Ryuichi Nishiyama

Determining the Efficacy of Ultrasonography for the Detection of Ureteral Stone

OBJECTIVE To assess the efficacy of ultrasonography (US) for the detection of ureteral stone using non-contrast-enhanced computed tomography (NCCT) as a standard reference. MATERIALS AND METHODS From January 2009 to September 2011, 428 patients underwent both NCCT and US on the same day. The sensitivity and specificity of US to detect ureteral stone was evaluated. The detection rates using US imaging were examined according to location and stone size. The sizes of stones determined in the longest axis of NCCT and US were compared. We also performed group classification based on size to examine whether stone sizes measured by NCCT and US were similar. Moreover, the factors that may affect the detection of ureteral stone by US were analyzed. RESULTS Out of 856 ureters, NCCT could detect 171 stones in 169 patients, whereas US could detect 98 stones, yielding a sensitivity of 57.3% and a specificity of 97.5%. Expectedly, detection rate of US increased with stone size but was lower for distal ureter. With hydronephrosis, the sensitivity of US improved from 57.3% to 81.3%. Stone sizes measured by US correlated positively with those by computed tomography, and were concordant with those of NCCT in 68 of 98 patients (69.4%). Interestingly, stone size and the presence of hydronephrosis were factors that independently affected ureteral stone detection by US. CONCLUSION These results indicate that US may be useful as an initial imaging modality for detecting ureteral stone.

CHYLOUS LEAKAGE AFTER LAPAROSCOPIC RENAL AND ADRENAL SURGERY

(Objectives) It is recognized that Chylous leakage is a rare complication but is a relevant clinical problem after major abdominal surgery. It was occasionally reported in urologic surgery, but the data about its incidence and treatment outcome is still lacking. In this study, we reviewed our cases of chylous leakage after laparoscopic adrenalectomy or nephrectomy. (Patients and methods) From January 2005 to September 2014, laparoscopic adrenalectomies or nephrectomies were performed in 300 patients. The factors that affected the development of chylous leakage were analyzed. (Results) The overall incidence of chylous leakage was 4.3% (13 of 300 cases). All chylous leakage was seen on the left side, and it was commonly developed in patients with lymph node dissection or excessive hilar dissection around the left renal pedicle. Importantly, all cases were successfully managed conservatively by a low fat diet with or without octreotide. (Conclusions) Our results suggest that chylous leakage is not a rare complication after laparoscopic adrenalectomy or nephrectomy, but most cases can be treated conservatively. Chylous leakage can occur in patients with lymphadenectomy or hilar dissection on the left side.

THE OPTIMAL TROCAR PLACEMENT FOR LAPAROSCOPIC EXCISION OF URACHAL REMNANTS

(Objective) Although laparoscopic excision of urachal remnants has been applied widely, the standard surgical method has yet to be established. The aim of this study, therefore, was to evaluate perioperative outcome and surgical techniques, including the trocar placement at our institution. (Subjects and methods) A total of 20 patients with urachal remnant were treated using laparoscopic surgery between October 2002 and August 2016. 3 trocars were inserted in the peritoneal cavity. Camera trocar was placed at right side of umbilicus and two working trocars were placed at the upper side of umbilicus and right lower quandrant. A 5 mm, 30° angled lens camera was used during operation. (Results) The mean age was 27 years old. There were 16 males and 4 females. The classifications of urachal remnants were urachal sinus (n=18) and urachal diverticulum (n=2). Umbilical excision was performed in 18 case and partial cystectomy were required in 4 cases. 4 trocars were inserted in only one case due to severe adhesion in the peritoneal cavity. Laparoscopic excision was successfully completed in all cases. The mean operative time was 220 minutes and the mean blood loss was minimal. The complications occurred in 5 cases including small intestinal injury (n=2), peritonitis (n=1), wound infection (n=1), intestinal obstruction (n=1) and acute renal failure (n=1) (intestinal obstruction and acute renal failure were occurred in the same case). (Conclusion) Although there are problems such as shortening the operative time and reducing complications, our unique port placement enables good surgical view and easy suturing during partial cystectomy.

Laparoscopic Partial Cystectomy With Excision of Mesh Migration Into the Bladder Following Repair of Inguinal Hernia

Migration of hernia mesh into the bladder is a rare complication of inguinal hernioplasty. We present the case of an 85-year-old man who complained of hematuria and fever some 20 years after right hernioplasty. Cystoscopy and computed tomography revealed mesh migration into the right anterior wall of the bladder. Laparoscopic partial cystectomy with excision of the migrated mesh was performed successfully. To our knowledge, this is the first case of mesh migration into the bladder treated by laparoscopic partial cystectomy.

CLINICAL FACTORS ASSOCIATED WITH SPONTANEOUS PASSAGE OF URETER STONES IN CONSERVATIVE MANAGEMENT: 6 mm IN MAXIMAL STONE SIZE MEASURED BY ULTRASONOGRAPHY CAN BE A PREDICTIVE BORDER

(Purpose) To date there was no consensus regarding expectant size of stone and time to expulsion in the conservative treatment of ureter stones. The aim of this study was to find the clinical factors associated with stone passage by evaluating the outcome of ureter stones with expectant management in Japanese. (Materials and methods) A total of 679 ureter stone cases who visited our hospital with acute real colic and/or hematuria between 2009 and 2013, and who had decided to be treated by expectant management with or without medical expulsive therapy were enrolled in this study. All cases were examined size, location and presence of stone, and degree of hydronephrosis with ultrasonography. The examined data plus clinical data such as gender, age, side and body mass index were analyzed to find the factors related to spontaneous passage of ureter stones. Statistical analysis was performed to predict whether the factors were associated with the ureteral stone expulsion or not. (Results) Accumulated residual stone curve using Kaplan-Meier method showed time to 50%-expulsion as 15.7 days in cases with stone size no more than 6.0 mm and that as 21.8 days in those with greater than 6.0 mm, and time to 50%-expulsion as 28.8 days in cases with upper ureter stone whereas 15.6 days in those with middle or distal ureter stone. Analysis in groups with 1 mm-interval in stone size showed statistical significance only when compared 5-6 mm group with 6-7 mm group in size. Multivariate analysis showed stone size and location as statistically significant and independent factors to predict time to expulsion within 30 days. (Conclusion) Stone size and location was statistically reconfirmed to be associated with spontaneous passage in expectant management of ureter stones. This study statistically demonstrated the possibility that 6 mm in maximal stone size measured by ultrasonography can be a predictive border. 75% of ureter stones within 6 mm in maximal size measured by ultrasonography may expect to be expelled within 30 days.

THE FACTORS THAT AFFECT THE DECISION TO PERFORM LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR SMALL RENAL TUMOR

(Objectives) Nephron sparing surgery (NSS) is strongly recommended for patients with T1a renal cell carcinoma (RCC) whenever surgically feasible. However, partial nephrectomy, particularly laparoscopic approach, remains underutilized in Japan compared to laparoscopic radical nephrectomy (LRN). In this study, we examined the safety and efficacy of laparoscopic partial nephrectomy (LPN) for T1a RCC compared to LRN. We also assessed the factors that affect the decision to perform LPN or LRN. (Patients and methods) From March 2001 to September 2014, 112 patients with T1a renal tumors received renal surgery at our institution. Of these, 100 patients (LPN: 36 patients, LRN: 64 patients) underwent laparoscopic surgery. Treatment outcomes including surgical and oncological outcomes among each approach were compared. In addition, multivariate analysis was performed to reveal the factors that affect the decision on surgical approach. (Results) The ratio of patients more than 75 years old and the RENAL nephrometry score were higher in LRN group than those in LPN group. Operating time was longer but renal function was well preserved in LPN group. Importantly, blood loss, intraoperative and postoperative complication rate, and oncological outcome (recurrence-free survival and overall survival) were similar in both groups. Multivariate analysis revealed that age (≥75 years old), high RENAL nephrometry score, operation period (before 2011), and the absence of Endoscopic Surgical Skill Qualification (ESSQ) in surgeon were independent predictive factors that select LRN. (Conclusions) Our data suggests that LPN for T1a renal tumor could be performed safely and the decision whether LPN or LRN were performed were associated with technical factors such as the presence of ESSQ or operation period, as well as patients factor such as age and tumor factor such as tumor complexity.

LAPAROSCOPIC RADICAL NEPHRECTOMY FOR RENAL TUMOR>7CM

(Objectives) Laparoscopic radical nephrectomy (LRN) is now a standard care for the treatment of renal tumors, but the limitation of LRN for large tumors remains to be elucidated. In this study, we examined the safety and efficacy of LRN for >7 cm renal tumors including tumors >10 cm. (Patients and methods) From March 2001 to September 2014, 167 patients received laparoscopic surgery for renal tumors at our institution. Of these, 126 patients (≤4.0 cm: 64 cases, 4.1-7.0 cm: 40 cases, 7.1-10.0 cm: 12 cases, >10.0 cm: 10 cases) underwent LRN. Treatment outcomes including surgical and oncological outcomes among each stage were compared. (Results) Operating time for 7.1-10.0 cm tumors were similar to that <7 cm tumors but that for >10 cm tumors was significantly longer than that <10 cm tumors. There was no significant difference among each stage in terms of complication rate. As expected, recurrence-free survival rate for >10 cm tumors were worse than <10 cm tumors. (Conclusions) Our data suggests that LRN for large tumors >7 cm can be performed safely, but LRN for >10 cm tumors are technically demanding and require longer operation time.

A NOVEL SCORING SYSTEM: PREDICTING SEPTIC SHOCK AT DIAGNOSIS EASILY IN ACUTE COMPLICATED PYELONEPHRITIS PATIENTS

(Objectives) Because acute complicated pyelonephritis can easily cause sepsis and concomitant shock status, it is a potentially lethal disease. However, the predictors for the severity of pyelonephritis is not well analyzed. In this study, we aimed at clarifying the clinical characteristic risk factors associated with septic shock in patients with acute complicated pyelonephritis. (Materials and methods) From May 2009 to March 2014, 267 patients with acute complicated pyelonephritis were treated at our institution. We investigated the characteristics of the patients associated with septic shock, and assessed risk factors in these patients. By using these risk factors, we established a novel scoring system to predict septic shock. (Results) 267 patients included 145 patients with ureteral calculi and 75 patients with stent-related pyelonephritis. Septic shock occurred in 35 patients (13%), and the mortality rate was 0.75%. Multivariate analysis revealed that (P): Performance Status ≥3 (p=0.0014), (U): Presence of Ureteral calculi (p=0.043), (S): Sex of female (p=0.023), and (H): the presence of Hydronephrosis (p=0.039) were independent risk factors for septic shock. P.U.S.H. scoring system (range 0-4), which consists of these 4 factors, were positively correlated with the rate of septic shock (score 0: 0%, 1: 5.3%, 2: 3.4%, 3: 25.0%, 4: 42.3%). Importantly, patients with 3-4 P.U.S.H. scores were statistically more likely to become septic shock than those with 0-2 score (p=0.00014). (Conclusions) These results suggest that P.U.S.H. scoring system using 4 clinical factors is useful to predict the status of septic shock in patients with acute complicated pyelonephritis.

MID-TERM ONCOLOGICAL OUTCOME AND TECHNICAL MODIFICATIONS FOR LAPAROSCOPIC RADICAL CYSTECTOMY AT OUR INSTITUTION: 60 CASES ANALYSIS

(Objective) Although laparoscopic radical cystectomy (LRC) is becoming a standard care for invasive and high-risk non-invasive bladder cancer in Japan, the data about mid-and long-term oncological outcome is still lacking. We previously reported our initial experience of LRC compared to open radical cystectomy. In this study, we evaluated mid-term oncological outcome for LRC by updating our clinical data. In addition, we evaluated the effect of technical modifications for LRC. (Patients and methods) From March 2005 to September 2015, 60 patients underwent LRC at our institution. Treatment outcomes including surgical and oncological outcomes were analyzed. We also assessed the effect of technical modifications between first 30 cases and second 30 cases as to blood loss, operating time and complication rate. (Results) The overall complication rate was 47%, including 18% serious complications (Clavien score 3 or greater). The 5-year recurrence-free survival, cancer-specific survival, and overall survival were 56.2%, 74.4%, and 63.6%, respectively. The recurrence occurred in 19 (32%) cases, including distant metastasis in 12 (20%) cases, local recurrence in 6 (10%) cases, and both in 1 (2%) cases. As for the effect of technical modifications for LRC, the blood loss decreased and postoperative recovery was faster in second 30 cases. (Conclusion) These results indicate that LRC could be performed safely with acceptable oncological outcomes.