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BACKGROUND: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. Such delays can lead to disease progression. OBJECTIVE: We aimed to develop guidance on criteria for prioritization for surgery and reconfiguring management pathways for non-metastatic stage of prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve low likelihood of COVID-19 hazard if radical prostatectomy was to be carried out during the outbreak and whilst the disease is endemic. DESIGN, SETTING AND PARTICIPANTS: An accelerated consensus process and systematic review. We conducted a systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n=34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. OUTCOME MEASURES: Consensus opinion was defined as ≥80% agreement, which were used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and develop measures to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritization criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as "COVID-19 cold sites". CONCLUSION: Re-configuring management pathways for prostate cancer patients is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing radical prostatectomy within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

BACKGROUND: Germline variants explain more than a third of prostate cancer (PrCa) risk, but very few associations have been identified between heritable factors and clinical progression.OBJECTIVE: To find rare germline variants that predict time to biochemical recurrence (BCR) after radical treatment in men with PrCa and understand the genetic factors associated with such progression.DESIGN, SETTING, AND PARTICIPANTS: Whole-genome sequencing data from blood DNA were analysed for 850 PrCa patients with radical treatment from the Pan Prostate Cancer Group (PPCG) consortium from the UK, Canada, Germany, Australia, and France. Findings were validated using 383 patients from The Cancer Genome Atlas (TCGA) dataset.OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A total of 15,822 rare (MAF RESULTS AND LIMITATIONS: Optimal Cox regression multifactor models showed that rare predicted-deleterious germline variants in "Hallmark" gene sets were consistently associated with altered time to BCR. Three gene sets had a statistically significant association with risk-elevated outcome when modelling all samples: PI3K/AKT/mTOR, Inflammatory response, and KRAS signalling (up). PI3K/AKT/mTOR and KRAS signalling (up) were also associated among patients with higher-grade cancer, as were Pancreas-beta cells, TNFA signalling via NKFB, and Hypoxia, the latter of which was validated in the independent TCGA dataset.CONCLUSIONS: We demonstrate for the first time that rare deleterious coding germline variants robustly associate with time to BCR after radical treatment, including cohort-independent validation. Our findings suggest that germline testing at diagnosis could aid clinical decisions by stratifying patients for differential clinical management.PATIENT SUMMARY: Prostate cancer patients with particular genetic mutations have a higher chance of relapsing after initial radical treatment, potentially providing opportunities to identify patients who might need additional treatments earlier.

Although salvage radiotherapy (SRT) for PSA recurrence after radical prostatectomy provides better oncological outcomes when delivered early, in the absence of detectable disease many patients are treated for macroscopic locally recurrent tumors. Due to limited data from prospective studies, we hypothesized an important variability in the SRT management of these patients. Our aim was to investigate current practice patterns of SRT for local macroscopic recurrence after radical prostatectomy. A total of 14 Swiss radiation oncology centers were asked to complete a survey on treatment specifications for macroscopic locally recurrent disease including information on pretherapeutic diagnostic procedures, dose prescription, radiation delivery techniques and androgen deprivation therapy (ADT). Treatment recommendations on ADT were analyzed using the objective consensus methodology. The majority of centers recommended pretreatment magnetic resonance imaging (MRI) of the pelvis and choline positron emission tomography (PET). The median prescribed dose to the prostate bed was 66 Gy (range 65-72 Gy) with a boost to the macroscopic lesion used by 79% of the centers with a median total dose of 72 Gy (range 70-80 Gy). Intensity-modulated rotational techniques were used by all centers and daily cone beam computed tomography (CT) was recommended by 43%. The use of concomitant ADT for any macroscopic recurrence was recommended by 43% of the centers while the remaining centers recommended it only for high-risk disease, which was not consistently defined. We observed a high variability of treatment paradigms when SRT is indicated for macroscopic local recurrences after prostatectomy. These data reflect the need for more standardized approaches and ultimately further research in this field.

BACKGROUND: Abiraterone acetate plus prednisolone improves survival in men with relapsed prostate cancer. We assessed the effect of this combination in men starting long-term androgen-deprivation therapy (ADT), using a multigroup, multistage trial design.METHODS: We randomly assigned patients in a 1:1 ratio to receive ADT alone or ADT plus abiraterone acetate (1000 mg daily) and prednisolone (5 mg daily) (combination therapy). Local radiotherapy was mandated for patients with node-negative, nonmetastatic disease and encouraged for those with positive nodes. For patients with nonmetastatic disease with no radiotherapy planned and for patients with metastatic disease, treatment continued until radiologic, clinical, or prostate-specific antigen (PSA) progression; otherwise, treatment was to continue for 2 years or until any type of progression, whichever came first. The primary outcome measure was overall survival. The intermediate primary outcome was failure-free survival (treatment failure was defined as radiologic, clinical, or PSA progression or death from prostate cancer).RESULTS: A total of 1917 patients underwent randomization from November 2011 through January 2014. The median age was 67 years, and the median PSA level was 53 ng per milliliter. A total of 52% of the patients had metastatic disease, 20% had node-positive or node-indeterminate nonmetastatic disease, and 28% had node-negative, nonmetastatic disease; 95% had newly diagnosed disease. The median follow-up was 40 months. There were 184 deaths in the combination group as compared with 262 in the ADT-alone group (hazard ratio, 0.63; 95% confidence interval [CI], 0.52 to 0.76; PCONCLUSIONS: Among men with locally advanced or metastatic prostate cancer, ADT plus abiraterone and prednisolone was associated with significantly higher rates of overall and failure-free survival than ADT alone. (Funded by Cancer Research U.K. and others; STAMPEDE ClinicalTrials.gov number, NCT00268476 , and Current Controlled Trials number, ISRCTN78818544 .).

Background: Data regarding the natural history of biochemical recurrence (BCR) after radical prostatectomy (RP) and adjuvant radiotherapy (aRT) are limited. Objective: To evaluate cancer-specific (CSM) and other-cause mortality (OCM) in prostate cancer patients with BCR after RP and aRT. Design, setting, and participants: We identified 336 patients with BCR treated between 1990 and 2006 at two tertiary care centers. Intervention: All patients underwent RP plus aRT. Outcome measurements and statistical analysis: Cox regression analyses were used to evaluate the association between clinicopathologic variables and CSM. The coefficients of CSM-independent predictors were used to develop a novel nomogram. Patients were stratified into groups according to nomogram-calculated CSM probability and median age. Competing-risks survival analyses were used to estimate CSM and OCM for each group. Results and limitations: Ten-year CSM and OCM were 21.5 and 21.7%, respectively. On multivariable analyses, short time to BCR, pathologic Gleason score >= 8, and positive lymph node count of more than two at RP were significantly associated with increased CSM rate (all p 10-30% versus >30%. On competing-risks analysis, 10-yr CSM rate for these groups was 6%, 15%, and 42%, respectively, for patients aged 68 yr. Likewise, 10-yr OCM rate was 24%, 9%, and 10%, respectively, for patients aged 68 yr. The study is limited by its retrospective design. Conclusions: Short time to BCR, pathologic Gleason score >= 8, and more than two positive lymph nodes were independent predictors of CSM in patients with BCR after RP and aRT. Men with these features may benefit from additional secondary therapies, ideally, in a clinical trial setting. (C) 2013 European Association of Urology. Published by Elsevier B. V. All rights reserved.

Considering the Health Care System in Brazil, a developing country, and public healthcare policies, robotic surgery is a reality to very few citizens. Therefore, robotic assisted radical prostatectomy is far removed from the daily practice of the vast majority of Brazilian urologists. Scientific evidence of the superiority of robotic assisted radical prostatectomy does not presently justify public investments for widespread development of robotic centers. Maybe over time and with reductions in costs, robotic technology will become a more established practice, as observed in other countries, and more feasible for the Brazilian urological community. RESUMO Levando em conta o Sistema de Saúde do Brasil, um país em desenvolvimento, e as políticas de saúde pública, a cirurgia robótica é uma realidade disponível a poucos cidadãos. Assim, a prostatectomia radical robô-assistida está longe da prática diária da grande maioria dos urologistas brasileiros. As evidências científicas da superioridade da prostatectomia radical assistida por robôs não justificam, no momento, os investimentos públicos para o desenvolvimento disseminado de centros de robótica. Talvez mais tarde e com redução nos custos, a tecnologia da robótica torne-se uma prática mais estabelecida, como já observado em outros países, e fique, assim, mais viável para a comunidade urológica do Brasil.

High intensity focused ultrasound (HIFU) under MRI guidance may provide minimally invasive treatment for localized prostate cancer. In this study, ex vivo and in vivo experiments were performed using a prostate-dedicated endorectal phased array (16 circular elements arranged on a truncated spherical cap of radius 60 mm) and a translation-rotation mechanical actuator in order to evaluate the lesion formation and the potential interest of dual-modality (electronic and mechanical) interleaved displacement of the focus for volumetric sonication paradigms. Different sonication sequences, including elementary lesions, line scan, slice sweeping and volume sonications, were investigated with a clinical 1.5 T MR scanner. Two orthogonal planes (axial and sagittal) were simultaneously monitored using rapid MR thermometry (PRFS method) and the temperature and thermal dose maps were displayed in real time. No RF interferences were detected in MR acquisition during sonications. The shape of the thermal lesions in vivo was examined at day 5 post-treatment by MRI follow-up (T2w sequence and Gd-T1w-TFE) and postmortem histological analysis. This study suggests that electronic displacement of the focus (along the ultrasound propagation axis) interleaved with mechanical X-Z translations and rotation around B(0) can be a suitable modality to treat patient-specific sizes and shapes of a pathologic tissue. The electronic displacement of focus (achieved in less than 0.1 s) is an order of magnitude faster than the mechanical motion of the HIFU device (1 s latency). As an example, for an in vivo volumetric sonication with foci between 32 and 47 mm (7 successive line scans, 11 lines/slice, 4 foci/line) with applied powers between 17.4 and 39.1 Wac, a total duration of sonication of 408.1 s was required to ablate a volume of approximately 5.7 cm(3) (semi-chronic lesion measured at day 5), while the maximum temperature elevation reached was 30 °C. While electronic focusing is necessary to speed up the procedure, one should consider as a potential drawback the non-negligible risk for generating secondary lobes with full steering in 3D. Reference-free PRFS thermometry accurately removed the effects of B(o) dynamic perturbation in the vicinity of the moving transducer. Therefore, the dual-modality volumetric sonication paradigm represents a cost-effective technological compromise to induce the desired shape of the lesion in the prostate through the limited endorectal space, in a reasonable period of time and without side effects.

Background: The role of extended pelvic lymph node dissection (ePLND) in treating prostate cancer (PCa) patients with lymph node invasion (LNI) remains controversial. Objective: The relationship between the number of removed lymph nodes (RLNs) and cancer-specific mortality (CSM) was tested in patients with LNI. Design, setting, and participants: We examined data of 315 pN1 PCa patients treated with radical prostatectomy (RP) and anatomically ePLND between 2000 and 2012 at one tertiary care centre. All patients received adjuvant hormonal therapy with or without adjuvant radiotherapy (aRT). Outcome measurements and statistical analysis: Univariable and multivariable Cox regression analyses tested the relationship between RLN number and CSM rate, after adjusting to all available covariates. Survival estimates were based on the multivariable model; patients were stratified according to RLN number using points of maximum separation. Results and limitations: The average number of RLNs was 20.8 (median: 19; interquartile range: 14–25). Mean and median follow-up were 63.1 and 54 mo, respectively. At 10-yr, the CSM-free survival rate was 74.7%, 85.9%, 92.4%, 96.0%, and 97.9% for patients with 8, 17, 26, 36, and 45 RLNs, respectively. By multivariable analyses, the number of RLNs independently predicted lower CSM rate (hazard ratio [HR]: 0.93; p = 0.02). Other predictors of CSM were Gleason score 8–10 (HR: 3.3), number of positive nodes (HR: 1.2), and aRT treatment (HR: 0.26; all p 0.006). The study is limited by its retrospective nature. Conclusions: In PCa patients with LNI, the removal of a higher number of LNs during RP was associated with improvement in cancer-specific survival rate. This implies that ePLND should be considered in all patients with a significant preoperative risk of harbouring LNI. Patient summary: We found that removing more lymph nodes during prostate cancer surgery can significantly improve cancer-specific survival in patients with lymph node invasion.

著者らは根治的前立腺摘除術後の尿失禁における前立腺尖部の処理ならび吻合法を改良したので, これを従来法と比較検討した.対象は, 前立腺癌に根治的恥骨後式前立腺摘除術を施行した36例で, うち24例(平均67.6歳)は従来法, 12例(平均64.8歳)は改良法を用いた.両群間で手術時間, 出血量に有意差は認めず, 尖部断端陽性率では差を認めなかった.術後尿失禁の消失率は出血量(1500cc未満と以上), 年齢(65歳未満と以上)では差は認めず, 従来法と改良法ではそれぞれ術後1ヵ月で8.3%, 41.7%, 3ヵ月で25.0%, 91.7%, 6ヵ月で29.2%, 100%, 12ヵ月で58.3%, 100%と改良法で有意に早期消失を認めた.術後合併症は従来法で創し開が4例, 膀胱尿道吻合部結石が1例あり, 改良法では術後血腫が1例, 一時的排尿障害が1例を認めたが, 吻合部狭窄は両群ともに認めなかった.以上, 本改良法は術後の尿失禁を軽減する有効な方法と考えられた, Urinary incontinence impairs the quality of life for patients following radical prostatectomy. We retrospectively reviewed the records of 36 patients who underwent radical retropubic prostatectomy between 1987 and 2002, and achieved the time from operation until urinary continence. A modification in the technique of apical dissection was introduced in 1999 and applied in 12 cases of consecutive radical prostatectomy. The principles for this technique were based on sharp division of the dorsal vein complex, continuous suturing cut edges of lateral pelvic fascia, and anterior anastomotic sutures including lateral pelvic fascia as well as urethra and bladder neck. None of the patients undergoing the new technique used pads at 6 months. With introduction of this technique, the rate of continence at 12 months increased from 58.3 to 100.0%. Our results suggest that the surgical technique of apical dissection is an important factor associated with postprostatectomy in continence.

Background: According to the TNM staging system, patients with prostate cancer (PCa) with lymph node invasion (LNI) are considered a single-risk group. However, not all LNI patients share the same cancer control outcomes. Objective: To develop and internally validate novel nomograms predicting cancerspecific mortality (CSM)-free rate in pN1 patients. Design, setting, and participants: We evaluated 1107 patients with pN1 PCa treated with radical prostatectomy, pelvic lymph node dissection, and adjuvant therapy at two tertiary care centers between 1988 and 2010. Outcome measurements and statistical analysis: Univariable and multivariable Cox regression models tested the relationship between CSM and patient clinical and pathologic characteristics, which consisted of prostate-specific antigen (PSA) value, pathologic Gleason score, pathologic tumor stage, status of surgical margins, number of positive lymph nodes, and status of adjuvant therapy. A Cox regression coefficient-based nomogram was developed and internally validated. Results and limitations: All 1107 patients received adjuvant hormonal therapy (aHT). Additionally, 35% of patients received adjuvant radiotherapy (aRT). The 10-yr CSM-free rate was 84% in the entire cohort and 87% in patients treated with aRT plus aHT versus 82% in patients treated with aHT alone (p = 0.08). At multivariable analyses, PSA value, pathologic Gleason score, pathologic tumor stage, surgical margin status, number of positive lymph nodes, and aRT status were statistically significant predictors of CSM (all p

Context Prostate cancer (PCa) patients with isolated clinical lymph node (LN) relapse, limited to the regional and/or retroperitoneal LNs, may represent a distinct group of patients who have a more favorable outcome than men with progression to the bone or to other visceral organs. Some data indirectly denote a beneficial impact of pelvic LN dissection on survival in these patients. Objective To provide an overview of the currently available literature regarding salvage LN dissection (SLND) in PCa patients with clinical relapse limited to LNs after radical prostatectomy (RP). Evidence acquisition A systematic literature search was conducted using the Medline, Embase, and Web of Science databases to identify original articles, review articles, and editorials regarding SLND. Articles published between 2000 and 2012 were reviewed and selected with the consensus of all the authors. Evidence synthesis Contemporary imaging techniques, such as 11C-choline positron emission tomography and diffusion-weighted magnetic resonance imaging, appear to enhance the accuracy in identifying LN relapse in patients with biochemical recurrence (BCR) and after RP. In these individuals, SLND can be considered as a treatment option. The currently available data suggest that SLND can delay clinical progression and postpone hormonal therapy in almost one-third of the patients, although the majority will have BCR. An accurate and attentive preoperative patient selection may help improve these outcomes. The most frequent complication after SLND was lymphorrhea (15.3%), followed by fever (14.5%) and ileus (11.2%). It is noteworthy that all examined cohorts originated from retrospective single-institution series, with limited sample size and short follow-up. Consequently, the current findings cannot be generalized and warrant further investigation in future prospective trials. Conclusions The current data suggest that SLND represents an option in patients with disease relapse limited to the LNs after RP; however, more robust data derived from well-designed clinical trials are needed to validate the role of SLND in this selected patient population. Patient summary Salvage lymph node dissection (SLND) represents a treatment option in for patients with prostate cancer relapse limited to the lymph nodes; however, more robust data derived from well-designed clinical trials are needed to validate the role of SLND in this selected patient population.

Endourologic management of stones and strictures in patients with a urinary diversion is often cumbersome because of the absence of standard anatomic landmarks. We report on our technique of minimally invasive management of urinary diversion-associated pathology by means of a combined antegrade and retrograde approach.Five patients with urinary diversion-associated pathology were treated at our institution between May 1997 and October 1998. Their problems were: an obstructing ureteral stone in a man with ureterosigmoidostomy performed for bladder extrophy; two men with a valve stricture in their hemiKock urinary diversions; an anastomotic stricture in a man with an ileal loop diversion; and a long left ureteroenteric stricture in a man with a right colon pouch diversion. After percutaneous placement of an guidewire across the area of interest, the targeted pathology was accessed via a retrograde approach using standard semirigid or flexible fiberoptic endoscopes. Postoperative follow-up with intravenous urography, differential renal scan, or both was performed at 3 to 24 months (mean 12 months).The combined antegrade and retrograde approach allowed successful access to pathologic areas in all patients. Holmium laser/Acucise incision of stenotic segments or ballistic fragmentation of stones was achieved in all cases without perioperative complications. None of the strictures with an initially successful outcome has recurred; however, in one patient, the procedure failed as soon as the internal stent was removed. The patient with the ureteral calculus remains stone free, and his ureterosigmoidostomy is patent without evidence of obstruction on his last imaging study, 24 months postoperatively.Combined antegrade and retrograde endoscopic access to the area of interest is our preferred method of approaching pathologic problems in patients with a urinary diversion. An antegrade nephrostogram provides better delineation of anatomy, while through-and-through access enables rapid and easier identification of stenotic segments that may be hidden by mucosal folds. Furthermore, this approach allows the use of larger semirigid or flexible endoscopes in conjunction with more efficient fragmentation devices, resulting in enhanced vision from better irrigation. Finally, an initial endoscopic approach may be preferred because its failure does not compromise the success of future open surgery.

70歳, 限局性前立腺癌に対する前立腺全摘除術+限局的骨盤内リンパ節郭清術の約4ヵ月後に悪心, 嘔吐, 右下腹部痛, 発熱, 排尿困難等が出現した.画像所見や臨床経過から感染性リンパ嚢腫を疑って経皮的嚢胞穿刺術を行い, 嚢胞貯留液の生化学的検査・培養検査所見から同症と診断された.持続ドレナージ, 抗菌薬の局所投与, 硬化療法などを行い, リンパ嚢腫は消失した, Symptomatic lymphocele presented after pelvic lymphadenectomy for localized carcinoma of the prostate is a relatively rare complication. We treated a case of infected lymphocele presenting 4 months after a limited staging pelvic lymphadenectomy and a radical prostatectomy for adenocarcinoma of the prostate. The patient was a 70-year-old Japanese man having the chief complaint of fever, right lower abdominal pain, nausea and vomiting. Pelvic computed tomography showed a 14 cm cystic mass with a thick capsule on the right iliopsoas muscle. It was suspected to be an infected lymphocele. After percutaneous drainage, sclerotherapy (povidone iodine, minocycline and ethanol) and antibiotic drugs, the infected lymphocele was resolved.

Background: The role of adjuvant radiotherapy (ART) after radical prostatectomy (RP) on survival of patients with prostate cancer (PCa) is still controversial. Objective: We tested the impact of ART on cancer-specific mortality (CSM) and overall mortality (OM) in PCa patients according to pathologic PCa features. Design, setting, and participants: We evaluated 1049 PCa patients treated with RP and extended pelvic lymph node dissection alone or in combination with adjuvant treatments between 1998 and 2008. All patients had positive surgical margins and/or pT3/pT4 disease with or without positive lymph nodes. Outcome measurements and statistical analysis: Cox regression analyses tested the relationship between pathologic characteristics and CSM rates. Independent predictors of survival were used to develop a novel risk score based on the number of risk factors. Finally, Cox regression models tested the relationship between ART and survival according to the number of risk factors. Results and limitations: On multivariable analyses, only pathologic Gleason score >= 8, pT3b/T4 stage, and presence of positive lymph nodes represented independent predictors of CSM (all p = 0.4). Conversely, in patients with a risk score >= 2, ART was associated with lower CSM and OM rates (all p = 0.006). The observational nature of the cohort represents a limitation of the study. Conclusions: ART significantly improved survival only in patients with at least two of the following pathologic features at RP: Gleason score >= 8, pT3/pT4 disease, and positive lymph nodes. These patients represent the ideal candidates for ART after RP. (c) 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Androgen-deprivation therapy is well-established for treating prostate cancer but is associated with bone loss and an increased risk of fracture. We investigated the effects of denosumab, a fully human monoclonal antibody against receptor activator of nuclear factor-kappaB ligand, on bone mineral density and fractures in men receiving androgen-deprivation therapy for nonmetastatic prostate cancer. In this double-blind, multicenter study, we randomly assigned patients to receive denosumab at a dose of 60 mg subcutaneously every 6 months or placebo (734 patients in each group). The primary end point was percent change in bone mineral density at the lumbar spine at 24 months. Key secondary end points included percent change in bone mineral densities at the femoral neck and total hip at 24 months and at all three sites at 36 months, as well as incidence of new vertebral fractures. At 24 months, bone mineral density of the lumbar spine had increased by 5.6% in the denosumab group as compared with a loss of 1.0% in the placebo group (P

Robotic prostatectomy has progressively emerged as an oncologic and functional equivalent to the gold standard of open surgery, with minimally invasive advantages such as a short hospital stay, less blood loss and early return to complete activity. However, mastering the technique remains delicate and requires regular and sufficient practice to reach the aforementionned advantages. Because of the marketing pressure, there is now a plethora of robots available in some areas. This will lead to the multiplication of occasional operators, whose negative impact on the efficiency of the procedure is demonstrated. The solution may be that of aviation: improve skills on a simulator in order to correctly perform clinically. It is now necessary to stimulate the elaboration of such a simulator.

Radical prostatectomy remains the gold standard for treatment of localised prostate cancer. Standardisation of the open retro-pubic anatomic prostatectomy by P Walsh allows skilled but not expert surgeons to achieve a high standard of performance. Learning curve is short with this technic, with minor morbidity. Rates of incontinence are low and impotency is now rather uncommon in the younger patient while oncological control is optimal for histologicaly organ confined cancer. "Mini invasive technics", laparoscopy and robot-assisted laparoscopy, have a longer learning curve, including a higher rate of complications that are unusual with open surgery. Operating time remains longer, costs are superior to the open technic and oncological control is not yet clearly validated while rates of classical late complications are not lower. Consequently, most urologist still prefer the open approach

circle tube nephrostomyを男性7例, 女性10例, 計17例に施行し, 手術操作とcircle tube交換の操作を容易にするため, 千葉大式のcircle tubeならびにconnectorを作製した.手術前後の腎機能をPSP, Ccrで比べてみると正常化12例(71%), 改善4例(24%), 不変1例で悪化例は認めなかった.水腎の程度も全例改善した.合併症としては5例29%に尿もれがみられたが一時的であった.発熱, 腎出血, 尿路結石形成はみられなかった, We performed circle tube nephrostomy in 17 patients using a newly designed catheter. The catheter which we called 'Chiba Nephrostomy Circle tube' consisted of a silicon tube which has three holes in the middle portion, and a metal connector. The renal function recovered to normal in 12 of the 17 patients (recovery rate 71%), improved in 4 (24%), and remained unchanged in only one patient. Although temporal urinary leakage occurred in 5 patients (29%), there were no serious complications with this newly designed tube. Furthermore, pyelonephritis, renal bleeding and urolithiasis, which occasionally occur by single nephrostomy, did not occur with this method. Thus, we proved the clinical usefulness of the newly designed circle tube.

最近3年間に経験したKock回腸膀胱による尿路変更75例につき, その手術成績を, 手術手技の改良時期別に検討した.1)本法を施行した75例中, 評価可能な症例は71例であり, うち63例に満足できる最終成績を得た.2)主な術後晩期合併症は, ニップル不全9例と結合形成6例であった.3)ニップル不全の最終手術成績は, CUSA(キャビトロン超音波外科用吸引装置)による腸間膜処置, およびニップルのパウチ壁への固定という二つの改良により, 著しく改善された.4)尿路変更としてKock回腸膀胱は, 手術手技の改善により安全で確実な手術法となり, 廃絶した膀胱を有する患者あるいは膀胱全摘を余儀なくされる患者の生活の質を高める術式と考える, Internal urinary reservoir type urinary diversions have been getting popularity since Kock reported a continent ileal reservoir in 1982. From November 1984 through October 1987, we performed Kock pouch operation in 75 patients (male 64, female 11; from 24 to 82 years old, mean age 56 years old). The underlined diseases were mostly bladder cancer patients; bladder cancer 70, rectal cancer 2, prostatic sarcoma 1, vesical exstrophy 1 and neurogenic bladder 1 case. The end results for 71 evaluable cases, followed up more than 3 months, were excellent in 49 (69%), good 14 (20%), fair 6 (8.5%) and poor 2 (2.8%), with success rate 89%. The most common complication was the nipple malfunction; prolapse, including intermittent prolapse, in 7 patients, slippage or sliding in 1, and eversion in one patient. Stone formation occurred in 6 patients, mild acidosis in 2 and a entero-pouch fistula in a patient who was re-diverted from a ileal conduit. There were 2 deaths postoperatively. Late complications were prominently decreased due to several important modifications of the operative technique, such as usage of Cavitron Ultrasonic Surgical Aspirator (CUSA) for defatting the mesentery, and fixing the nipple to the pouch. In conclusion, Kock pouch can be a safe and sound operative modality for patients who need urinary bladder replacement.

Subcapsular orchiectomy is the most commonly p erformed procedure in the endocrine treatment of prostatic carcinoma. However, it has been described by McDonald et al. and O'Conor et al. that there are significant numbers of Leydig- like cells remaining in the tunica albuginea and neighboring area of testis after subcapsular orchiectomy. Therefore, the orchiectomy including tunica albuginea and epididymis is considered to require in eradicating androgen-secreting tissue in the scrotum. A technique of transvaginal orchiectomy w as presented here, which was considered more radical than subcapsular orchiectomy and more beneficial in cosmetic reason than total orchiectomy. Te chnique : A transverse incision is made on the anterior scrotal skin under local or spinal anethesia. The incision is carried through the skin, cremasteric fascia, cremaster and tunica vaginalis testis preserving the tunica albuginea (Fig. 1). After the incision entering the vaginal space, the vas deferens is clamped, ligated and severed transvaginally at the level of upper pole of the testis, then vascular element is similarly isolated (Fig. 2, 3 and 4). The gubernaculum and remaining mesorchium are cross clamped and transected to complete the removal of the organs (Fig. 5). The incision is then approximeted and closed with skin sutures.

Since 1964 we have utilized the ileal conduit for the urinary d i v ersion, and the data for this report came from the study of 17 cases out of 34 patients who underwent the ileal conduit during the years from 1964 to 1970. Four modified techniques of the ileal conduit were performed, but there was no significant difference observed between them in the transport of urine. The ileum and the ureter, which are the main com ponents of the ileal conduit, have own different activity, but few investigations have been made whether the motion of ileal conduit itself has some untoward effects on the transport of urine in the upper urinary tracts or not. Cinefluorographic studies by the retrograde ileal conduitography (ileal loopography) and excretory urograms were chiefly used, in addition, routine intravenous pyelograms, the PSP excretion test, the manometric studies of ileal conduit, and the bacteriological examinations of urine were carried out. And the following results were obtained. 1) The frequency of systolic movements observed at the ureteropelvic junction was 2 to 3 times per minute in supine position, and 3 to 4 times per minute in erect position after the diversion to the ileal conduit. It remained within normal limits of the frequency observed in the normal persons. 2) Unle s s there was no obstruction of urine passage distal to the ureteroileostomy, the systolic movements of ileal conduit itself gave cinefluorographically little influence to the transport of urine in the upper urinary tracts. 3) The ureteral reflux was obs e r ved in 53 % of the renal units in the retrograde ileal conduitography. But it seems to be an artificial phenomenon, and from the following facts the spontaneous occurrence of ureteral reflux seems to be uncommon in the ileal conduit in ordinary life. A) No relationship was observed between the occurrence of reflux and the postoperative improvement of pyelograms, the pattern of PSP excretion curve, the frequency of systolic movements at the ureteropelvic junction, or the persistence of infected urine. B) Small air bubbles were sent to the renal pelvis with the contr a st medium in some cases of the retrograde ileal conduitography. In such cases the air bubbles were transported into the ureter after the removal of Foley catheter, but were never backflowed again. C) The occurrence of reflux from the conduit into the ureter was difficult t o observe in the excretory cinefluorography with the intravenous injection of large dose contrast medium. 4) All of five cases with advanced hydronephrosis were improved to normal or t o minimal hydronephrosis. Consequently, it is emphasized that the ileal conduit is a safe and adequate urinary diversion for the patients with advanced hydronephrosis if the duration of urinary stasis has not been so long and the renal parenchymal damage has not been so serious. 5) The systolic movements at the ureteropelvic junction were often observe d cinefluorographically in hydronephrosis which was improving to the lower grade after the urinary diversion. 6) The elevation of intraluminal pressure, induced by the obstruction of the stoma with a balloon catheter, was recorded by the electromanometer with the sensitive strain gauge. The resting pressure was 2 to 10 mmHg (the average was 5.9 mmHg). The maximum pressure, which was recorded at the onset of spike wave, was 38 to 100 mmHg (the average was 58 mm Hg). The interval of the spike waves was comparatively constant. Some patients complained of the colic flank pain suggesting the occurrence of ureteral reflux when the spike wave was recorded. 7) The PSP excretion curve gives a clue to see the change of the dead space and the state of renal function when comparing the curves monthly or annually after the urinary diversion. 8) The excretory cinefluorography of the ileal conduit and the cinefluoro-conduitography often showed the weak nonpropulsive movements Although the propulsive peristalsis were rarely noted, the stasis of urine in the ileal conduit was not so much and never increased. This means that the urine in the conduit is discharged little by little with the weak and nonpropulsive movements of the conduit. The urinary stasis was rare in the short and straight.

Minerva Urol