Hitoshi Tachiki

Prediction of muscle invasion of bladder cancer by cystoscopy.

OBJECTIVES Urologists make a decision on whether to indicate staging procedures for primary lesions of bladder cancer by findings of cystoscopy. However, cystoscopic findings for prediction of muscle-invasive bladder cancer have not been fully evaluated. METHODS Two hundred seventy consecutive events of 165 patients with bladder cancer were included in this study. Multivariate analysis by a logistic regression model was applied to analyze cystoscopic findings for prediction of muscle invasion of bladder cancer. RESULTS Logistic regression analysis revealed that the size, stalk and configuration of the cancer were independent and significant factors that predict muscle invasion of bladder cancer. CONCLUSIONS Cystoscopic findings of bladder cancer may predict muscle invasion. When invasion is suggested by cystoscopy, imaging studies may be necessary before TUR of the cancer as well as deep resection of it.

Efficacy of treatment with carbapenems and third-generation cephalosporins for patients with febrile complicated pyelonephritis.

The purpose of this study was to clarify the clinical relevance of carbapenem and third-generation cephalosporin treatment for febrile complicated pyelonephritis, which often leads to urosepsis. Parenteral antimicrobial treatment with a carbapenem or third-generation cephalosporin was administered to febrile patients and the treatment was switched to oral antimicrobial agents after they became afebrile. In principle, the duration of the course of antimicrobial chemotherapy was limited to a total of 14 days. Clinically, the success rates were 97.3% in the carbapenem group and 96.0% in the third-generation cephalosporin group. For microbiological efficacy, the success rates were 89.2% in the carbapenem group and 92.0% in the third-generation cephalosporin group. There were no serious adverse events in the course of the study. The treatment regimen with a carbapenem or a third-generation cephalosporin was highly effective for patients with febrile complicated pyelonephritis and was well tolerated. Either of these regimens could become one of the standard treatments for patients with febrile complicated pyelonephritis.

TESTICULAR FINDINGS, ENDOCRINE FEATURES AND THERAPEUTIC RESPONSES OF MEN WITH ACQUIRED HYPOGONADOTROPIC HYPOGONADISM

Background Men with acquired hypogonadotropic hypogonadism (AHH) who desire restoration of fertility are treated with exogenous gonadotropin. However, gonadotropin (Gn) therapy does not always restore testicular function. It is unknown whether the therapeutic responses to Gn therapy correlate with their testicular histological findings. Thus, we analyzed factors influencing testicular dysfunction and therapeutic responses in AHH.

Construction of Predictive Models for Cancer-specific Survival of Patients with Non-muscle-invasive Bladder Cancer Treated with Bacillus Calmette-Guerin: Results from a Multicenter Retrospective Study

OBJECTIVE The aims of this study were to clarify the prognostic factors and to validate the bacillus Calmette-Guérin failure classification advocated by Nieder et al. in patients with non-muscle-invasive bladder cancer who had intravesical recurrence after bacillus Calmette-Guérin therapy. METHODS Data from 402 patients who received intravesical bacillus Calmette-Guérin therapy between January 1990 and November 2011 were collected from 10 institutes. Among these patients, 187 with bacillus Calmette-Guérin failure were analyzed for this study. RESULTS Twenty-nine patients (15.5%) were diagnosed with progression at the first recurrence after bacillus Calmette-Guérin therapy. Eighteen (62.1%) of them died of bladder cancer. A total of 158 patients were diagnosed with non-muscle-invasive bladder cancer at the first recurrence after bacillus Calmette-Guérin therapy. Of them, 23 (14.6%) underwent radical cystectomy. No patients who underwent radical cystectomy died of bladder cancer during the follow-up. On multivariate analysis of the 135 patients with bladder preservation, the independent prognostic factors for cancer-specific survival were age (≥70 [P = 0.002]), tumor size (≥3 cm [P = 0.015]) and the Nieder classification (bacillus Calmette-Guérin refractory [P < 0.001]). In a subgroup analysis, the estimated 5-year cancer-specific survival rates in the groups with no positive, one positive and two to three positive factors were 100, 93.4 and 56.8%, respectively (P < 0.001). CONCLUSIONS Patients with stage progression at the first recurrence after bacillus Calmette-Guérin therapy had poor prognoses. Three prognostic factors for predicting survival were identified and used to categorize patients with non-muscle-invasive bladder cancer treated with bacillus Calmette-Guérin into three risk groups based on the number of prognostic factors in each one.

Male idiopathic hypogonadotropic hypogonadismの精巣および内分泌学的所見とその治療への反応

The purpose of this study is to clarify the pathological and endocrinological variations of male idiopathic hypogonadotropic hypogonadism (IHH) from the viewpoint of testicular maturation. Twenty-five patients with IHH were classified into 3 groups according to the degree of germ cell maturation. The most mature germ cells in patients with severe IHH, moderate IHH and mild IHH were spermatogonia, primary spermatocytes and postmeiotic germ cells, respectively. All patients were treated with hCG alone or a combination of hMG-hCG for 1 year or more. The therapeutic efficacy of gonadotropin therapy was evaluated by findings of semen analysis, spermatogenesis and sexual maturation. The total GCI, which was expressed as the number of germ cells per Sertoli cell, diameter of the seminiferous tubules and testicular volume in mild IHH were the largest among the 3 IHH groups, and those in severe IHH were the smallest. Even in mild IHH, spermatogonial proliferation and meiotic activity were quantitatively smaller than those of normal pubertal boys. All patients showed extremely low basal testosterone levels. Response of serum testosterone to hCG administration correlated to the maturity of germ cells. Basal serum gonadotropin levels and responses to GnRH administration varied widely among the 3 groups. In particular, the response of serum gonadotropin to GnRH correlated to the maturity of the germ cells. Spermatogenesis could be initiated by hCG alone in IHH patients without cryptorchidism. Normal sperm density was obtained by hCG alone in the case of mild IHH; however, in moderate and severe IHH groups, hMG-hCG therapy was required for sufficient spermiogenesis. Sexual maturation was completely obtained by gonadotropin therapy within 1 year in moderate and mild IHH. However, in severe IHH, satisfactory sexual maturation could not be obtained within 1 year. The therapeutic prognosis for sexual maturation could be made based on the response to the hCG test at 6 months of gonadotropin therapy. In conclusion, the maturity of germ cells before treatment, which varies widely among patients with IHH, is a sensitive parameter for hypothalamo-pituitary-testicular function and the efficacy of gonadotropin therapy for testicular function. In severe IHH groups, to obtain satisfactory sexual maturation, the administration of testosterone should be considered in addition to gonadotropin replacement.

Upper tract urothelial carcinoma following intravesical bacillus Calmette-Guérin therapy for nonmuscle-invasive bladder cancer: Results from a multi-institutional retrospective study

OBJECTIVES The aim of this study was to clarify the prognostic indicators for upper tract urothelial carcinoma (UTUC) following intravesical bacillus Calmette-Guérin (BCG) therapy for nonmuscle-invasive bladder cancer (NMIBC). METHODS Data from 402 patients who received intravesical BCG therapy between January 1990 and November 2011 were collected from 10 institutes. The median follow-up interval from transurethral resection of the bladder tumor (TURBT) followed by BCG treatment was 50.0 months (IQR: 31.8-77.0). Of these patients, 186 (46.3%) had intravesical recurrence during the follow-up period after BCG therapy. RESULTS Thirty patients (7.5%) were diagnosed with UTUC after BCG therapy. The 10-year recurrence-free survival rates for UTUC (RFS-UTUC) was 87.5%. In univariate and multivariate analyses, the independent predicting factors for UTUC were intravesical recurrence (P = 0.016) and tumor morphology at TURBT before BCG (P = 0.045). The 10-year RFS-UTUC of patients with intravesical recurrence and others, were 80.6% and 95.0%, respectively. The 10-year RFS-UTUC of patients with papillary pedunculated tumors and nonpapillary or nonpedunculated were 96.1% and 84.6%, respectively. CONCLUSIONS The frequency of UTUC in patients with NMIBC after BCG therapy is not negligible. Two independent predicting factors (intravesical recurrence and nonpapillary nonpedunculated at TURBT before BCG) were identified for UTUC. These results might be useful to predict UTUC after BCG therapy for NMIBC.

Neoadjuvant chemotherapy with gemcitabine and cisplatin for muscle-invasive bladder cancer: multicenter retrospective study

Objectives The aim of this study was to evaluate the efficacy of neoadjuvant gemcitabine and cisplatin (GC) therapy for muscle-invasive bladder cancer (MIBC). Methods We retrospectively evaluated patients who underwent neoadjuvant GC therapy followed by radical cystectomy from April 2009 through December 2015 in the Sapporo Medical University Urologic Consortium. The efficacy of neoadjuvant chemotherapy (NAC) was assessed based on the pathological T0 (pT0) rate in radical cystectomy specimens, and the recurrence-free survival, cause-specific survival and overall survival (OS) rates. To compare the oncological benefit of NC with GC to that of the methotrexate, vinblastine, adriamycin and cisplatin (MVAC) regimen, we also utilized historical clinical data of patients who were treated with MVAC as NAC followed by radical cystectomy in our institute from 1986 through 2010. Results Fifty-eight patients receiving neoadjuvant GC therapy and 74 receiving neoadjuvant MVAC were included. The pT0 achieving rates were comparable between the two groups (20.7% vs. 18.9%, P = 0.83). Neoadjuvant GC was associated with a better 2-year OS rate than neoadjuvant MVAC for clinical T2 disease (95.2% vs. 70.8%, P = 0.036). In contrast, in patients with clinical T3 or more advanced disease, neoadjuvant MVAC provided more pT0 (20.0% vs. 5.6%, P = 0.07) and better 2-year OS than neoadjuvant GC (71.1% vs. 55.0%, P = 0.142), although the difference did not reach statistical significance. Conclusions Neoadjuvant GC had no inferiority in oncological outcomes to MVAC for MIBC.

Bilateral Deoxycorticosterone‐Secreting Adrenocortical Adenoma

A case of a 58‐year‐old man with bilateral deoxycorticosterone (DOC)‐secreting adrenocortical adenoma is reported. Before surgery, plasma levels of DOC and corticosterone were markedly elevated, but both adrenal hormone levels normalized after the surgical removal of the bilateral adrenal tumors. The histologic examination revealed bilateral adrenocortical adenoma, but curiously, the tissue concentrations of DOC and corticosterone were elevated only in the right adrenal gland.