It has already been reported that MR imaging is a superior imaging technique to detect minute anatomical changes in the kidney after ESWL. However, the morphological abnormalities found by MR imaging do not necessarily mean deterioration of the renal function. The purpose of this study is to assess the morphological changes in the kinney and changes in renal function after the ESWL treatment by dynamic MR imaging. A total of 16 patients underwent axial MR imaging before and after ESWL. Dynamic MR was also performed on 11 patients of them within 24 hours after ESWL, and both before and after ESWL in the remaining 5 patients. Eight kidneys showed morphological abnormalities on T1-weight images, and 4 of them showed loss of corticomedullary demarcation. Furthermore, the first MR imaging after injection of GdDTPA revealed focal areas of decreased signal intensity in only 2 of these 4 patients who showed loss of corticomedullary demarcation on previous MR images. However, the second MR imaging 6 months after ESWL showed no abnormality in either of them. The percent contrast of signal intensity increase to fat signal intensity was one minute after GdDTPA injection compared before and after ESWL in 5 of the 16 patients. The values before and after ESWL revealed no statistically significant difference, and no patient showed any remarkable decrease of signal intensity after ESWL. These results suggest that loss of corticomedullary demarcation after ESWL does not necessarily reflect damage to the renal function and that the shock-wave exposure causes no premanent damage to the renal function but only temporary impairment.
To observe the mechanism of alcoholic testicular damage, in a previous experiment we used weanling male SD rats aged 45 days, weighing about 200g, and fed a liquid diet (Lieber's) containing 5% ethanol. The latter accounted for 36% of total caloric intake for 7 weeks, but did not result in testicular atrophy. In a later experiment, we used a liquid diet in which ethanol accounted for 46% of the total calorie count. It provided a high-fat, low-protein content which simulated the nutritional background of patients with alcoholic liver diseases. This diet resulted in testicular atrophy. Histological and biochemical changes accompanying this experimental testicular atrophy included the following: 1) The testes of alcohol-fed animals contained smaller seminiferous tubules with reduced numbers of total cells, but no degeneration was seen in the spermatids. 2) In the peritubular wall of the seminiferous tubules, we observed curvature, irregularities, infolding of the basement membrane, and lamellation of the lamina densa, as well as hyperplasia of collagen fibers in the tunica propria. 3) In the cytoplasm of the Sertoli cells, deposits of gigantic fat droplets and stratification of the mitochondria were observed. The permeability of the Sertoli cell tight junction was confirmed using the Lanthanum method. 4) Testosterone levels in both the serum and testes declined. 5) Lactate dehydrogenase-X (LDH-X) activity in the testes declined. 6) Low Km alcohol dehydrogenase (ADH) activity localized in the testicular interstitial tissue was increased. These results indicate that the composition of three major nutritional elements as well as alcohol concentration are important in the mechanism of alcoholic testicular damage, and this damage affects both the testicular interstitial cell and the seminiferous tubules, particularly the Sertoli cells and peritubular wall of the latter. In addition, the findings suggest that ADH is involved in alcohol metabolism in the interstitial cells of the testes.
An assessment has been made of the histopathological characteristics of latent prostatic carcinoma and the tumor volume in 500 male Japanese patients who underwent dissection at The Jikei University since 1983. A microscopic observation was made of the prostatic glands extirpated totally at the necropsy, fixed with formalin and prepared as a step-section in a thickness of 3mm. In the cases of latent carcinoma, after photographing the lesion in the same magnification and measuring the area of the carcinoma lesion with a digitizer, the volume was calculated by multiplying the thickness of 3mm, and carcinoma volume was determined by integrating the value of each slice and adjusted by a conversion formula. The incidence of latent carcinoma was 104 cases out of 500 (22%). The incidence increased as the age layer becomes higher, and latent carcinoma was observed in 44% of the patients aged 80 and above. Complication of latent carcinoma with prostatic hyperplasia was presumed to be an independent phenomenon in so far as it is seen from the statistical aspect. The patients were classified histopathologically into well-differentiated type (64%), mixed type (27%) and poorly-differentiated type (9%), showing high incidence in the low-aged layer of well-differentiated lesions and in the high-aged layer of mixed type lesions and in the high-aged layer of mixed type lesions. The average tumor volume of latent carcinoma was so small as 231mm3, but many of the lesions in the cases of well-differentiated type were small, being on average 103.9mm3, but many of the lesions in the cases of poorly-differentiated type were large, being on average 642.2mm3. Statistically, with a tumor size of 200mm3 as the boundary, a difference was observed in the distribution of histological constitution between the group with smaller lesions and the group with larger lesions. As an application of this result to the clinical carcinoma of stage A, the value of volume of 200mm3 was considered to be important as a diagnostic criterion in deciding the necessity of treatment.
To clarify the recent clinical characteristics of renal cell carcinomas and to evaluate possible determinants for metastasis and venous tumor thrombi, the authors reviewed data from 99 renal cell carcinoma patients treated at Nagoya University Hospital between 1980 and 1989. According to Robson's classification, stage I tumors were found in 48 patients, stage II in 9, stage III in 16, and stage IV in 26. Incidentally detected tumors appeared to be on the increase in recent years. Grade 1 tumors were significantly associated with low-stage tumors and expansive growth. Univariate and multivariate analyses using a logistic regression model demonstrated that venous tumor thrombi and histological grade were significantly related to distant metastasis. Univariate analysis revealed relative risks of 4.7 for venous tumor thrombus presence (pV1b-pV2 vs. pV0-pV1a, p=0.005) and 8.5 for histological grade (grades 2 and 3 vs. grade 1, p=0.04). Local invasion (pT3 vs. pT2a-pT2b: a relative risk of 7.5, p=0.0009) and infiltration pattern (INFβ and INFγ vs. INFα: a relative risk of 11.5, p=0.002) were associated with venous tumor thrombi. Local invasion (pT3 vs. pT2a-pT2b: a relative risk of 6.6, p=0.03) was the only significant determinant for lymph node metastasis. The 5-year actuarial survival rate was 60.0% for all 99 patients. The 5-year survival rates for stage I and II tumors were, respectively, 91.8% and 64.8%. The 3-year survival rates for stage III and IV tumors were 32.8% and 23.6%, respectively, indicating that venous tumor thrombi, and lymph node and distant metastasis were associated with the poor patient survival. The 5-year survival rate for patients treated between 1985 and 1989 (64.5%) was higher than that of patients treated between 1980 and 1984 (52.3%), although the difference was not statistically significant.
The adrenergic alpha-1 and-2 receptors in the three layers of the prostate (capsule, adenoma and urethra) were measured in humans with or without benign prostatic hypertrophy to examine the differences between the hypertrophied and non-hypertrophied (normal) prostate. Both alpha-1 and-2 receptors were found to exist in similar amounts in prostatic adenoma of both hypertrophied and normal prostate groups. In the prostatic capsule and urethra of both groups alpha-1 receptors were more abundant than alpha-2 receptors. Both alpha-1 and-2 receptors in all three prostatic layers were found to be increased significantly in hypertrophied group compared to normal group. further more the increases in alpha-1 and-2 receptors of hypertrophied group were most remarkable in prostatic adenoma. These results seems to demonstrate that not only alpha-1 but also alpha-2 receptors play some important roles in benign prostatic hypertrophy.
The adrenergic alpha-1 and-2 adrenoceptors in six human hypertrophied prostatic adenomas were measured in the saturation experiment using 3H-prazosin and 3H-yohimbine. Not only alpha-1 adrenoceptons but also alpha-2 adrenoceptors were found to exist in large amounts in prostatic adenomas. In the inhibition experiment selective alpha-1 antagonists inhibited the 3H-prozosin or 3H-yohimbine bindings to adenomas. The potency of alpha-1 antagonists in the order prazosin>bunazosin>alfuzosin>urapidil>terazosin and that of alpha-2 antagonists is urapidil>alfuzosin>terazosin>bunazosin>prazosin. These data suggest that urapidil, alfuzosin and terazosin may affect the human hypertrophied prostatic adenoma like phenoxybenzamine, nonselective alpha-1 antagonist, which was used for benign prostatic hypertrophy.
In this report, the clinical value of a new interferon (INF) assay and measuring serum tumor necrosis factor (TNF) titer in renal cell carcinoma (RCC) patients is described. In order to find out ineffective cases, we established a new in vitro IFN assay system which was modified from human tumor clonogenic assay (HTCA) using an underlayer including monocytes (5×104/dish) and lymphocytes (5×105/dish) as the feeder cells obtained from human peripheral venous blood. This assay can evaluate both direct and indirect (immune mediated) antitumor effects. Various kinds of cytokines (TNFα, IL-1α, -1β) were measured simultaneously in the cultured supernatants in vitro as well as the serum value in vivo by sandwich immunoenzymometric assay to compare the relationship between antitumor effect and clinical course. In the basic study, cultured ACHN cell line was used as the target cells. The inhibition of colony growth was observed in a dose relative manner. Continuous IFN-α exposure of 50 and 500IU/ml in the presence of feeder cells showed a significant reduction of colony growth in comparison with cultured plates containing the drug only. Among the cytokines in the supernatants after incubation for 24 hours with IFN-α (500IU/ml) including feeder cells, only TNFα showed significant elevation. In the clinical study, 31 RCC patients were tried for sensitivity testing using modified HTCA system. The sufficient colony growth was observed in 19 cases (61%). In 25 cases serum cytokines were compared with preoperative and postoperative values; twenty cases received post-operative INF-α administrations, and 5 cases did not. Seven of the 20 cases with IFN-α therapy had some evaluable lesions. 1) The rates of colony survivals were correlated with TNFα titers in the supernatants (r=-0.90, p<0.01). 2) The serum levels of TNFα rose in 15 of the 20 cases (75%) after IFN-α therapy. The elevated value was significantly higher than the value of pretreatment period (p<0.05, paired t-test). 3) There was a significant correlation between the TNFα titers in the supernatants (in vitro) and in the sera (in vivo) treated with IFN-α. 4) All of 3 cases with low serum TNFα titers during IFN therapy showed progressive disease. But in 4 cases with high serum TNFα titers metastatic lesions did not change in more than one year. These results indicate that antiproliferative effects in vitro assay system were corresponded to TNFα, and that the serum TNFα titers in vivo also had some relation to IFN-α therapy and clinical course. We conclude that this new assay system can predict the indirect antitumor effect of IFN-α, and that serum levels of TNFα titers are useful to monitor the immune mediated actions of IFN in RCC patients.
The case is a 45-year-old female who underwent right total nephroureterectomy and partial cystectomy for renal pelvic cancer. During the operation, she received blood transfusion. On the 10th postoperative day, she developed high fever and skin rush on the face, which were followed by liver dysfunction and pancytopenia. On the 18th post-operative day, she died of sepsis. Autopsy revealed hypoplasia and aplasia of the bone marrow and severe atrophy of the systemic lymph nodes and spleen. The characteristic clinical course and autopsy findings of this case closely resembled graft-versus-host disease which is observed after bone marrow transplantation or blood transfusion given to patients with severe immunodeficiency. It is therefore strongly suggested that postoperative erythroderma of this case was induced by graft-versus-host reaction due to blood transfusion given during the operation.
Twenty cases (fourteen males, six females, mean age 66.0) with locally advanced (T2-4 N0, M0, n=9) or metastatic (N2-3 or M1, n=11) urothelial cancer were treated sequentially with methotrexate (MTX) and 5-fluorouracil (5-FU), Doxorubicin (ADM), and cisplatin (CDDP) since August, 1988. Primary tumors were in the bladder in fifteen patients and in the renal pelvis or ureter in five cases. Histological findings were adenocarcinoma in one and transitional cell carcinoma in the other cases. Histological grades were grade 2 in four, grade 3 in fifteen, poorly differentiated adenocarcinoma in one. Seven patients were treated by neoadjuvant chemotherapy. Three were treated for recurrent lesions. Ten were treated for the unresectable disease. The patients received one to four cycles of this regimen (average: 2.8 cycles). Complete clinical response was observed in seven of twenty patients (35%) with bidimentionally measurable indicator lesions. Seven patients (35%) had a partial clinical response. Significant tumor regression was noted in fourteen of twenty patients (70%) in total, in eight of ten (80%) treated with full dose chemotherapy. The group of full dose chemotherapy showed an improved trend in survival rate as compared with the group treated by 80% and less dose chemotherapy. Toxicity was relatively mild, with anemia, leukopenia, thrombocytopenia, and no drug related death. The results suggest that the combined chemotherapy with sequential MTX and 5-FU, ADM, and CDDP is remarkably effective on advanced urothelial cancer.
Sensation of the bladder trigone and bladder neck induced by traction of an indwelling balloon catheter with a spring balance and cystometry was evaluated in 393 males and 106 females. Male patients with an average age of 56.9±15.9 (mean±standard deviation) years old (range 17 to 88 years) were divided into 7 groups as follows: 19 patients without any micturitional disturbance, uregency and chronic prostatitis (11 patients), benign prostate hypertrophy (BPH) (131 patients), cervical or thoracic cord compression disorders (67 patients), lumbar vertebral disorders (114 patients), other peripheral nerve disorders associated with diabetes mellitus, post operative status of rectum cancer and others (27 patients) and brain diseases (24 patients). Female patients with an average age of 55.2±15.5 years old (range 17 to 88 years) were divided into 6 groups as follows: 24 patients without any neurological problems, urgency (7 patients), cervical or thoracic cord compression disorders (11 patients), lumbar vertebral disorders (37 patients), other peripheral nerve disorders (18 patients) and brain diseases (9 patients). The observed sensation, first desire to void (FDV) and maximum cystometric capacity (MCC) were evaluated statistically in relation to clinical factors (e. g. disease group, generation and patterns of cystometrogram). The correlation between the sensation and FDV or MCC in these patients were assessed by linear regression analysis. Sensation of normal males was 334.2±159.7g on the average and correlated well with FDV (r=0.88, y=375x-189.4). Sensation of normal females was 373.3±199.5g on the average. However, there was no correlation (r=0.35) between sensation and FDV in females. In males, the means of sensation obtained in patients with other peripheral nerve disorders (557.3±314.5g) was significantly larger than the means of normal subjects (p<0.001), and patients with uregency and chronic prostatitis (236.4±148.3g, p<0.01), BPH (424.1±215.6g, p<0.001), cervical or thoracic cord compression disorders (349.0±229.5g p<0.001), lumbar vertebral disorders (349.7±201.7g, p<0.001) or brain diseases (490.6±305.0g, p<0.05). Furthermore, the differences in the means of sensation between BPH and lumbar vertebral disorders (p<0.05) or brain diseases (p<0.05) were statistically significant. In females, the means of sensation in patients with other peripheral nerve disorder (571.7±279.7g) was significantly larger than the means of normal subjects or patients with lumbar vertebral disorders (377.5±221.6g). All patients were divided into three groups according to the pattern of cystometrogram. Two hundred nineteen males and 62 females, 56 males and 10 females, 116 males and 34 females had the normal, overactive, and underactive pattern, respectively. The means of sensation of 116 male patients with underactive bladder (541.5±266.6g) was significantly larger than those with normal bladder (330.9±175.6g, p<0.001) or overactive bladder (325.0±222.9g, p<0.001). However there was a significant difference only between underactive and normal bladder (p<0.001) in females. There was a good correlation (r=0.68, y=2.42x-12.33) between FDV and sensation in males with normal bladder. But, there was a poor correlation between them in males with overactive bladder (r=0.50) or with underactive bladder (r=0.41). In females, there was a good correlation (r=0.63, y=821.9-0.47x) between FDV and sensation only in the cases of overactive bladder. In male patients, in spite of patterns of cystometrogram, the older the age was, the larger the sensation became, therefore, the bladder sensation seem to have degeneration with age. These results suggest that the measurement of trigonal sensitivity using a spring balance is clinically useful as a screening test of underactive neurogenic bladder
We evaluated histological changes induced by intravesical instillation of Bacillus Calmette Guerin (BCG) and doxorubucin hydorochloride (Adriamycin, ADM) for transitional cell carcinoma of the experimental bladder tumor. We administered rats N-butyl-N (4-hydroxybutyl) nitrosamine (BBN) by mixing it in the drinking water, and performed intravesical instillation of BCG, ADM or physiological saline solution as control in the 16th and 17th weeks and sacrificed in the 18th week after BBN exposure, and observed histological changes by light microscopy and electron microscopy. In the BCG group, the enlargement of the intercellular spaces of superficial tumor cells was found, and electron microscopic findings revealed a decrease or disappearance of the junctional complex. In the ADM group, hydrolytic and vacuolated cytoplasm was revealed. But such change as that in the BCG group was not found in the ADM and control groups. These results indicate that BCG may enlarge the intercellular spaces by changing the junctional complex, and lead to desquamate the tumor cells from the superficial cell layer.
Thirty-five patients with benign prostatic hyperplasia (age range: 45-88 years; average: 67.5 years) underwent local thermotherapy with prostathermer. Clinical therapeutic effect was evaluated in 30 of the 35 patients: 2 patients interrupting from therapy and 3 receiving pretherapeutic indwelling catherters were not included. A total of 6 treatments (2per week) were performed, each lasting for 60 minutes. As for subjective improvement, improvement of nocturia was noted in 70.0% of all patients and sense of residual urine in 70.7%. Post-therapeutic nocturnal and daytime decreases in urination frequency were statistically significant (p<0.01). Objective improvement in residual urine volume occurred in 19 of the 30 cases, and elevation in uroflowmetric maximal flow rate following therapy was statistically significant (p<0.05). Among complications ascribable to catheter insertion were urethral bleeding (3 cases), epididymitis (1 case) and pyuria (1 case). Therapeutic result based primarily on subjective symptoms and partly on objective findings was fairly good in 17 cases (about 57%), and slightly good in 25 cases (about 83%). In conclusion, this therapy seems to be useful in the treatment of benign prostatic hyperplasia.
Between March 1986 and May 1991 the Mainz pouch urinary diversion was performed in 23 patients with bladder cancer. In 12 of these 23 patients, stoma was constructed in the umbilicus. As the efferent stomal limb, the ileum was used in 10 cases and the appendix was used in 2 cases. The skin at the bottom of the umbilicus and the abdominal fascia under the umbilicus were excised roundly. The stomal limb was pulled through the fasciall hole and the stomal margin was sutured to the skin. The cosmetic results of the umbilical stoma were satisfactory in these 12 patients. Pouch capacity ranged from 330ml to 560ml and good urinary continence without difficulty of self-catheterization was obtained in 11 patients. In 1 patient difficulty in catheterization occurred due to a pocketformation in the stomal limb and the operative revision was performed. Stomal stenosis occurred in 1 patient. Acute renal failure followed by intestinal bleeding occurred in 1 patient who was cured with intensive care including hemodialysis. The results of our study show the superiority of the umbilical stoma in the Mainz pouch in regard to good cosmetic appearance, no need to use a Marlex collar, little bending of catheterization route and low incidence of complications such as parastomal hernia or nipplee valve prolapse.
Laparoscopic surgery has been widely performed for removing the gallbladder and the pelvic lymph-nodes in recent years. We have applied laparoscopy technique to nephrectomy and here we describe our procedures and the clinical results. The patient is placed in the supine position under general anesthesia. After a 4 liter CO2 pneumoperitoneum is induced, five trocars are inserted into the abdominal cavity through the ipsilateral abdominal wall. The patient is then turned to the lateral position to displace the bowel medially. The ipsilateral colon is reflected medially after incision of the parietal peritoneum was made along the line of Todt to expose the retroperitoneum. The ureter was identified and dissected. It was secured with 4 clips (2 clips on the renal side and 2 on the distal side) and then cut with scissors. The renal vein and artery were then dissected and separately ligated with clips as described above. These vessels were also cut. The upper pole of the kidney was dissected out and the adrenal gland was left in place. The kidney thus became completely free within the abdomen. It was then grasped by the forceps through a 10mm sheath positioned below the umbilicus. After incising the abdominal wall, the kidney was removed from the abdominal cavity with the grasping forceps and the sheath. By this procedure right nephrectomy was completely performed in a 56-year-old female patient and left nephrectomy in a 56-year-old male patient. The underlying disease was recurrent pyelonephritis secondary to renal calculi in both cases. The operative times were 221min and 346min, respectively. There were no severe complications in either case. This procedure may be useful for removing kidneys, since it is less invasive than conventional nephrectomy.
Laparoscopic nephrectomy was carried out on 6 sows in order to develop the procedures of clinical laparoscopic nephrectomy and the equipments necessary for this operation. Based on the animal experiments, it was shown that (1) retroperitoneal approach was difficult due to narrow space. (2) there must be at least 5cm distance between each trocar and 4 or 5 trocars 1cm in diameter were basically required. (3) The procedure consisted of incision and dissection of the peritoneum around the kidney, cutting and ligation of the ureter, dissection along the medial side of the ureter to approach the renal pedicle and clipping and cutting of the renal vessels. (4) The equipments required for this surgery must be functionally equivalent to those used in the open surgery. (5) In addition, the specifically designed equipments, such as a morcellator and an instrument to ligate renal vessels are necessary. The first clinical case of laparoscopic nephrectomy was a 34 years old man with a right non-functioning hydronephrosis due to ureteropelvic junction stricture. The surgery was successfully performed with a 110ml blood loss. It took 7 and half hours because of abundant pen-renal fatty tissue and large extra-renal pelvis. The convalescence was uneventful. Laparoscopic nephrectomy can be applied on selected cases and the development of equipments will make the surgery more popular.
Twe male patients underwent supralevator pelvic exenteration, preserving their normal voiding and evacuating function. Case 1 was a 19-year-old man with pineal region tumor, and a metastatic lesion in the bottom of the rectovesical pouch, possibly through the ventriculo-peritoneal shunt. Following supralevator pelvic exenteration, the construction of double pouches, a colonic J pouch and Mainz pouch to the urethra, were performed. Case 2 was a 39-year-old man with bulky retrovesical tumor. He underwent supralevator pelvic exenteration by sigmoid colo-proctostomy and U-pouch to the urethra. Both patients achieved continent except for urinary leakage at night and were able to defecate and. urinate voluntarily. Urodynamic study revealed that the pressure in their urinary pouches was low.
A case of bilateral renal cell carcinoma with multilocular cysts is described. A 42-year-old female was admitted to our hospital for the purpose of further examination or right renal cystic mass discovered incidentally by ultrasonography. After she was examined by CT-scan and angiography, right nephrectomy was performed under the diagnosis of right renal cancer. Histological diagnosis was multilocular cystic renal cell carcinoma. One year later a small cystic legion was found in the left kidney. Under the diagnosis of left renal cancer, left partial nephrectomy was performed. Histological diagnosis was multilocular cystic renal cell carcinoma same as the right kidney. Multilocular renal cyst is classified into several classes by its style of development. This case of bilateral renal cell carcinoma which grew to be multilocular cysts is the first case in Japan as far as we can search.
A 57-year-old male patient was admitted because of a severe lumbar pain and gross hematuria. The rectal examination revealed a fist-sized soft tissue mass in the small pelvic space. A huge non-papillary tumor, which occupied the intravesical space, was found on cystoscopic examination. CEA IAP, TPA, CA19-9 and NSE were abnormally elevated in the serum. The pelvic CT scan shown an enormous polypoid tumor arising from the anterior vesical wall, while no abnormal lesion was found in the head, neck, chest and abdominal CT scans. The bone scintigraphy revealed multiple abnormal accumulations. The transurethral biopsy of the tumor was carried out. The pathological examination revealed homogeneous and small tumor cells arranged in sheet and solid patterns, which were positive for the anti-NSE stain and anti-NF stain, but negative for Grimelius stain. The final diagnosis was small cell undifferentiated carcinoma of the urinary bladder. The patient died of cancer five months after diagnosis.