ABSTRACTIntroductionAdrenocortical carcinoma (ACC) is a rare and aggressive malignancy. Recent studies suggest that immune checkpoint inhibitors exhibit antitumor activity in selected ACC patients.Case PresentationWe report a case of a 49‐year‐old man with advanced ACC and pulmonary metastasis treated with EDP‐M chemotherapy, followed by pembrolizumab based on high tumor mutational burden (TMB, 27.1/Mb). Despite suspected pseudo‐progression, transient tumor shrinkage was observed. However, the patient died of liver failure 9 months after diagnosis.ConclusionThis case suggests a therapeutic role for ICIs in ACC. Moreover, it highlights the importance of TMB and immune RECIST criteria in evaluating treatment response.

Horseshoe kidney is the most common congenital renal fusion anomaly and is associated with aberrant anatomy and a complex vascular supply, which can complicate nephron-sparing surgery. A 43-year-old woman was incidentally diagnosed with a small hypovascular tumor in the right renal moiety of a horseshoe kidney. Three-dimensional computed tomography with blood flow analysis using SYNAPSE VINCENT (Fujifilm, Japan)demonstrated that the tumor was supplied exclusively by the upper pole renal artery. Because the right renal moiety was largely covered by the liver, a conventional midaxillary retroperitoneal approach was unsuitable, and the retroperitoneal space was established via a pararectus approach. A hybrid laparoscopic-robotic technique was adopted due to the limited working space. Preoperative blood flow analysis enabled selective arterial clamping, and a tailored surgical approach allowed safe robot-assisted partial nephrectomy with minimal blood loss and preserved renal function.

Epithelioid angiomyolipoma is a subtype of perivascular epithelioid cell tumors that may exhibit malignant behavior. While mammalian target of rapamycin inhibitors are commonly used for systemic treatment, the efficacy of immune checkpoint inhibitors remains unclear. A 58-year-old man was diagnosed with epithelioid angiomyolipoma after partial nephrectomy of a right renal mass. The tumor recurred locally, and multiple lung metastases developed despite surgical resection. Nivolumab was initiated after disease progression on everolimus, resulting in durable disease control for over 3 years. Immunohistochemistry revealed high PD-L1 expression and CD8+ T-cell infiltration within the primary tumor. Immune checkpoint inhibitors may be effective treatment options for malignant epithelioid angiomyolipoma with PD-L1 expression and CD8+ T-cell infiltration.

Primary malignant neoplasms of the epididymis are rare. In this case report, we describe clear cell carcinoma associated with papillary cystadenoma of the epididymis (PCE). A 77-year-old man presented with a painless, enlarged left scrotum. Magnetic resonance imaging (MRI) revealed two different abnormal signals in the left epididymis. A left high inguinal orchiectomy and histopathological examination revealed a benign component consistent with PCE and a malignant component showing solid growth with cell nuclear enlargement, atypical mitotic figures, and invasion into surrounding tissues. The final diagnosis was malignant transformation to clear cell carcinoma of PCE. Although this epididymis tumor may follow an indolent course, the presence of areas with higher proliferative potential suggests surgical excision be recommended as definitive treatment.

Extraperitoneal tubeless umbilical cutaneous ureterostomy is a useful urinary diversion technique for patients with shortened ureters or high risk of upper urinary tract recurrence. However, radical nephroureterectomy following this diversion has not been previously reported. A 67-year-old man underwent radical cystoprostatourethrectomy with extraperitoneal tubeless umbilical cutaneous ureterostomy for high-risk urothelial carcinoma with bilateral ureteral shortening. Twenty-four months later, left-sided upper tract urothelial carcinoma was diagnosed, and laparoscopic left radical nephroureterectomy was performed. Although dense adhesions necessitated partial small-bowel resection, complete nephroureterectomy was achieved without major complications. To the best of our knowledge, this is the first report of radical nephroureterectomy performed after umbilical cutaneous ureterostomy. This urinary diversion may represent a reasonable option for selected patients at high risk of upper urinary tract recurrence.

ABSTRACTIntroductionAnti‐melanoma differentiation‐associated gene 5 antibody‐positive interstitial lung disease is a rare but fatal adverse event following immune checkpoint inhibitor treatment for cancers. However, such cases have not been previously reported in patients with urothelial carcinoma.Case PresentationA 79‐year‐old Japanese woman with advanced unresectable bladder cancer was treated with first‐line enfortumab vedotin plus pembrolizumab. During the second treatment cycle, interstitial lung disease developed, and the patient immediately received steroid pulse therapy. As interstitial lung disease rapidly progressed after the initiation of steroid pulse therapy, immunosuppressive treatment with cyclophosphamide and tacrolimus was added. However, interstitial lung disease did not improve, and the patient died on day 54 after initiating treatment. Detailed antibody examination revealed positive anti‐melanoma differentiation‐associated gene 5 antibodies.ConclusionWe report the first case of anti‐melanoma differentiation‐associated gene 5 antibody‐positive interstitial lung disease induced by enfortumab vedotin plus pembrolizumab in a patient with advanced urothelial carcinoma.

ABSTRACTIntroductionWe report the case of a patient with severe uterine prolapse who underwent successful vaginal pessary removal after pelvic floor muscle training.Case PresentationA 63‐year‐old woman presented with urinary dysfunction and residual urine. She was diagnosed with stage III pelvic organ prolapse by an obstetrician‐gynecologist, and a vaginal pessary was inserted. The patient underwent pelvic floor muscle training for 4 months while the vaginal pessary remained in situ. M‐mode ultrasonography revealed improved pelvic floor function, necessitating vaginal pessary removal. The patient's uterine prolapse improved to pelvic organ prolapse‐quantification stage II without recurrence of pelvic organ prolapse, urinary dysfunction, or residual urine after 2 years.ConclusionsIn patients with severe uterine prolapse who use a vaginal pessary, appropriate pelvic floor muscle training guided by a physical therapist may eliminate the need for continued pessary use.

ABSTRACTIntroductionIntramural ureteral urothelial carcinoma can be difficult to diagnose, especially when presenting without mucosal abnormalities or positive cytology. In such cases, percutaneous biopsy may provide an alternative diagnostic approach.Case PresentationA 74‐year‐old man presented with acute renal failure caused by bilateral hydronephrosis. Cystoscopy showed no mucosal abnormality. Retrograde pyeloureterography revealed bilateral distal ureteral strictures, but urine cytology from ureteral catheters was negative. Imaging revealed a submucosal mass on the right dorsal bladder wall. Urothelial carcinoma was diagnosed on a computed tomography‐guided percutaneous trans‐extraperitoneal and transvesical biopsy. Neoadjuvant chemotherapy was administered and radical cystectomy performed. Pathology confirmed invasive urothelial carcinoma originating from the right intramural ureter at the ureterovesical junction with bladder muscle invasion.ConclusionThis case highlights the diagnostic challenges of intramural ureteral urothelial carcinoma presenting as a submucosal bladder tumor. Computed tomography‐guided percutaneous biopsy can be a safe and effective diagnostic option in such challenging cases.