Robot-assisted intracorporeal ileal conduit urinary diversion: A two-center comparative study of Bricker versus Wallace ureteroileal anastomosis

INTRODUCTION

This study was performed to evaluate the differences in the perioperative results, renal function, and incidence of hydronephrosis over time between the use of Bricker anastomosis and Wallace anastomosis for robot-assisted intracorporeal ileal conduit urinary diversion (RICIC).

METHODS

Fifty-five patients who underwent RICIC at two institutions were evaluated (Bricker, n = 23; Wallace, n = 32). We investigated changes in estimated glomerular filtration rate and hydronephrosis before surgery and at 3, 6, and 12 months after surgery.

RESULTS

The patients in the Bricker group were significantly older than those in the Wallace group. The urinary diversion time was significantly longer in the Bricker group. No significant difference in postoperative renal function was observed. Additionally, no significant difference was observed in the incidence of postoperative hydronephrosis. However, the incidence of right hydronephrosis tended to be high overall, especially in the Wallace group. No patients in either group required repair surgery or ureteral stent placement.

CONCLUSIONS

In patients undergoing RICIC, there was no difference in postoperative renal function or the incidence of hydronephrosis between Wallace and Bricker anastomosis. Symptomatic hydronephrosis was not observed in either group. The present study showed that each method was equally effective and safe.

Impact of lymph node dissection on surgical and oncological outcomes in patients undergoing robot-assisted radical cystectomy for bladder cancer: a multicenter retrospective study

This study was performed to clarify the therapeutic and diagnostic roles of lymph node dissection (LND) by examining the impact of LND and lymph node yield (LNY) on oncological outcomes in patients undergoing robot-assisted radical cystectomy (RARC). Between 2014 and 2021, 216 patients underwent LND during RARC at Tokushima University Hospital and affiliated hospitals. Among the 216 patients, we compared 115 patients with an LNY of ≥ 20 and 101 with an LNY of < 20 to investigate the impact of LNY on surgical and oncological outcomes. Furthermore, we investigated the impact of LNY and the extent of LND on oncological outcomes by dividing the extent of LND into two groups (standard and extended). The 3-year rates of overall survival (OS) (p = 0.256), cancer-specific survival (CSS) (p = 0.791), and recurrence-free survival (RFS) (p = 0.953) did not differ between the two groups divided by the LNY. A higher LNY was associated with a significantly higher lymph node positivity rate (p = 0.020). The incidence of LND-related major complications was not significantly different between the two groups (p = 0.910). The 3-year survival rates did not differ between the two groups divided by the extent of LND: OS (p = 0.366), CSS (p = 0.814), and RFS (p = 0.689). The LNY and extent of LND were not associated with oncological outcomes in patients undergoing LND during RARC, whereas a higher LNY was associated with lymph node positivity. In the era of adjuvant therapy with immune checkpoint inhibitors, LND during RARC has an important diagnostic role in the detection of pathological node positivity.

The importance of laparoscopic surgery for young urologists remains unwavering even in the era of robot-assisted surgery

Robot-assisted surgery (RAS) cannot be achieved without the performance of laparoscopic surgical techniques by a patient-side surgeon (PSS). In many medical institutions in Japan, young urologists often take on the role of a PSS. Participating in RAS as a PSS provides a good opportunity to acquire not only the knowledge necessary for surgery, but also skills in laparoscopic surgical techniques. Learning laparoscopic surgery as a PSS may contribute to improving the quality of RAS. Furthermore, it will lead to skill improvement as an operator in laparoscopic surgery. However, notably, opportunities for young urologists to perform laparoscopic surgery are decreasing in the current era of RAS. Under these circumstances, we believe that cadaver surgical training will become increasingly important in the future. We believe that performance of cadaver surgical training will contribute to increased motivation, enhance the understanding of surgical procedures, and facilitate the acquisition of surgical techniques.

Lymph node dissection during radical cystectomy for bladder cancer: A two-center comparative study of robotic versus open surgery

INTRODUCTION

This study was performed to evaluate the safety and efficacy of lymph node dissection (LND) during robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC).

METHODS

From October 2003 to December 2021, 122 patients underwent LND during RARC and 103 patients underwent LND during ORC at Tokushima University Hospital and Tokushima Prefectural Central Hospital. We investigated the safety and efficacy of LND during RARC by comparing the surgical and oncological outcomes between the two groups.

RESULTS

The patients were significantly older in the RARC than the ORC group. The operative time was significantly shorter and the estimated blood loss was significantly lower in the RARC than the ORC group. Although the lymph node yield was significantly higher in the RARC than the ORC group, there was no significant difference in lymph node positivity between the groups. There was no significant difference in the incidence of local recurrence or distant metastasis between the two groups. The 5-year survival rates (overall survival, cancer-specific survival, and recurrence-free survival) were not different between the RARC and ORC groups.

CONCLUSION

This study suggests that the surgical and oncological safety and efficacy of LND during RARC are greater than those of LND during ORC. We believe that LND during RARC is a higher-quality procedure than LND during ORC.

Effect of Positive Biopsy Core Rate on Low-dose-rate Brachytherapy Outcomes in Intermediate-risk Prostate Cancer

BACKGROUND/AIM

Intermediate-risk prostate cancer (PCa) is a highly heterogeneous disease. Although low-dose-rate brachytherapy (LDR-BT) is mainly used for low- to intermediate-risk PCa, limited reports have evaluated the detailed differences in outcomes, including differences between patients with ISUP grade group (GG) 2 and GG3 intermediate-risk PCa. This study aimed to investigate the differences in outcomes between intermediate-risk Japanese patients with GG2 and GG3 PCa who underwent LDR-BT.

PATIENTS AND METHODS

This single-center retrospective study included 342 consecutive patients with intermediate-risk PCa; 232 patients with GG2 and 110 with GG3 were treated with LDR-BT at Tokushima University Hospital between July 2004 and December 2019.

RESULTS

No significant difference in 5-year biochemical progression-free survival and cancer-specific survival was observed between patients with GG2 and those with GG3 (p=0.649 and p=0.633, respectively). Multivariate analysis showed that radiation doses up to 90% of the prostate volume (D90) and the percentage of positive cores were predictors of recurrence in all patients with intermediate-risk PCa. Group analyses showed that D90 was a predictor for recurrence in patients with GG2. In contrast, a high percentage of positive cores was a significant risk factor for recurrence in patients with GG3.

CONCLUSION

Positive core ratios observed on prostate biopsy correlated with higher recurrence rates after LDR-BT. This indicates that the proportion of positive cores in the biopsy may be an important factor in predicting the likelihood of recurrence, especially for patients with GG3 PCa.

Insulin receptor expression to predict resistance to axitinib and elucidation of the underlying molecular mechanism in metastatic renal cell carcinoma

BACKGROUND

The study aimed to examine the significance of insulin receptor (INSR) expression in predicting resistance to axitinib in clear cell renal cell carcinoma (ccRCC).

METHODS

Clinicopathological data were collected from 36 consecutive patients with metastatic RCC who received axitinib. Thirty-three primary tumours were obtained for immunohistochemistry. Patient-derived xenograft (PDX) models were created by transplanting primary tumours into immunodeficient mice, establishing axitinib-resistant PDX models. RCC cell lines were co-cultured with human renal glomerular endothelial cells (HGECs) treated with siRNA of INSR (HGEC-siINSR). Gene expression alteration was analysed using microarray.

RESULTS

The patients with low INSR expression who received axitinib had a poorer outcome. Multivariate analysis showed that INSR expression was the independent predictor of progression-free survival. INSR expression decreased in axitinib-resistant PDX tumours. RCC cell lines showed upregulated interferon responses and highly increased interferon-β levels by co-culturing with HGEC-siINSR. HGECs showed decreased INSR and increased interferon-β after axitinib administration. RCC cell lines co-cultured with HGEC-siINSR showed high programmed death-ligand 1 (PD-L1) expression, which increased after interferon-β administration.

CONCLUSIONS

Decreased INSR in RCC could be a biomarker to predict axitinib resistance. Regarding the resistant mechanism, vascular endothelial cells with decreased INSR in RCC may secrete interferon-β and induce PD-L1.

Efficacy of fresh-frozen cadaveric surgical training for arteriovenous fistula in vascular access

BACKGROUND

Creation of an arteriovenous fistula (AVF) as vascular access is a basic operation that should be learned by all surgeons involved in renal failure treatment. AVF creation is often challenging for inexperienced young surgeons because it requires comprehensive surgical techniques. For such young surgeons, we introduced cadaveric surgical training (CST) for AVF creation using fresh-frozen cadavers (FFCs). This study was performed to identify the differences in AVF surgical techniques between FFCs and living bodies and to examine the impact of CST on young surgeons.

METHODS

Twelve CST sessions were performed for AVF creation at the Clinical Anatomy Education and Research Center of Tokushima University Hospital from March 2021 to June 2022. Seven young surgeons (1st- and 2nd-year) performed the operation, and two surgeons (10th- and 11th-year) supervised it. We conducted an anonymous questionnaire survey using a 5-point Likert scale to examine the impact of CST on young surgeons.

RESULTS

Twelve CST sessions were performed on nine FFCs. All training sessions allowed completion of AVF creation with a median operative time of 78.5 min. Although veins and arteries were more difficult to identify than in a living body, other surgical operations could be performed in the same way as in a living body. All the respondents stated that it was good for them to experience CST. In addition, 86% of surgeons responded that CST improved their surgical techniques, and 71% of surgeons responded that they were less anxious about AVF creation.

CONCLUSIONS

CST for AVF creation is useful for surgical education because it enables learning of surgical techniques that are almost equivalent to those in living bodies. In addition, this study suggested that CST not only contributes to the improvement of surgical skills of young surgeons but also promotes the reduction of anxiety and stress about AVF creation.

Comparison of robot-assisted partial nephrectomy with soft coagulation and double-layer technique for complex and non-complex tumors

OBJECTIVES

To compare the postoperative outcomes of robot-assisted partial nephrectomy when only the inner layer is sutured (single-layer technique with soft coagulation) with those when sutures are placed in the inner and outer layers (double-layer technique) in patients with and without complex renal tumors.

METHODS

This retrospective three-institution study included 371 patients with renal tumors who underwent robot-assisted partial nephrectomy with a double-layer technique or a single-layer technique with soft coagulation. Tumors that were cT1b, completely embedded, located in the renal portal, or had a RENAL score of ≥10 were considered complex. Relevant data were collected from hospital records. Propensity score matching was performed to minimize selection bias.

RESULTS

Propensity score matching created 83 patient pairs with non-complex tumors and 32 with complex tumors. Regardless of tumor complexity, there was no significant difference in operation time, console time, warm ischemia time, positive surgical margin rate, or length of hospital stay between the double-layer and single-layer groups. Although Clavien-Dindo grade I-II urinomas not requiring intervention were significantly more common in the single-layer group regardless of tumor complexity, there was no significant between-group difference in the rate of decline in renal function or grade III-IV complications.

CONCLUSION

Single-layer suturing with soft coagulation achieves renal function and perioperative outcomes comparable to those of double-layer suturing regardless of complexity.

Prostate-specific Antigen Levels Following Brachytherapy Impact Late Biochemical Recurrence in Japanese Patients With Localized Prostate Cancer

BACKGROUND/AIM

Evaluation of long-term outcomes is essential for the successful treatment of localized prostate cancer; however, the risk of late recurrence following brachytherapy is still not clear. This study aimed to evaluate the long-term outcomes of low-dose-rate brachytherapy (LDR-BT) for localized prostate cancer in Japanese patients and identify factors associated with late recurrence after treatment.

PATIENTS AND METHODS

This single-center, cohort study included patients who underwent LDR-BT at the Tokushima University Hospital in Japan between July 2004 and January 2015; 418 patients, who were followed-up at least 7 years after LDR-BT, were included in the study. Biochemical progression free survival (bPFS) was defined according to the Phoenix definition (nadir PSA+2 ng/ml) and bPFS and cancer specific survival (CSS) were calculated using Kaplan-Meier survival curves. Univariate and multivariate analyses were performed using Cox proportional hazard regression models.

RESULTS

Approximately half of the patients with PSA >0.5 ng/ml at 5 years after LDR-BT had a recurrence within the next 2 years. However, only 1.4% of the patients with a PSA ≤0.2 ng/ml at 5 years post-treatment showed tumor recurrence, including those at high risk of treatment failure according to the D'Amico classification. In multivariate analysis, PSA level at 5 years post-treatment was the only predictor of late recurrence after 7 years of treatment.

CONCLUSION

PSA levels at 5 years post-treatment were associated with long-term recurrence of localized prostate cancer, which can help alleviate patient anxiety concerning prostate cancer recurrence if PSA levels remain low at 5 years after LDR-BT.

Assistent guide: A novel device for ureteral stent placement in robot-assisted intracorporeal ileal conduit

INTRODUCTION

Ureteral stent placement in robot-assisted intracorporeal ileal conduit formation (RICIC) is more challenging than extracorporeal urinary diversion. We developed a novel dedicated device called the Assistent guide for safe and smooth performance of ureteral stent placement by the patient-side surgeon (PSS).

METHODS

This study reviewed the clinical records of 59 patients underwent RICIC with a total of 110 ureteral stent placements: 59 stents were placed using the Assistent guide, and 51 stents were placed using a suction tip.

RESULTS

The stenting time was significantly shorter in the Assistent guide group than in the suction tip group. Even for beginners, the stenting time was significantly shorter. The PSSs' satisfaction score was significantly higher in the Assistent guide group. No complications associated with ureteral stent placement occurred.

CONCLUSIONS

We showed the safety and efficacy of the Assistent guide for ureteral stent placement in RICIC.

Efficacy of the Mercedes-Benz closure technique for vaginal reconstruction in female robot-assisted radical cystectomy

INTRODUCTION

Vaginal reconstruction using the posterior vaginal wall is required following radical cystectomy in women with resection of the uterus, adnexa, and anterior vaginal wall. Roll closure and clamshell closure are two widely known techniques. Of these, clamshell closure is recommended because roll closure has a high likelihood of breakdown or a resultant canal that is too narrow for sexual intercourse. In clamshell closure, however, folding the posterior vaginal wall anteriorly can be difficult. Therefore, we devised Mercedes-Benz closure, in which the vaginal wall is sutured from three directions to form a Mercedes-Benz shape, for anastomosis without tension on the vaginal wall. The present study was performed to investigate the efficacy of this alternative surgical technique for vaginal reconstruction.

METHODS

Twenty-six patients who underwent vaginal reconstruction following robot-assisted radical cystectomy were divided into two groups: 15 underwent clamshell closure and 11 underwent Mercedes-Benz closure. The patients' characteristics and surgical outcomes were compared between the two groups.

RESULTS

There were no significant differences in clinical characteristics, including age, body mass index, and prior abdominal surgery between the two groups. The median vaginal reconstruction time tended to be longer in the Mercedes-Benz closure group than in the clamshell closure group (35.0 vs. 27.0 min, p = 0.102). No complications associated with vaginal reconstruction were identified.

CONCLUSION

The surgical outcomes were comparable between Mercedes-Benz closure and clamshell closure. If vaginal reconstruction with clamshell closure is difficult, Mercedes-Benz closure is a valuable alternative technique.

The impact of nutritional status and changes of body composition on the prognosis of metastatic renal cell carcinoma patients

PURPOSE

This study aimed to analyze the impact of patients' nutritional status and changes in body composition on the prognosis of metastatic renal cell carcinoma (mRCC) patients who received systemic therapy with tyrosine kinase inhibitors (TKIs).

METHODS

A total of 57 mRCC patients who received systemic therapy with TKIs as first-line therapy at our facility between November 2004 and October 2018 were included. The Prognostic Nutritional Index (PNI) was used to evaluate their nutritional status. The volumes of skeletal muscle mass and fat tissue were calculated using the SYNAPSE VINCENT system. The effects of nutritional status and body composition of mRCC patients on progression-free survival (PFS) and overall survival (OS) were analyzed using Cox regression methods.

RESULTS

Low PNI at the start of systemic therapy was a significant prognostic predictor for OS (HR 3.807 [95% CI 1.205-12.027], P=0.046), and it was related to loss of muscle mass three months after systemic therapy. Although the loss of muscle mass at the start of systemic therapy was not associated with OS, loss of muscle mass during treatment predicted worse OS.

CONCLUSIONS

Nutritional status of mRCC patients may predict changes in body composition and be associated with their prognosis. J. Med. Invest. 70 : 80-87, February, 2023.

Impact of early urinary catheter removal on successful voiding and physical function in stroke patients

OBJECTIVE

The aim of the present study was to identify factors related to the success of trial without catheter (TWOC) in patients with stroke and to examine the effect of the timing of urinary catheter removal on the course of stroke.

METHODS

Patients who were admitted to the Stroke Care Unit of our institution between March 2018 and October 2021 were included. To identify factors related to success of TWOC, a multivariate analysis was performed on the patient's condition at admission and catheter indwelling time. The patients were divided into two groups by the timing of catheter removal, and we assessed the relationship between the timing of catheter removal successful TWOC and recovery of physical function.

RESULTS

A total of 118 patients were included. The presence of comorbidities and scores of severity and function at admission were not predictors of successful voiding. The time to achieve voiding sussess was significantly shorter in the early catheter removal group than in the later group (p<0.005). Interestingly, the early group also showed better improvements in physical function.

CONCLUSION

Early removal of catheters may lead to early recovery of bladder function, improvement of physical function, and lower risk of complications in patients with stroke. J. Med. Invest. 70 : 436-442, August, 2023.

A propensity score matching study on robot-assisted radical cystectomy for older patients: comparison of intracorporeal ileal conduit and cutaneous ureterostomy

BACKGROUND

Robot-assisted radical cystectomy (RARC) and intracorporeal urinary diversion are less invasive than conventional procedures. However, for older patients, cutaneous ureterostomy (CUS) may be preferred because urinary diversion using the intestine has a high incidence of perioperative complications and is highly invasive. The purpose of this study was to demonstrate the safety and efficacy of intracorporeal ileal conduit (ICIC) compared with CUS in patients aged 75 years or older who underwent RARC.

METHODS

From October 2014 to December 2021, 82 patients aged 75 years or older who underwent RARC at Tokushima University Hospital, Tokushima Prefectural Central Hospital, or Ehime Prefectural Central Hospital were retrospectively reviewed. Of these, 52 and 25 patients who underwent ICIC and CUS, respectively, were included. After adjusting the patients' characteristics using propensity score-matching, surgical results and prognoses were retrospectively compared. The propensity score was based on age, Eastern Cooperative Oncology Group Performance Status Scale (ECOG-PS), American Society of Anesthesiologists physical status classification (ASA-PS), clinical tumor stage, and neoadjuvant chemotherapy.

RESULTS

The median age was lower in the ICIC group compared with the CUS group, and the proportion of high-risk cases (ECOG-PS ≥ 2 or ASA-PS ≥ 3) did not differ. The median operation time was longer in the ICIC group, and estimated blood loss was higher, compared with the CUS group. There were no significant differences in the incidence of complications within the first 30 postoperative days, incidence of complications 30-90 days after surgery, 2-year overall survival, 2-year cancer-specific survival, and 2-year recurrence-free survival. The stent-free rate was significantly lower in the CUS group than that in the ICIC group.

CONCLUSION

In older patients, the ICIC group showed non-inferior surgical and oncological outcomes compared with the CUS group. Urinary diversion following RARC in older patients should be carefully selected by considering not only the age but also the general condition (including comorbidities) of the patient.

Recurrent multiple liver metastases of clear cell renal cell carcinoma with a significant response to sunitinib after nivolumab treatment

Introduction

A case of multiple liver metastases of clear cell RCC with a significant response to sunitinib as the fifth line after nivolumab is reported.

Case presentation

The patient was a 65-year-old man who underwent open nephrectomy for RCC. After the nephrectomy, he had recurrences several times, and metastasectomy had been performed for each recurrence. At 13 years after the nephrectomy, multiple liver, and lung metastases appeared. The treatment was switched to axitinib, followed by cabozantinib, then nivolumab. The best response was PR, SD, and PD for these three drugs, and treatment duration was 14, 3, and 3 months, respectively. As the fifth line, sunitinib was administered, with significant shrinkage of the multiple liver metastases, and PR has been maintained for 34 months.

Conclusion

Sunitinib after an IO-drug showed a significant effect in spite of only slight efficacy with other VEGFR-TKIs, which may have occurred through the alteration of the immunological microenvironment.

[Two Cases of Robot-Assisted Total Pelvic Exenteration and Intracorporeal Ileal Conduit for Locally Advanced Rectal Cancer]

We describe two cases of locally advanced rectal cancer (LARC) treated with robot-assisted total pelvic exenteration (Ra-TPE) and intracorporeal ileal conduit (ICIC). The first case was in a 71-year-old man with LARC (RbP, T4bN2bM0, cStage IIIc). He was started on bevacizumab+S-1/oxaliplatin therapy in July 2019. In April 2020, he developed Fournier's gangrene due to subcutaneous penetration of rectal cancer. Emergency drainage and colostomy were performed simultaneously, and a percutaneous vesical fistula was created. In May 2020, Ra-TPE and ICIC were performed. Histopathological analysis revealed moderately differentiated tubular adenocarcinoma (ypT3N0, RM0). At postoperative 9 months, thoracoscopic right upper lobectomy was performed for a right metastatic lung tumor. At present, ie, at postoperative 12 months, the patient has been free of recurrence and metastasis, with a carcinoembryonic antigen (CEA) level of 1.4 ng/ml and carcinoma antigen (CA) 19-9 level of 11 U/ml. The second case was in a 61-year-old man with fistula-associated anal cancer (PRb, T4N3M1b, cStage IVb). In April 2019, he was started on FOLFOXIRI+cetuximab therapy. In August 2020, Ra-TPE, ICIC, and transperineal total mesenteric excision were performed. Histopathological analysis revealed adenocarcinoma (ypT4N0, RM0). At postoperative 11 months, thoracoscopic left lower lobectomy was performed for a left metastatic lung tumor. At present, ie, at postoperative 12 months, the patient remains free of recurrence and metastasis, with a CEA level of 7.3 ng/ml and CA19-9 level of 12 U/ml. Ra-TPE, which allows transperineal removal of a specimen, can be performed as a minimally invasive surgery in combination with ICIC.

[A Case of Pappilary Renal Cell Caircinoma which Responded Well to the Combination Therapy of Ipilimumab and Nivolumab --A CASE REPORT-]

We report a case of papillary renal cell carcinoma that responded well to the combination of ipilimumab and nivolumab. The patient was a 68-year-old male who was being followed up for a small left renal mass without treatment. Two years later, computed tomography (CT) showed enlarged cervical and para-aortic lymph nodes, and lymph node biopsy suggested metastases of the cancer. After resection of the renal tumor, we performed pararenal aortic lymph node biopsy, and we diagnosed the case as papillary renal cell carcinoma type 1 with lymph node metastasis. The combination of ipilimumab and nivolumab each metastatic site showed regression on CT. Since immune-related adverse events occurred during the therapy nivolumab was discontinued, but partial response of the metastases was maintained.

Efficacy of the direct grasping technique using pean forceps under fluoroscopy to replace ureteral stents in women

Purpose : To evaluate the efficacy of the direct grasping technique using pean forceps under fluoroscopic guidance for ureteral stent replacement in women. Methods : Between April 2018 and September 2020, 28 female patients underwent ureteral stent replacements at our facility, and 184 stent replacement procedures were performed. A total of 127 stents were replaced using pean forceps under fluoroscopic guidance (pean forceps group), and 57 stents were replaced using the cystoscope (cystoscopy group). Clinical characteristics and surgical outcomes were compared between the groups. Results : All stents were successfully replaced. There was a statistically significant difference in the procedure time between the two groups (median [interquartile range], pean forceps group : 10.8 [8.2-13.9] minutes vs. cystoscopy group : 15.8 [11.1-20.9] minutes, P < 0.001). There were no intraoperative complications in either group and no difference in the incidence of postoperative complications (pean forceps group : 1.6% vs. cystoscopy group : 1.8%, P = 1.000). Fluoroscopy time was longer in the pean forceps group, although this difference was not statistically significant (pean forceps group : 38.9 [22.6-60.1] seconds vs. cystoscopy group : 33.0 [20.0-48.9] seconds, P = 0.0558). Conclusion : The direct grasping technique using pean forceps under fluoroscopy may be a beneficial alternative to cystoscopy for ureteral stent replacement in women. J. Med. Invest. 68 : 326-329, August, 2021.

The significance of insulin receptor expression to predict the resistance to VEGFR-TKIs and induce PD-L1 expression in advanced clear cell renal cell carcinoma

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Background: Previously we have identified the prognostic gene set of ccRCC patients, where insulin receptor (INSR) expression was decreased in the patients with poor outcome (Proc Natl Acad Sci U S A., 2001). We examined the clinical significance of decreased INSR expression and sought to elucidate the underlying mechanisms. Methods: The INSR expression was immunohistochemically examined in the nephrectomy specimens of RCC patients (n = 33) who then received axitinib. We established patient derived Xenograft model (PDX) of ccRCC and examined the INSR expression in the axitinib resistant PDX tumors by Western blotting. As the INSR is expressed in the vascular endothelial cells, we co-cultured the RCC cell lines with the human renal glomerular endothelial cells (HGEC) treated with si-RNA of INSR (si-INSR) and the microarray experiment was conducted. Results: In RCC patients with axitinib, those with low INSR expression had poor outcome (median PFS 19.5 vs 2.3 months, p < 0.001; median OS 34.2 vs 5.6 months, p = 0.001). The INSR expression was the significantly independent predictor of PFS (p = 0.006). In the axitinib-resistant PDX tumors, the expression of INSR was decreased. In the co-culture experiments, the microarray experiments revealed that the decreased INSR expression in the HGECs may be involved with the important signaling pathway including interferon response in Caki-1 cells. Interferon- β was highly expressed in HGECs with si-INSR. The decreased INSR expression and the increased interferon-β expression in HGEC were confirmed when axitinib was administered. The Caki-1 cells that was co-cultured with HGECs treated with si-INSR demonstrated high expression of PD-L1. The PD-L1 expression was increased in a concentration-dependent manner of recombinant interferon-β and increased phosphorylation of STAT1 and STAT3 were observed. Conclusions: In conclusion, the decreased INSR expression could be a biomarker to predict the resistance to VEGFR-TKIs. The decreased INSR expression was correlated with the increased interferon-β expression in HGECs, which leads to the induction of PD-L1 through increased phosphorylation of STAT1 and STAT3.

Low Expression of Toll-like Receptor 4 Is Associated With Poor Prognosis in Bladder Cancer

BACKGROUND/AIM

The aim of this study was to elucidate the relationship between the progression of bladder cancer (BCa) and TLR4 expression.

MATERIALS AND METHODS

The relationship between TLR4 expression and prognosis of BCa patients was analyzed using a publicly available database and immunohistochemical staining of clinical samples. The effect of TLR4 knockdown was also examined on the invasive capabilities of BCa cells. Finally, to investigate the biological function of TLR4, the gene expression profile of TLR4-depleted BCa cells was analyzed by microarray analysis.

RESULTS

Expression of TLR4 was inversely associated with prognosis of patients with invasive BCa, and depletion of TLR4 significantly enhanced the invasive capability of BCa cells. Gene expression profiling revealed that depletion of TLR4 led to high expression of epithelial differentiation genes. Furthermore, expression of TLR4 was found to be extremely low in areas of squamous differentiation.

CONCLUSION

Low TLR4 expression was correlated with tumor progression.

Correlation of insulin-receptor expression with efficacy of axitinib in patients with advanced renal cell carcinoma

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Background: Axitinib has demonstrated high efficacy with well-controlled adverse events (AEs) for advanced renal cell carcinoma (RCC). Recently, nivolumab has been approved for advanced RCC. However, it is very expensive in Japan and may cause severe immune-related AEs. There is no clue to choose axitinib or nivolumab as the second-line for advanced RCC. Previously we identified the gene set which may predict poor prognosis of RCC patients (Takahashi m et.al., Proc Natl Acad Sci U S A., 98: 9754, 2001) and have sought to elucidate whether insulin receptor (INSR) expression in the gene set may predict the resistance for axitinib as a biomarker. Methods: Axitinib was administered in 36 patients in our department between January 2008 and April 2015. Median age was 70 (36-84) years old with 22 males and 14 females. Histological subtype included clear cell RCC (n=27, 75.0%), clear cell + sarcomatoid component (n=3), collecting duct carcinoma (n=2), papillary, sarcomatoid, mucinous tubular and spindle cell carcinoma (MTSCC), and unknown in each one. Axitinib was administered in two patients as the first line, 21 patients as the second line, and 13 patients as ≥ the third line. Tissue of primary tumor was available in 20/36 patients, including 16 clear cell RCC and 4 other subtypes. Immunohistochemical INSR expression was examined and correlated with survival of the patients with axitinib. Results: Objective response rate was 27.6%, progression-free survival (PFS) was 16.3 months, and overall survival (OS) was 41.9 months in clear cell RCC patients. Patients with low INSR expression (n=7) had significantly shorter PFS (68 vs. 586 days, p<0.001) and OS (169 vs. 1027 days, p=0.004) compared with those with high INSR expression (n=13). If only clear cell RCC was evaluated, patients with low INSR expression (n=3) had significantly shorter PFS (77 vs. 586 days, p=0.008) and OS (294 vs. 1027 days, p=0.016) compared with those with high INSR expression (n=13). Conclusions: Axitinib was highly effective for advanced clear cell RCC. However, immunohistochemically low expression of INSR in the primary tumor may predict the resistance for axitinib and those patients may be more suitable for immune checkpoint inhibitors.

The Involvement of Hepatocyte Growth Factor-MET-Matrix Metalloproteinase 1 Signaling in Bladder Cancer Invasiveness and Proliferation. Effect of the MET Inhibitor, Cabozantinib (XL184), on Bladder Cancer Cells

OBJECTIVE

To clarify the invasive mechanisms of muscle-invasive bladder cancer (BCa) would be useful for the determination of appropriate treatment strategies. We previously showed that hepatocyte growth factor (HGF)-MET signaling is correlated with invasiveness of BCa cells. Here, we investigated the effects of the MET inhibitor, cabozantinib (XL184), on BCa cells.

METHODS

We first conducted Western blot analysis to investigate MET expression in BCa cell lines. Next, we examined the effect of cabozantinib on their proliferation and invasive abilities using MTT and Matrigel invasion assays, respectively. Invasion assays were performed using the xCELLigence system. Additionally, to investigate the biological function of HGF-MET signaling, we analyzed gene expression profiles and performed real-time polymerase chain reaction analyses of 5637 cells that were cultivated with or without HGF stimulation, with or without cabozantinib.

RESULTS

MET was highly expressed in 4 of 5 BCa cell lines, and 5637 and T24 cells showed especially high protein expression of MET. Cabozantinib suppressed cell proliferation and invasion (cell index; mock, 1.49 vs HGF, 2.26 vs HGF + XL184, 1.47, P < .05). Gene expression profile analysis indicated that matrix metalloproteinase 1 (MMP1) was significantly elevated at the mRNA level with addition of HGF. Moreover, cabozantinib suppressed HGF-induced MMP1 expression in 5637 T24 cells.

CONCLUSIONS

These data indicate that cabozantinib suppressed MMP1 expression by blocking HGF-MET signaling and that HGF-MET-MMP1 signaling is involved in the invasiveness and proliferation of BCa cells. These results suggest that cabozantinib might prove useful for future treatment of muscle-invasive BCa.

Clinical Significance of Neoadjuvant Combined Androgen Blockade for More Than Six Months in Patients with Localized Prostate Cancer Treated with Prostate Brachytherapy

INTRODUCTION

The aim of this study is to clarify the clinical significance of neoadjuvant combined androgen blockade (CAB) for ≥ 6 months in patients with localized prostate cancer.

PATIENTS AND METHODS

A total of 431 patients with localized prostate cancer who underwent prostate brachytherapy (BT) with or without neoadjuvant CAB for ≥ 6 months with mean follow-up time of 64.6 months (range 24-108 months) were evaluated retrospectively. Of those 431, 232 patients received BT in combination with neoadjuvant CAB for ≥ 6 months. Biochemical recurrence-free rates (BRFRs) in 364 patients with at least 3 years of follow-up were evaluated by log-rank test.

RESULTS

BRFR in patients with low-, intermediate- and high-risk prostate cancer were 98.1, 94.2 and 89.1%, respectively. In patients with intermediate-risk prostate cancer only, neoadjuvant CAB was significantly associated with BRFR (p = 0.0468). Especially in patients with intermediate-risk prostate cancer with radiation dose received by 90% of the prostate (D90) < 180 Gy, neoadjuvant CAB exerted a favorable impact on BRFR (p = 0.0429). On multivariate analyses, neoadjuvant CAB and D90 were independent predictors of BRFR (p = 0.0061 and p < 0.0001, respectively).

CONCLUSIONS

Neoadjuvant CAB for ≥ 6 months has a favorable impact on BRFR in patients with intermediate-risk prostate cancer, particularly in patients with relatively low radiation doses of D90.

Complications of Flexible Ureteroscopic Treatment for Renal and Ureteral Calculi during the Learning Curve

BACKGROUND

The flexible ureterorenoscope (URS) and associated devices have developed rapidly. However, despite its therapeutic benefits, URS may be associated with some complications. To the best of our knowledge, there are no studies discussing the complications of flexURS during the learning curve.

METHODS

A retrospective review of the records of patients who underwent flexURS from January 2005 to June 2013 was performed. To compare the complications after the introduction of flexURS, patients were divided into four groups based on the surgeon's training experience, that is, based on the number of cases performed by the surgeon. A total of 219 cases underwent flexURS. Groups 1, 2, 3, and 4 included 35, 50, 50, and 84 cases, respectively. The complications were classified using the Clavien system (I-IV).

RESULTS

The mean operation time and stone-free rate were significantly different (p < 0.001, p = 0.013, respectively). The total complication rates were 13.6, 10, 8.3, and 3.2%, respectively (p = 0.068). The more the surgeon's experience, the less was the complication rate. Despite our best efforts, the incidence of urosepsis was not reduced (p = 0.902).

CONCLUSIONS

To reduce severe complications, it is necessary to have performed about 100 cases. Increased surgeon experience tended to decrease the risk of severe complications, but the incidence of urosepsis was not reduced.

Docetaxel-prednisolone combination therapy for Japanese patients with hormone-refractory prostate cancer: a single institution experience

OBJECTIVE

To evaluate the efficacy and toxicity of docetaxel plus prednisolone treatment in Japanese patients with hormone-refractory prostate cancer (HRPC).

METHODS

From April 2004 through August 2008, we used docetaxel plus prednisolone to treat 55 HRPC patients (median age, 72 years). Eighteen patients (32.7%) had measurable soft tissue lesions, whereas 52 patients (94.5%) had bone metastases. During the 21-day treatment cycle, docetaxel (70 mg/m(2)) was administered once every 21 days and oral prednisolone (5 mg), twice daily. Prostate-specific antigen (PSA) response, defined as a reduction of at least 50% in the baseline levels for 4 weeks, was evaluated.

RESULTS

The median follow-up period was 30.1 months; median overall survival, 15.3 months and median progression-free survival, 7.5 months. During follow-up, 37 patients (67.3%) achieved the PSA response, and 5 of 18 (27.8%) patients with measurable disease showed a partial response. Among the 27 patients who experienced cancer pain before treatment initiation, 15 (55.5%) reduced their analgesic drug intake. Multivariate analysis of the prognostic variables revealed a significant association between the overall survival and pain (P = 0.033). Hematological toxicity (grades 3-4) included neutropenia (87.3%), febrile neutropenia (25.5%) and thrombocytopenia (5.5%). Frequent non-hematological adverse events were general edema (52.7%), general fatigue (32.7%) and sensory neuropathy (30.9%). Three patients died of adult respiratory distress syndrome (ARDS).

CONCLUSION

Docetaxel plus prednisolone treatment is effective in Japanese HRPC patients. The main toxicity is neutropenia, which can be safely controlled by outpatient treatment with granulocyte-colony stimulating factor. However, the Japanese patients in our study developed ARDS more frequently than other patients in previous studies did.

[A case of retroperitoneal serous cyst resected by laparoscopic surgery]

A 40-year-old woman was referred to our hospital because of pain extending from the left lateral abdomen to the left inferior limb. The abdominal computed tomography (CT) revealed an 8x7x12 cm retroperitoneal serous cystic mass. The serum carcinoembryogenic antigen (CEA) level was slightly elevated to 2.7 ng/ml. Therefore, we suspected it to be malignant, and we performed laparoscopic resection carefully. The retroperitoneal cyst was not adherent to the surrounding tissues and was easily dissected and removed under laparoscopy. Carbohydrale antigen (CA)19-9, CA125 and CEA levels in the fluid were elevated, but a cytology of the fluid was negative and no malignant sign was seen in the cyst wall. To our knowledge, this is the second reported case of retroperitoneal serous cyst resected by laparoscopic surgery in the Japanese literature.

Health-related quality of life using SF-8 and EPIC questionnaires after treatment with radical retropubic prostatectomy and permanent prostate brachytherapy

OBJECTIVE

The health-related quality of life (HRQOL) after treatment of prostate cancer is examined using a new HRQOL tool. HRQOL, based on the expanded prostate cancer index composite (EPIC) and SF-8 questionnaires, was prospectively compared after either a radical retropubic prostatectomy (RRP) or a permanent prostate brachytherapy (PPB) at a single institute.

METHODS

Between October 2005 and June 2007, 96 patients were treated by an RRP and 88 patients were treated by a PPB. A HRQOL survey was completed at baseline, and at 1, 3, 6 and 12 months after treatment, prospectively.

RESULTS

The general HRQOL in the RRP and PPB groups was not different after 3 months. However, at baseline and 1 month after treatment, the mental component summary was significantly better in the PPB group than in the RRP group. Moreover, the disease-specific HRQOL was worse regarding urinary and sexual functions in the RRP group. Urinary irritative/obstructive was worse in the PPB group, but urinary incontinence was worse in the RRP group and had not recovered to baseline after 12 months. The bowel function and bother were worse in the PPB group than in the RRP group after 3 months. In the RRP group, the patients with nerve sparing demonstrated the same scores in sexual function as the PPB group.

CONCLUSIONS

This prospective study revealed the differences in the HRQOL after an RRP and PPB. Disease-specific HRQOL is clarified by using EPIC survey. These results will be helpful for making treatment decisions.

The major outer membrane protein rOmpB of spotted fever group rickettsiae functions in the rickettsial adherence to and invasion of Vero cells

The role of one of the major outer membrane proteins, rOmpB, of spotted fever group rickettsiae was examined. Antibodies generated against native rOmpB inhibited plaque formation by Rickettsia japonica in Vero cells when applied at the time of inoculation of the rickettsiae. However, antibodies to heat-denatured rOmpB did not. Moreover, the soluble recombinant rOmpB also inhibited plaque formation to some extent. Thus it seems that rOmpB functions at least in the adherence of rickettsiae to host cells. To obtain direct evidence of its function in the adherence to and invasion of Vero cells, we generated Escherichia coli transformed by the vector pET-22b(+) inserted with the ompB open reading frame of R. japonica. The recombinant bacteria expressed a 165-kDa protein consistent with the precursor of rOmpB. The protein reacted with monoclonal antibodies to heat-labile epitopes of rOmpB. Immunofluorescence of the recombinant bacteria demonstrated surface expression of the protein. It was shown by light microscopy and transmission and scanning electron microscopy that the bacteria adhered to and invaded Vero cells. Thus, although the recombinant precursor rOmpB was not processed on the outer membrane of E. coli, it functions during these steps. The manner of entry was similar to that of rickettsiae although at a slower rate.

Construction of an infectious cDNA clone of Aichi virus (a new member of the family Picornaviridae) and mutational analysis of a stem-loop structure at the 5' end of the genome

Aichi virus is the type species of a new genus, Kobuvirus, of the family Picornaviridae. In this study, we constructed a full-length cDNA clone of Aichi virus whose in vitro transcripts were infectious to Vero cells. During construction of the infectious cDNA clone, a novel sequence of 32 nucleotides was identified at the 5' end of the genome. Computer-assisted prediction of the secondary structure of the 5' end of the genome, including the novel sequence, suggested the formation of a stable stem-loop structure consisting of 42 nucleotides. The function of this stem-loop in virus replication was investigated using various site-directed mutants derived from the infectious cDNA clone. Our data indicated that correct folding of the stem-loop at the 5' end of the positive strand, but not at the 3' end of the negative strand, is critical for viral RNA replication. The primary sequence in the lower part of the stem was also suggested to be crucial for RNA replication. In contrast, nucleotide changes in the loop segment did not so severely reduce the efficiency of virus replication. A double mutant, in which both nucleotide stretches of the middle part of the stem were replaced by their complementary nucleotides, had efficient RNA replication and translation abilities but was unable to produce viruses. These results indicate that the stem-loop at the 5' end of the Aichi virus genome is an element involved in both viral RNA replication and production of infectious virus particles.

Sequence analysis of genes encoding structural and nonstructural proteins of a human group B rotavirus detected in Calcutta, India

Nucleotide sequences of RNA segments encoding structural proteins(VP4, VP6, and VP7) and nonstructural proteins(NSP1 and NSP3) of a human group B rotavirus CAL-1, which was detected in Calcutta, India, were determined and their relatedness with cognate genes of other group B rotaviruses was analyzed. The CAL-1 genes showed generally high sequence identities (more than 90%) to those of human group B rotavirus, adult diarrheal rotavirus (ADRV) in China, while identities with bovine, murine, and ovine viruses were considerably lower (58-73%). Among RNA segments analyzed, sequence identity of the VP6 gene was relatively high compared with other gene segments. In the CAL-1 VP7 sequence, many characteristics were shared by ADRV, but not by other animal group B rotaviruses. In contrast, VP4 and NSP3 of CAL-1 were single amino acid and 23 amino acids longer than those of ADRV strain, respectively, due to differences of a few nucleotides. These findings suggested that human group B rotaviruses CAL-1 and ADRV might have originated from a common ancestral virus distinct from animal group B rotaviruses reported so far, while some notable sequence differences indicated the distinct nature of these viruses.

IgE deposition in brain microvessels and on parasitized erythrocytes from cerebral malaria patients

Postmortem brain tissues of 21 cerebral malaria cases were obtained in Myanmar and Vietnam. The tissues were examined by light microscopy and by an immunohistochemical method. Brain microvessels (capillaries and venules) were examined for the presence of immunoglobulins IgE and IgG, Plasmodium falciparum antigen, and parasitized erythrocytes (PRBC). Deposition of IgE, IgG, and P. falciparum antigen was observed in the microvessels from all specimens examined. Sequestered PRBC in the microvessels were positive for IgG in all 21 cases and for IgE in six cases. In the latter cases, the percentage of microvessels with sequestered PRBC was > 50%, with the frequency of IgE-positive cells ranging from 42% to 52%. In contrast, in five cases that were only weakly positive for IgE, the percentage of microvessels with sequestered PRBC was remarkably low (< 1%). These data indicate that the degree of deposition of IgE in microvessels and on PRBC from cerebral malaria patients correlated with that of PRBC sequestration. As IgE-containing immune complexes are known to induce local overproduction of tumor necrosis factor-alpha (TNF-alpha), a major pathogenic factor in cerebral malaria, IgE may contribute to the pathogenesis of this severe disease.

Isolation of antigen from the circulating immune complex in mice infected with Plasmodium berghei

Circulating immune complex (CIC) is known to play a role in pathological glomerular alterations in malaria. However, the nature of the antigens comprising the CIC is still not fully understood. We report here the isolation of the antigen in CIC and its localisation in mice infected with Plasmodium berghei NK65. The antigen was successfully isolated from CIC extracted from the blood of mice infected with P. berghei, by using C1q-coated microplates. The molecular mass of the antigen separated from CIC bound to C1q was found to be 78 kDa. Furthermore, localisation of the antigen was examined by the fluorescent antibody technique and immunoelectron microscopy. The antigen was detected in the parasitised erythrocyte and the mesangial matrix by both methods. These results suggest that the 78 kDa protein might be associated with the glomerular alterations in malaria infection.

Tenascin takes part in the progress of pathological severity in cerebral falciparum infection

We examined plasma level of circulating form of tenascin (TC) in falciparum malaria patients, cerebral malaria and non cerebral malaria, and compared them to uninfected healthy persons. Plasma level of TC examined were significantly higher in malaria patients than in control persons (p< 0.01). The results also show that among malaria patients, TC level was higher in the cerebral malaria patients compare to non cerebral malaria patients (p<0.10). Kinetics of TC level in plasma were related to kinetics of TNF-alpha level. Moreover, patients with higher level of TC showed higher level of parasitized erythrocytes binding ratio. Immunohistochemical study showed that TC was found in the cerebral microvessels of postmortem cerebral tissues from nine cerebral malaria cases. These results provide evidence that plasma level of TC correlates with the severity in cerebral malaria patients.

Serum concentrations of carotenoids, retinol, and alpha-tocopherol in healthy persons determined by high-performance liquid chromatography

Serum concentrations of alpha-carotene (AC), beta-carotene (BC), lycopene (LY), beta-cryptoxanthin (CR), zeaxanthin (including lutein. ZX), canthaxanthin (CX), retinol (RE), and alpha-tocopherol (TO) in healthy persons (618 males and 1,196 females) aged 7-86 years were determined by HPLC. Serum concentrations of BC among persons aged 20-49 years were higher with increasing age in females, but not in males. Serum CR concentrations decreased with age ranging from 7 to 39 years, while ZX concentrations rose in the age group of 20 to 59 years for both sexes. In contrast, serum RE concentrations and ratios of RE/BC and RE/CR, especially in males aged 20-49, were higher with age. Serum TO values in both sexes rose with age and were similar.