Mitsuhiro Narita

Bilateral single ectopic ureters with hypoplastic bladder: How should we treat these challenging entities?

Bilateral single ectopic ureters with hypoplastic bladder are rare and difficult to treat. Urinary diversion (e.g. by ileal conduit) is usually performed because of small bladder capacity. We report a case treated by staged operation without urinary diversion or bladder augmentation. The outcome shows that ureterovesicostomy between the dilated ureter and the bladder is a feasible method to increase capacity for bilateral single ectopic ureters with hypoplastic bladder.

Urological laparoendoscopic single-site and reduced port surgery: A nationwide survey in Japan

To evaluate the current status of urological laparoendoscopic single‐site and reduced port surgery in Japan.

A natural variant of bovine dopamine β-monooxygenase with phenylalanine as residue 208: purification and characterization of the variant homo- and heterotetramers of (F208)4 and (F208)2(L208)2

Bovine dopamine β‐monooxygenase was purified from each of 18 individual adrenal glands by the method we have developed for the rapid purification of the enzyme from a single adrenal gland. Differential peptide mapping of the 18 enzyme preparations following fluorescence labeling of their cysteine residues revealed the presence of a novel variant with Phe as residue 208 in 14 adrenal glands; seven of them were homozygous for the variant allele and the remaining seven heterozygous. The variant enzyme was a tetramer and exhibited kinetic and structural properties similar to those of the wild‐type tetramer (L208)4. These results indicate an allelic polymorphism and codominant expression of the two alleles of the enzyme gene.

Prediction of intravesical recurrence of non-muscle-invasive bladder cancer by evaluation of intratumoral Foxp3+ T cells in the primary transurethral resection of bladder tumor specimens

Patients with a history of non-muscle-invasive bladder cancer sometimes have recurrence of tumors after transurethral resection of bladder tumor treatment. To find factors related to the recurrence of non-muscle-invasive bladder cancer, we examined tissue specimens taken at transurethral resection of bladder tumor as an initial treatment. We revealed the association between prognosis of non-muscle-invasive bladder cancer and infiltration of Foxp3+ T cells that suppress anti-tumor immunity in 115 primary non-muscle-invasive bladder cancer patients retrospectively identified and followed for at least 3 months after primary transurethral resection. In immunohistological staining, we counted the number of cells positive for CD3 and positive for CD3 and Foxp3 together and calculated the percentage of Foxp3+ T cells among the CD3+ T cells. The recurrence-free survival rate was calculated by the Kaplan-Meier method, and a Cox regression analysis of recurrence factors was performed. The median (interquartile range) percentage of Foxp3+ T cells in all cases was 17.1% (11.9, 11.4–23.3%). Compared by risk stratification, it was 11.4% (10.4, 7.8–18.2%) in the low-risk group (n = 32), 16.8% (12.6, 11.6–24.2%) in the intermediate-risk group (n = 45), and 22.0% (9.7, 16.4–26.1%) in the high-risk group (n = 38). The Kaplan-Meier survival analysis indicated that the Foxp3+ T cell high group (≥ 17.1%) had a worse RFS rate than did the low group (< 17.1%) (P = 0.006). In multivariate analysis, the percentage of Foxp3+ T cells was an independent risk factor for intravesical recurrence (hazard ratio 2.25). Thus, peritumoral Foxp3+ T cell infiltration was correlated to risk stratification and recurrence-free survival. Therefore, the percentage of Foxp3+ T cells in tumor specimens may predict a risk for intravesical recurrence.

Indocyanine Green Angiography-assisted Laparoendoscopic Single-site Varicocelectomy

OBJECTIVE To study the efficacy of a new laparoscopic varicocelectomy technique using indocyanine green (ICG) angiography. METHODS Laparoendoscopic single-site (LESS) varicocelectomy using ICG angiography was performed in a single institution on 11 patients with a grade 2 or 3 varicocele. Adult men (N = 9, 82%) who were apparently infertile and had a varicocele, as well as prepubertal boys (N = 2, 18%) with testicular growth retardation, underwent a LESS varicocelectomy using ICG angiography. After the separation of testicular veins, arteries, and lymphatics, ICG was injected intravenously, and arterial and venous blood flows were observed by ICG fluorescence. Spermatic veins were cauterized by bipolar forceps and cut. The spermatic artery and lymphatics were preserved. RESULTS The mean time to the arterial phase (AP) from the ICG injection was 34.9 seconds and the mean time to the venous phase was 58.3 seconds. The mean interval from the arterial phase to the venous phase was 23.3 seconds, and in all cases, this time interval facilitated the identification of arteries and veins. The rates of residual varicocele 3 and 6 months after surgery were 9.1% and 0%, respectively. Serious postoperative complications were not observed nor were adverse events induced by ICG. CONCLUSION ICG angiography appears to be safe and appears to facilitate the detection of artery and veins during LESS varicocelectomy. Continuing investigations of efficacy are required of this new and promising procedure in a larger number of patients.

V9-05 LAPAROSCOPIC VARICOCELECTOMY USING INTRAOPERATIVE NAVIGATION: INDOCYANINE GREEN ANGIOGRAPHY AND INDIGO CARMINE LYMPHATIC DYE

INTRODUCTION AND OBJECTIVES: Male circumcision (MC) provides a variety of medical benefits, including a 50-60% reduced risk of HIV transmission. The ShangRing is one of two WHO-prequalified MC devices and it comprises a key component of the scale-up of MC services in Africa. The No-Flip ShangRing circumcision technique represents a further simplification of this procedure. The objective of this study was to evaluate the outcomes of this technique in African adults and adolescents with regard to procedure duration, pain, adverse events, healing time, and patient satisfaction. Further, we sought to compare safety, healing rates and patient satisfaction after ring removal at 7 days versus spontaneous detachment. METHODS: We enrolled patients 10 years of age or older at two study sites in Kenya. All procedures were performed by physicians or nurses trained in the No-Flip ShangRing technique. Patients were randomized in 1:1 fashion to ring removal at 7 days versus spontaneous detachment. Outcomes were assessed weekly until 42 days or complete wound healing. RESULTS: 230 patients were enrolled in this study, age ranges 10 to 54. Over 80% of circumcisions were performed by nurses trained in the No-Flip technique. All patients (230/230) were suitable for ShangRing MC regardless of the presence of phimosis or adhesions. On subgroup analysis of patients 10-15 years of age versus >15 years, though more patients in the younger group required a dorsal slit and breaking down of adhesions prior to ring insertion, there was no difference in operative time and all circumcisions were successfully completed (Table 1). There was no difference in pain or adverse events between the age groups, and there was 97% patient satisfaction in both groups. Within the group randomized to spontaneous detachment, 72.4% of patients experienced detachment at median 14 days; 27.6% of patients requested ring removal due to pain or discomfort. There were no differences between spontaneous detachment and 7-day removal with regard to healing time, adverse events, or patient satisfaction. CONCLUSIONS: The No-Flip ShangRing procedure is simple, safe, effective, and acceptable for use in patients 10 years of age or older. Spontaneous detachment is safe and effective, and has the potential to reduce the burden of service provision in resource-poor settings.

ENDOSCOPIC SHIELDING OF RECTOURETHRAL FISTULA AFTER LAPAROSCOPIC RADICAL PROSTATECTOMY; REPORT OF A CASE.

Rectourethral fistulais a relatively rare complication of radical prostatectomy but is extremely difficult to treat. We report a case with post-laparoscopic radical prostatectomy rectourethral fistula, treated with only endoscopic shielding.A 75-year-old man had undergone laparoscopic radical prostatectomy for prostate cancer, cT2cN0M0. Although there was no finding of rectal injury during the operation, pneumaturia, pyuria and diarrhea appeared at postoperative day 21 and diagnosed rectourethral fistula by colonoscopy and amidotrizoic acid enema. The fistula did not close spontaneously. Four months after the prostatectomy, we treated with endoscopic shielding by use of polyglycolic acid sheets and fibrin glue. The fistula have not recurred for 20 months after the endoscopic procedure.This method is simple and less-invasive for patients. We think it is worth trying this method before surgical management for narrow rectourethral fistula following radical prostatectomy.

V11-05 LAPAROENDOSCOPIC SINGLE-SITE PARTIAL CYSTECTOMY COMBINED WITH CYSTOSCOPY FOR BLADDER PARAGANGLIOMA.

INTRODUCTION AND OBJECTIVES: We present a case report of our initial experience with laparoendoscopic single-site surgery (LESS) combined with cystoscopy for primary bladder paraganglioma. METHODS: A 41 years old woman consulted for headache and palpitation after micturition for 10 years. Ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and cystoscopy revealed a solitary 2cm mass lesion in the top of the bladder (Fig.1,2). High levels of noradrenaline were found both in plasma and urine. 123IMIBG scintigraphy showed an abnormal accumulation in the bladder. Thus, paraganglioma of the bladder was diagnosed. A LESS partial cystectomy combined with cystoscopy was performed. OCTOport ,>R was inserted through 2cm skin incision through the umbilicus, and one 2-mm port was added (Fig.3,j. Cystoscopic guidance was helpful to determine the excision line of the tumor during laparoscopic surgery,@,iFig.4,j. RESULTS: She has been free from symptom after operation. Histological examination of the resected specimen showed a paraganglioma. CONCLUSIONS: LESS partial cystectomy combined with cystoscopy for bladder paraganglioma can easily identify the margins of tumor and is safe technique.

Metastatic Prostatic Ductal Adenocarcinoma Successfully Treated with Docetaxel Chemotherapy: A Case Report

A 68-year-old man presented with gross hematuria. A papillary urethral tumor adjacent to the verumontanum was found by cystourethroscopy. Serum prostate-specific antigen (PSA) was 3.246 ng/ml. A transurethral biopsy specimen was most suggestive of a primary urothelial carcinoma of the prostate, for which a radical cystoprostatectomy was performed. The final pathology was prostatic ductal adenocarcinoma with very focal acinar features (Gleason score 5 + 4 = 9, pT3bN0M0). Local recurrence and pelvic bone metastases developed 17 months later, and his PSA rose to 10.806 ng/ml. He was treated with combined androgen blockade and radiation. Two years later, the lesion showed progressive growth. Treatment followed with docetaxel (70 mg/m2 every 3 weeks) and prednisolone 5 mg twice daily. After 10 cycles of chemotherapy, all lesions disappeared and PSA decreased to <0.005 ng/ml. Three years after chemotherapy, he maintains a complete response without any additional treatments. Docetaxel chemotherapy can be an effective treatment for patients with recurrent prostatic ductal adenocarcinoma.

Successful treatment of disseminated extragonadal germ cell cancer with intensive conventional chemotherapy after first-line high-dose chemotherapy

High-dose chemotherapy (HDCT) with peripheral blood stem cell (PBSC) support has been investigated as a first-line treatment in patients with poor risk germ cell cancer. However, effective management of patients with residual cancer after HDCT has not been well addressed, and the outcome in such patients is poor. Here, we report a case of disseminated germ cell cancer successfully treated with intensive conventional chemotherapy after HDCT. A 31-year-old man presented with a bulky mass at the retroperitoneum, which had invaded the lumbar and sacral vertebra, and multiple lung and liver metastases. The patients serum beta subunit of human chorionic gonadotrophin (β-hCG) was elevated to 2600 IU (cut-off value <0.1 IU). At the time of diagnosis of poor risk germ cell cancer of extragonadal origin, he underwent two cycles of BEP (bleomycin, etoposide, and cisplatin) chemotherapy and PBSC harvest followed by three cycles of HDCT with PBSC transplantation. The liver metastases disappeared. The retroperitoneal bulky mass and multiple lung metastases shrank but were still present, and the serum β-hCG level was not completely normalized. An additional three courses of BEP and five courses of VIP (cisplatin, ifosfamide, etoposide) normalized the β-hCG level. Pathological evaluation of the residual masses revealed no viable cancer cells at either site. The patient is alive without disease recurrence 5 years after completion of chemotherapy.