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A 71-year-old man presented with exertional dyspnea. Chest radiography revealed multiple pulmonary nodules, and contrast-enhanced computed tomography showed findings suspicious of right renal pelvic cancer. Percutaneous lung tumor biopsy revealed a histological diagnosis of urothelial carcinoma, and right renal pelvic cancer cT3N2M1 was diagnosed. Favorable response was shown during primary chemotherapy with gemcitabine and cisplatin but resulted in tumor progression after four cycles. The patient was switched to a second-line treatment, pembrolizumab, which resulted in rapid tumor growth. Hyper-progression was suspected, and the patient was promptly switched to a third-line treatment, enfortumab vedotin. The tumor shrank significantly. After three treatment cycles, an adverse event of enteritis was observed. A biopsy of the intestinal mucosa led to a histopathologic diagnosis of late-onset immune-related adverse event; therefore, enfortumab vedotin could be continued.

From April 2007 to April 2018, we performed lymph node dissection in 305 cases of laparoscopic radical prostatectomy and 202 cases of robot-assisted radical prostatectomy at our hospital, and there were 68 cases with positive lymph node metastasis (pN1). Of these 68 cases, we examined retrospectively 62 cases in which extended lymph node dissection (ELND) was performed. The median number of removed lymph nodes was 25 (interquartile range [IQR] ; 18-34) and the median number of metastatic lymph nodes was 1 (IQR ; 1-3). Postoperative prostate-specific antigen (PSA) recurrence was observed in 40 of the 62 patients. The median time to PSA recurrence was 24 months. After univariate analysis, PSA at initial diagnosis (iPSA) of 10 ng/ml or more, pathological Gleason score (pGS) of 8 or more, total number of lymph node metastases of 2 or more, and positive surgical margin (RM＋) were found to be riskfactors of PSA recurrence. In multivariate analysis, iPSA of 10 ng/ml or more, pGS of 8 or more and RM＋ were independent riskfactors of PSA recurrence (p＜0.05). In the cases without riskfactors such as iPSA≥10, pGS≥8, and RM＋, immediate postoperative adjuvant therapy may be avoided even with pN1.

Herein we present simple methods to prevent postoperative inguinal hernia (IH) after extraperitoneal and transperitoneal robot-assisted radical prostatectomy (RARP). Among 275 patients who underwent RARP between January 2014 and December 2016 at our institution, we evaluated 143 and 115 patients who underwent extraperitoneal-RARP (e-RARP) and transperitoneal-RARP (t-RARP), respectively, after excluding those with intraoperative detection of IH (17 patients). In the e-RARP group, all 143 patients (286 groins) underwent an IH prevention procedure. In the t-RARP group, the first 22 patients (44 groins) did not undergo an IH prevention procedure, whereas 29 patients (37 groins) with patent processus vaginalis (PPV) among the last 93 patients underwent the procedure. The IH prevention procedure during e-RARP included release of the vas deferens from the peritoneum and spermatic cord, and peritoneal dissection of the spermatic cord at the internal inguinal ring. The IH prevention procedure during t-RARP included release of the vas deferens from the peritoneum and spermatic cord, complete circumferential dissection of the peritoneum around the PPV at the level of the internal inguinal ring, and ligation of the PPV with a Hem-o- Loc○R clip. In the e-RARP group, postoperative IH occurred in 3 of the 143 patients (1.9%) during the follow-up period of 22.0±9.2 months. In the first subgroup of t-RARP, postoperative IH developed in 4 of the 22 patients (18%) during the follow-up period of 33.1±12.1 months, whereas in the last t-RARP group, postoperative IH developed in 3 of the 93 patients (3.3%) during the follow-up period of 20.1±8.6 months. Different IH prevention procedures performed in patients undergoing e-RARP and t-RARP were simple and effective in preventing postoperative IH.

Sixty eight patients had robot-assisted radical prostatectomy (RARP) from January 2016 to April 2017 with estimated blood loss of less than 500 ml. We compared the postoperative complication rates and the length of hospital stay between 34 of these patients who had pelvic drain placement (PD group), and the remaining 34 patients who had no drain placement (ND group). The approach was intraperitoneal in 25 patients in each group. The PD and ND groups were comparable for age (69.5 vs 70 yrs, P=0.459), clinical Gleason Score (6/7/≧8) 2/17/15 vs 3/8/23 (P=0.077), clinical stage (1c/2/3) 3/25/6 vs 1/25/8 (p=0. 539), operative time (311 vs 309 min, P=0.868), and estimated blood loss (p=0.166). The PD group had significantly higher median PSA level than the ND group (8.01 vs 6.25 ng/ml, P=0.023). Incidence of 30- day overall complications in the PD group (35 events) was lower than that in the ND group (38 events). All complications were classified as Clavien Dindo grade I. The postoperative hospital stay was 8 days in the PD group and 7 days in the ND group, showing no prolongation in the ND group. Pelvic drainage may be omitted after RARP without increasing postoperative complications or prolonging the hospital stay.

Traumatic adrenal injury is quite rare. From January 2008 to March 2018, out of 287 patients with genitourinary trauma, 23 patients (8%) were diagnosed with traumatic adrenal injury at Kobe City Medical Center General Hospital. We retrospectively reviewed the medical records and assessed the traumatic category, image findings and outcome. All 23 patients were bluntly injured. The causes of traumatic adrenal injury were motor vehicle accident (11 patients : 48%) and falls (9 patients : 39%). The majority of injuries occurred on the right side (18 patients : 78%). Associated injuries occurred in all 23 patients, most frequently in the liver (57%) and ribs (57%). Extravasation of contrast materials was identified on computed tomography (CT) in 4 patients (17%). Although 22 patients (96%) were conservatively managed, only 1 patient was treated by transcatherter arterial embolization because of hypotension. One patient died of intraabdominal bleeding. To our knowledge, the present study is the largest on traumatic adrenal injury in Japan.

A 76-year-old man with a history of hypertension was admitted with high fever and left scrotal pain. Laboratory findings revealed high serum C-reactive protein levels. The left epididymis appeared to be swollen on computed tomography. The patient was diagnosed with bacterial epididymitis and treatment with antibiotics was initiated. Despite treatment, his left scrotal pain and fever did not improve. Additionally, he developed right scrotal and posterior neck pain. For histopathological diagnosis, a left high orchiectomy was performed and the findings revealed thickened arteriolar walls with infiltration of inflammatory cells around the testis, leading to a final diagnosis of systemic polyarteritis nodosa. Treatment with steroids led to complete resolution of the patient’s systemic pain and inflammation.

A 63-year-old man with microscopic hematuria underwent contrast-enhanced CT, which showed multiple bilateral renal masses. Percutaneous biopsy results indicated renal oncocytosis. The tumors remained unchanged for 3 years. Renal oncocytosis is a very rare tumor, but it is an established disease entity characterized by numerous oncocytic tumors and diffuse (sporadic) renal parenchymal epithelial oncocytic changes on an analysis histopathology. Although renal oncocytosis can be sporadic or part of Birt-Hogg-Dube syndrome (BHDS), our case did not associate with BHDS because of absence of lung cyst.

From April 2007 to April 2018, we performed lymph node dissection in 305 cases of laparoscopic radical prostatectomy and 202 cases of robot-assisted radical prostatectomy at our hospital, and there were 68 cases with positive lymph node metastasis (pN1). Of these 68 cases, we examined retrospectively 62 cases in which extended lymph node dissection (ELND) was performed. The median number of removed lymph nodes was 25 (interquartile range [IQR] ; 18-34) and the median number of metastatic lymph nodes was 1 (IQR ; 1-3). Postoperative prostate-specific antigen (PSA) recurrence was observed in 40 of the 62 patients. The median time to PSA recurrence was 24 months. After univariate analysis, PSA at initial diagnosis (iPSA) of 10 ng/ml or more, pathological Gleason score (pGS) of 8 or more, total number of lymph node metastases of 2 or more, and positive surgical margin (RM＋) were found to be riskfactors of PSA recurrence. In multivariate analysis, iPSA of 10 ng/ml or more, pGS of 8 or more and RM＋ were independent riskfactors of PSA recurrence (p＜0.05). In the cases without riskfactors such as iPSA≥10, pGS≥8, and RM＋, immediate postoperative adjuvant therapy may be avoided even with pN1.

Sixty eight patients had robot-assisted radical prostatectomy (RARP) from January 2016 to April 2017 with estimated blood loss of less than 500 ml. We compared the postoperative complication rates and the length of hospital stay between 34 of these patients who had pelvic drain placement (PD group), and the remaining 34 patients who had no drain placement (ND group). The approach was intraperitoneal in 25 patients in each group. The PD and ND groups were comparable for age (69.5 vs 70 yrs, P=0.459), clinical Gleason Score (6/7/≧8) 2/17/15 vs 3/8/23 (P=0.077), clinical stage (1c/2/3) 3/25/6 vs 1/25/8 (p=0. 539), operative time (311 vs 309 min, P=0.868), and estimated blood loss (p=0.166). The PD group had significantly higher median PSA level than the ND group (8.01 vs 6.25 ng/ml, P=0.023). Incidence of 30- day overall complications in the PD group (35 events) was lower than that in the ND group (38 events). All complications were classified as Clavien Dindo grade I. The postoperative hospital stay was 8 days in the PD group and 7 days in the ND group, showing no prolongation in the ND group. Pelvic drainage may be omitted after RARP without increasing postoperative complications or prolonging the hospital stay.

We report the surgical procedures and perioperative outcomes of off-clamp, non-renorrhaphy robotassisted partial nephrectomy (RAPN) in 7 out of 76 patients who underwent RAPN with off-clamp and nonrenorrhaphy between February 2015 and August 2017. The approach was chosen depending on the location of the tumor. Tumor enucleation was performed by using sharp incision and blunt dissection. For hemostasis, the soft-coagulation system was used and TachoSil○R was placed on the resection bed. As a rule, renorrhaphy was not performed. Median (range) patient age was 67 years (40-79), tumor size ; 14 mm (12-18), operative time ; 139 minutes (102-166), console time ; 51 minutes (41-75), estimate blood loss ; 10 ml (0-100). No patients required a perioperative blood transfusion. Median (range) tumor intraparenchymal depth was 10.4 mm (4.3-15.5) and distance from urinary collecting system was 9.3 mm (4.1-13.0). Pseudoaneurysm and urine leakage were not observed. No complications classified as Clavien-Dindo grade higher than grade 1 appeared. No cases had a positive surgical margin. Median (range) estimated glomerular filtration rate (eGFR) change rate at 3 months after surgery was 0% (−12.7-14.5). Off-clamp, non-renorrhaphy RAPN with the soft-coagulation system and TachoSil® is a feasible and safe procedure for patients carefully selected among those with superficial tumors.

We report the incidence and characteristics of lymphoceles after robot-assisted radical prostatectomy (RARP). Computed tomography was performed on 79 patients one month after RARP or when symptoms appeared. The lymphocele was defined as a cystic lesion over 10 mm in diameter. Symptomatic and asymptomatic lymphoceles were identified in 25% (20/79) of all cases, and in 40.9% (18/44) of the cases with lymph node dissection (LND). Symptomatic lymphoceles were identified in 2.5% (2/79) of all cases. Lymphoceles were significantly associated with LND, pathological stage over T3, longer period of indwelling drain tube, and higher volume fluid of drain tube (p

A 61-year-old man with a left renal mass, which was detected by ultrasound during a routine health examination, was referred to our department. The patient had a surgical history of two pneumothorax operations, and the patient's brother also had a history of pneumothorax surgery. A case of Birt-Hogg-Dubé (BHD) syndrome was suspected based on patient history. The pathological diagnosis of the resected tumor, which used robot-assisted laparoscopic partial nephrectomy, was determined to be chromophobe renal cell carcinoma (grade 2, pT1a). BHD syndrome was confirmed by genetic testing, where a nonsense mutation of exon 9 in the FOLLICULIN (FLCN) gene was detected. The patient is currently alive 10 months after surgery.

Recently, holmium laserenucleation of the prostate (HoLEP) was associated with less bleeding compared with transurethral resection of prostate. Since 2012, we have performed HoLEP for benign prostatic hyperplasia (BPH) under continuous oral antithrombotics (OA). Between October 2004 and March 2015, 54 patients with BPH underwent HoLEP while on OA at our hospital. Eight patients underwent HoLEP without OA cessation and 46 patients with temporary OA cessation. No significant between-group difference was observed in age, prostate volume, transitional zone prostate volume, operation time, resection weight, resection weight per minute, urethral catheter duration, Hb decrease on day 1 post- HoLEP, hospital stay after HoLEP, bleeding intraoperative rate, bleeding rate after HoLEP and transfusion rate. None presented embolic complications. HoLEP was safe without OA cessation. However, highvolume BPH patients without OA cessation required intraoperative transfusion. Thus, high-volume BPH patients may benefit from OA cessation.

Urosepsis is not uncommon and sometimes causes a critical condition including death. We retrospectivelyanaly zed the risk factors for mortalityin urosepsis. We treated 80 patients as urosepsis from 2010 to 2014 in our hospital. Five patients (6%) died within 30 days of hospitalization. The median age of the patients who died of urosepsis was 92 years (range, 83-95 years). The main causes of urosepsis were complicated pyelonephritis in 4 patients and emphysematous pyelonephritis in one. In the subgroup analysis of elderly patients over 75 years old, bad performance status and lower serum albumin were significantlyrelated to mortality(p ＝0.033, 0.046). The elderlypatients, especiallywith bad performance status and lower serum albumin, are more likelyto die.

Traumatic adrenal injury is quite rare. From January 2008 to March 2018, out of 287 patients with genitourinary trauma, 23 patients (8%) were diagnosed with traumatic adrenal injury at Kobe City Medical Center General Hospital. We retrospectively reviewed the medical records and assessed the traumatic category, image findings and outcome. All 23 patients were bluntly injured. The causes of traumatic adrenal injury were motor vehicle accident (11 patients : 48%) and falls (9 patients : 39%). The majority of injuries occurred on the right side (18 patients : 78%). Associated injuries occurred in all 23 patients, most frequently in the liver (57%) and ribs (57%). Extravasation of contrast materials was identified on computed tomography (CT) in 4 patients (17%). Although 22 patients (96%) were conservatively managed, only 1 patient was treated by transcatherter arterial embolization because of hypotension. One patient died of intraabdominal bleeding. To our knowledge, the present study is the largest on traumatic adrenal injury in Japan.

A 63-year-old man with microscopic hematuria underwent contrast-enhanced CT, which showed multiple bilateral renal masses. Percutaneous biopsy results indicated renal oncocytosis. The tumors remained unchanged for 3 years. Renal oncocytosis is a very rare tumor, but it is an established disease entity characterized by numerous oncocytic tumors and diffuse (sporadic) renal parenchymal epithelial oncocytic changes on an analysis histopathology. Although renal oncocytosis can be sporadic or part of Birt-Hogg-Dube syndrome (BHDS), our case did not associate with BHDS because of absence of lung cyst.

A 76-year-old man with a history of hypertension was admitted with high fever and left scrotal pain. Laboratory findings revealed high serum C-reactive protein levels. The left epididymis appeared to be swollen on computed tomography. The patient was diagnosed with bacterial epididymitis and treatment with antibiotics was initiated. Despite treatment, his left scrotal pain and fever did not improve. Additionally, he developed right scrotal and posterior neck pain. For histopathological diagnosis, a left high orchiectomy was performed and the findings revealed thickened arteriolar walls with infiltration of inflammatory cells around the testis, leading to a final diagnosis of systemic polyarteritis nodosa. Treatment with steroids led to complete resolution of the patient’s systemic pain and inflammation.

Oncocytic papillary renal cell carcinoma isa variant of papillary renal cell carcinoma (PRCC). We herein report two cases treated with retroperitoneoscopic partial nephrectomy. Histologically, tumor cells of both cases exhibit round and regular nuclei with CK7 positive areas in the cytoplasm typical of TYPE1 PRCC and eosinophilic granular cytoplasm with E-cadherin positive areas in the cytoplasmic membrane, which indicates TYPE2 PRCC. Out of 46 cases reported in the literature, only one died of disease, which revealsitslow malignant potential.

Prostate ductal adenocarcinoma is a rare variant of prostate cancer and considered to be more aggressive than the common acinar type of adenocarcinoma. The appropriate treatment guideline for prostate ductal adenocarcinoma has not been established. The aim of the present study was to examine the clinical characteristics and the effectiveness of treatment for prostate ductal adenocarcinoma. From 2005 to 2012, 41 patients were diagnosed to have prostate ductal adenocarcinoma in Kyoto University Hospital. The mean±SD age was 68.6±7.0 years, and the median (range) initial serum PSA level was 9.3 (3.7-217) ng/ml. Among 17 patients who underwent radical prostatectomy, 10 (58.8%) had pT3 disease and 5 (29.4%) had biochemical recurrence during median follow-up of 22.9 months. Out of 19 patients treated with definitive EBRT with endocrine therapy, 2 patients (10.5%) experienced biochemical recurrence with median follow-up of 37.3 months. Five patients were treated with endocrine therapy alone, and 2 (40.0%) of them died of prostate ductal adenocarcinoma. In conclusion, patients with prostate ductal adenocarcinoma were more likely diagnosed as locally advanced diseases than those with prostate acinar adenocarcinoma. However, for patients without metastasis, either surgery or EBRT with endocrine therapy is effective with goodprognosis.

We report the incidence and characteristics of lymphoceles after robot-assisted radical prostatectomy (RARP). Computed tomography was performed on 79 patients one month after RARP or when symptoms appeared. The lymphocele was defined as a cystic lesion over 10 mm in diameter. Symptomatic and asymptomatic lymphoceles were identified in 25% (20/79) of all cases, and in 40.9% (18/44) of the cases with lymph node dissection (LND). Symptomatic lymphoceles were identified in 2.5% (2/79) of all cases. Lymphoceles were significantly associated with LND, pathological stage over T3, longer period of indwelling drain tube, and higher volume fluid of drain tube (p<0.05). In conclusion, lymphoceles are quiet common after RARP. However, they rarely become symptomatic.

A 61-year-old man with a left renal mass, which was detected by ultrasound during a routine health examination, was referred to our department. The patient had a surgical history of two pneumothorax operations, and the patient's brother also had a history of pneumothorax surgery. A case of Birt-Hogg-Dubé (BHD) syndrome was suspected based on patient history. The pathological diagnosis of the resected tumor, which used robot-assisted laparoscopic partial nephrectomy, was determined to be chromophobe renal cell carcinoma (grade 2, pT1a). BHD syndrome was confirmed by genetic testing, where a nonsense mutation of exon 9 in the FOLLICULIN (FLCN) gene was detected. The patient is currently alive 10 months after surgery.

In cases of advanced renal cell carcinoma with inferior vena cava (IVC) thrombus, surgical resection of both tumor and thrombus contributes to the improvement of patient's prognosis, but the risk of perioperative complication is still high. We experienced two cases of advanced renal tumors with IVC tumor thrombus downsized by presurgical treatment of axitinib. Axitinib treatment showed a marked tumor reduction effect without any severe adverse event. We could remove both tumor and thrombus without perioperative complications. In these two cases, downsizing of IVC thrombus enabled us to reduce the extent of the surgery.

In patients receiving pelvic irradiation for gynecological or genitourinary malignancies, urinary diversion is sometimes required for complete resection of malignancies or treatment of urological complications by irradiation. We report our attempts to promote healing and prevent complications by urinary diversion using a transverse colon conduit in cases in which urinary reconstruction was performed with irradiated lower abdominal organs such as small intestine or distal ureters. Between 2008 and 2012, 9 patients with pelvic irradiation received transverse colon conduit urinary diversion. Six patients received diversion for genitourinary complications, while 3 patients received complete resection of pelvic malignancies. Colostomy formation and lithotripsy of vesical stones were simultaneously performed in 4 cases. Wallace method was adopted for ureterointestinal anastomosis. There was no operative mortality. Although acute pyelonephritis, ileus, wound dehiscence and pelvic abscess formation were seen as postoperative complications, all but two improved without any additional procedure. Cases of pelvic abscess or wound dehiscence were treated by abscess drainage. In observation periods, no patients required urinary stent placement and none suffered from defecation problems. We think that transverse colon conduit can be a viable option for patients with pelvic irradiation history, affording them reasonable quality of life postoperatively.

We report a case in a 44-year-old man with known past history of sarcoidosis associated with uveitis that was first diagnosed when he was 20 years old. He developed renal dysfunction 6 years after the diagnosis of sarcoidosis. At that time, a renal biopsy revealed non-necrotizing granulomatous interstitial nephritis, typical findings of renal involvement of sarcoidosis. Despite corticosteroid therapy administered soon after the biopsy, the renal dysfunction gradually progressed to end-stage renal disease. The patient underwent kidney transplantation from a living donor and the renal graft has been functioning well with no evidence of recurrence 10 months postoperatively, and with a serum creatinine level between 1.2 and 1.5 mg/dl.

A 20-year-old man with end-stage renal disease was scheduled to have an ABO-incompatible living kidney transplantation donated by his mother. His complete blood count including differential white blood cell count was normal before preoperative immunosuppressive therapy including mycophenolate mofetil (MMF), tacrolimus (FK506), and prednisolone was started 3 weeks before the operation. The dosage of MMF was initially 2, 000 mg/day, but was reduced to 500 mg/day due to diarrhea 10 days before the operation. He received rituximab 13 days before the operation. The neutrophil (Neu) count was 3, 100/μl a day before the operation. Transplant surgery was finished without any complications. The Neu count was found to be 300/μl on the day and 80/μl the next day. Granulocyte colony-stimulating factor was administered daily. Then the Neu count increased to 9, 100/μl on postoperative day (POD) 2, and was maintained within the normal range. MMF was re-started on POD 12. The dosage was 500 mg, and was increased to 1, 000 mg on POD 21. On POD 30 the 12-hr blood concentration of MMF was 117.2 mg× hr/l, which was almost double the adequate target dose. Then the dosage was reduced to 500 mg. In this case MMF is the most suspected drug for drug-induced agranulocytosis. Although MMF-induced neutropenia is frequently observed in transplant recipients, it usually happens three months after transplantation or later. The present case is a rare case as it occurred on the day of transplantation. The pharmacokinetics of MMF varies with the individual. Although routine monitoring of blood concentration of MMF is not recommended, specific attention to prevent overdosage should be given particularly in a patient presenting possible adverse effects including diarrhea and depilation.

We retrospectively reviewed the records of 11 patients with small cell carcinoma of the bladder, who were diagnosed at Kyoto University Hospital between June 1995 and November 2010. The median age was 79 years. Two patients had stage I disease, 4 had stage II disease, 2 had stage III disease, and 3 had stage IV disease. All 3 patients with stage IV disease had metastatic disease. They had very poor prognosis with a median survival of only 9.1 months (range 3.2-13.0 months). Of 8 patients without metastatic disease, 3 patients who had been treated with neoadjuvant chemotherapy followed by cystectomy had longterm survival. The median survival of these 3 patients was 85.5 months (range 38.0-102.8 months), and all of them are still alive without cancer. The median survival of the other 5 patients was 12.6 months (range 9. 9-33. 8 months). There were significant differences in survival between patients with neoadjuvant chemotherapy followed by cystectomy and with other treatments (p＝0.024). In conclusion, these results suggested that neoadjuvant chemotherapy followed by cystectomy could cure patients with small cell carcinoma of the bladder without metastatic disease.