大山 雄大

INTRODUCTION: Although several clinical guidelines for prostate cancer (PC) recommend extended pelvic lymph node dissection (ePLND) during radical prostatectomy for high-risk cases, there are several issues to consider, including certain technical aspects. A simplified approach to the medial internal iliac region and paravesical arteries has not been established. The uretero-hypogastric nerve fascia (UHF) envelopes the ureter, hypogastric nerve, and pelvic autonomic nerves. To preserve the UHF, it is possible to approach the medial side of the internal iliac vessels without injuring any important tissue. We analyzed technical feasibility and lymph node (LN) yields. PATIENTS AND METHODS: After obtaining institutional review board approval, 265 high-risk PC patients with ePLND were identified. A da Vinci S or Xi robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used. We divided the patients into conventional (non-UHF) method and modified (UHF) groups. The numbers of LNs removed, procedure-related complications, and surgical outcomes were analyzed. RESULTS: The median number of LNs removed was 19.0 in the non-UHF group and 22.0 in the UHF group (p = 0.004). Significantly more LNs were removed from the internal iliac region in the UHF group (p = 0.042). There was no difference in overall operative, console, or LN dissection time, or the severe complication rate (Clavien-Dindo grade ≥ III), between the non-UHF and UHF groups. CONCLUSIONS: Our simplified approach using the UHF development technique is technically feasible, has no major complications, and allows for the removal of significantly more LNs compared with the conventional method.

INTRODUCTION: Several studies have been published on direct rectal invasion in patients with advanced metastatic prostate cancer, but few have directly confirmed intraoperative invasion of prostate cancer into the peritoneum. CASE PRESENTATION: We report the case of a 73-year-old man with prostate cancer who exhibited peritoneal invasion during robot-assisted radical prostatectomy. His prostate-specific antigen level fell to 0.38 ng/mL after surgery; he was therefore prescribed radiation and androgen-deprivation therapies that controlled the cancer for more than 1 year. CONCLUSIONS: We encountered a case showing direct peritoneal invasion of prostate cancer during robot-assisted radical prostatectomy. If invasion of the seminal vesicle is suspected, the vesicorectal fossa should be examined during robot-assisted radical prostatectomy. Preoperative confirmation by diffusion magnetic resonance imaging of the peritoneum is also useful.

INTRODUCTION: The pathophysiology of benign prostatic hyperplasia (BPH) remains incompletely understood but is likely multifactorial. Inflammation and metabolic factors may increase the risk of BPH. Several studies have evaluated the possible roles played by genetic factors. Here, we describe two cases of suspected familial BPH. CASE PRESENTATIONS: We report the cases of two brothers, aged 77 and 69 years, with giant BPH. As both exhibited urinary retention, we performed Holmium Laser Enucleation of the Prostate (HoLEP) and obtained tissue samples weighing 276 g and 153 g, respectively. The postoperative courses were good. CONCLUSION: We experienced two cases of sibling BPH with volumes exceeding 200 mL and successfully treated them with HoLEP.

INTRODUCTION: Hem-o-Lok® clips are widely used in robot-assisted radical prostatectomy because of their ease of application and secure clamping. Although there have been some reports of their migration into the urinary tract, this usually occurs a few months after robot-assisted radical prostatectomy. Late-onset cases of Hem-o-Lok® clip migration, that is, after more than 1 year, are rare. CASE PRESENTATIONS: We report three cases of delayed endourethral Hem-o-Lok® clip migration more than 2 years after robot-assisted radical prostatectomy. The Hem-o-Lok® clips were almost completely endoluminal, and were attached at one end to the vesicourethral anastomosis. We successfully removed them via transurethral surgery using a holmium laser. CONCLUSION: This case series describes late-onset Hem-o-Lok® clip migration into the bladder more than 1 year after robot-assisted radical prostatectomy. Transurethral holmium laser surgery was very effective for Hem-o-Lok® clip removal. To avoid involvement of Hem-o-Lok® clips in the vesicourethral anastomosis, appropriate resection at the time of bladder neck transection is important.