Published papers

© 2019 The Authors. Cancer Science published by John Wiley & Sons Australia, Ltd on behalf of Japanese Cancer Association. The prognostic role of CD44v9, a variant isoform of CD44 and a new cell surface marker of cancer stem cells, remains unclear in bladder cancer (BC) patients. Furthermore, limited information is available on the functional role of sulfasalazine (SSZ), which could modulate the CD44v9-xCT system in order to enhance cisplatin (CDDP)-induced cytotoxicity and inhibit the metastatic potential of BC. CD44v9 protein expression was examined immunohistochemically in 63 muscle invasive BC (MIBC) patients who underwent radical cystectomy. CD44v9 expression was independently associated with disease recurrence and cancer-specific death in MIBC. Cytotoxic effects, glutathione levels, and reactive oxygen species production by SSZ and CD44v9 and phospho-p38 MAPK protein expression by SSZ with or without CDDP were assessed in MBT-2V cells with highly metastatic potential. Sulfasalazine exerted cytotoxic effects against MBT-2V cells by inhibiting glutathione levels and inducing the production of reactive oxygen species. Sulfasalazine in combination with CDDP appeared to exert strong cytotoxic effects against MBT-2V cells by inhibiting CD44v9 expression and upregulating phospho-p38 MAPK expression. The inhibitory effects of SSZ with or without CDDP were also investigated using an MBT-2V lung metastatic model. In the murine lung metastatic BC model, SSZ significantly prolonged animal survival. Furthermore, the combination of SSZ with CDDP exerted stronger inhibitory effects on the establishment of lung tumor nodules than SSZ or CDDP alone. CD44v9 expression could be a clinical biomarker for predicting poor outcomes in MIBC patients. Sulfasalazine in combination with CDDP has potential as a novel therapy against metastatic BC.

© 2019 Elsevier Inc. Objective: To investigate the influence of the zonal origin of prostate cancer and extraprostatic extension on biochemical recurrence (BCR). Patients and methods: We included 638 consecutive patients undergoing radical prostatectomy between 2005 and 2015 who did not receive neoadjuvant/adjuvant therapy. The largest lesion was defined as the index tumor. We categorized each patient into the transition zone (TZ) or peripheral zone (PZ) group based on the lesion where the index tumor existed. Differences in the BCR defined as increasing prostate-specific antigen rate between groups were examined by Kaplan-Meier analysis and the Cox proportional hazards model. Results: There were 293 (46%) patients with TZ cancer and 345 (54%) with PZ cancer. TZ cancer was significantly associated with a higher prostate-specific antigen (P = 0.012), lower biopsy positive core rate (P = 0.020), lower pathological Gleason score (P = 0.017), lower pathological stage (P = 0.002), and lower rate of seminal vesicle invasion (P = 0.002). During a median follow-up period of 59 months, 79 patients (12%) developed BCR. In the entire cohort, the PZ origin (hazard ratio: 1.68, P = 0.033) and extraprostatic extension were independent risk factors for BCR. The 3-, 5-, and 7-year BCR-free survival rates of patients with pT3a TZ cancer were 89%, 88%, and 86%, respectively, which were significantly better than those of patients with pT3a PZ cancer (80%, 74%, and 62%, P = 0.012), but were similar to those of the pT2 cancer cohort (92%, 91%, and 90%, P = 0.376). Conclusion: TZ cancer had more favorable pathological characteristics and oncological outcome than PZ cancer especially in pT3a cases.

© 2019, Japan Society of Clinical Oncology. Background: The later-line treatment of metastatic renal cell carcinoma (mRCC) has been drastically changing by the development of immune-oncology drugs and molecular targeted treatment in recent years. Although the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) model is useful for second-line setting, this model has the problem that over 50% patients are classified as intermediate risk group. The aim of this study is to evaluate whether the serum C-reactive protein (CRP) levels prior to second-line treatment could divide intermediate risk group patients. Methods: We retrospectively reviewed 82 consequent intermediate-risk mRCC patients who received second-line molecular targeted therapy. We classified patients who had serum CRP higher than 0.5 mg/dl in elevated CRP group because the median baseline serum CRP level before second-line treatment was 0.51 mg/dl. We assessed the prognostic impact of serum CRP levels prior to second-line treatment initiation to predict overall survival (OS). Results: Thirty-three out of 82 (40%) patients demonstrated elevated baseline CRP levels. The median OS of elevated and non-elevated CRP group was 11.5 (95% CI 5.4–17.5) and 29.4 (95% CI 25.5–33.5) months, respectively (p = 0.001). The serum CRP elevation could predict prognosis in intermediate risk patients treated with second-line treatment (HR 2.5, 95% CI 1.4–4.2, p = 0.001). Conclusions: The serum CRP levels after first-line treatment termination could divide intermediate risk group mRCC patients into two prognostic subgroups in second-line targeted treatment setting.

© 2018 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd. INTRODUCTION: Laparoscopic radical nephrectomy is the gold standard for treatment of renal cell carcinoma. However, previous abdominal surgery is generally regarded as a contraindication to the laparoscopic approach because it causes intraperitoneal adhesions, which are thought to interfere with subsequent laparoscopic procedures inside the abdominal cavity. Few studies have examined the influence of prior surgery on laparoscopic nephrectomy. Therefore, the aim of this study was to evaluate the impact of previous laparotomy on laparoscopic nephrectomy. METHODS: The records of 251 consecutive patients who had undergone laparoscopic nephrectomy for renal cell carcinoma at our hospital between 2005 and 2015 were reviewed retrospectively. RESULTS: Of the 251 laparoscopic nephrectomy patients, 76 patients (30%) had undergone prior abdominal surgery (surgery group), whereas the remaining 175 patients (70%) had not previously had abdominal surgery (control group). There were no significant differences between the control group and the surgery group with regard to pneumoperitoneum time (143 vs 135 min, P = 0.241) or blood loss (39 vs 36 mL, P = 0.763). Next, we divided the patients into two cohorts based on surgeon experience: 98 patients had been treated by an expert (i.e. someone who performs more than 50 laparoscopic procedures per year) and 153 patients had been treated by a non-expert. There was no significant difference in pneumoperitoneum time between the control and surgery groups in each cohort (treated by experts, 108 vs 103 min; treated by non-experts: 162 vs 166 min). CONCLUSION: We conclude that laparoscopic nephrectomy may be feasible after previous abdominal surgery and could be one of the surgical options.

Objective: It is considered that laparoscopic single-site surgery should be performed by specially trained surgeons because of the technical difficulty in using special instruments through limited access. We investigated suitable patients for single-port laparoscopic radical nephrectomy, focusing on the anatomy and distribution of the renal artery and vein. Methods: This retrospective study was conducted in 52 consecutive patients who underwent single-port radical nephrectomy by the transperitoneal approach. In patients undergoing right nephrectomy, a 2-mm port was added for liver retraction. We retrospectively re-evaluated all of the recorded surgical videos and preoperative computed tomography images. The pneumoperitoneum time (PT) was used as an objective index of surgical difficulty. Results: The PT was significantly shorter for right nephrectomy than left nephrectomy (94 vs. 123 min, P = 0.004). With left nephrectomy, dissection of the spleno-renal ligament to mobilize the spleen medially required additional time. Also, the left renal vein could only be divided after securing the adrenal, gonadal and lumbar veins. In patients whose renal artery was located cranial to the renal vein, PT tended to be longer than in the other patients (131 vs. 108 min, P = 0.070). In patients with a superior renal artery, the inferior renal vein invariably covered the artery and made it difficult to ligate the renal artery via the umbilical approach at the first procedure. Conclusions: These findings indicate that patients undergoing right nephrectomy in whom the renal artery is not located cranial to the renal vein are suitable for single-port laparoscopic radical nephrectomy.

OBJECTIVE: To investigate the multiparametric prostate magnetic resonance imaging (mpMRI) findings in patients treated with testosterone replacement therapy (TRT) while on active surveillance for low-risk prostate cancer. METHODS: We retrospectively reviewed 12 patients who underwent mpMRI before and after TRT while on active surveillance. Changes in serum testosterone level, prostate-specific antigen (PSA), prostate biopsy findings, prostate volume, and Prostate Imaging Reporting and Data System Version 2 (PI-RADSv2) score before and after TRT were summarized. RESULTS: After TRT, there was a significant increase in serum testosterone (516.5ng/dl vs. 203.0ng/dl), PSA (4.2ng/ml vs. 3.3ng/ml), and prostate volume (55.2cm(3) vs. 39.4cm(3)). In total, 2 patients had biopsy progression during the study period. The PI-RADSv2 scores before and after TRT were unchanged in 10/12 patients; none of these demonstrated biopsy progression on post-TRT. The PI-RADSv2 scores increased after TRT in 2/12 patients; both showed Gleason score upgrade on follow-up biopsy. Of these 2 patients, 1 patient underwent radical treatment due to clinical progression. The area under the curve for detecting biopsy progression calculated from PI-RADSv2 score after TRT was 0.90, which was better than that calculated from post-TRT PSA level (0.48). CONCLUSIONS: After TRT, mpMRI findings remained stable in patients without biopsy progression, whereas PI-RADSv2 score increase was identified in patients with Gleason score upgrade on follow-up biopsy.

PURPOSE: Accurate identification of the source of a detectable serum prostate-specific antigen (PSA) in the postprostatectomy setting is a major challenge among the urologic community. The aim of this study was to assess positivity rates of imaging examinations performed in patients with early PSA rise after prostatectomy and to summarize the management strategies adopted in this clinical scenario. METHODS: Institutional Review Board-approved retrospective study of 142 postprostatectomy patients with PSA rise up to 1ng/ml who underwent evaluation with combination of multiparametric pelvic magnetic resonance imaging (MRI)+/-whole-body or bone MRI, bone scintigraphy, computed tomography (CT) chest-abdomen-pelvis, (18)F-fludeoxyglucose-positron emission tomography (PET)/CT or (18)F-sodium fluoride-PET/CT at a single tertiary cancer center. Imaging results were summarized per modality and compared with pathology findings. RESULTS: Pelvic MRI was positive in 15/142 (11%) patients (14 patients with local recurrence in the surgical bed and 1 patient with pelvic osseous metastases). Of these 15, 10 patients underwent additional imaging examinations; none revealed positive findings. Of the 127 patients with negative pelvic MRI, 54 (43%) underwent additional imaging examinations; only 1/54 had positive findings (false-positive T8 lesion on bone scintigraphy and FDG-PET/CT; biopsy was negative for cancer). Overall, 12/16 patients with positive imaging findings and 75/126 (60%) patients with negative imaging received treatment (radiation, hormones or chemotherapy). CONCLUSION: The conventional imaging identified sites of disease, almost always in the form of local recurrence, in a minority of patients with early PSA rise postprostatectomy.

BACKGROUND: Our aim was to evaluate the effect of visceral obesity and impact of severe hydronephrosis on surgical complexity in patients undergoing laparoscopic radical nephroureterectomy (LRNU). METHODS: From January 2000 to December 2013, 169 patients underwent radical nephroureterectomy at our institution. We retrospectively reviewed the medical records of 70 patients who underwent LRNU. We measured total fat area (TFA) and visceral fat area (VFA) at the level of the umbilicus using computed tomography. We defined accumulated visceral fat distribution as a VFA/TFA ratio >/=0.45. Ipsilateral hydronephrosis was graded from 0 to 4 by two uro-radiologists blinded to the clinical outcomes. RESULTS: Among the 70 patients, VFA/TFA ratio was >/=0.45 in 40 patients (57.1%) and 28 (40.0%) had severe hydronephrosis (grade 3 or greater). Patients with a VFA/TFA ratio >/=0.45 had significantly longer pneumoperitoneum and total operation times compared to their counterparts (p = 0.047 and p = 0.002, respectively). Patients with severe hydronephrosis had significantly longer pneumoperitoneum and total operative times compared to their counterparts (p = 0.006 and p = 0.002, respectively). Multivariate logistic regression analysis showed that a high VFA/TFA and severe hydronephrosis were independent predictive factors for prolonged pneumoperitoneum (p = 0.048, HR = 2.90; p = 0.015, HR = 3.82, respectively) and total operative times (p < 0.001, HR = 18.7; p = 0.003, HR = 10.7; respectively). Other pre-clinical factors such as age, gender, BMI, clinical stage, tumor size, location, laterality, degree of perinephric stranding, and surgical procedure did not affect the operation times. CONCLUSION: The present data indicated that the visceral type of adipose accumulation and presence of severe hydronephrosis could provide preoperative information on the degree of technical difficulty associated with LRNU.

NVP-BEZ235 is an inhibitor of both phosphatidylinositol 3-kinase (PI3K) and mammalian target of rapamycin complex 1/2 (mTORC1/2), and its antitumor activity is expected to be higher than that of mTORC1 inhibitors because it inhibits the upregulation of pAkt through mTORC2. We examined the efficacy of intravesical NVP-BEZ235 therapy in the treatment of bladder cancer using an orthotopic bladder cancer model. The cytotoxic effects of various concentrations of NVP-BEZ235 in MBT-2 cells were examined using a WST assay. The expression of pAkt, pS6 and p4EBP1 was evaluated in MBT-2 cells treated with NVP-BEZ235 using western blotting. Orthotopic models were established by implanting MBT-2 cells into the bladders of female C3H/He mice. We assigned C3H/He mice to 2 groups: a control group treated with vehicle control (n=15), and a group intravesically administered 40 microM (18.78 mg/l) of NVP-BEZ235 (n=15). NVP-BEZ235 inhibited the viability of MBT-2 cells in a dose-dependent manner. Furthermore, the expression of pAkt, pS6, and p4EBP1 was inhibited in NVP-BEZ235-treated MBT-2 cells. Bladder weights were significantly lower in the NVP-BEZ235-treated group than in the control group (P<0.05). An analysis of the tumor tissues revealed that the NVP-BEZ235 treatment strongly reduced pAkt, pS6 and p4EBP1 levels. An immunohistochemical analysis showed that NVP-BEZ235 significantly inhibited the expression of pS6. Intravesically administered NVP-BEZ235 exerted significant antitumor effects in the orthotopic bladder cancer model by inhibiting the PI3K/Akt/mTOR pathway. The intravesical instillation of a dual PI3K/mTORC1/2 inhibitor may represent a novel therapy for the treatment of bladder cancer.

BACKGROUND: The optimal timing of catheter removal following laparoscopic radical prostatectomy (LRP) has not yet been determined. This prospective study was designed to compare the efficacy and safety of catheter removal on postoperative day (POD) 2 versus POD 4 after LRP and its impact on urinary continence outcomes. METHODS: One hundred and thirteen patients underwent LRP and were prospectively randomized into two groups: group 1 (n = 57) had the urinary catheter removed on POD 2 while group 2 (n = 56) had the catheter removed on POD 4. The urine loss ratio (ULR) was defined as the weight of urine loss in the pad divided by the daily micturition volume. Continence was defined as a pad-free status. RESULTS: No significant differences were observed in clinical features between groups 1 and 2. Acute urinary retention (AUR) after catheter removal occurred in 21 patients (18.6%) (13 (22.8%) in group 1 and 8 (14.3%) in group 2 (p = 0.244). The first-day mean ULR values were 1.16 +/- 4.95 in group 1 and 1.02 +/- 3.27 in group 2 (p = 0.870). The last-day mean ULR values were 0.57 +/- 1.60 in group 1 and 2.78 +/- 15.49 in group 2 (p = 0.353). Continence rates at 3, 6, 9, and 12 months were 21.8, 41.1, 58.0, and 71.4% in group 1 and 34.5, 66.0, 79.2, and 83.7% in group 2 (p = 0.138, 0.009, 0.024, and 0.146, respectively). In AUR cases, continence rates at 3, 6, 9, and 12 months were 0, 23.1, 38.5, and 54.5% in group 1 and 37.5, 75.0, 87.5, and 87.5% in group 2 (p = 0.017, 0.020, 0.027, and 0.127, respectively). A multivariate analysis identified AUR after catheter removal on POD 2 as the only predictive factor for incontinence 6 and 9 months after LRP (p = 0.030 and 0.018, respectively). CONCLUSIONS: Our results demonstrated that early catheter removal on POD 2 after LRP may increase the risk of incontinence. TRIAL REGISTRATION: The study was registered as Clinical trial: (UMIN000014944); registration date: 12 March 2012.

OBJECTIVE: In a previous study, we described the relationship between operating time and obesity, particularly visceral obesity, in laparoscopic surgery. Operating time in laparoscopic surgery is affected by the experience and technique of the surgeon. Here, we investigated whether a difference in the surgeon's experience affects the operating time for laparoscopic radical nephrectomy in patients with visceral obesity. METHODS: From January 2006 to February 2012, 167 laparoscopic radical nephrectomies were performed at our institution. Visceral fat area was measured at the level of the umbilicus using computed tomography. A visceral fat area >/= 100 cm(2) was used as the definition of visceral obesity. All laparoscopic radical nephrectomies were performed by six surgeons. Two of the six surgeons perform 50 cases or more laparoscopic surgeries every year and they were defined as the expert group. We analyzed the relationships between clinical findings, methods, surgeon experience, body mass index or visceral fat area and operating time. RESULTS: The expert and non-expert surgeons performed 77 and 90 laparoscopic radical nephrectomies, respectively, and the median operating time was 167.0 +/- 44.0 and 227.5 +/- 60.6 min. Twenty-five patients underwent laparoendoscopic single-site nephrectomy by the expert surgeons. For all surgeons, visceral obesity was a significant factor for prolonged operating time. Multivariate analysis showed that visceral obesity and clinical T stage were independent risk factors for prolonged operating time for the non-expert surgeons [P = 0.004, hazard ratio (HR): 5.15, P = 0.037, HR:10.41]. However, for the expert surgeons, clinical T stage was the only independent risk factor for prolonged operating time (P = 0.039, HR: 4.33). CONCLUSION: Visceral obesity was a factor of prolonged operating time in laparoscopic radical nephrectomy. The non-expert surgeons were particularly affected by visceral obesity.

INTRODUCTION: We investigated the impact of unidirectional barbed suture (UBS) for vesicourethral anastomosis (VUA) during laparoscopic radical prostatectomy. METHODS: The polyglyconate UBS V-Loc 180 was used for VUA during laparoscopic radical prostatectomy in 30 consecutive patients who were diagnosed with organ-confined prostate cancer between January and October 2012. The operative and postoperative parameters were then compared with those of 30 consecutive patients who had previously undergone the same procedure but with the monofilament poliglecaprone suture Monocryl. All procedures were performed by the same experienced surgeon. RESULTS: VUA time was significantly shorter in the V-Loc group (13.2 +/- 2.3 min) than in the Monocryl group (19.1 +/- 3.3 min) (P < 0.001). The V-Loc group required significantly more stitches than the Monocryl group (11.4 +/- 1.3 vs 10.6 +/- 1.6 stitches; P = 0.031). The percentage of patients who required no more than one pad per day at 3 months postoperatively was significantly higher in the V-Loc group (63.3%) than in the Monocryl group (23.3%) (P = 0.020). No significant differences in other perioperative parameters were observed between the two groups. CONCLUSION: Using UBS prevents suture slippage and enables tieless anastomosis. VUA using a UBS may relieve surgeon stress because a rapid and secure anastomosis is achievable.

INTRODUCTION: The aim of this study was to investigate if neoadjuvant hormone therapy (NHT) is associated with surgical outcomes of laparoscopic radical prostatectomy. METHODS: A total of 286 patients with organ-confined prostate cancer and a preoperative prostate volume that could be estimated by transrectal ultrasound underwent laparoscopic radical prostatectomy between 2006 and 2011 at our institution. We examined whether NHT was associated with pneumoperitoneum time (PT) or estimated blood loss during laparoscopic radical prostatectomy. RESULTS: NHT was performed in 80 patients; the mean duration of NHT was 5.2 +/- 0.2 months. Multivariate analysis demonstrated that history of NHT and no NHT were not independent predictors of prolonged PT or higher estimated blood loss. Next, we evaluated 57 patients whose estimated preoperative baseline prostate volume was over 50 mL. Multivariate analysis demonstrated that no history of NHT (P = 0.011) was an independent predictor of prolonged PT. PT was significantly shorter in the NHT group (164.5 +/- 39.0 min, n = 26) than in the non-NHT group (184.0 +/- 36.7 min, n = 31) (P = 0.048). In the NHT group, mean prostate volume was reduced from 63.7 +/- 16.0 mL to 42.1 +/- 18.6 mL (33.9% reduction) by NHT. CONCLUSION: NHT shortened the PT of the patients whose preoperative baseline prostate volume was over 50 mL. This suggests NHT downsized prostate volume, resulting in greater working space and shorter PT.

OBJECTIVE: To evaluate the effect of visceral obesity on surgical outcomes in laparoscopic radical prostatectomy (LRP). METHODS: Visceral fat area (VFA) and periprostatic fat area (PPFA) were used as index of visceral obesity. In addition to VFA and PPFA, age, body mass index (BMI), prostate weight, cross-section area of Retzius space, history of previous abdominal surgery, repeated transrectal needle biopsy, and neoadjuvant hormone therapy were recorded. LRP was separated into 7 steps (1: port insertion and lymph node dissection, 2: endopelvic fascia incision, 3: dorsal vein complex ligation, 4: prostate dissection from bladder neck, 5: dissection of seminal vesicle and vas deferens, 6: prostate dissection from rectum, and 7: vesicourethral anastomosis). Potential factors that prolonged total operative time (OT), pneumoperitoneum time, and duration of each step were assessed by multivariate logistic regression analysis. The association between visceral obesity and other surgical outcomes was also evaluated. RESULTS: One hundred sixteen LRPs were performed by a single experienced surgeon. High PPFA and prostate weight were independent factors that prolonged total OT and pneumoperitoneum time. High BMI was not a factor. PPFA affected steps 1, 4, 5, and 6, and prostate weight affected prolonged steps 5 and 6. Estimated blood loss, duration of urethral catheterization, postoperative hospital stay, perioperative complications, and margin status were not affected by visceral obesity. CONCLUSION: PPFA was more useful to accurately predict prolonged OT than VFA or BMI. Safety and margin status were not compromised even in high PPFA group when operations were performed by an experienced surgeon.

OBJECTIVE: To investigate the effect of visceral fat on operative time and discuss whether the measurement of adipose accumulation could be used as a sensitive predictor of technical difficulty in performing laparoendoscopic single-site adrenalectomy (LESS-A) and laparoscopic adrenalectomy (LA). METHODS: We reviewed the medical records of 106 patients undergoing LA or LESS-A at our institution. Total fat area (TFA) and visceral fat area (VFA) were measured at the level of the L4 vertebra by computed tomography. To categorize the type of obesity, the VFA/TFA ratio was calculated. Multiple logistic regression analyses were performed to identify independent predictors of prolonged operative time. RESULTS: The VFA/TFA ratio does not always coincide with body mass index (BMI, r = 0.415), and a higher correlation coefficient was observed between operative time and the VFA/TFA ratio (r = 0.359) than with that of BMI (r = 0.189). Multivariate analysis revealed that pheochromocytoma, tumor size >/= 5 cm, and the VFA/TFA ratio >/= 0.35, defined as the visceral type of adipose accumulation, were independent predictive factors for prolonged operative time in LA and LESS-A. We were able to stratify patients into short, intermediate, and long operative times using these preoperative variables. CONCLUSION: This study revealed that the visceral type of adipose accumulation increases operative complexity in LA and LESS-A as measured by operative time. The VFA/TFA ratio might be a more sensitive indicator of technical difficulty than that of BMI.

OBJECTIVES: Lymphocele development is the most frequently reported postoperative complication of pelvic lymph node dissection (PLND) performed with laparoscopic radical prostatectomy (LRP). This study evaluated the efficacy of a vessel-sealing device (VSD) for the prevention of lymphocele development. METHODS: A total of 120 patients who underwent LRP with PLND were prospectively enrolled. The patients were randomly assigned to one of the two groups: PLND using a conventional technique (group 1), and PLND performed with VSD (group 2). All patients underwent computed tomography (CT) scanning 1 month postoperatively to evaluate the maximum sectional area of the lymphoceles. RESULTS: Lymphoceles developed in 63 cases (52.5%). One case (0.8%) was symptomatic with infection, and drainage tube placement was required. In the other 62 patients, the lymphoceles developed asymptomatically and were detected by CT scanning. There was no significant difference in the lymphocele development ratio between the two groups. However, when we defined a lymphocele over 1500 mm(2) as being a significant size, lymphoceles were present in 16 of 60 patients in group 1 and 4 of 60 patients in group 2. The incidence of significant lymphoceles over 1500 mm(2) in the group using VSD was much lower than that of the group without VSD (p<0.01). Multivariate analysis demonstrated that VSD was the only independent factor that had an effect on preventing the development of lymphoceles over 1500 mm(2) (p<0.01, odds ratio=4.96). CONCLUSION: The results indicate that the development of large lymphoceles can be prevented by using VSD in LRP with PLND.

PURPOSE: Interest in laparoendoscopic single-site (LESS) surgery has increased in recent years. The aim of this study was to evaluate the feasibility and safety of transumbilical LESS adrenalectomy and to elucidate the technical differences between LESS and conventional laparoscopic surgery. METHODS: This study was comparing 10 consecutive transumbilical LESS adrenalectomies and 10 conventional laparoscopic adrenalectomies performed between March 2006 and April 2010 for benign adrenal tumors. Perioperative parameters were compared, and we reviewed our surgical videos and analyzed technical characteristics of the surgeries. RESULTS: There was no open conversion in laparoscopic group, no additional port placement in LESS group, and no perioperative complications in either group. No significant differences in operative time, estimated blood loss, or resumption of oral intake were observed between two groups. Pneumoperitoneum time did not differ between LESS and laparoscopic groups (91.2 vs. 74.3 min, P = 0.257). In LESS group only, time was needed for adjustment of roticulator (14.5 +/- 8.1 min). After subtracting the time needed for adjustment, operative time between two groups was more comparable (76.7 vs. 74.3 min, P = 0.880). One-handed manipulation time in LESS group decreased in a time-dependent manner (r = -0.806, P < 0.0049). Tissue re-grasping during operation was more frequently observed in LESS group (16.2 vs. 2.2 times, P < 0.001). CONCLUSIONS: Transumbilical LESS adrenalectomy is feasible and comparable to conventional laparoscopic adrenalectomy. There are still obvious technical difficulties associated with LESS surgery, and it is essential that these be overcome in order to improve this surgical technique.

OBJECTIVE: Several studies have associated urachal carcinoma with a poor prognosis, because the disease tends to be detected later as the patient is asymptomatic, there are few therapeutic options, and it has a high local recurrence rate. We review our experience with urachal carcinoma and discuss the role of surgical management and chemotherapeutic options. PATIENTS AND METHODS: We reviewed the records of 10 cases with urachal carcinoma evaluated at Keio University Hospital from 1998 to 2009, and examine the surgical and chemotherapeutic options in the management of urachal carcinoma. RESULTS: Median age was 55.0 years. Applying the TNM staging system, 1 case was in stage I, 4 cases in stage II, 4 cases in stage III, and 1 case was in stage IV. Nine cases were managed initially with surgery; 5 by partial cystectomy and 4 by total cystectomy. The median follow-up period was 3.5 years and the survival rate at 2 years was 87.5%. Six of the resected cases remain disease-free. Salvage chemotherapy was performed in 3 cases, and adjuvant chemotherapy was performed in 2 cases. CONCLUSIONS: We had 10 cases with urachal carcinoma. While there is still no standard chemotherapy combination, CPT-11 plus TS-1 produced stable disease in 1 case.

PURPOSE: To determine predictive factors for perioperative complications of laparoscopic adrenalectomy (LA) including single-site surgery performed or supervised by experienced laparoscopic surgeons. PATIENTS AND METHODS: We retrospectively reviewed 265 consecutive unilateral LAs performed at a single institution from 2001 to 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. The transabdominal approach was used in 248 patients, while a retroperitoneal approach was used in 17 patients. Laparoendoscopic single-site adrenalectomy was performed in 58 patients. Predictive factors for postoperative complications were analyzed. RESULTS: There were no postoperative deaths. At least one postoperative complication occurred in 12 (4.6%) patients. No patient underwent reoperation for a complication. Only one (0.4%) patient's procedure was converted to open surgery, and only this patient needed a blood transfusion during the operation. One patient who underwent laparoendoscopic single-site adrenalectomy had the procedure converted to conventional laparoscopic adrenalectomy. Multivariable logistic regression analysis showed that an American Society of Anesthesiologists-physical status grade 3 or above was the only predictive factor for perioperative complications. CONCLUSION: American Society of Anesthesiologists-physical status grade 3 or above was a statistically significant factor for perioperative complications associated with laparoscopic adrenalectomy that involved laparoendoscopic single-site adrenalectomy, which was performed or supervised by an experienced laparoscopic surgeon. According to the findings of this retrospective study, single-site operation, obesity, adrenal tumor size, and tumor type may not be considered as risk factors for perioperative complications after LA performed or supervised by an experienced laparoscopic surgeon.