A Retroperitoneal Dedifferentiated Liposarcoma Producing Granulocyte Colony-Stimulating Factor Accompanied by Spontaneous Rupture: PET/CT Imaging of a G-CSF-Producing Tumor

The patient was a 63-year-old man who was referred to our hospital as an emergency case with the chief complaint of abdominal pain. An abdominal CT revealed a right retroperitoneal tumor of 15 cm and retroperitoneal bleeding. After a transcatheter arterial embolization was performed, the patient was transferred to our department. There was no infective focus. The white blood cell (WBC) count (37,820/μl, normal range <8 pg/ml) and the serum granulocyte colony-stimulating factor (G-CSF) level (2,670 pg/ml, normal range <8 pg/ml) were high. Bone marrow biopsy revealed little fat, significant hyperplasia, and predominantly increased neutrophils, but no findings of bone metastasis or bone marrow involvement. A G-CSF-producing tumor was diagnosed and right nephrectomy and retroperitoneal tumorectomy were performed. However, the tumor had infiltrated into the inferior vena cava, diaphragm and abdominal wall, and only part of the tumor could be removed. In histopathological tests, hematoxylin-eosin staining showed malignant fibrous histiocytoma-like findings mixed with those for well-differentiated liposarcoma, and the case was diagnosed as dedifferentiated liposarcoma. Preoperative 18F-FDG-PET computed tomography showed diffuse 18F-FDG uptake throughout the bone marrow and elevated uptake at the tumor site. However, since bone biopsy and bone scintigraphy indicated no bone metastasis or bone marrow involvement, we concluded that PET/CT imaging gave false-positive results in the bone marrow. This is the first report of PET/CT imaging of a G-CSF-producing tumor in a urological disease. The imaging results may be useful for differential diagnosis for this tumor in patients with high WBC counts without infection

Retroperitoneoscopic Nephrectomy for Treatment of a Case of Left Single Ectopic Ureter Accompanied by Dysplastic Kidney

We report the case of a 7-year-old girl with a single ectopic ureter who was treated with retroperitoneoscopic nephrectomy for a chief complaint of urinary incontinence. Preoperative CT showed a contrasted dysplastic kidney of 1cm in the renal fossa and a left ureteral opening into the vagina. Retroperitoneoscopic left nephrectomy was conducted with opening of the lateroconal fascia to enable identification of the dysplastic kidney. No intraoperative complications were encountered. Urinary incontinence improved immediately after surgery. This case shows that a retroperitoneal approach can be used in nephrectomy if the position of the kidney can be determined preoperatively

Robot-assisted laparoscopic radical prostatectomy - A report of our current robotic surgery -

　This report is an examination of the results of the initial 200 cases that underwent robot assisted laparoscopic radical prostatectomy (RALP) at Kawasaki Medical School General Medical Center in Okayama, Japan. Two hundred patients that had RALP using the da Vinci Xi Surgical System from August 2016 to October 2019 were examined retrospectively. The median age was 70 years old, and the median PSA was 7.65 ng/ml. 35% of the cases had received a previous abdominal surgery. RALP was performed on all the patients. The median surgery time was 237.5 minutes, the median console time was 173 minutes and the median amount of bleeding was 150 ml. There were no intraoperative blood transfusions, complications or anastomotic failures. Histopathological examination found pT2 in 73.0% of cases and pT3 in 26.5% with positive surgical margins in 10.3% and 50.9% of cases, respectively. There were 17 postoperative cases confirmed to have an inguinal hernia and 3 cases with an incisional hernia. Also, one case had postoperative bleeding from the trocar insertion site, which required hemostasis and a blood transfusion. Urinary continence rates three months after surgery was 76.6% and was 95.3% after twelve months. RALP is a safe and minimally invasive method, but there are aspects that require improvement such as the pT3 positive surgical margin rate and postoperative continence

Outcomes of robot-assisted partial nephrectomy in the treatment of renal cell carcinoma at Kawasaki Medical School Hospital

　Robot-assisted partial nephrectomy (RAPN) was introduced in our hospital for treating small renal cell carcinoma in May 2018; we examined treatment outcomes in 24 patients (25 kidneys) who had undergone this procedure till 2019. The median observation period was 11 months (range, 1-17 months). The patients’ age range was 43-77 years (median, 68 years). Fourteen men and 10 women underwent the procedure. Their BMI was 17.9-39.7 (median, 24.1) kg/m2 . In one patient, RAPN was performed twice at different times for treating bilateral renal cancer. The right kidney was affected in 12 cases and the left kidney in 13 cases. The clinical cancer stage was T1a in 20 cases and T1b in 5 cases. Tumor sizes were 0.9-6.2 cm (median, 2.5 cm), and RENAL nephrometry scores were 4-10 (median, 7). The transperitoneal approach was used in 22 cases, and the retroperitoneal approach in 3. The operating durations were 147-358 min (median, 225 min), console durations were 59-394 min (median, 152 min), and renal ischemia durations were 8-54 min (median, 21 min). Blood loss was 10-700 ml (median 10 ml), and none of the patients underwent blood transfusion. The histopathological analysis of the resected tumors revealed clear cell renal cell carcinoma in 20 cases, chromophobe renal cell carcinoma in 2 cases, and papillary renal cell carcinoma, angiomyolipoma, and leiomyoma in 1 case each. All margins were negative. The postoperative hospital stay lengths were 5-14 days (median, 9 days). The postoperative deterioration in renal function was mild, and there were no severe complications. In the early stages after its introduction, RAPN was safely performed and allowed for the preservation of renal function. We plan to continue studying more cases going forward

Treatment outcomes of laparoscopic radical prostatectomy at Kawasaki Medical School Hospital

　Laparoscopic radical prostatectomy (LRP) was carried out in 196 patients with prostate cancer between December 2009 and November 2017 at Kawasaki Medical School Hospital, and the therapeutic outcomes were assessed. An extraperitoneal approach was used in all cases except 1 and the median follow-up period was 55 months (range, 10-117 months). The median patient age was 69 years (range, 56-79 years), median body mass index was 23.3 kg/m2 (range, 15.2-33.2 kg/m2 ), and median prostate-specific antigen (PSA) level at diagnosis was 7.4 ng/mL (range, 2.2-42.0 ng/mL). Clinical stages of T1c, T2a, T2b, T2c, T3a, and T3b accounted for 63, 43, 31, 57, 1, and 1 case, respectively, while Gleason scores at biopsy of ≥ 6, 7, and ≥ 8 accounted for 26, 138, and 32 cases, respectively. The median prostate volume was 22.0 mL (range, 7.3-65.6 mL), median operating time was 266 minutes (range, 142-540 minutes), and median blood loss (including in urine) was 650 mL (range, 10-5,800 mL). During the initial induction period, 94 patients received autologous blood transfusion and 7 received allogeneic blood transfusion. Nerve-sparing prostatectomy was performed in 17 cases (bilateral in 3, unilateral in 14). Capsular invasion was observed in 57 cases (29.1%) and positive resection margins were observed in 51 cases (26.4%). The median indwelling catheter duration was 6 days (range, 4-26 days) and the median hospital stay after surgery was 11 days (range, 8-34 days). The main complications were intraoperative rectal injury in 7 cases (3.6%), postoperative inguinal hernia in 28 (14.3%), and urethral stenosis in 8 (4.1%). The rate of urinary incontinence at ≥ 1 year after surgery was 32.7% and the rate of PSA recurrence was 15.8%. The overall survival rate was 95.6% at 5 years and 94.7% at 10 years. In conclusion, the oncological outcomes were similar to that reported by previous reports, but postoperative stress urinary incontinence and complications were slightly worse. In the future, further improvement of the surgical technique was desired

泌尿器科領域癌患者におけるレボカルニチン投与のQOL に関する初期検討

　今回我々は初の試みとして，泌尿器科領域癌における抗癌剤治療前後での血清カルニチン値を測定し，QOL への影響について検討した．さらに癌治療中の患者においてカルニチン補充が及ぼすQOL への効果について検討を加えた．　2016年６月１日から2018年９月30日までに当科で化学療法もしくは分子標的薬治療を行った泌尿器科領域癌患者17例を対象とした．抗癌剤治療前後での血清カルニチンを測定し，その後レボカルニチン1,500 mg/ 日の経口投与を行い，QOL についてprospective に評価を行った．抗癌剤治療前，治療３カ月，レボカルニチン経口投与１カ月，３カ月の４ポイントで血清遊離カルニチンを測定し，QOL については Brief Fatigue Inventory（ BFI）を用いた global fatigue score（GFS）で評価した．　年齢中央値は69歳（52～82歳）で男女比は12：５であった．疾患は尿路上皮癌が10例，前立腺癌が５例，腎癌が２例であった．　治療内容は尿路上皮癌に対するgemcitabine/cisplatin が10例，前立腺癌に対するdocetaxel が３例，cabazitaxel が１例，etoposide/cisplatin が１例，腎癌に対する分子標的薬（sunitinib，pazopanib）が２例であった．血清遊離カルニチンは，抗癌剤治療前：49.0±12.1μmol/L，抗癌剤治療後：36.0±10.3μmol/L と抗癌剤治療後に統計学的に有意な低下を認めた（p<0.05）．　また抗癌剤治療前と比して17例中13例（76.5％）が，抗癌剤治療３カ月でカルニチンの低下を認めた．血清遊離カルニチン値が基準値未満に低下した症例（<36μmol/L）をカルニチン低値群（n=9），基準値を保っていた症例をカルニチン非低値群（n=8）として２群間について検討した．カルニチン低値群においてレボカルニチン内服３カ月で，内服前と比して統計学的に有意なGFSの低下が認められ，QOL の改善が得られた（p<0.05）．一方，カルニチン非低値群では，レボカルニチン内服前後でGFS に差異は認めなかった．またレボカルニチン内服３カ月でGFS が改善した症例をレボカルニチン有効例とすると，カルニチン低値群で88.9％（8/9）が有効，カルニチン非低値群で50.0％（4/8）が有効であった．　抗癌剤治療中のカルニチン欠乏症では，カルニチン補充でQOL の改善が期待できると考えられた．レボカルニチンは泌尿器科領域癌患者の治療の際に補助薬の一端を担うことが期待される．また泌尿器科領域癌患者において，抗癌剤治療によって血清遊離カルニチン値が低下することが示唆された．　In this study, the serum carnitine level was measured before and after chemotherapy for urologic cancer, and its correlation with QOL was examined. The effect of levocarnitine on chemotherapy-induced QOL reduction was also investigated.　The subjects were 17 patients with urologic cancer who received chemotherapy or molecular targeted drug therapy at our department between June 1, 2016 and September 30, 2018. The serum carnitine level was measured before and after therapy. Levocarnitine hydrochloride 1,500 mg/day was then administered orally, and QOL was prospectively evaluated. The serum free carnitine level was measured at 4 time-points: before therapy, after 3 months of therapy, and 1 and 3 months after initiation of levocarnitine hydrochloride. QOL was evaluated based on the global fatigue score (GFS) using the Brief Fatigue Inventory (BFI).　The subjects had a median age of 69 years old (52-82 years old) and the male:female ratio was 12:5. The disease was urothelial carcinoma in 10 patients, prostate cancer in 5, and renal cancer in 2. Chemotherapy of gemcitabine/cisplatin for urothelial carcinoma was administered in 10 patients, docetaxel for prostate cancer in 3, cabazitaxel in one, and etoposide/cisplatin in one; and a molecular targeted drug (sunitinib, pazopanib) for renal cancer was used in 2 patients. The free carnitine levels before and after chemotherapy were 49.0±12.1μmol/L and 36.0±10.3μmol/L respectively. After 3 months of chemotherapy, the free carnitine level was significantly decreased. The free carnitine level after 3 months of chemotherapy was lower than that before therapy in 13 patients (76.5%). The groups of patients with serum free carnitine lower than (n=9) and above (n=8) the standard level were compared. GFS showed significant improvement at 3 months of levocarnitine treatment in the low carnitine group. However, significant improvement at 3 months of levocarnitine treatment in the standard carnitine group was not observed. Levocarnitine was effective for 88.9% (8/9) and 50.0% (4/8) of patients in the respective groups.　Levocarnitine supplementation may have a role as adjuvant therapy that improves QOL of patients with carnitine deficiency during chemotherapy. Our results show that serum free carnitine is reduced by chemotherapy in patients with urological cancer

当院の女性過活動膀胱患者における抗コリン薬とβ3アドレナリン受容体作動薬の内服継続率に関する検討

　過活動膀胱（overactive bladder：以下OAB）は，尿意切迫感や頻尿などの下部尿路症状を有し，加齢とともに増加する傾向がある．OAB 患者の治療薬として，本邦では抗コリン薬とβ3アドレナリン受容体作動薬が推奨，使用されている．今回，女性OAB 患者に対する，抗コリン薬とβ3アドレナリン受容体作動薬の内服継続率，副作用，内服中止理由に関してretrospective に検討した．対象は，2013年１月から12月の１年間に当院泌尿器科を受診した初診の女性OAB 患者，87名とした．β3アドレナリン受容体作動薬投与群と抗コリン薬投与群の内服継続率は，β3アドレナリン受容体作動薬投与群は，12か月で38.8％，60か月で18.1％，抗コリン薬投与群は，12か月18.4%，60か月で7.9％であり，β3アドレナリン受容体作動薬投与群の方が若干継続率は良いものの，両群間に差は認めなかった．副作用に関しては，抗コリン薬投与群の方が多く，口喝が17例（44.7%），便秘が15例（39.5%）であった．薬剤中止の理由は両群とも自然寛解によるものが多かった．　Overactive bladder (OAB) involves lower urinary tract symptoms such as urinary urgency and polyuria, and tends to increase with age. In Japan, the drugs recommended and used for treatment of OAB patients are anticholinergic agents and β3 adrenalin receptor agonists. The present study was a retrospective investigation of the rates of long-term administration of anticholinergic agents and β3 adrenalin receptor agonists, adverse effects with these drugs, and reasons for discontinuation of administration, with female OAB patients. The subjects were 87 female patients who were examined at this hospital\u27s Urology Dept. over 1 year between January and December 2013, and diagnosed as having OAB for the first time. With respect to the rates of long-term administration, in the β3 adrenalin receptor agonist group the rates of administration for 12 and 60 months, respectively, were 38.8% and 18.1%, and these rates in the anticholinergic agent group were 18.4% and 7.9%, so the long-term administration rates were somewhat higher in the β3 adrenalin receptor agonist group, but no difference between the groups was found. Adverse effects were more frequent in the anticholinergic agent group, with 17 subjects in that group (44.7%) developing buccal dryness, and 15 (39.5%) developing constipation. In both groups, the most frequent reason for discontinuation of administration was spontaneous remission