Akio Hoshi

A 58-year-old Japanese female was admitted to our hospital for treatment of ovarian cancer. She had no urinary tract symptoms at the time of presentation. Preoperative CT (Computed Tomography) was performed for surgical planning, and it revealed two left-sided ureters including a short ureter with a blind, cystic ending and a short ureter joined to the main ureter before entering into the bladder. On CT urography, these radiological findings were compatible with a blind-ending bifid ureter. Preoperatively, a double J stent was inserted into the normal left ureter, and then the blind-ending bifid ureter was resected before an ovarian cancer operation.

Objectives: To develop a modified technique of “total pelvic floor reconstruction” during non‐nerve‐sparing laparoscopic radical prostatectomy, and to determine its effect on postoperative urinary outcomes.Methods: A total of 128 patients who underwent non‐nerve‐sparing laparoscopic radical prostatectomy were evaluated, including 81 with total pelvic floor reconstruction and 47 with non‐total pelvic floor reconstruction. Nerve‐sparing cases were excluded. Urinary outcomes were assessed with self‐administrated questionnaires (Expanded Prostate Cancer Index Composite) at 1, 3, 6 and 12 months after laparoscopic radical prostatectomy. The total pelvic floor reconstruction technique included two concepts involving posterior and anterior reconstructions. In posterior reconstruction, Denonvilliers' fascia was approximated to the bladder neck and the median dorsal raphe by slipknot. The anterior surface of the bladder‐neck was approximated to the anterior detrusor apron and the puboprostatic ligament collar for anterior reconstruction.Results: There were no significant differences between the two groups in the patients' characteristics, and in perioperative and oncological outcomes. In the total pelvic floor reconstruction group, the continence rates at 3, 6 and 12 months after laparoscopic radical prostatectomy were 45.7%, 71.4%, and 84.6%, respectively. In the non‐total pelvic floor reconstruction group, the continence rates were 26.1%, 46.8% and 60.9%, respectively. The total pelvic floor reconstruction technique resulted in significantly higher continence rates at 3, 6 and 12 months after laparoscopic radical prostatectomy, respectively (all P < 0.05). The mean interval to achieve continence was significantly shorter in the total pelvic floor reconstruction group (mean 7.7 months) than in the non‐total pelvic floor reconstruction group (mean 9.8 months; P = 0.0003).Conclusion: The total pelvic floor reconstruction technique allows preservation of the blood supply to the urethra and physical reinforcement of the pelvic floor. Therefore, this technique is likely to improve urinary continence outcomes after laparoscopic radical prostatectomy.

Objectives: To describe a novel dorsal vein complex preserving technique for intrafascial nerve‐sparing laparoscopic radical prostatectomy and to evaluate its postoperative outcomes.Methods: A total of 109 patients who underwent laparoscopic radical prostatectomy by a single surgeon were evaluated, including 44 patients with dorsal vein complex preserving technique for intrafascial nerve‐sparing laparoscopic radical prostatectomy, 20 patients with conventional intrafascial nerve‐sparing laparoscopic radical prostatectomy and 45 patients with non‐nerve‐sparing laparoscopic radical prostatectomy. Functional outcomes were evaluated using a self‐administered questionnaire (Expanded Prostate Cancer Index Composite). Continence was defined as zero to one security pad per day. Oncological outcomes were evaluated based on positive surgical margin.Results: In the dorsal vein complex preserving technique for intrafascial nerve‐sparing laparoscopic radical prostatectomy group, the continence rate was 57%, 77% and 95% at 1, 3 and 12 months, respectively. The continence rate in the conventional intrafascial nerve‐sparing laparoscopic radical prostatectomy group was 37%, 63% and 90%, and in the non‐nerve‐sparing laparoscopic radical prostatectomy group it was 23%, 57% and 82% at 1, 3, and 12 months, respectively. The dorsal vein complex preserving technique for intrafascial nerve‐sparing laparoscopic radical prostatectomy group showed a significantly earlier recovery from incontinence compared with that in the conventional intrafascial nerve‐sparing laparoscopic radical prostatectomy and non‐nerve‐sparing laparoscopic radical prostatectomy groups (log–rank test, P = 0.044 and P < 0.001). Similarly, the dorsal vein complex preserving technique for intrafascial nerve‐sparing laparoscopic radical prostatectomy group tended to show a more early recovery in relation to urinary function of the Expanded Prostate Cancer Index Composite. Regarding sexual function, there were no significant differences between the dorsal vein complex preserving technique for intrafascial nerve‐sparing laparoscopic radical prostatectomy and conventional intrafascial nerve‐sparing laparoscopic radical prostatectomy groups. In pT2 patients, the positive surgical margin rate of the dorsal vein complex preserving technique for intrafascial nerve‐sparing laparoscopic radical prostatectomy group (11%) was similar to that of the other two groups (conventional intrafascial nerve‐sparing laparoscopic radical prostatectomy 7%; non‐nerve‐sparing laparoscopic radical prostatectomy 11%).Conclusions: The dorsal vein complex preserving technique for intrafascial nerve‐sparing laparoscopic radical prostatectomy technique provides early recovery from incontinence without adversely affecting the oncological outcome.

A 71-year-old man underwent a radical nephrectomy for right renal cell carcinoma in April, 2005. Pathological findings revealed clear cell carcinoma, G3＞G2, pT3a. Three years later, he underwent a craniotomy for tumor resection of solitary brain metastasis. In October, 2008, he came to our hospital because of urinary retention. Benign prostate hypertrophy was diagnosed by ultrasonography and digital rectal examination. Serum prostate specific antigen level was 2.55 ng/dl. While he was treated with oral α 1-blocker initially, a urethral catheter was inserted in December, 2009. Because of frequent obstruction of the catheter by hematuria, transureathral prostectomy was performed. Pathological findings revealed prostatic metastasis of renal cell carcinoma. Metastasis of renal cell carcinoma to the prostate is rare, and only 7 cases including the present case have been reported.

We report a case of marginally resectable gastrointestinal stromal tumor (GIST) in the pelvis treated with neoadjuvant intent before subsequent successful surgical resection. A 46-year old man presented with urinary frequency and rectal discomfort with tenesmus. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a 12 cm diameter mass between the bladder and rectum and the margin of the tumor and prostate was unclear. No metastases were evident. Trans-rectal needle core biopsy confirmed c-kit positive GIST. Because of the locally advanced nature of the tumor,immediate surgical resection would have required total pelvic exenteration with eternal colostomy and urinary diversion. Therefore,the patient was treated with imatinib mesylate 400 mg daily in anticipation of adequate tumor size reduction to enable a more simplified surgical approach. After 3 months of imatinib therapy,MRI demonstrated a reduction in tumor size of 60%. Consequently,a complete surgical resection including the bladder,prostate and part of the sigmoid colon with temporary ileostomy and ileal conduit was performed. Pathological findings of the resected specimen showed widespread degeneration with cystic changes,necrosis, and hypocellularlity,as well as nodules of residual viable c-kit positive tumor cells. The patient has been treated with imatinib mesylate for 39 months following the operation without tumor recurrence.

A 71-year-old man with dysuria was referred to our hospital. The level of serum prostate specific antigen was slightly elevated (4.66 ng/ml), and digital rectal examination revealed a stony hard prostate mass. We performed a transrectal prostate biopsy because malignancy was suspected. Histological examination revealed leukemia-like cells, and bone-marrow examination (aspiration) was performed to determine the location of the original lesion. However, no leukemia-like cells or any other form of malignant cells were identified. Clinical imaging confirmed the absence of any other lesions, and granulocytic sarcoma of the prostate was subsequently diagnosed. We treated the cancer with radiotherapy at a dose of 40 Gy and dysuria improved. Furthermore, significant reduction in prostate volume was confirmed. Four months after initial presentation, the patient developed acute myeloid leukemia [M2 by French-American-British classification]. Induction chemotherapy was initiated, and the patient was successfully induced to complete remission. Twenty months later, the patient showed relapse. Despite salvage chemotherapy, he died of brain hemorrhage twenty-four months after complete remission.

We present a case of laparoscopic radical nephrectomy in right renal cell carcinoma with left inferior vena cava in a 65-year-old male. Abdominal contrasted CT scan revealed that the left inferior vena cava crossed the aorta at the level of third lumbar vertebra. Laparoscopic radical nephrectomy was performed transperitoneally. A right gonadal vein drained into the right renal vein. We indentified a right renal vein easily with tracing the right gonadal vein. Left inferior vena cava is a very rare congenital anomaly among malformation of inferior vena cava. Recognition of such venous anomalies and making a detailed strategy before operation is important especially in laparoscopic surgery.

A cross-sectional study for certain symptoms of postoperative incontinence was done for patients who underwent laparoscopic radical prostatectomy (LRP) using our original self-administered questionnaire. A total of 104 patients, who underwent LRP from April 2002 to March 2005 in our institute and related hospitals, participated in our questionnaire study. Mean age and median observation period was 64.6 years old (range 51-74) and 18 months (range 3-36). The patients were classified into "D group" (disappearance of incontinence during 3 months after LRP) and "C group" (continuous incontinence more than 3 months). Then age, body mass index, preoperative PSA level, status of voiding, defecation and potency were compared. Patients with incontinence were divided according to observation period into "short period group" (S group; 3-11 months), "intermediate period group" (IM group; 12-23 months) and "long period group" (L group; more than 23 months). Incitant factors of incontinence, status of taking pads and QOL score were compared. There were no differences between the D and C groups at any measurements. About 40% of incontinence patients were pad-free, although most of these patients did not satisfy the status of voiding. The incitant factor in 90% of the S group was "cough or sneeze", but that in the L group was "without notice" (about 40%) and "too late to toilet (voiding)" (about 25%). After all, postoperative QOL score was still lower in the patients with incontinence regardless of its volume. Further study to revolutionary improve incontinence is required.