杉原 亨

OBJECTIVE: To compare nationwide outcomes of tension-free vaginal mesh surgery and laparoscopic sacrocolpopexy for the treatment of pelvic organ prolapse in Japan. METHODS: Using the Diagnosis Procedure Combination database, we collected data on female patients who underwent tension-free vaginal mesh surgery or laparoscopic sacrocolpopexy for pelvic organ prolapse from April 2014 to March 2015. We compared the proportion of perioperative adverse events, duration of anesthesia, total costs and postoperative length of stay between the groups. Univariate and multivariate analyses were carried out for age, comorbidity, mesh volume, additional concomitant surgery and hospital volume. RESULTS: We identified 3023 patients, including 2388 who underwent tension-free vaginal mesh surgery, and 635 who underwent laparoscopic sacrocolpopexy. The median age at the time of surgery was significantly higher in the tension-free vaginal mesh group (71 vs 66 years; P < 0.001). The tension-free vaginal mesh group had a higher proportion of all adverse events (7.1% vs 1.8%; P < 0.001) and a higher proportion of genitourinary complications (5.7% vs 1.1%; P < 0.001). The median duration of anesthesia was shorter in the tension-free vaginal mesh group (150 vs 286 min; P < 0.001). The total cost was significantly lower in the tension-free vaginal mesh group. CONCLUSIONS: Both procedures offer favorable results for surgical treatment of pelvic organ prolapse. Overall, the tension-free vaginal mesh procedure seems to represent a good option for high-risk women, such as elderly patients, whereas laparoscopic sacrocolpopexy is useful for younger patients with a higher level of sexual activity.

INTRODUCTION: We hypothesized that presence of plasma cell neoplasms might be a risk for thrombosis of arteriovenous fistulas (AVFs) as well as other well-known factors including age, sex, race, and presence of diabetes mellitus or certain vascular disorders. METHODS: In this single-center, retrospective study based on medical record data, we investigated the influence of plasma cell neoplasms and the above-mentioned factors on the occurrence of complete occlusive thrombosis of the AVF within 30 days after surgery for creation of the AVF. Thrombosis was defined as the absence of bruit or thrill on auscultation and palpation, throughout systole and diastole. FINDINGS: We retrospectively assessed the medical records of 91 patients with end-stage renal failure, including 8 patients with plasma cell neoplasm (5 with multiple myeloma and 3 with amyloid light-chain amyloidosis), who underwent surgical creation of an AVF at the wrist or anatomical snuff box for the first time between April 2014 and December 2016. Early thrombosis (i.e., within 30 days of surgery) occurred in 50.0% (4/8) and 10.8% (9/83) of patients with and without plasma cell neoplasm, respectively (P = 0.013). Multivariate analysis revealed that, after adjusting for baseline characteristics, plasma cell neoplasm was the only significant risk factor for early AVF thrombosis (odds ratio, 38.8; 95% confidence interval, 4.0-378.9; P = 0.0017). DISCUSSION: Considering the poor prognosis of plasma cell neoplasm and its association with higher risk for AVF thrombosis, another type of vascular access is likely to be more suitable than AVF in such patients.

To investigate the impact of the time interval (TI) between prostate biopsy and robot-assisted radical prostatectomy (RARP) on the risk of biochemical recurrence (BCR). We retrospectively reviewed the medical records of 793 consecutive patients who were treated with RARP at our institution. Patients were divided into three groups, according to TI, to compare BCR-free survival (BCRFS) rates: Group 1 (n = 196), TI &lt; 3 months; Group 2 (n = 513), 3 &lt;= TI &lt; 6 months; Group 3 (n = 84), TI &gt;= 6 months. Eighty-three patients with TI &gt;= 6 months were matched with an equal number of patients with TI &lt; 6 months based on propensity scores by using four preoperative factors: prostate-specific antigen (PSA), primary (pGS) and secondary (sGS) Gleason score and positive prostate biopsy. The 5-year BCRFS rates for TI Groups 1, 2, and 3 were 76%, 80.7% and 82.6% (P = 0.99), respectively. The multivariate analysis revealed that PSA, pGS, sGS and a positive prostate biopsy were independent preoperative risk factors for BCR. The propensity adjusted 5-year BCRFS for patients with TI &gt;= 6 months was 84.0%. This was not worse than that of patients with TI &lt; 6 months (71.0%, P = 0.18). In our cohorts, a delay in the time from biopsy to RARP did not significantly affect recurrence. Therefore, hasty treatment decisions are unnecessary for at least 6 months after diagnosis of early prostate cancer.

ObjectivesTo investigate predictors of continence outcomes after robot-assisted radical prostatectomy. MethodsClinical records of 272 patients who underwent robot-assisted radical prostatectomy were investigated. Preoperative Overactive Bladder Symptom Score, International Prostate Symptom Score and clinicopathological factors were investigated, and relationships between factors and recovery of continence after robot-assisted radical prostatectomy were assessed. The presence of overactive bladder was defined as having urgency for more than once a week and having 3 points according to the Overactive Bladder Symptom Score. ResultsAge (66 years) was significantly associated with continence within 6 months after robot-assisted radical prostatectomy (P = 0.033). The absence of overactive bladder and lower Overactive Bladder Symptom Score (&lt;3) were significantly associated with recovery of continence within 12 months after surgery (both variables P = 0.009). In terms of achieving recovery of continence after robot-assisted radical prostatectomy, Kaplan-Meier curves showed earlier recovery in age 66 years, prostate weight 40 g and overactive bladder symptom score &lt;3 (P = 0.0072, 0.0172 and 0.0140, respectively). Multivariate analysis showed that the presence of overactive bladder was an independent negative predictor for recovery of continence within 12 months after surgery (P = 0.019). ConclusionsThe presence of baseline overactive bladder seems to represent an independent negative predictor for recovery of continence at 12 months after robot-assisted radical prostatectomy.

To examine how surgical robot emergence affects prostate-cancer patient behavior in seeking radical prostatectomy focusing on geographical accessibility. In Japan, robotic surgery was approved in April 2012. Based on data in the Japanese Diagnosis Procedure Combination database between April 2012 and March 2014, distance to nearest surgical robot and interval days to radical prostatectomy (divided by mean interval in 2011: % interval days to radical prostatectomy) were calculated for individual radical prostatectomy cases at non-robotic hospitals. Caseload changes regarding distance to nearest surgical robot and robot introduction were investigated. Change in % interval days to radical prostatectomy was evaluated by multivariate analysis including distance to nearest surgical robot, age, comorbidity, hospital volume, operation type, hospital academic status, bed volume and temporal progress. % Interval days to radical prostatectomy became wider for distance to nearest surgical robot &lt; 30 km. When a surgical robot emerged within 30 and 10 km, the prostatectomy caseload in non-robot hospitals reduced by 13 and 18% within 6 months, respectively, while the robot hospitals gained +101% caseload (P &lt; 0.01 for all) Multivariate analyses including 9759 open and 5052 non-robotic minimally invasive radical prostatectomies in 483 non-robot hospitals revealed a significant inverse association between distance to nearest surgical robot and % interval days to radical prostatectomy (B = -17.3% for distance to nearest surgical robot a parts per thousand&lt;yen&gt;30 km and -11.7% for 10-30 km versus distance to nearest surgical robot &lt; 10 km), while younger age, high-volume hospital, open-prostatectomy provider and temporal progress were other significant factors related to % interval days to radical prostatectomy widening (P &lt; 0.05 for all). Robotic surgery accessibility within 30 km would make patients less likely select conventional surgery. The nearer a robot was, the faster the caseload reduction was.

Background: The pathological and oncological outcomes of retro-pubic radical prostatectomy (RRP) and robot-assisted radical prostatectomy (RARP) have not been sufficiently investigated. Methods: Treatment-naive patients with localized prostate cancer (PC) (n = 908; RRP, n = 490; and RARP, n = 418) were enrolled in the study. The clinicopathological outcomes, rate and localization of the positive surgical margin (PSM), localization of PSM, and biochemical recurrence (BCR)-free survival groups were compared between RRP and RARP. Results: The median patient age and serum PSA level (ng/mL) at diagnosis were 67 years and 7.9 ng/ml, respectively, for RRP, and 67 years and 7.6 ng/ml, respectively, for RARP. The overall PSM rate with RARP was 21%, which was 11% for pT2a, 12% for pT2b, 9.8% for pT2c, 43% for pT3a, 55% for pT3b, and 0% for pT4. The overall PSM rate with RRP was 44%, which was 12% for pT2a, 18% for pT2b, 43% for pT2c, 78% for pT3a, 50% for pT3b, and 40% for pT4. The PSM rate was significantly lower for RARP in men with pT2c and pT3a (p &lt; 0.0001 for both). Multivariate analysis showed that RARP reduced the risk of BCR (hazard ratio; 0.6, p = 0.009). Conclusions: RARP versus RRP is associated with an improved PSM rate and BCR. To examine the cancer-specific survival, further investigations are needed.

An 87-year-old man undergoing radical cystectomy and bilateral nephrostomy visited our hospital 19 days postoperatively because of a lack of urine flow from the left 14-Fr Malecot nephrostomy catheter. The catheter was apparently firmly anchored to the kidney, and an attempt to reposition the catheter failed. Three-dimensional computed tomography volume rendering indicated a deformity of the left catheter compared with the right, implying that something was lodged in the Malecot flanges. Surgical removal of the catheter 2 days later revealed granulation tissue overbridging the Malecot wings. We cut the tissue, and the catheter was successfully exchanged.

Background: Robot-assisted radical prostatectomy (RARP) has now become a gold standard approach in radical prostatectomy. The aim of this study was to investigate incidence and risk factors of inguinal hernia (IH) after RARP. Methods: This study included 307 consecutive men who underwent RARP for the treatment of prostate cancer from January 2011 to August 2015. The incidence of IH after RARP was investigated. Clinical and pathological factors were also investigated to assess relationship with development of postoperative IH. Results: Median follow-ups were 380 days, and median age of patients was 67 years. Incidence of IH was 11.3, 14.0, and 15.4% at 1, 2, and 3 years after RARP, respectively. Postoperative IH occurrence was significantly associated with low surgeon experience and postoperative incontinence at 3 or 6 months after surgery (P = 0.019, P = 0.002, and P = 0.016, respectively). Conclusions: Most of the IH occurred within the first 2 years with a rate of 14%. Incidence of IH after RARP was significantly associated with surgical experience and incontinence outcomes.

We analyzed 112 patients with castration-resistant prostate cancer (CRPC) treated with docetaxel-based chemotherapy to identify risk factors for severe neutropenia (SN) in the first cycle of chemotherapy. Age and baseline neutrophil counts were significant independent risk factors. Based on the risk factors, we developed a nomogram for predicting SN in the first cycle of docetaxel-based chemotherapy for patients with CRPC. Background: Neutropenia is a major adverse event of docetaxel-based chemotherapy. The present study was undertaken to evaluate the incidence of neutropenia and to develop a nomogram for predicting Grade 4 neutropenia during the first cycle of docetaxel-based chemotherapy in patients with castration-resistant prostate cancer (CRPC). Patients and Methods: This study included 112 patients with CRPC treated with docetaxel-based systemic chemotherapy. We evaluated the incidence and risk factors for Grade 4 neutropenia in the first cycle of chemotherapy. Results: Sixty-two of 112 patients (55.4%) developed Grade 4 neutropenia in the first cycle of docetaxel-based chemotherapy. There were significant differences in age, baseline white blood cell count, and baseline neutrophil count between patients with non-Grade 4 neutropenia and those with Grade 4 neutropenia in univariate analyses. The serum prostate-specific antigen level, hemoglobin level, creatinine, albumin, Eastern Cooperative Oncology Group performance status, metastatic sites, extent of disease, and history of external beam radiotherapy to the prostate were not significantly different between the 2 groups. Multivariate logistic regression analysis showed that age (odds ratio [OR], 1.08; P = .019) and baseline neutrophil counts (OR, 0.79; P =.045) were significant independent risk factors for severe neutropenia. A nomogram and a calibration plot on the basis of these results were developed from a multivariate logistic regression analysis to predict the probability of Grade 4 neutropenia. Conclusion: Age and baseline neutrophil counts were significant independent risk factors for Grade 4 neutropenia. The nomogram to predict it provides useful information for the management of patients with CRPC treated with docetaxel chemotherapy.

Purpose. To investigate the prognostic significance of sarcopenia on long-term outcomes in patients with bladder cancer after radical cystectomy (RC). Methods. We retrospectively reviewed 136 patients undergoing RC for urothelial carcinoma at our institution. Prognostic impact of the preoperative clinical, laboratory, and radiologic parameters were evaluated by Cox proportional hazard model analyses, and a nomogram was developed to predict cancer-specific survival (CSS) after RC. Results. Themean follow-up was 46.7 months. Patients with sarcopenia had a significantly shorter CSS than those without sarcopenia. On univariate Cox analysis, clinical T stage, histology of transurethral resection of bladder tumor (TURBT) specimen, pretreatment hemoglobin, pretreatment neutrophil-to-lymphocyte ratio (NLR), pretreatment serum C-reactive protein level, pretreatment serum albumin level, presence of hydronephrosis, and presence of sarcopenia were associated with significantly worse CSS. On multivariate Cox stepwise analysis, sarcopenia (hazard rate [HR] = 2.3, p = 0.015), clinical T stage (cT4: HR = 5.3; p = 0.0096), presence of hydronephrosis (HR = 2.0; p = 0.033), histology ofTURBT specimen (HR = 2.2, p = 0.044), and NLR (HR = 1.3; p = 0.0048) were significant independent predictors of an unfavorable prognosis Based on the results of the multivariate analysis, we developed a nomogram to predict 1-, 3-, and 5-year CSS after RC. Conclusions. Sarcopenia, clinical T stage, presence of hydronephrosis, histology of TURBT specimen, and NLR are novel preoperative prognostic factors even after adjustment for other known preoperative predictors in patients undergoing RC for bladder cancer.

Background: Prognostic value of immune cells is not clear in testicular germ cell tumors (TGCTs). We aimed to investigate the prognostic value of tumor-infiltrating neutrophils in TGCTs. Methods: A total of 102 patients who underwent orchiectomy for TGCT were investigated for CD66b positive tumor-infiltrating neutrophils (CD66b + TINs). Immmunostaining for CD66b was performed in 102 sections as described. Clinicopathological parameters as well as cancer specific survival and overall survival were assessed for correlation with CD66b + TIN density. Results: High density group was significantly correlated with tumor diameter = 10 cm, presence of nodal/ distant metastasis, S stage, diagnosis of nonseminomatous germ cell tumor (NGCT), and presence of venous invasion (p = 0.0198, p &lt; 0.0001, p = 0.0275, p = 0.0004, and p = 0.0287, respectively). It was also significantly associated with cancer-specific and overall survival (logrank p = 0.0036, and p = 0.0002, respectively). Multivariate analysis showed that increased CD66b + TIN was an independent prognostic factor for overall survival (p = 0.0095). Conclusions: Increased CD66b + TIN was significantly associated with presence of metastasis, S stage, and nonseminomatous germ cell tumor diagnosis. It was also an independent prognostic factor of overall survival in patients with TGCT.

Primary small-cell carcinoma arising from the bladder (SmCCB) is uncommon. It differs from urothelial carcinoma (UC), the most common type of bladder cancer, with respect to its cell of origin, biology, and prognosis. Biologically, prostatic SmCCB is much more aggressive than UC, and the prognosis for cases with distant metastasis is especially poor. We report here a case of primary SmCCB (cT3bN1M0) treated with radical cystectomy.

Purpose: To compare the perioperative outcomes and costs between open and laparoscopic nephroureterectomy for malignant diseases on a contemporary population-based level. Patients and Methods: Based on the Japanese Diagnosis Procedure Combination database for 2010 to 2012, we compared six end points of in-hospital mortality, intraoperative and postoperative complications, transfusion, anesthesia time, postoperative length of stay, and costs between open and laparoscopic nephroureterectomy under one-to-one matching based on the propensity scores. Multivariate analyses included sex, age, Charlson comorbidity index, body mass index, oncologic stage, hospital volume, and hospital academic status. Missing values were filled in by five-copy multiple imputations. Results: Among 3595 open and 3349 laparoscopic nephroureterectomies, an average of 2902 matched pairs were generated by the imputation and matching process. The outcomes showing significantly favorable association with the laparoscopic approach over the open approach were in-hospital mortality (0.3% vs 0.7%; odds ratio [OR], 0.41 [95% confidence interval, CI, 0.17 to 0.99]), postoperative complications (9.4% vs 12.6%; OR, 0.73 [0.58 to 0.91]), transfusion (12.9% vs 20.6%; OR, 0.54 [0.46 to 0.64]), postoperative length of stay (median, 11 vs 12 days; Beta, -0.041 [-0.059 to -0.023]), and costs without the operating room (median, $6607 vs $7077; Beta, -0.030 [-0.048 to -0.013]), while significantly longer anesthesia time (median, 278 vs 245min; Beta, 0.057 [0.041 to 0.074]) and higher total costs (median, $15691 vs $12846; Beta, 0.078 [0.068 to 0.088]) for laparoscopic than for open nephroureterectomies were noted. There was no difference in intraoperative complications (P=0.774). Conclusion: Several favorable perioperative outcomes including low mortality were observed in laparoscopic nephroureterectomy compared with open nephroureterectomy.

ObjectiveTo characterize nocturia in men based on frequency volume chart data and symptom profiles assessed using the Core Lower Urinary Tract Symptom Score and Athens Insomnia Scale questionnaires. MethodsThe Core Lower Urinary Tract Symptom Score and Athens Insomnia Scale questionnaires were administered to 299 consecutive treatment naive men with nocturia (one time per night). Frequency volume chart data were recorded for 2days. Correlations between nocturia and clinical characteristics including symptom scores, clinical diagnosis, Charlson Comorbidity Index, estimated glomerular filtration rate, uroflowmetry and prostate volume were analyzed. ResultsPatients were divided into five groups: one time (n=36), two times (n=65), three times (n=85), four times (n=78) and five times (n=34) of nocturia. Age, prevalence or severity of chronic kidney disease, hyperlipidemia, low bladder capacity, nocturnal polyuria, urgency, bladder pain and sleep disorders were significantly correlated with the severity of nocturia. The Spearman correlation analysis identified eight possible independent factors for nocturia: age, estimated glomerular filtration rate, urgency, bladder pain, sleep quality, sleepiness during the day, average voided volume and nocturnal volume divided by body weight. Logistic regression analysis showed that nocturnal volume divided by body weight was the strongest factor of nocturia, and 7, 9 and 9.7mL/kg were practical cut-off values of three, four and five times per night of nocturia, respectively. ConclusionsNocturia in men is a chaotic condition dominated by nocturnal polyuria, and related to multiple factors including age, renal function, urgency, bladder pain, insomnia and bladder volume.

Little is known about the disparity of choices between three urinary diversions after radical cystectomy, focusing on patient and institutional factors. We identified urothelial carcinoma patients who received radical cystectomy with cutaneous ureterostomy, ileal conduit or continent reservoir using the Japanese Diagnosis Procedure Combination database from 2007 to 2012. Data comprised age, sex, comorbidities (converted into the Charlson index), TNM classification (converted into oncological stage), hospitals' academic status, hospital volume, bed volume and geographical region. Multivariate ordinal logistic regression analyses fitted with the proportional odds model were performed to analyze factors affecting urinary diversion choices. For dependent variables, the three diversions were converted into an ordinal variable in order of complexity: cutaneous ureterostomy (reference), ileal conduit and continent reservoir. Geographical variations were also examined by multivariate logistic regression models. A total of 4790 patients (1131 cutaneous ureterostomies [23.6 %], 2970 ileal conduits [62.0 %] and 689 continent reservoirs [14.4 %]) were included. Ordinal logistic regression analyses showed that male sex, lower age, lower Charlson index, early tumor stage, higher hospital volume (a parts per thousand yen3.4 cases/year) and larger bed volume (a parts per thousand yen450 beds) were significantly associated with the preference of more complex urinary diversion. Significant geographical disparity was also found. Good patient condition and early oncological status, as well as institutional factors, including high hospital volume, large bed volume and specific geographical regions, are independently related to the likelihood of choosing complex diversions. Recognizing this disparity would help reinforce the need for clinical practice uniformity.

To investigate survival of hormone-na &lt; ve prostate cancer patients diagnosed with prostate-specific antigen a parts per thousand yen500 ng/ml, stratified according to the prostate-specific antigen level and type of therapy. Data of prostate cancer patients with prostate-specific antigen a parts per thousand yen500 ng/ml diagnosed between 2001 and 2003 and receiving primary androgen deprivation therapy were extracted from the Japan Study Group of Prostate Cancer database. Cancer-specific survival and overall survival were assessed according to the prostate-specific antigen level (500-999, 1000-4999 and a parts per thousand yen5000 ng/ml) and type of therapy using Kaplan-Meier analyses and multivariate Cox proportional hazards models including age, Gleason score, oncological stage and comorbidity. The median follow-up was 27 months (interquartile range, 13-51) and a total of 1961 patients were included. Five-year cancer-specific and overall mortalities were 39.0 and 33.0%, respectively. There was a significant inverse relationship between overall survival and prostate-specific antigen magnitude among combination therapy patients, but not monotherapy patients (log-rank test, P = 0.034 and 0.558, respectively). The median overall survival in combination therapy patients with low-, intermediate- and high prostate-specific antigen and monotherapy patients with any prostate-specific antigen were 79, 59, 45 and 43 months, respectively. Multivariate analysis showed that combination therapy in patients with low- and intermediate prostate-specific antigen was significantly associated with a favorable overall survival compared with monotherapy (hazard ratios 0.66 and 0.75, respectively, both P &lt; 0.001). Similar results were obtained for cancer-specific survival. There are major survival differences in extremely high prostate-specific antigen cases according to the prostate-specific antigen level and hormone therapy type and those patients would benefit notably from combination androgen blockade.

Purpose: In this study we used nationwide population based data to compare perioperative outcomes, including severe bladder injury, between monopolar and bipolar transurethral resection of bladder tumors. Materials and Methods: Data of patients with clinical T2 or less bladder cancer who underwent monopolar or bipolar transurethral bladder tumor resection were collected from 788 hospitals in the Japanese Diagnosis Procedure Combination database 2007-2012. One-to-one propensity score matching was performed. End points assessed were severe bladder injury requiring placement of a drainage tube or repair surgery within 3 postoperative days, hemostasis procedures consisting of clot removal or transurethral coagulation within 3 postoperative days, transfusion, other complications, anesthesia duration, postoperative length of stay and total costs. Multivariate analyses compared outcomes of bipolar and monopolar transurethral bladder tumor resection with gender, age, Charlson comorbidity index, clinical stage, hospital volume and hospital academic status as covariates. Results: A total of 8,188 pairs were generated. Compared with monopolar transurethral bladder tumor resection, bipolar resection was associated with a significantly lower incidence of severe bladder injury (0.3% vs 0.6%, OR 0.57), other complications (4.6% vs 5.8%, OR 0.78), slightly shorter postoperative stay (mean 6.4 vs 6.7 days, difference -3.3%) and slightly lower total costs (mean $4,628 vs $4,727; difference -1.1%, all p &lt; 0.05). There were no differences in postoperative hemostasis procedures, transfusion and anesthesia duration. Conclusions: Bipolar transurethral bladder tumor resection was associated with a substantially lower incidence of several perioperative complications including severe bladder injury. The findings support the benefit of bipolar transurethral bladder tumor resection over monopolar resection in real-world clinical practice.

ObjectivesTo elucidate the differences in clinical practice between the USA and Japan in major types of uro-oncological surgery by a head-to-head comparison of national databases in the two countries. MethodsWe compared variations in surgical modality, length of stay, total charges, caseload centralization, transfusion incidence, and in-hospital mortality between the two countries for four major types of uro-oncological surgery (radical prostatectomy, radical cystectomy, nephrectomy and nephroureterectomy) in 2011. Additionally, the chronological changes in surgical modalities were investigated for 2009-11. The national estimates were based on data from the Japanese Diagnosis Procedure Combination database and the US National Inpatient Sample. ResultsFor radical prostatectomy, radical cystectomy, nephrectomy and nephroureterectomy, minimally-invasive surgery accounted for 24.2% versus 70.2%, 0% versus 14.0%, 50.7% versus 30.7% and 50.2% versus 30.5%, respectively, in Japan versus the USA in 2011. Although minimally-invasive surgery has become increasingly frequent in both countries, the major procedures were robot-assisted surgery in the USA and laparoscopic surgery in Japan. The USA was generally characterized by a slightly younger age at operation, far higher hospital volume, a shorter length of stay, higher charges and less use of transfusion than Japan. ConclusionsThe findings suggest substantial differences between the USA and Japan regarding clinical practices in uro-oncological surgery. Standing at the beginning of robotic surgery era in Japan, the precise recognition of these differences will aid a proper understanding of clinical practices.

In 2012, Japanese national insurance started covering robot-assisted surgery. We carried out a population-based comparison between robot-assisted and three other types of radical prostatectomy to evaluate the safety of robot-assisted prostatectomy during its initial year. We abstracted data for 7202 open, 2483 laparoscopic, 1181 minimal incision endoscopic, and 2126 robot-assisted radical prostatectomies for oncological stage T3 or less from the Diagnosis Procedure Combination database (April 2012-March 2013). Complication rate, transfusion rate, anesthesia time, postoperative length of stay, and cost were evaluated by pairwise one-to-one propensity-score matching and multivariable analyses with covariants of age, comorbidity, oncological stage, hospital volume, and hospital academic status. The proportion of robot-assisted radical prostatectomies dramatically increased from 8.6% to 24.1% during the first year. Compared with open, laparoscopic, and minimal incision endoscopic surgery, robot-assisted surgery was generally associated with a significantly lower complication rate (odds ratios, 0.25, 0.20, 0.33, respectively), autologous transfusion rate (0.04, 0.31, 0.10), homologous transfusion rate (0.16, 0.48, 0.14), lower cost excluding operation (differences, -5.1%, -1.8% [not significant], -10.8%) and shorter postoperative length of stay (-9.1%, +0.9% [not significant], -18.5%, respectively). However, robot-assisted surgery also resulted in a+42.6% increase in anesthesia time and +52.4% increase in total cost compared with open surgery (all P&lt;0.05). Introduction of robotic surgery led to a dynamic change in prostate cancer surgery. Even in its initial year, robot-assisted radical prostatectomy was carried out with several favorable safety aspects compared to the conventional surgeries despite its having the longest anesthesia time and the highest cost.

Purpose: Genes of androgen and estrogen signaling cells and stem cell-like cells play crucial roles in prostate cancer. This study aimed to predict clinical failure by identifying these prostate cancer-related genes. Experimental Design: We developed models to predict clinical failure using biopsy samples from a training set of 46 and an independent validation set of 30 patients with treatment-naive prostate cancer with bone metastasis. Cancerous and stromal tissues were separately collected by laser-captured microdissection. We analyzed the association between clinical failure andmRNAexpression of the following genes androgen receptor (AR) and its related genes (APP, FOX family, TRIM 36, Oct1, and ACSL 3), stem cell-like molecules (Klf4, c-Myc, Oct 3/4, and Sox2), estrogen receptor (ER), Her2, PSA, and CRP. Results: Logistic analyses to predict prostate-specific antigen (PSA) recurrence showed an area under the curve (AUC) of 1.0 in both sets for Sox2, Her2, and CRP expression in cancer cells, AR and ERa expression in stromal cells, and clinical parameters. We identified 10 prognostic factors for cancer-specific survival (CSS): Oct1, TRIM36, Sox2, and c-Myc expression in cancer cells; AR, Klf4, and ERa expression in stromal cells; and PSA, Gleason score, and extent of disease. Onthe basis of these factors, patients were divided into favorable-, intermediate-, and poor-risk groups according to the number of factors present. Five-year CSS rates for the 3 groups were 90%, 32%, and12% in the training set and 75%, 48%, and0% in the validation set, respectively. Conclusions: Expression levels of androgen-and estrogen signaling components and stem cell markers are powerful prognostic tools. (C) 2014 AACR.

Objectives: To investigate the perioperative outcomes of cytoreductive nephrectomy according to clinical T stage, and to analyze factors affecting these outcomes. Methods: The Japanese Diagnosis Procedure Combination database from 2007 to 2012 was used to evaluate perioperative outcomes including in-hospital mortality, complications, blood transfusion, anesthesia time, postoperative length of stay and total cost in patients who underwent cytoreductive nephrectomy for metastatic renal cell carcinoma, according to clinical T stage. Multivariable regression analyses including sex, age, clinical N stage, hospital volume, type of hospital, Charlson Comorbidity Index and clinical T stage were carried out to identify outcome predictors. Results: The present study enrolled 1074 patients including 270 with T1, 215 with T2, 479 with T3 and 110 with T4. Age, sex and Charlson Comorbidity Index were not significantly different among the four stages. A low clinical T stage was associated with minimally-invasive surgery (P &lt; 0.001). The blood transfusion rate, anesthesia time, postoperative length of stay and total cost increased significantly with increasing clinical T stage (all P &lt; 0.001). Multivariable regression analyses showed that increasing clinical T stage was significantly associated with unfavorable perioperative outcomes except in-hospital mortality (T4/T1: postoperative complications OR 2.34; blood transfusion OR 5.27; anesthesia time + 14%; postoperative length of stay + 13.2%; total cost + 13.4%; all P &lt; 0.05). Clinical N stage was the only significant predictive factor for in-hospital mortality (N1/N0: OR 3.34, P = 0.004; N2/N0: OR 3.48, P = 0.008). Conclusions: Clinical T stage is significantly associated with perioperative outcomes, other than in-hospital mortality, in patients with metastatic renal call carcinoma undergoing cytoreductive nephrectomy. Clinical N stage is significantly associated with in-hospital mortality.

Objective To evaluate whether mechanical bowel preparation before radical prostatectomy ameliorates damage from rectal injury in radical prostatectomy. Methods Among 35099 radical prostatectomy cases in the Japanese Diagnosis Procedure Combination database 2007-2012, those where a rectal injury occurred were stratified into a preoperative mechanical bowel preparation group (polyethylene glycol electrolyte, magnesium citrate solution and sodium picosulfate) and a non-mechanical bowel preparation group. The associations between mechanical bowel preparation and rectal injury were evaluated by multivariate regression analysis for: (i) subsequent infectious complications; (ii) requirement of delayed colostomy formation after primary closure; (iii) postoperative length of stay; and (iv) total costs. Covariates were age, surgical approach, Charlson Comorbidity Index, T and N category, hospital volume, hospital academic status, and colostomy formation. Results Overall, 151 rectal injury cases (0.43%) were identified. Of those, 73 patients (48%) received mechanical bowel preparation. Multivariate analyses showed that all four outcomes were not statistically different between mechanical bowel preparation and non-mechanical bowel preparation groups (infectious complication rate: 12% vs 10%, P=0.80; delayed colostomy rate: 21% vs 31%, P=0.34; length of stay: 28 vs 30 days, P=0.84; and total costs: $24665 vs $23837, P=0.81). Conclusion Our analysis did not detect a beneficial impact of mechanical bowel preparation on perioperative morbidity associated with rectal injury during radical prostatectomy. This finding suggests that mechanical bowel preparation might be safely omitted before radical prostatectomy.

Idiopathic scrotal calcinosis is a rare, benign condition characterized by progressive calcification of the scrotal skin. A 29-year-old man who had undergone primary surgical excision of idiopathic scrotal calcinosis 7 years previously presented with recurrence that he had first noticed 3 years after surgery. Multiple yellowish nodules were observed in the scrotal skin and were confirmed by computed tomography. He underwent repeat resection without any postoperative complications. Histological examination of the surgical specimens revealed diffusely calcified areas within and beneath the squannous epithelium, some of which were associated with epithelial cysts. Immunopathological stains for antibodies against carcinoembryonic antigen, epithelial membrane antigen, and gross cystic disease fluid protein-15 were negative. This is the first reported case of recurrence of scrotal calcinosis. One possible reason for the relapse is that there were remnant seeds of calcification after the primary surgery. This case demonstrates the importance of careful identification and resection of all calcified areas, and of counseling patients about the possibility of relapse after surgical treatment. Copyright (C) 2013 S. Karger AG, Basel

BACKGROUND: Despite increasing interest in minimally invasive surgery, prevalence data are completely absent. Our objective was to analyze clinico-epidemiological variations of surgery for renal malignancy in Japan with emphasis on annual trends and regional gaps, and to analyze factors affecting choice of open versus minimally invasive surgery. METHODS: We identified patients who underwent open (n = 8646), laparoscopic (n = 5932), or minimum incision endoscopic surgery (MIES) (n = 381) nephrectomy for renal malignancy, using the Japanese Diagnosis Procedure Combination database, 2007-2010. Clinical and regional variations in these three approaches were determined, and the annual per-population incidence of nephrectomy was estimated. Multivariate logistic regression was used to analyze factors affecting choice of minimally invasive surgery (laparoscopy or MIES). RESULTS: The proportion of open nephrectomy decreased from 65.3 % in 2007 to 51.6 % in 2010. Laparoscopic nephrectomy accounted for 51.0 % of procedures for T1 tumors. The estimated incidence of nephrectomy in males and females was 14.3 and 6.1 per 100,000 person-years, respectively. Multivariate analysis showed that minimally invasive nephrectomy was more likely to be selected for patients in their 30-50s who had less comorbidity, better performance status, or lower TNM stage, in high-volume or academic hospitals, especially in western Japan. Hemodialysis use was a favorable factor. CONCLUSION: Despite differences between eastern and western Japan, minimally invasive surgery is becoming widespread throughout Japan, especially for patients with low operative risks and early-stage cancer who are hospitalized in high-volume institutes.

ObjectivesTo evaluate risk factors of severe adverse events after percutaneous nephrolithotomy with an emphasis on operation time, and to develop a nomogram for predicting them. MethodsThis was an observational retrospective study including 1511 patients who underwent percutaneous nephrolithotomy in 332 hospitals identified from the Japanese Diagnosis Procedure Combination database between 2007 and 2010. Severe adverse events were defined as follows: (i) in-hospital mortality; (ii) postoperative medications including catecholamine, gamma-globulin products, protease inhibitors and medications for disseminated intravascular coagulation; and (iii) postoperative interventions including central vein catheterization, dialysis and mechanical cardiopulmonary support. Univariate and multivariate logistic regression analyses were carried out for the occurrence of severe adverse events, and a nomogram was generated from this model. ResultsOverall, 126 severe adverse events (8.34%) were identified. In the multivariate model, a linear trend between severe adverse events and operation time was observed (OR 4.72 for 120-179min to 17.95 for 300min compared with 119min; each P&lt;0.05) after adjustment for sex, age, Charlson Comorbidity Index and type of admission. Female sex and emergency admission were also significant risk factors (OR 1.92 and 2.04, respectively), and hospital volume did not reach statistical significance. The nomogram based on these results was well fitted to predict a probability between 0.05 and 0.40 (concordance index 0.696). ConclusionsLonger operation time is a significant and independent risk factor for severe adverse events after percutaneous nephrolithotomy. Our nomogram can be an effective tool for predicting postoperative complications.

A newly developed genetic risk score derived from studies of several single nucleotide polymorphisms has the potential to improve the prediction of prostate cancer detection on biopsy for men with PSA levels of 1-3 ng/ml. Understanding the score's characteristic differences from biomarkers is important in order to utilize it correctly.

Differences in effectiveness between haloperidol injection and oral atypical antipsychotics in the acute-phase treatment of schizophrenia are not well examined. We retrospectively investigated whether these treatment options affected the length of mechanical restraint. We used the Japanese Diagnosis Procedure Combination Database to identify schizophrenia patients who were involuntarily hospitalized and receiving mechanical restraint between July and December, 2006-2009. Data included patient demographics, use of antipsychotics, and number of days on which patients underwent mechanical restraint. Propensity score matching was performed to compare the number of days of mechanical restraint between the haloperidol injection group and the oral atypical antipsychotics group. We used survival analysis to examine whether the initial difference in treatment affected the number of days of mechanical restraint. Cox regression was performed to compare the concurrent effects of various factors. Among 1731 eligible patients, 574 were treated with haloperidol injections and 420 with atypical antipsychotics. Matching produced 274 patients in each group. Cox regression analysis showed that the initial therapeutic agents did not significantly affect the number of days of mechanical restraint. The results indicate that atypical antipsychotics were as effective as haloperidol injections in the acute-phase treatment of schizophrenia. (C) 2013 Elsevier Ireland Ltd. All rights reserved.

Objectives: To reveal individual, institutional and regional factors affecting selection of minimally invasive nephroureterectomy in Japan. Methods: The Japanese Diagnosis Procedure Combination database was queried to retrieve cases of nephroureterectomy for pelvic or ureter malignancies carried out between 2007 and 2010. A multivariate logistic regression analysis with variables including age, sex, pre-existing comorbidities, tumor location, tumor-nodes-metastasis classification, academic status of hospitals, hospital volume, geographic region and year of surgery was modeled to evaluate predictors of carrying out a minimally invasive (including laparoscopic and minimum incision endoscopic) nephroureterectomy. Results: Overall, 3863 open (58.2%), 2635 laparoscopic (39.7%) and 139 minimum incision endoscopic nephroureterectomy (2.1%) cases from 713 hospitals were identified. The proportion of minimally invasive procedures increased from 35.7% to 48.6%. Minimally invasive nephroureterectomy was the most frequently carried out in the Kinki and Chugoku regions (50.9% and 50.4%, respectively) compared with the least in the Kanto region (31.3%). Multivariate analysis showed that lower Charlson Comorbidity Index, lower tumor-nodes-metastasis stage, academic hospitals, higher operative volume centers, western regions of Japan and later year were independently associated with the use of minimally invasive nephroureterectomy. Age, sex and tumor location were not significant factors. Conclusions: Despite regional and institutional variations, the proportion of minimally invasive nephroureterectomy has gradually increased in Japan. Minimally invasive nephroureterectomy is more likely to be carried out in patients with low tumor stage and low risk at higher volume academic hospitals. Our findings provide fundamental data for future health policies to foster nationwide healthcare uniformity.

What's known on the subject? and What does the study add? Recently, the ineffectiveness of bowel mechanical preparation prior to colorectal surgery was focused on. Although its effectiveness was widely accepted in laparoscopic prostatectomy, the data were limited. This retrospective multicentre study compared laparoscopic prostatectomy cases with and without bowel preparation and did not demonstrate the preparation's preferable effect in operation time and complication incidence, which suggested justification of the omission of bowel preparation. Objective To evaluate the effect of mechanical bowel preparation (MBP) prior to laparoscopic radical prostatectomy on peri-operative outcomes. Patients and Methods Patients undergoing laparoscopic radical prostatectomy for T1-T2 tumours between 2008 and 2010 were identified in the Japanese Diagnosis Procedure Combination database. Patients were classified into a preoperative MBP group and a non-MBP group. The effects of MBP were evaluated by multivariate regression analysis of overall complication rate, operation time, postoperative length of stay (PLOS) and total costs with generalized estimating equations adjustment involving age, body mass index, Charlson score, hospital academic status and hospital volume. Results Comparing the 154 non-MBP and 580 MBP patients, overall complication rate, operation time, PLOS and total costs were 6.5% vs 6.9% (P = 0.860), 222 vs 250min (P = 0.001), 11 vs 10 days (P &lt; 0.001) and 18941 vs 19015 US dollars (P = 0.032), respectively. In the multivariate analyses, no significant differences were observed for the four outcomes (P = 0.961, 0.194, 0.383 and 0.993, respectively). Complications were more frequently observed in older patients, and operation time tended to be longer in patients with higher body mass index and in hospitals with lower volumes. Longer PLOS and higher total costs were associated with older age, higher Charlson score and lower hospital volume. Conclusions We could not find any superiority of MBP on overall complications, operation time, PLOS and total costs in laparoscopic radical prostatectomy. The results support that MBP can be omitted prior to laparoscopic radical prostatectomy for T1-T2 prostate cancer.

We compared perioperative outcomes and costs between open and laparoscopic radical prostatectomy for prostate cancer. The Japanese Diagnosis Procedure Combination database, including cases from 2007 to 2010, was used by one-to-one propensity-score matching. The following items were compared: complication rate; homologous and autologous transfusion rate; first cystography day and cystography repeat rate; anesthesia time; postoperative length of stay; and costs. Multivariate analyses were carried out by including age, Charlson Comorbidity Index, T stage, hospital volume and hospital academic status as variables. As a result, among 15616 open and 1997 laparoscopic radical prostatectomies, 1627 propensity-score matched pairs were generated. The laparoscopic approach showed a better overall complication rate (3.4% vs 5.0%), homologous transfusion rate (3.3% vs 9.2%), autologous transfusion rate (44.9% vs 79.3%), first cystography day (mean 6th vs 7th day), mean postoperative length of stay (mean 11 vs 13 days), and cost without surgery and anesthesia (mean $7965 vs $9235; all P&lt;0.001). Anesthesia time was longer (mean 345 vs 285min) and total cost was higher (mean $14980 vs $12356) for the laparoscopic approach (both P&lt;0.001). The secondary cystography rates were comparable between the groups (18.3% vs 15.7%, P=0.144). The multivariate analyses showed similar trends. In conclusion, these findings confirm several benefits of laparoscopy over open approach for radical prostatectomy.

OBJECTIVE To assess the effect of mechanical bowel preparation (MBP) before laparoscopic nephrectomy in terms of operation time and perioperative complications. MATERIALS AND METHODS Patients undergoing laparoscopic nephrectomy for T1-T3 tumors were identified in the Japanese Diagnosis Procedure Combination database from 2008 to 2010. The patients were stratified into a preoperative MBP group (polyethylene glycol electrolyte, magnesium citrate solution, and sodium picosulfate) and a non-MBP group and were matched using one-to-one propensity score matching according to age, sex, Charlson score, T category, hospital volume, and hospital academic status. The operation time, postoperative length of stay, and overall complication rate were assessed by multivariate regression analyses. RESULTS Of 2740 patients in 355 hospitals, 1110 pairs were generated. The median operation time, postoperative stay, and overall complication rate (MBP vs non-MBP group) was 278 and 268 minutes (P &lt; .004), 10.3 and 10.0 days (P = .695), and 11.8% and 11.4% (P = .740), respectively. The multivariate regression analyses did not find significant superiority of MBP for the 3 endpoints (all P &gt; . 05). A shorter operation time was significantly associated with female sex and early-stage tumor. Older age, greater Charlson score, and lower hospital volume adversely affected the postoperative stay and overall complication rate. Stage T3 tumor was unfavorable for the postoperative stay. CONCLUSION Our large-scale propensity score-matched analysis did not demonstrate a benefit for MBP in operation time, postoperative stay, or overall complications. The results suggest that MBP can be safely omitted before laparoscopic nephrectomy for T1-T3 tumors. UROLOGY 81: 74-79,2013. (C) 2013 Elsevier Inc.

OBJECTIVE To examine how early surgical intervention influenced cases of Fournier's gangrene (FG) fatality. PATIENTS AND METHODS Patients with FG (defined as an International Classification of Diseases-10 code of M72.6 [necrotizing fasciitis] at the perineum or external genitalia), who received surgical intervention &lt;= 5 days after admission, were identified from the Diagnosis Procedure Combination database for the 6-month period July to December, in the years 2007-2010. Data included age, sex, comorbidities, ambulance use, operations and debridement ranges. Multivariate logistic regression analysis of mortality was performed to show whether early (&lt;= 2 hospital days) or delayed (3-5 hospital days) surgical treatment affected FG outcomes. RESULTS A total of 302 male and 77 female patients with FG were identified for which the overall case fatality rate was 17.1% (65 cases). There were no significant differences in patient characteristics between the early operation group (n = 327) and the delayed operation group (n = 52), with the exception of ambulance use (33.3% vs 17.3%, P = 0.020). Cystostomy, colostomy, orchiectomy/penectomy (male patients only), or debridement &gt;= 3000 cm(2) were performed on 42 (8.8%), 56 (11.5%), 46 (10.8%) and 17 (4.4%) patients, respectively. Multivariate analysis showed that there was a significantly lower case fatality rate among the early operation group (odds ratio [OR] = 0.38; P = 0.031). Older age (OR 1.80, for 10-year increments), Charlson comorbidity index score (OR = 1.33, for 1-point increments), sepsis or disseminated intravascular coagulation at admission (OR 4.01), and debridement range &gt;= 3000 cm(2) (OR 5.22, compared with other operations) were significantly associated with a higher case fatality rate. CONCLUSION Early (&lt;= 2 hospital days) surgical intervention for FG is significantly associated with lower mortality than delayed (3 -5 hospital days) action.

OBJECTIVE To assess clinical and mechanical risk factors of clinically significant renal haemorrhage after extracorporeal shock wave lithotripsy (ESWL). PATIENTS AND METHODS Patient data were extracted from the Diagnosis Procedure Combination (DPC) database from 6 months per each year, 2006-2008. The availability of lithotripters in each hospital was identified. We performed logistic regression analysis, which included the generator type (electrohydraulic, electromagnetic or piezoelectric), age, gender, laterality of stones (right, left or uncertain), location of stones (kidney, ureter or uncertain), total number of treatment sessions, anaesthesia and hospital volume (HV), focal size (greater or less than 400 mm(3)) and F2 angle (greater or less than 70 degrees). Renal haemorrhage events were identified within the database. RESULTS Overall, 81 renal haemorrhage events in 26 969 patients (32 476 ESWL sessions) at 482 hospitals with 38 lithotripter models were identified. The incidence of events was 0.50% with renal stones and 0.14% with ureter stones. Specifications of 34 lithotripter models were available. Use of piezoelectric lithotripters (vs electromagnettic, OR 0.13, P = 0.044) and high HV (&gt;= 140/year, vs &lt;= 70/year, OR 0.49, P = 0.012) significantly decreased the risk of renal haemorrhage events. Age, gender, focal size and F2 angle did not show statistical significance. CONCLUSION There is a low incidence of renal haemorrhage after ESWL. The less invasive nature of piezoelectric lithotripters and an inverse volume-outcome relationship with ESWL procedures was revealed. Age, focal size and F2 angle do not appear to have a significant impact on renal haemorrhage.

Purpose: We compared the in-hospital outcomes between bipolar and monopolar transurethral resection of the prostate (B-TURP and M-TURP, respectively) on a real-world practice using a large database. Patients and Methods: Patients who underwent TURP were extracted from the Diagnosis Procedure Combination database, which is a case-mix administrative claims database in Japan. TURP procedures were classified into M-TURP and B-TURP groups according to intraoperative use or nonuse of D-sorbitol solution, respectively, which is the only nonelectrolyte bladder irrigation fluid for M-TURP available in Japan. To exclude causality among autologous and homologous transfusion events, we confined eligible hospitals to those in which no autologous blood preparation was undertaken for TURP and whose annual surgical caseloads were 15 cases or more. Multivariate analyses were conducted for homologous transfusion, postoperative complications, operative time, postoperative length of stay, and total costs. Results: There were 5155 M-TURP and 1531 B-TURP patients identified. The results for M-TURP vs B-TURP (effect sizes were evaluated with reference to M-TURP) were 2.3% vs 1.3% for transfusion (odds ratio [OR] = 0.54; P = 0.013), 3.3% vs 1.7% for postoperative complications (OR = 0.46; P &lt; 0.01), 98 vs 116 minutes for operative time (20.5% increase; P &lt; 0.001), 8.65 vs 8.45 days for postoperative stay (3.6% reduction; P = 0.003), and $6103 vs $6062 for cost (1.7% reduction; P = 0.018). Conclusion: B-TURP had significantly lower rates of transfusion and postoperative complications, but a longer operative time. The impacts of B-TURP on shortening the hospital stay and lowering the costs were of little clinical significance.

Objectives: To show the characteristics and therapeutic trends of renal trauma in Japan using a nationwide database. Methods: All renal trauma cases from the Diagnosis Procedure Combination database during 6 months of each year from 2006 to 2008 were included in the analysis. The following variables were considered: demographics, ambulance use, comorbid trauma, interventions, mechanism of injury and the Abbreviated Injury Scale. Patients were divided into two groups by trauma range: limited to rib, abdomen and pelvis (group A) or more extended (including supradiaphragmatic regions or lower extremities; group B). Rib fracture impact was assessed as a predictor of comorbid organ trauma. The incidences of angioembolization failure and nephrectomy were also evaluated. Results: A total of 1505 renal trauma cases (1014 and 491 in groups A and B, respectively) were identified. Comorbid trauma in the liver, spleen and lumbar/pelvic fractures were 7.4%, 5.6% and 5.1% in group A and 24.0%, 11.2% and 17.5% in group B, respectively. The rates of angioembolization (and its failure proportion), nephrectomy, transfusion and mortality were 7.9% (12.5%), 3.3%, 15.6% and 1.1% in group A, and 17.1% (11.9%), 2.6%, 28.3% and 8.1% in group B, respectively. Risks of coincident traumas in the liver, spleen and pelvic fracture were 2.23, 2.35 and 2.72 times higher if a rib fracture was observed. The incidences of renal trauma and nephrectomy (per 100 000 person-years) were estimated as 2.06 and 0.063, respectively. Conclusions: Angioembolization failure is not rare, and nephrectomy is an important last resort. Patients with comorbid rib fracture should be explored for coincident traumas.

OBJECTIVE International Prostate Symptom Score (IPSS) has been commonly used to assess lower urinary tract symptoms (LUTS). We have recently developed Core Lower Urinary Tract Symptom Score (CLSS). The aim of this study is to compare IPSS and CLSS for assessing LUTS in men. PATIENTS AND METHODS Consecutive 515 men fulfilled IPSS and CLSS questionnaires. IPSS QOL Index was used as the QOL surrogate. The clinical diagnoses were BPH (n = 116), BPH with OAB wet (n = 80), prostate cancer (n = 128), prostatitis (n = 68), underactive bladder (n = 8), others (n = 72), and controls (e.g., occult blood) (n = 42). Simple statistics and predictability of poor QOL (QOL Index 4 or greater) were examined. RESULTS All symptom scores were significantly increased in symptomatic men compared with controls. Scores of corresponding symptoms of two questionnaires were significantly correlated (r = 0.58-0.85, all P &lt; 0.0001). A multivariate regression model to predict poor QOL indicated nine symptoms (daytime frequency, nocturia, urgency, urgency incontinence, slow stream, straining, incomplete emptying, bladder pain and urethral pain) as independent factors. The hazard ratios for bladder pain (2.2) and urgency incontinence (2.0) were among the highest. All the nine symptoms are addressed in CLSS, while three symptoms (urgency incontinence, bladder, and urethral pain) are dismissed in IPSS. CONCLUSION CLSS questionnaire is more comprehensive than IPSS questionnaire for symptom assessment of men with various diseases/conditions, although both questionnaires can capture LUTS with possible negative impact on QOL.

We estimated the incidence of admissions related to interstitial cystitis in Japan using a national administrative claims database, the Diagnosis Procedure Combination database, which included information for 53.6% of urological training hospitals certified by the Japanese Urological Association. Admissions related to interstitial cystitis was defined as those cases whose ICD-10 code for the main reason for admission was N301 (interstitial cystitis) between 2007 and 2009. Among 8.42 million inpatient cases, 784 female and 212 male patients with interstitial cystitis were identified. The ratio of females to males was 3.69 and the median age was 67 years (range 592 years). The admission incidence (per 100 000 person-years) in females and males was estimated to be 1.35 (95% confidence interval 1.251.46) and 0.37 (0.310.42), respectively. This incidence is low compared with other reports. Possible reasons for this finding include racial difference, clinical examination methods, lack of outpatient data and poor health-care coverage of interstitial cystitis.

Objective: Japan experienced a nationwide outbreak of hydrogen sulfide suicides (HSS) between April and May 2008. The annual number of HSS skyrocketed from 19 in 2007 to 1,056 in 2008. However, the factors affecting this enormous increase remain unknown. The present study aimed to examine the effect of media coverage of the incidents on the subsequent epidemic of HSS. Method: We collected time series data from the 1st week of February to the last week of September 2008 (34 weeks), including the number of HSS (S-t), the number of articles on HSS published in the five major newspapers (N-t), and the number of Internet searches with the keyword "hydrogen sulfide suicide" (G(t)). The generalized method of moments was applied to model the concurrent effects of N-t and G(t) on S-t. Results: The increase in the number of newspaper articles significantly induced the increase in HSS (coefficient, 0.84; 95% confidence interval (CI), 0.28-5.3), while the number of Internet searches did not significantly affect the number of HSS (coefficient, -0.75; 95%CI, -19.3-0.45). Conclusions: Exposure to information on HSS from newspaper articles could have directly affected the subsequent increase in the number of suicides. On the other hand, the number of the Internet searches did not have a direct influence on HSS. (Int'l. J. Psychiatry in Medicine 2012;44:133-140)

Purpose: We analyzed the impact of hospital volume and laser use on postoperative complications and in-hospital mortality in transurethral prostatic surgery. Materials and Methods: We evaluated data from 18,578 patients in 686 hospitals who underwent transurethral prostatic surgery between July and December, 2006 to 2008, using the Diagnosis Procedure Combination database in Japan. Cases were divided into low (14 or less per year), medium (14 to 29 per year) or high (30 or more per year) hospital volume groups. Logistic regression analyses were conducted to determine the concurrent effects of hospital volume, laser use and other factors on postoperative complications, transfusion and in-hospital mortality. Laser devices included neodymium: yttrium aluminum garnet and holmium: yttrium aluminum garnet lasers. Results: The overall in-hospital mortality was 0.05% (10 of 18,578 patients) and was not significantly different among groups. The transfusion rates of the low, medium and high volume groups were 8.3%, 7.0% and 5.5%, respectively (low vs high volume adjusted odds ratio 1.55, p &lt;0.01), and postoperative complication rates were 3.7%, 3.2% and 2.6% (low vs high volume OR 1.425, p = 0.016), respectively. An absence of laser use was also a significant risk factor on both measures (OR 1.46 and 2.02, both p &lt;0.01). Teaching hospitals were associated with a higher transfusion rate (OR 1.75), and comorbidities of chronic lung disease, chronic renal failure and malignancy were related to complication rates (OR 1.89, 2.32 and 1.50, respectively). Conclusions: The mortality rate of transurethral prostatic surgery is extremely low and is not affected by hospital volume. However, higher surgical volumes and laser use were significantly associated with lower rates of complications and transfusions.

OBJECTIVES To use a contingent valuation method to compare the willingness of well-informed and ill-informed men to pay for PSA screening. Prostate cancer screening by analysis of prostate-specific antigen (PSA) levels has recently been confirmed to reduce prostate cancer death. However, PSA screening is associated with considerable risks, and men should be well informed about the risks before deciding to undergo the test. METHODS A total of 1800 men aged 50-69 years old participated in an Internet-based, computer-assisted questionnaire survey. The subjects were randomly divided into 2 groups. Group 1 (n = 900) was provided with information about the procedure, detection rate, and mortality-reducing effects of PSA screening. Additional information was given to group 2 (n = 900), including the possibility of false-positive or false-negative results, the risks of close examination, and the possibility of overdiagnoses. The willingness to pay (WTP) was assessed using a double-bound dichotomous choice method. RESULTS The average WTP was significantly greater in group 1 than in group 2 ($31.1 vs $25.1, P &lt; .01). Weibull regression analysis showed that patients with a history of receiving PSA screening or with greater incomes had a significantly greater WTP. CONCLUSIONS Although providing information on the risks of PSA screening significantly decreased men&apos;s WTP for such tests, the well-informed group was still willing to pay $25.1. These findings suggest that men can balance the potential disadvantages of PSA screening against its effectiveness in saving lives. UROLOGY 77: 1325-1329, 2011. (C) 2011 Elsevier Inc.

Malignant fibrous histiocytoma (MFH) of the kidney is a rare sarcoma that often undergoes local recurrence and/or distant metastasis. However, little is known about the outcome of metastatic diseases. We present the case of a 46-year-old male suffering from renal MFH with pulmonary metastasis, who has undergone complete response for 3 years after surgical resection and MAID chemotherapy. He is now well, and without any evidence of recurrent disease. Copyright (C) 2010 S. Karger AG, Basel

A direct shunt between the inferior mesenteric vein and the inferior vena cava was detected in a patient with hepatic encephalopathy. The authors performed balloon-occluded retrograde transvenous obliteration (BRTO) for this shunt. Before the obliteration, the shunt was occluded by using a balloon catheter and it was confirmed that the portal venous flow was redirected to the liver. The encephalopathy disappeared immediately after BRTO. The improvement of the liver function, the disappearance of the shunt, and the increase in the size of the portal vein and liver volume were confirmed at computed tomography performed 5 months after treatment.