Takeshi Namekawa

Clinical predictors of prolonged postresection hypotension after laparoscopic adrenalectomy for pheochromocytoma

BACKGROUND Although the perioperative management of patients with pheochromocytoma has been improving recently, severe hypotensive episodes can occur that require postoperative catecholamine support and are challenging to manage. Our aim was to identify the clinical factors that predict prolonged postresection hypotension in patients after laparoscopic adrenalectomy for pheochromocytoma. METHODS The records of 73 Japanese patients who underwent unilateral laparoscopic adrenalectomy for pheochromocytoma were surveyed retrospectively. Patients were divided into 2 groups according to whether catecholamine support was needed after postoperatively. Clinical and biochemical data were evaluated at baseline and after operation. RESULTS Thirty-four of 73 patients (47%) required continuous infusion of catecholamine to maintain systolic blood pressure >90 mm Hg at the end of the operation. The median duration of postoperative catecholamine support was 17 hours (range, 3-130) in these 34 patients. On multivariate analysis, tumor size >60 mm, urinary epinephrine levels >200 μg/day, and urinary norepinephrine levels >600 μg/day were independent predictors of prolonged hypotension requiring postoperative catecholamine support. Tumor size and urinary norepinephrine levels were significantly correlated with the duration of postoperative catecholamine support. CONCLUSION Larger tumor size and greater values of urinary epinephrine and norepinephrine levels were significant predictors of prolonged hypotension requiring postoperative catecholamine support. Moreover, tumor size and urinary norepinephrine levels were positively correlated with the duration of postoperative catecholamine support. Clinicians can identify and manage patients more effectively with a greater risk of prolonged hypotension after tumor resection using these preoperative clinical variables.

Efficacy of traditional and alternative sunitinib treatment schedules in Japanese patients with metastatic renal cell carcinoma

We report the adverse events and efficacy of traditional (4 weeks on 2 weeks off) and alternative sunitinib treatment schedules for Japanese patients with metastatic renal cell carcinoma. We retrospectively investigated 54 patients who received sunitinib for metastatic renal cell carcinoma between May 2006 and June 2012: 32 received a traditional treatment schedule and 22 received an alternative schedule. According to the Memorial Sloan‐Kettering Cancer Center risk classification, five patients had favorable prognoses, 42 had intermediate prognoses and seven had poor prognoses. The mean observation periods were 16.3 and 20 months for the traditional and alternative schedule groups, respectively. Adverse events were significantly less common in the alternative schedule group, including most high‐grade events. In the traditional and alternative schedule groups, median times to failure were 4.1 and 11.6 months (P = 0.040), median progression‐free survival times were 4.1 and 11.3 months (P = 0.031), and median overall survival times were 12.0 and 32.1 months (P = 0.018), respectively. Each of these measures was better in the group of patients who received an alternative treatment schedule, suggesting that individualized changes to the sunitinib administration schedule can be effective.

Analysis of Preoperative Detection for Apex Prostate Cancer by Transrectal Biopsy

Background. The aim of this study was to determine concordance rates for prostatectomy specimens and transrectal needle biopsy samples in various areas of the prostate in order to assess diagnostic accuracy of the transrectal biopsy approach, especially for presurgical detection of cancer in the prostatic apex. Materials and Methods. From 2006 to 2011, 158 patients whose radical prostatectomy specimens had been evaluated were retrospectively enrolled in this study. Concordance rates for histopathology results of prostatectomy specimens and needle biopsy samples were evaluated in 8 prostatic sections (apex, middle, base, and transitional zones bilaterally) from 73 patients diagnosed at this institution, besides factors for detecting apex cancer in total 118 true positive and false negative apex cancers. Results. Prostate cancer was found most frequently (85%) in the apex of all patients. Of 584 histopathology sections, 153 (49%) from all areas were false negatives, as were 45% of apex biopsy samples. No readily available preoperative factors for detecting apex cancer were identified. Conclusions. In Japanese patients, the most frequent location of prostate cancer is in the apex. There is a high false negative rate for transrectal biopsy samples. To improve the detection rate, transperitoneal biopsy or more accurate imaging technology is needed.

Therapeutic outcomes of neoadjuvant and concurrent androgen-deprivation therapy and intensity-modulated radiation therapy with gold marker implantation for intermediate-risk and high-risk prostate cancer

To investigate the therapeutic outcomes of neoadjuvant and concurrent androgen‐deprivation therapy and intensity‐modulated radiation therapy with gold marker implantation for intermediate‐ and high‐risk prostate cancer.

Composite pheochromocytoma with a malignant peripheral nerve sheath tumor: Case report and review of the literature

Adrenal tumors with more than one cellular component are uncommon. Furthermore, an adrenal tumor composed of a pheochromocytoma and a malignant peripheral nerve sheath tumor is extremely rare. A composite pheochromocytoma with malignant peripheral nerve sheath tumor in a 42-year-old man is reported here. After adequate preoperative control, left adrenalectomy was performed simultaneously with resection of the ipsilateral kidney for spontaneous rupture of the left adrenal tumor. Pathological findings demonstrated pheochromocytoma and malignant peripheral nerve sheath tumor in a ruptured adrenal tumor. To date, there have been only four reported cases of composite pheochromocytoma with malignant peripheral nerve sheath tumor, so the present case is only the fifth case in the world. Despite the very poor prognosis of patients with pheochromocytoma and malignant peripheral nerve sheath tumors reported in the literature, the patient remains well without evidence of recurrence or new metastatic lesions at 36 months postoperatively.

Vasovasostomy and vasoepididymostomy: Review of the procedures, outcomes, and predictors of patency and pregnancy over the last decade

In the era of improving assisted reproductive technology (ART), patients with obstructive azoospermia (OA) have 2 options: vasal repair or testicular sperm extraction with intracytoplasmic sperm injection. Vasal repair, including vasovasostomy (VV) and vasoepididymostomy (VE), is the only option that leads to natural conception.

Editorial Comment from Dr Namekawa to Differences in semen characteristics between patients with testicular cancer and other malignancies using various cut-off values

treatment: a 15-year monocentric experience. Reprod. Biomed. Online 2012; 24: 321–30. 26 Botchan A, Karpol S, Lehavi O et al. Preservation of sperm of cancer patients: extent of use and pregnancy outcome in a tertiary infertility center. Asian J. Androl. 2013; 15: 382–6. 27 Sonnenburg DW, Brames MJ, Case-Eads S, Einhorn LH. Utilization of sperm banking and barriers to its use in testicular cancer patients. Support. Care Cancer 2015; 23: 2763–8. 28 Hamano I, Hatakeyama S, Nakamura R et al. Onco-testicular sperm extraction (Onco-TESE) from a single testis with metachronous bilateral testicular cancer: a case report. Basic Clin. Androl. 2018; 28: 1. 29 Tomlinson M, Lewis S, Morroll D; British Fertility Society. Sperm quality and its relationship to natural and assisted conception: British fertility society guidelines for practice. Hum. Fertil. (Camb). 2013; 16: 175–93. 30 Kobayashi H, Tamura K, Tai T, Nagao K, Nakajima K. Semen cryopreservation as an oncofertility treatment in 122 Japanese men with cancer: a decadelong study. Reprod. Med. Biol. 2017; 16: 320–4.

Reply to: The necessary preoperative dose of alpha-blockers reflects higher tumor activity in pheochromocytoma.

Response to the Editors: We previously identified the clinical factors that can predict prolonged postresection hypotension in patients following laparoscopic adrenalectomy for pheochromocytoma. In our study, 34 of 73 patients (46.6%) required continuous infusion of catecholamine to maintain systolic blood pressure >90 mm Hg. Furthermore, tumor size >60 mm, urinary epinephrine levels >200 mg/day, and urinary norepinephrine levels >600 mg/day were independent predictors of prolonged hypotension that required postoperative catecholamine support. Preoperative medical management has helped to steadily lower the risk of perioperative hemodynamic instability, including reduction of postoperative hypotension, and alpha blockers have a central role in preoperative antihypertensive therapy. Recently, calcium channel blockers also have been shown to lessen the risk of perioperative hemodynamic instability. Brunaud et al previously reported that severe hypotensive episodes were more frequent and longer lasting with alpha blockers than with calcium channel blockers. Additionally, because calcium channel blockers are less expensive than alpha blockers, the researchers advocated calcium channel blockers as an alternative preoperative therapy. Therefore, they want to know what impact preoperative medical preparation had on the incidence and severity of the hypotensive episodes discussed in our previous study. To answer the questions that Brunaud et al asked, we provide additional data on the relationship between preoperative medical management and postoperative prolonged hypotension, using the same patients group as previously reported. In October 2010, we switched from the alpha blocker prazosin to doxazosin in preoperative medical preparation. In our series, prazosin was preoperatively used for 48 patients, doxazosin for 24 patients, and phentolamine for 1 patient. When measured against preoperative prazosin, used in about two thirds of our patients, the frequency of postoperative hypotension that required continuous catecholamine support was significantly higher in patients taking higher doses of prazosin (prolonged hypotension versus no prolonged hypotension: 60.4% vs 39.6%, P < .01). Furthermore, the necessary preoperative dose of prazosin correlated significantly with the duration of catecholamine support (r = 0.32, P = .03); tumor size (r = 0.35, P = .02); and levels of catecholamine, including serum norepinephrine (r = 0.41, P # .01), urinary norepinephrine (r = 0.58, P < .01), and urinary normetanephrine (r = 0.49, P < .01). Necessary preoperative dose of prazosin correlated with the incidence and severity of postoperative hypotension. Because we tilted alpha blockers dosing according to preoperative blood pressure, the patients with larger pheochromocytomas and higher levels of catecholamine tended to receive higher amounts of preoperative alpha blockers. Necessary preoperative dose of alpha blockers reflects tumor endocrine activity. Because we scarcely used calcium channel blockers in the study, we could not examine the effects of calcium channel blockers as preoperative medical preparation. Thus, whether alpha blockers or calcium channel blockers can prevent postoperative hypotension is the subject of future investigation. Brunaud et al are right. We cannot deny that doses of alpha blockers have a potential impact on the incidence of postoperative hypotensive episodes. However, higher doses of alpha blockers reflect higher tumor severity, including size or endocrine activity. Again, we emphasize our original thesis that patients with high tumor activity tend to need postoperative catecholamine support. We appreciate the research of Brunaud et al concerning postoperative hypotension in pheochromocytoma.

44 ONGOING KIDNEY IMPAIRMENT IN JAPANESE PATIENTS WITH PRIMARY ALDOSTERONISM: PREDICTORS OF NEW-ONSET CHRONIC KIDNEY DISEASE AFTER ADRENALECTOMY

INTRODUCTION AND OBJECTIVES: Inappropriately high aldosterone levels impair renal function in patients with primary aldosteronism (PA), because hyperaldosteronism is associated with glomerular hyperfiltration and reduced glomerular filtration rate. Aldosterone excess, such as in PA, thus probably contributes to the development of chronic kidney disease (CKD). While CKD develops postoperatively with estimated glomerular filtration rate (eGFR) 60 ml/min/1.73 m, subtle kidney impairment is often masked by hyperfiltration before surgery. Interpreting renal function in patients with PA can therefore be difficult using conventional preoperative eGFR. This study investigated postoperative changes in renal function for all PA patients, to identify predictors of postoperative CKD development in patients without preexisting CKD. METHODS: This retrospective study included 78 Japanese patients with PA who underwent unilateral adrenalectomy between 1990 and 2011. Patients followed for 1 year were excluded. As eGFR is known to be limited by differences in creatinine generation among ethnicities, values were obtained using a new 3-variable Japanese equation that was developed and validated in a Japanese population: eGFR (ml/min/1.73 m) 194 (serum creatinine) 1.094 (age) 0.287 0.739 (if female). Changes in eGFR were compared by 1-way ANOVA, with multiple comparisons using the Bonferroni method. Uniand multivariate analyses were performed to identify clinical predictors for CKD within 1 year after surgery. RESULTS: Patients with preoperative eGFR 60 ml/min/1.73 m showed a significant decrease in postoperative eGFR, while patients with preoperative eGFR 60 ml/min/1.73 m showed no significant postoperative decrease. Of the 66 patients without pre-existing CKD, 24 developed CKD within 1 year postoperatively. In all patients with new-onset CKD, preoperative eGFR was 60-89 ml/min/1.73 m. Multivariate analysis identified preoperative eGFR as an independent predictor of new-onset CKD. Based on univariate analysis, additional factors associated with new-onset CKD included older age and medical history of hyperlipidemia (P 0.05). CONCLUSIONS: Patients with preoperative eGFR of 60-89 ml/min/1.73 m showed a higher proportion of new-onset CKD after surgery. Clinicians should be attentive to patients at greater risk of significant declines in renal function after adrenalectomy. These data may offer indications for early intervention to prevent declines in renal function.