT1 in tumour cells is associated with prolonged survival in patients with metastatic bladder cancer treated with gemcitabine–cisplatin-based combination chemotherapy.

OBJECTIVE To investigate the association between metabolic syndrome and urinary stone disease, and whether insulin resistance associated with adiposity affects the risk of urinary stone formation, using a rat model of metabolic syndrome. MATERIALS AND METHODS Four-week-old male Otsuka Long-Evans Tokushima 'Fatty' (OLETF, a model of human type 2 diabetes and metabolic syndrome) rats, and Long-Evans Tokushima (LETO, a non-diabetic control) rats (10 each) were given a standardized diet and free access to water. Body weight and serum and urinary biochemistry were determined every 4 weeks. Ten-week-old male OLETF and LETO rats were divided into three groups of nine each and treated with vehicle or oral administration of 3 or 10 mg/kg/day pioglitazone, an agent that improves insulin resistance. After 4 weeks, body weight and serum and urinary biochemistry were determined. RESULTS The OLETF rats had significantly lower urinary pH and citrate excretion, and higher urinary uric acid and calcium excretion, than the LETO rats, with increases in body weight, serum triglyceride, glucose and insulin. The administration of pioglitazone to the OLETF rats for 4 weeks significantly increased urinary pH dose-dependently. There was no change in the urinary excretion of citrate, uric acid, calcium, oxalate or magnesium. CONCLUSION These results indicate that metabolic syndrome causes the changes in urinary constituents, leading to increased risk of both uric acid and calcium stone formation. Improvement in insulin resistance, a central cause of metabolic syndrome, might prevent uric acid stone formation by raising urinary pH.

A 78-year-old female complained high fever and vomiting. The ultrasonographic examination revealed a giant tumor above the left kidney. She was referred to our hospital for further examinations and treatments. Radiographic examination showed a solid mass of 10 cm in diameter, smooth surface, and sharply-delimited, above the left kidney corresponding to the left adrenal gland. Other organs showed no evidence of disease. Hormonal examination was normal. She was diagnosed as left non-functioning adrenal tumor, and underwent surgery. The resected specimen was 11 x 10 x 7 cm, 460 g with a part of normal adrenal tissue on the surface. Histopathological examination revealed it as leiomyosarcoma. She has no evidence of disease twenty months after the operation. Primary adrenal leiomyosarcoma is extremely rare. To the best of our knowledge, there were only 22 reported cases including ours in the English and Japanese literature.

INTRODUCTION AND OBJECTIVES: Cancer stem-like cells (CSCs) are small population of cancer cells with superior tumor initating, seilf-renewel, and differentiation properties. In the previous study, we found that HSP40 family member DNAJB8 contributes to the CSC phenotype in renal cell carcinoma(RCC). HSF1 has been described to induce heat shock proteins by heat shock stress and be related to initiation and progression of cancer. In this study, we investigated the relations of HSF1 and CSC phenotype including DNAJB8. METHODS: RCC cell lines ACHN was given heat shock by incubating in 45 degrees for 60 minutes. HSF1 and DNAJB8 expression was evaluated by RT-PCR and Western blot analysis. CSCs were isolated by side population method by flowcytometry. SP(side population) cells mean CSCs, MP(main population) cells mean non-CSCs. As an inhibitor of HSF1, temsirolimus (mTOR inhibitor) was used. The cell viability was assessed by MTT assay. RESULTS: Heat shock stress enhanced the expression of DNAJB8 as well as SOX2. The expression of these molecules reached maximum 24 hours after heat shock, and the SP population increased at the same time. When MP cells sorted by flowcytometry were stimulated by heat shock, SP population could be newly detected. This fact implies that heat shock stress could induce the reversion from MP cells to SP cells. Concerning the mechanism of the reversion from MP cells to SP cells by heat shock, HSF1 seems to play an important role. We found that the expression of phosphorylated HSF1 increased by heat shock, although the expression level of HSF1 itself did not change. Interestingly, when HSF1 was knocked down by siRNA, DNAJB8 could not be induced even after heat shock stress. This suggests that the stress-inducible expression of DNAJB8 is regulated by HSF1, which bind to the heat shock element(HSE) in the promoter of DNAJB8 gene and stimulate its transcription. Treatment with temsirolimus to ACHN cells could inhibit phosphorylation of HSF1, followed by down regulation of DNAJB8, resulting in the decrease of SP population. SP cells were more susceptible by temsilolimus treatment than MP cells. CONCLUSIONS: Stress including heat shock such as hyperthermia might induce DNAJB8 expression, which is related to CSC phenotype. Phosphorylation of HSF1 is required in this process. mTOR inhibitor could inhibit CSC specifically by inhibiting phosphorylation of HSF1.

INTRODUCTION AND OBJECTIVES: In patients with upper urinary tract urothelial cancer (UTUC), the significance of lymphadenectomy not only in diagnostic aspect but also in therapeutic benefit has not been clarified yet. In order to examine its significance, we are currently conducting a prospective clinical trial of extended lymphadenectomy in patients with UTUC. Furthermore, we applied qRT-PCR technique to retrieved lymph nodes by extended lymphadenectomy in patients with UTUC for more accurate and sensitive diagnosis. In addition, We examined the association with the clinicopathologic findings and prognosis. METHODS: We included 41 patients with UTUC who underwent extended lymphadenectomy. Tissue sections of retrieved LNs from each patient were divided in two parts. One of them was assessed by qRT-PCR assay, and the other one was assessed by routine pathological examination. Four kinds of molecules (FXYD3, KRT19, KRT20, UPK2) were selected as markers to detect urothelial cancer cells. In addition, about a representative sample, We performed the immunohistological examination in order to perform a supplementary examination of the qRT-PCR result. We regarded specimen in which all marker molecules was positive as presence of micrometastasis. RESULTS: As total, 21 out of 738 LNs (2.8%) showed amplification of all marker. In 4 out of 41 patients (9.8%), LN metastasis was confirmed by not only qRT-PCR but also by histological examination. In 7 patients (17.1%), amplification of all marker genes was observed by qRT-PCR without evidence of metastasis by histological examination, indicating the presence of micrometastais. Based on this result, We divided the 41 patients into three groups and evaluated the association with conventional prognostic factors or progression free survival. qRT-PCR findings was associated with the lymphovascular invasion (p

The aim of this study was to evaluate the effect of zoledronic acid (ZA) on bone mineral density (BMD) in patients with prostate cancer receiving combined androgen blockade (CAB) as a first-line androgen deprivation therapy. Patients receiving CAB for prostate cancer without bone metastasis were candidates for this study. Forty-two patients were randomly assigned to receive either ZA or no treatment. BMD were measured at baseline and at 12 months. Bone-turnover markers, including cross-linked N-telopeptide of type I collagen (NTX), C-telopeptide of type I collagen (ICTP), and bone-specific alkaline phosphatase (BAP), were assessed during study periods. Patients on ZA maintained BMD after a year of treatment. Change in T-score from baseline differed significantly between the two groups (P=0.009). An inverse correlation was demonstrated between baseline and change in T-score in the ZA group. While ZA prevented an increase in ICTP and BAP, the increase in NTX was suppressed only in patients with low baseline T-score. ZA prevented a decrease in BMD in patients undergoing CAB, especially those with lower baseline BMD.

To investigate the effect of weight loss intervention on the urinary stone risk parameters in a rat model of metabolic syndrome.In a prevention study, 4-week-old male Otsuka Long-Evans Tokushima "Fatty" rats were randomly assigned to three groups: control, food-restricted and food-restricted + exercise-trained groups. In a treatment study, 24-week-old male Otsuka Long-Evans Tokushima "Fatty" rats that had already developed type 2 diabetes were randomly assigned to the same three groups. Blood and 24-h urine chemistry were measured after 16 weeks.In both studies, food-restricted and food-restricted + exercise-trained rats showed significantly higher urinary pH and higher excretion of urinary citrate than control rats. In the prevention study, ion-activity products of calcium oxalate in the food-restricted and food-restricted + exercise-trained groups were significantly lower than that of control rats. In the treatment study, ion-activity products of calcium oxalate index in food-restricted + exercise-trained rats was significantly lower than that of control rats.Weight loss intervention seems to reduce the risk of uric acid stone formation by improving low urine pH and calcium oxalate stone formation by increasing urinary citrate excretion. The present study provides the first theoretical evidence to support weight loss intervention programs for nephrolithiasis patients with metabolic syndrome.

INTRODUCTION AND OBJECTIVES: In idiopathic calcium stone formers (ICSFs), most stones are known to grow attached to Randall0s plaque, which can be identified by measuring computed tomography (CT) attenuation value of renal papilla. The purpose of the present study was to test the hypothesis that CT attenuation value of renal papilla can predict the severity and recurrence of the stone disease. METHODS: We retrospectively reviewed the charts of ICSFs who underwent non-contrast CT scan from February 2005 to May 2012. Two observers independently measured the Hounsfield unit (HU) of the renal papilla from the upper pole, middle region and lower pole in both kidneys. Patients were classified into highand low-HU value groups based on the mean HU values of all papillae. The median value was used for differentiation. Proportions of patients with severe disease (recurrent and/or multiple stones), urine chemistries and recurrence rates were compared between the groups. RESULTS: A total of 134 patients, 89 men and 45 women, with at least one-year follow-up, were included in the analysis. Median HU value of all papillae was 49.3. The proportion of patients with recurrent and/or multiple stones was significantly higher in high-HU group compared to low-HU group (94.0% vs. 76.1%, p

Purpose: We determined prognostic factors associated with prolonged survival after metastasectomy for urothelial carcinoma. Materials and Methods: A total of 42 patients who underwent resection of urothelial carcinoma metastases with curative intent at 4 Japanese university hospitals were included in analysis. Of the patients 41 of 42 underwent systemic chemotherapy before and/or after metastasectomy. Overall survival was analyzed using the Kaplan-Meier method. The relationship between clinical characteristics and survival was analyzed using the log rank test. Results: Metastasectomy included lymph node dissection in 20 cases, pulmonary resection in 12, pelvic exenteration in 3, resection of local recurrence in 2, resection of subcutaneous metastasis in 2, liver resection in 1 and other in 2. Median overall survival was 29 months (IQR 19-80) from the initiation of treatment for metastases and 26 months (IQR 11-90) from metastasectomy. The overall 5-year survival rate after metastasectomy was 31%. On univariate analysis patients treated with metastasectomy for a solitary lung or solitary lymph node metastasis had significantly longer survival than the others who underwent metastasectomy (81 vs 19 months, log rank test p = 0.0296). Conclusions: Long-term cancer control could be achieved in a subgroup of patients who undergo metastasectomy, especially those with a solitary lung or solitary lymph node metastasis.

In December 2003, a 32-year-old man underwent puncture for right renal cyst at a clinic. Since puncture fluid was dark red color in spite of negative cytology, he was being followed, but after a while he did not show up for further examination. In November 2007, he revisited the clinic due to low-grade fever. Computed tomographic findings showed an enlarged cystic mass with a solid component invading the liver and lymph node swelling. He underwent right radical nephrectomy combined with partial liver resection and lymphadenectomy. Histological findings showed collecting duct carcinoma associated with clear cell carcinoma directly invading the liver with lymph node metastasis (pT4N2M0). Although he underwent 4 cycles of gemcitabine-cisplatin therapy and alfa interferon injection 3 times a week thereafter as adjuvant setting, multiple liver metastasis occurred 15 months after surgery. He died of cancer 31 months after surgery in spite of molecular targeted therapy including sorafenib and sunitinib.

A 66-year-old woman had a 22 mm right kidney stone accompanied with a horseshoe kidney. The size of this stone had been increasing gradually from 7 mm to 22 mm during the past 5 years. Although apparent pelviuretic junction stenosis could not be identified by intravenous urography, external pelvis was dilated in both kidneys. Complete excretion of fragmented stones by extracorporeal shockwave lithotripsy seemed to be difficult because impaired urinary passage from the renal pelvis to the ureter was suspected. Percutaneous nephrolithotomy was also difficult due to malrotation of the pelvic-caliceal system and possible interposition of bowel loops between kidney and abdominal wall. Therefore, we chose laparoscopic pyelolithotomy. This procedure made it possible to remove the stone completely with minimum invasiveness. We assume that laparoscopic pyelolithotomy is a safe and effective approach for renal pelvic stone in case of horseshoe kidney.

Systemic combination chemotherapy, such as the methotrexate, vinblastine, doxorubicin and cisplatin (MVAC) regimen, has shown certain activity in advanced bladder cancer, but is associated with a significant toxicity burden, with a treatment-related mortality of about 4%. Therefore, a great deal of interest has been focused on the gemcitabine-cisplatin (GC) combination chemotherapy which showed the same antitumor effect as MVAC chemotherapy with far less toxicity. Indeed, the GC regimen is now frequently administered as the first-line chemotherapy against metastatic bladder cancer. For the present, GC/MVAC regimens constitute alternative platform chemotherapy, until new evidence based strategy can be demonstrated. Accordingly it is important to be able to predict whether a regimen is effective in each patient with bladder cancer before the initiation of chemotherapy. Clinicopathological factors as the Karnofsky performance status and the presence of visceral metastases are well-established prognostic markers for poor survival. However, they are inadequate to predict the optimal therapeutic regimen for each individual patient. As for the predictive marker of cisplatin, ERCC1 may predict survival in bladder cancer treated by platinum-based therapy. The predictive potential of gemcitabine has not been previously considered in advanced bladder cancer treated by gemcitabine-combined systemic chemotherapy. In our retrospective study, the predictive value of a high expression level of hENT1 was assessed in bladder cancer treated by gemcitabine combined combination chemotherapy.

COM increased linearly by increasing solution undersaturation. In addition dissolution rate was found to be depended on stirring rate for the same undersaturation. This implies that the dissolution mechanism is determined by the diffusion of crystal units to the solution. Furthermore in the present study the effect of pH on dissolution rate was examined and it was found that by decreasing the pH to 4,5 dissolution rate increased by 28 %. SEM showed that synthetic COM crystals developed changes in their morphology during the dissolution process. CONCLUSIONS: In vitro methods based on measurements at constant solution undersaturation provide high accuracy and reproducibility to COM system. Monitoring of the dissolution process at carefully controlled conditions provide information on the initiation, the mechanism and the morphology of the crystals. It was found that under the applied experimental conditions dissolution mechanism is dominated by diffusion from the crystal surface to the undersaturated solution. It is concluded also that at slightly acidic pH dissolution rate of COM crystals increased. The above observations can assist to a better understanding of in vivo dissolution of COM urinary stones.

A 22-year old female had an episode of acute heart and respiratory failure requiring mechanical ventilation ducing a trip overseas. Echocardiography demonstrated akinesis of the apical area (left ventricle ejectionfraction(LVEF) =15%). Since computed tomography (CT) with coronary angiography to rule out acute coronary syndrome showed no abnormalities, she was diagnosed with morphological stress cardiomyopathy due to akinesis of the apical area. After returning to Japan, she was admitted to our hospital for further examination. She had an increased level of catecholamines in 24-hour urine. ¹³¹Imetaiodobenzyguanidine scintigraphy, CT scan and fluorodexyglucose positron emission tomography revealed a retroperitoneal mass. From these results, a diagnosis of extra-adrenal pheochromocytoma with catecholamine-induced cardiomyopathy was made. Histological diagnosis of the laparoscopically resected tumor was pheochromocytoma. After the operation, the level of catecholamines in 24-hour urine was normalized.

To evaluate the expression of the human equilibrative nucleoside transporter 1 (hENT1) and excision repair cross complementing 1 (ERCC1) as possible prognostic factors for patients with metastatic bladder cancer treated with gemcitabine-cisplatin-based combination chemotherapy.The present study retrospectively evaluated the expression of hENT1 and ERCC1 by immunostaining in chemo-naive primary bladder tumour specimens from 40 patients with metastatic bladder cancer who received treatment with gemcitabine-cisplatin-based combination chemotherapy at Wakayama Medical University Hospital and affiliated hospitals from May 2002 to July 2009. Immunohistochemistry on formalin-fixed, paraffin-embedded tissues was performed with specific hENT1 and ERCC1 antibodies scored by two pathologists who were blinded to clinical outcomes. The clinical and histopathological variables were analyzed to evaluate predictive values for survival.The median survival time in patients with high and low hENT1 expression was 17.3 and 11.6 months, respectively (log-rank test, P = 0.003). This contrasted with the median survival in patients with high and low ERCC1 expressions, which did not differ significantly (high ERCC1, 13.6 months; low ERCC1, 17.1 months; P = 0.178). In univariate Cox regression analyses for pretreatment clinicopathological variables, performance status (P = 0.02) and hENT1 expression (P = 0.004), but not ERCC1 expression (P = 0.182), were associated with overall survival. Multivariate analysis using a Cox proportional hazards model showed that hENT1 expression was an independent prognostic factor (P = 0.008).The data obtained in the present study show that high expression of hENT1 in tumour cells is associated with prolonged survival in patients with metastatic bladder cancer treated with gemcitabine-cisplatin-based combination chemotherapy.

To investigate the association between metabolic syndrome and urinary stone disease, and whether insulin resistance associated with adiposity affects the risk of urinary stone formation, using a rat model of metabolic syndrome.Four-week-old male Otsuka Long-Evans Tokushima 'Fatty' (OLETF, a model of human type 2 diabetes and metabolic syndrome) rats, and Long-Evans Tokushima (LETO, a non-diabetic control) rats (10 each) were given a standardized diet and free access to water. Body weight and serum and urinary biochemistry were determined every 4 weeks. Ten-week-old male OLETF and LETO rats were divided into three groups of nine each and treated with vehicle or oral administration of 3 or 10 mg/kg/day pioglitazone, an agent that improves insulin resistance. After 4 weeks, body weight and serum and urinary biochemistry were determined.The OLETF rats had significantly lower urinary pH and citrate excretion, and higher urinary uric acid and calcium excretion, than the LETO rats, with increases in body weight, serum triglyceride, glucose and insulin. The administration of pioglitazone to the OLETF rats for 4 weeks significantly increased urinary pH dose-dependently. There was no change in the urinary excretion of citrate, uric acid, calcium, oxalate or magnesium.These results indicate that metabolic syndrome causes the changes in urinary constituents, leading to increased risk of both uric acid and calcium stone formation. Improvement in insulin resistance, a central cause of metabolic syndrome, might prevent uric acid stone formation by raising urinary pH.

An infant normally delivered at the 38th week of gestation was referred to our department one day after birth for a firm and painless right hemiscrotal mass with bluish coloration. Since contralateral scrotum showed swelling, we performed emergency surgery on that day. The right spermatic cord was constricted due to extravaginal torsion, and degree and direction of torsion was unclear since the spermatic cord was already organized. Right testis showed irreversible necrotic change, requiring orchiectomy. We confirmed that left testis was intact and performed orchidopexy. Since high incidence of contralateral asymptomatic torsion has been reported in patients with prenatal testicular torsion, emergency surgery should be considered when contralateral scrotum shows abnormal findings.

Introduction and objective Human Equilibrative Nucleoside Transporter 1 (hENT1) and Ribonucleotide reductase M1 (RRM1) play important roles in pharmacokinetics of gemcitabine, and excision repair cross-complementing 1 (ERCC1) is related to drug resistance to CDDP. We evaluated the expression level of these molecules in patients with metastatic bladder cancer treated with gemcitabine—cisplatin (GC)-based chemotherapy. Methods Clinical data were retrieved from the databases from May 2002 to October 2011 in 40 patients (age 35–88; male 36; female 4) with advanced bladder cancer treated by GC (Gemcitabine + Cisplatin) regimen (17 patients) and GCT (GC + Paclitaxel) regimen (23 patients). Inclusion criteria for this study were clinically and/or histologically documented advanced and/or metastatic (stage 4) bladder cancer. We carried out immunohistochemical staining chemo-naive primary bladder tumor specimens with specific hENT1, RRM1 and ERCC1 antibodies. Pathologist blinded to clinical outcomes evaluated the expression level of these molecules. The clinical and histopathological data were analyzed to evaluate predictive factors. Results With regards to anti tumor response, high hENT1 expression group showed better clinical response comparing with low hENT1 expression group (90% versus 35%, P = 0.001). High hENT1 expression group and low RRM1 expression group showed significantly better survival (log-tank test P Conclusions The expression of hENT1 and RRM1 was associated with prolonged survival in patients with metastatic bladder cancer treated with GC-based chemotherapy. The combined analysis of hENT1 and RRM1 expression can be a promising biomarker which can predict the clinical response and the prognosis of patients with advanced bladder cancer treated by gemcitabine-based chemotherapy.