Akito Yamaguchi

Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy: A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study

PURPOSE The study investigated factors that affect operating times and bleeding complications associated with percutaneous nephrolithotomy (PCNL) in the PCNL Global Study. PATIENTS AND METHODS All patients who underwent PCNL for primary or secondary treatment of kidney stone indications during the study period (November 2007-December 2009) were eligible for inclusion. PCNL procedures were performed according to local clinical guidelines and practices. Nephrostomy tract dilation was performed using balloon dilation, metal telescopic dilation, or Amplatz serial dilation. Hematologic complications assessed included bleeding rates, transfusion rates, and preoperative and postoperative hematocrit values. RESULTS The median operating time with balloon dilation (n=2277) was significantly longer than with telescopic/serial dilation (n=3260) at 94.0 vs 60.0 minutes, respectively (P<0.0001). In the balloon dilation group, there was significantly more bleeding (9.4% vs 6.7%, respectively; P<0.0001) and more transfusions (7.0% vs 4.9%, respectively; P=0.001) compared with the telescopic/serial dilator group. Univariate analysis showed that the probability of bleeding complications was higher with balloon vs telescopic/serial dilation (odds ratio [OR] 1.75; P=0.0001) and larger sheath size (OR 1.42; P=0.0001). By multivariate analysis, sheath size but not dilation method was predictive of bleeding complications. Other significant predictive factors included operating time, stone load, and caseload. CONCLUSION This study shows that in PCNL, factors that are associated with bleeding/transfusion include sheath size, operating time, stone load, and caseload.

Laparoscopic Radical Nephroureterectomy: A Multicenter Analysis in Japan

BACKGROUND Laparoscopic nephroureterectomy (LNUx) is prevalent in Japan and throughout the world, but long-term outcome data remain limited. OBJECTIVE To understand the present state of LNUx in Japan, we conducted a multicenter analysis of clinical outcome and long-term cancer control for patients who underwent the procedure. DESIGN, SETTING, AND PARTICIPANTS Between January 1995 and December 2005, 1003 patients with urothelial cancer in the upper urinary tract were treated with LNUx at 51 institutions in Japan, and patient data were collected retrospectively. MEASUREMENTS Patient profiles were gathered and analyzed for survival, intravesical recurrence, and risk factors influencing them. RESULTS AND LIMITATIONS Median operative time was 320 min. Median bleeding volume was 232 ml. Complications occurred in 93 cases (9.3%) intraoperatively and in 107 cases (10.7%) postoperatively. Overall survival rate was 70% at 5 yr. Grade 3, pT3 or pT4, multifocal tumor, lymph-node metastasis, and previous or coexistent bladder tumor were independent risk factors for overall survival. Intravesical recurrence rate was 43% at 5 yr. Intravesical recurrence occurred more frequently in males, in patients with multifocal tumors, in patients with previous or coexistent bladder tumors, and in patients who underwent the hand-assisted approach. CONCLUSIONS Our report represents the largest multicenter analysis of LNUx reported to date. Male sex and the use of the hand-assisted approach were shown for the first time to be risk factors for recurrence-free survival and intravesical recurrence. To further analyze the effectiveness of LNUx, a long-term outcome comparison with risk stratification must be made between LNUx and open nephroureterectomy.

Maintenance therapy with bacillus Calmette-Guérin Connaught strain clearly prolongs recurrence-free survival following transurethral resection of bladder tumour for non-muscle-invasive bladder cancer.

Study Type – Therapy (RCT)

Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction

To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO).

Evaluation of the learning curve for photoselective vaporization of the prostate over the course of 74 cases.

PURPOSE To evaluate the learning experience, in addition to its impact on outcomes, in patients with benign prostatic hyperplasia (BPH) who undergo photoselective vaporization of the prostate (PVP). PATIENTS AND METHODS The study included 74 Japanese patients who underwent PVP. All patients were assessed for treatment efficacy in outcome variables including the International Prostate Symptom Score (IPSS), quality-of-life (QOL) score, peak urinary flow rate (Q(max)), and post-void residual urine volume (PVR) at 12 months after PVP. The impact of the learning curve in terms of efficacy and morbidity following PVP were also analyzed. RESULTS There was a significant improvement in each outcome variable after surgery. The median (25% and 75%) values of the improved rate (IR) at 12 months after PVP were 75% (57%, 87%), 67% (50%, 83%), 103% (50%, 176%), and 85% (68%, 96%) in IPSS, QOL score, Q(max) and PVR, respectively. The IR in each outcome variable did not significantly change as the surgeons experience increased. The time required for tissue vaporization of the adenoma and the total applied laser energy, along with the vaporized weight, significantly increased, but the efficiency of tissue vaporization did not increase as experience increased. A significant correlation was not evident between the learning curve and the total incidence of adverse events or blood loss following PVP. CONCLUSION PVP is a safe and effective treatment option for patients with BPH, providing good treatment efficacy and minimal bleeding, even when the surgeon has minimal experience.

The efficacy and safety of degarelix, a GnRH antagonist: a 12-month, multicentre, randomized, maintenance dose-finding phase II study in Japanese patients with prostate cancer.

OBJECTIVE To assess the efficacy and safety of degarelix, a new gonadotropin-releasing hormone antagonist, for achieving and maintaining serum testosterone suppression (≤0.5 ng/ml) during the 12-month treatment of Japanese patients with prostate cancer. METHODS This Phase II study was conducted as a multicentre, randomized, parallel-group, open-label study. A total of 273 patients with adenocarcinoma of the prostate (any stage) were treated. Degarelix was administered subcutaneously at an initial dose of 240 mg followed by monthly maintenance doses of either 80 or 160 mg for a total of 12 doses. The treatment continued for 12 months. RESULTS Dose regimens of 240/80 and 240/160 mg maintained castrate levels of testosterone in 94.5 and 95.2% of the patients, respectively. After 3 days, 99.3 and 98.5% of the patients, respectively, reached these levels without a testosterone surge. Prostate-specific antigen levels decreased rapidly following degarelix administration and remained low throughout the study. Best overall response rates according to RECIST were 71.4 (20/28) and 72.7% (16/22), respectively. Eighteen patients (6.6%) withdrew from the study due to adverse events. The most common adverse events were injection site reactions; other adverse events included hot flush, nasopharyngitis, weight increase and pyrexia. CONCLUSIONS Both monthly degarelix dosing regimens were found to be effective in testosterone suppression without a testosterone surge, prostate-specific antigen reductions and anti-tumour effect in Japanese patients with prostate cancer, as was shown in the overseas Phase III study. Degarelix was also well tolerated.

Adverse drug reactions of intravesical bacillus Calmette-Guérin instillation and risk factors of the development of adverse drug reactions in superficial cancer and carcinoma in situ of the bladder

Background: We examined the incidence and severity of adverse drug reactions following intravesical bacillus Calmette–Guérin (BCG) instillation for superficial bladder cancer including carcinoma in situ. We investigated the relationship between adverse drug reactions and patient background to clarify risk factors for the development of adverse drug reactions.

Effects of Photoselective Vaporization of the Prostate on Urodynamics in Patients With Benign Prostatic Hyperplasia

PURPOSE We evaluated the effects of photoselective vaporization of the prostate on efficacy outcomes and urodynamic parameters in patients with benign prostatic hyperplasia. MATERIALS AND METHODS The efficacy and morbidity of photoselective vaporization of the prostate were prospectively analyzed in 135 patients who underwent this therapy. Treatment efficacy was assessed regarding outcome variables, including International Prostate Symptom Score, quality of life score, peak urinary flow rate and post-void residual urine volume 3, 6 and 12 months postoperatively. Urodynamic evaluations, including cystometry and a pressure flow study, were performed before and after the operation in 78 patients. Perioperative values and postoperative complications were also noted. RESULTS Significant improvement was observed in all outcome variables with significant relief of bladder outlet obstruction and detrusor overactivity, and a minimal change in detrusor contractility following photoselective vaporization of the prostate. The preoperative and postoperative overall rate of detrusor overactivity was 47.4% and 26.9%, respectively. The median preoperative and postoperative degree of obstruction according to the Schafer nomogram was 4 (IQR 3, 4) and 1 (IQR 0, 1), respectively. Decreases in serum sodium and hemoglobin were negligible. Two patients required intervention for postoperative bleeding. There were 2 newly documented cases of urethral stricture. Two patients required reoperation for postoperative dysuria. CONCLUSIONS Photoselective vaporization of the prostate is considered a safe and effective treatment with minimal bleeding and no hyponatremia, thus providing successful relief of bladder outlet obstruction and detrusor overactivity without affecting detrusor contractility in patients with benign prostatic hyperplasia.

Importance of Urinary Interleukin-18 in Intravesical Immunotherapy with Bacillus Calmette-Guérin for Superficial Bladder Tumors

Objective: Intravesical immunotherapy with bacillus Calmette-Guérin (BCG) remains the most efficient modality for the treatment of carcinoma in situ and prevention of recurrences of Ta and T1 bladder tumors. Although elevations in a variety of urinary cytokines have been reported after BCG instillation, the mechanism by which BCG mediates antitumor activity has not been clearly established. Based upon our murine study (J Urol 2000;163:1549–1552), we reevaluated urinary cytokines before and after BCG instillations from the point of T helper (Th) 1/2 lymphocyte cytokine profiles. Methods: Urinary interleukin (IL)-2, interferon (IFN)-γ, IL-12, and IL-18 for Th1, and IL-4 for Th2 cytokines were measured by enzyme-linked immunosorbent assay just before and 4 h after the 4th or 5th instillation of 8 weekly instillations of 40–80 mg BCG, Tokyo strain, in 12 patients with superficial stages Ta and T1 bladder cancer, and carcinoma in situ. Results: Two representative Th1 cytokines, IL-2 and IFN-γ, significantly increased in urine after intravesical BCG instillations. Interestingly, IL-12, a strong inducer of Th1 cytokines, did not increase in the urine after BCG instillations. Instead, IL-18, that has recently been reported to induce IFN-γ production in T and NK cells in synergy with IL-12, obviously elevated in urine after BCG instillations. Urinary IL-4, a representative of Th2 cytokines, did not change at all after intravesical BCG instillations. Conclusion: Our results clearly show the predominant importance of IL-18 followed by increases in Th1 cytokines, such as IL-2 and IFN-γ, in the mechanisms of intravesical immunotherapy with BCG.

Comparison of photoselective vaporization and standard transurethral resection of the prostate on urodynamics in patients with benign prostatic hyperplasia.

Objectives:  To compare photoselective vaporization of the prostate (PVP) and transurethral resection of the prostate (TURP) in patients with benign prostatic hyperplasia.