Minato Yokoyama

With the spread of minimally invasive surgery (MIS), various MIS-specific iatrogenic complications have been reported; however, subserosal bile infiltration of the gallbladder has not been documented. We report a case of subserosal bile infiltration occurring during robot-assisted radical right nephrectomy for clear cell renal carcinoma after robot-assisted partial nephrectomy. Following right kidney resection, dark green discoloration of the gallbladder was observed. Reviewing the operative video revealed that the color change developed during retraction with a snake retractor. Although no bile spillage was observed, laparoscopic cholecystectomy was performed because gallbladder injury was suspected. During dissection from the gallbladder bed, bile was observed within the subserosal layer, confirming subserosal bile infiltration. Subserosal bile infiltration is a rare form of gallbladder injury; however, it may progress to bile peritonitis and should be recognized as a potential complication requiring careful attention during surgery.

Introduction: To investigate the nationwide trends in pharmacological treatment for overactive bladder among Japanese adults, specifically focusing on the β3‐agonists to anticholinergics prescribed tablet ratio (BAPR) and how this ratio differs by sex and age. Methods: National Database Open Data from fiscal year 2015 to 2023 were utilized and the prescription volumes of β3‐agonists (mirabegron and vibegron) and anticholinergics (propiverine, solifenacin, imidafenacin, and fesoterodine) were aggregated. The data were categorized by sex and 10‐year age groups to analyze prescribed tablet trends per 1000 population for each demographic. We calculated the BAPR by dividing the number of prescribed tablets for β3‐agonists by those for anticholinergics and investigated the annual trends for younger and older men and women using an ordinary least squares linear regression model. Results: During the study period, the total number of prescribed tablets for β3‐agonists, anticholinergics, and overall total showed changes of +285.3%, −24.7%, and +59.3%, respectively. Total and β3‐agonist prescriptions rose annually across all groups, whereas anticholinergic use declined beginning in fiscal year 2018. Additionally, nearly all drugs showed an increase in prescribed tablets per 1000 population as age progressed. Although the BAPR increased significantly in all groups, there were significant differences in the rates of change between groups ( p < 0.001), with older men exhibiting the highest rate of increase. Conclusions: A nationwide shift in overactive bladder treatment, where the growth in β3‐agonist prescriptions outweighed the decline in anticholinergics, was observed across all demographic groups in Japan.

Introduction: Port‐site hernia is a rare but serious complication that can occur after robot‐assisted radical prostatectomy and requires surgical repair. Case Presentation: In 2024, we experienced two cases of port‐site hernia after robot‐assisted radical prostatectomy. In response, we developed a preventive technique to reduce the risk of port‐site hernia. Here, we present one of the two cases of port‐site hernia after robot‐assisted radical prostatectomy and a case in which port‐site hernia did not occur after receiving the new preventive technique. We also describe the preventive method currently employed at our institution, where an anti‐adhesion agent is applied to the removal site of a 12‐mm port and closure suture involves fascia without peritoneum. This technique is simple, safe, and applicable to all patients. Conclusion: We developed a new and simple procedure to prevent port‐site hernia based on our experience. Our method may have the potential to effectively prevent its occurrence.

Background: Urachal carcinoma (URC) is a rare tumor of the urinary bladder, of which the histology usually resembles that of colorectal adenocarcinoma. Achievement of cure in patients with metastatic URC is difficult, and the survival rate of these patients has remained unsatisfactory despite various efforts.Case: A 74‐year‐old female patient presented to us complaining of gross hematuria. Abdominal and thoracic computed tomography revealed a mass in the dome of the bladder with a single lung nodule. The two tumors, which were resected by partial cystectomy and video‐assisted thoracic surgery, respectively, were diagnosed by postoperative histopathology as adenocarcinomas. Subsequent to the surgeries, bilateral ovarian metastases and another lung metastasis, which appeared metachronously, were also resected. The repeated cytoreductive surgery combined with administration of S‐1 plus cisplatin chemotherapy at each instance of disease progression eventually yielded a durable progression‐free survival; even at 5 years after the initial therapy, the patient remained asymptomatic with no limitation of activities despite the failure to achieve “cure”.Conclusion: Not only some degree of sensitivity of the tumor to chemotherapy, but also the repeated cytoreductive surgeries might allow prolonged survival with a good quality of life in elderly patients with metastatic URC, even in the absence of cure and failure of genetic testing to suggest any potentially effective second‐line drugs. To improve the survival of patients with metastatic URC, complementary therapy suggested by the results of genomic profiling may be necessary along with other multimodality therapy, including sequential metastasectomy and chemotherapy.

Pembrolizumab has emerged as a significant therapeutic option for the treatment of solid tumors with a high tumor mutational burden (TMB-high). However, there have been no reports of its use in treatment-related neuroendocrine prostate carcinoma (t-NEPC) with TMB-high. We present the case of a 66-year-old man with metastatic prostate cancer (adenocarcinoma with a Gleason score of 4 + 5, initial prostate-specific antigen [PSA] level of 267 ng/mL, clinical stage T3bN0M1b) who was initially treated with doublet therapy, including apalutamide and leuprorelin, leading to a reduction in circulating levels of PSA < 0.001 ng/mL. However, 35 months after diagnosis, a retroperitoneal mass developed and neuron-specific enolase (NSE) levels were elevated 62.6 ng/mL. Computed tomography-guided biopsy of the tumor confirmed metastasis of t-NEPC, while genetic profiling revealed a TMB-high status. Pembrolizumab treatment was initiated at the 39-month after diagnosis. At the 41-month after diagnosis, a 75% reduction in the retroperitoneal mass and a decrease in NSE levels to 31 ng/mL were observed. This case suggests that pembrolizumab is a potential treatment option for t-NEPCs with TMB-high.

To evaluate in-hospital fees and surgical outcomes of robot-assisted radical cystectomy (RARC), laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC) using a Japanese nationwide database. All data were obtained from the Diagnosis Procedure Combination database between April 2020 and March 2022. Basic characteristics and perioperative indicators, including in-hospital fees, were compared among the RARC, LRC and ORC groups. Propensity score–matched comparisons were performed to assess the differences between RARC and ORC. During the study period, 2931, 1311 and 2435 cases of RARC, LRC and ORC were identified, respectively. The RARC group had the lowest in-hospital fee (median: 2.38 million yen), the shortest hospital stay (26 days) and the lowest blood transfusion rate (29.5%), as well as the lowest complication rate (20.9%), despite having the longest anesthesia time (569 min) among the three groups (all P < 0.01). The outcomes of LRC were comparable with those of RARC, and the differences in these indicators between the RARC and ORC groups were greater than those between the RARC and LRC groups. In propensity score–matched comparisons between the RARC and ORC groups, the differences in the indicators remained significant (all P < 0.01), with an ~50 000 yen difference in in-hospital fees. RARC and LRC were considered to be more cost-effective surgeries than ORC due to their superior surgical outcomes and comparable surgical fees in Japan. The widespread adoption of RARC and LRC is expected to bring economic benefits to Japanese society.

Objectives: To evaluate longitudinal changes in lower urinary tract symptoms (LUTS) after artificial urinary sphincter (AUS) implantation in patients undergoing radiation therapy (RT) in comparison to those in non‐irradiated patients.Methods: This retrospective study included 20 and 51 patients with and without a history of pelvic RT (RT and non‐RT group, respectively) who were treated with primary AUS implantation for post‐radical prostatectomy incontinence between 2010 and 2020. Longitudinal changes in the International Consultation on Incontinence Questionnaire‐Short Form (ICIQ‐SF), the International Prostate Symptom Score (IPSS), and the Overactive Bladder Symptom Score (OABSS) were calculated with a linear mixed model.Results: In the RT and non‐RT group, 18 (90%) and 48 (94%) patients achieved social continence, defined as daily pad use ≤1 at 1 month after activation of AUS, respectively (p = .555). During the mean follow‐up of 38 months, ICIQ‐SF, IPSS, and OABSS significantly improved after AUS implantation in both the RT and non‐RT groups. In the RT group, ICIQ‐SF, IPSS, and OABSS subsequently deteriorated with a slope of 0.62/year (p = .010), 0.55/year (p = .025), and 0.30/year (p = .007), respectively. In the non‐RT group, no significant longitudinal changes in subsequent IPSS and OABSS were observed, although ICIQ‐SF significantly deteriorated (0.43/year, p = .006). Comparing between the groups, the slopes of IPSS and OABSS were significantly greater in the RT group than in the non‐RT group (p < .001, and .015, respectively).Conclusions: Longitudinal deterioration in LUTS that improved immediately after AUS implantation was observed in patients with a history of pelvic RT, but not in patients without a history of pelvic RT.

Objectives: To analyze the incidence and risk factors of intraoperative hypotension related to photodynamic diagnosis‐assisted transurethral resection of bladder tumor (PDD‐TURBT) with oral 5‐aminolevulinic acid (5‐ALA).Methods: We retrospectively analyzed 487 patients with bladder tumors who underwent PDD‐TURBT (n = 184) or conventional TURBT (conv‐TURBT) (n = 303) between 2018 and 2021. Intraoperative hypotension was defined as hypotension requiring vasopressors during TURBT, and its incidence was compared between the two groups. Potential risk factors of intraoperative hypotension, including preoperative change in mean arterial pressure (MAP), were further investigated in patients receiving PDD‐TURBT.Results: The median age was 72 years, 392 patients (81%) were male, and 203 (42%) had hypertension. TURBT was performed under general and spinal anesthesia in 76 (16%) and 411 (84%) patients, respectively. The incidence of intraoperative hypotension was significantly higher in PDD‐TURBT compared to conv‐TURBT (43% vs. 17%, respectively). The median change in MAP until the induction of anesthesia was +6.5 mmHg (range: −29.0 to +46.3) in the PDD‐TURBT group and +14.7 mmHg (range: −35.3 to +67.7) in the conv‐TURBT group, showing a significantly smaller increase in the PDD‐TURBT group (p < 0.001). In the multivariable analysis for PDD‐TURBT patients, advanced age, general anesthesia, and lower MAP change (<+6.5 mmHg) until anesthesia induction were significantly associated with intraoperative hypotension (p = 0.0104, <0.001, and <0.001, respectively).Conclusions: Intraoperative hypotension occurred more frequently in patients who underwent PDD‐TURBT than in those who underwent conv‐TURBT. Using oral 5‐ALA decreases preoperative blood pressure elevation and may be responsible for intraoperative hypotension.

Objectives: To evaluate the incidence and risk factors of a 20% decrease from new baseline (NB)-estimated glomerular filtration rate (eGFR) within 2 years after radical nephrectomy (RN) and partial nephrectomy (PN) and to examine the difference in the incidence of end-stage renal disease (ESRD) with or without the 20% decrease. Methods: This retrospective study included 238 patients undergoing RN and 369 undergoing PN for cT1a-cT3a renal cancer. The incidence of a 20% decrease from NB-eGFR within 2 years after RN/PN was examined and its potential risk factors including surgery type were assessed by multivariate logistic regression analysis. The development of ESRD was analyzed as an endpoint and its incidence was compared according to the presence or absence of the 20% decrease from NB-eGFR within 2 years. Results: Overall, the 20% decrease from NB-eGFR within 2 years was observed in 37 patients (6.1%), including 10 (4.2%) and 27 (7.3%) after RN and PN, respectively (p = 0.117). Diabetes mellitus, proteinuria, and perioperative complications were shown to be independent risk factors for the 20% decrease from NB-eGFR, while surgery type was not. During the median follow-up of 65 months, the ESRD-free survival rate at 6 years was 75.5% and 99.6% in patients with and without the 20% decrease from NB-eGFR, respectively (p < 0.001), while no significant difference was observed between patients undergoing RN and PN (98.1% and 98.7%, p = 0.561). Conclusions: Because the incidence of ESRD after the 20% decrease from NB-eGFR within 2 years was as high as 24.5% at 6 years, these patients should be followed with utmost care.