(Background) The conventional surgical treatment for vesioureteral reflux (VUR) in spina bifida patients is ureterocystoneostomy. Various newer therapies, including augmentation enterocystoplasty and minimally invasive subureteral collagen injection, have been introduced. However, all of these procedures have specific advantages and disadvantages, and no guidelines for deciding on the surgical treatment of VUR in spina bifida patients have yet been established. In this study, the longterm outcome of the Cohen procedure, a method of ureterocystoneostomy, was examined. (Patients and methods) Among spina bifida patients in whom VUR was treated by the Cohen procedure alone from 1984 to 1989, 27 patients who could be followed up for 5 years or longer were enrolled in the study (11 males and 16 females, with a mean age of 13.4 years at surgery). In principle, they were followed up using annual cystography, excretory urography, and blood and urine tests. At the final assessment, they were examined for the presence at VUR and for morphological abnormalities of the urinary tract. Their renal function was also assessed. They were followed for 6 to 13 years (mean: 8.9 years), and the mean age at final assessment was 22.2 years. (Results) Among 42 ureters in the 27 patients examined, 38 ureters (90.5%) in 22 patients (81.5%) did not have VUR postoperatively. Four ureters in 4 patients had the recurrence of VUR, and in another patient new cccurrence was detected postoperatively. Augmentation ileocystoplasty was performed to treat the postoperative decrease of bladder compliance in 4 patients. Among 22 patients who had hydronephrosis preoperatively, 9 (40.9%) showed improvement and none suffered from aggravation of this condition. None of the patients showed a decline of renal function, except for 1 who had a serum creatinine of 2.5mg/dl preoperatively and developed end-stage renal failure at 7 years postoperatively. (Conclusions) The Cohen procedure has an excellent anti-reflux effect. It is one of the therapeutic options for VUR in patients with good bladder compliance.
(Objective) To study the feasibility of vaporization prostatectomy by potassium-titanyl-phosphate (KTP/532) laser in men with bladder outlet obstruction due to benign prostatic hyperplasia (BPH) and to evaluate their clinical and voiding outcome 2 weeks and 6 months after operation. (Patients and methods) Laser vaporization prostatectomy with the KTP/532 laser at 20W was performed in 21 BPH patients varying from 56 to 75 years of age. All cases were performed under the spinal anesthesia. The laser was produced by MODEL SL20/50™ and ADD/Stat™ side-firing fibers were used. A urethral catheter was inserted post-operatively and was removed within 6 days after operation. The hemoglobin value was examined on the first day after operation and uroflowmetry was executed 2 weeks and 6 months after operation with the examination of the residual urine volume. IPSS and QOL score were recorded by patients 2 weeks and 6 months after operation. (Results) The prostate volumes ranged from 22 to 52mL (mean 37.3±10.4). None of the 21 patients had any significant blood loss or any fluid absorption. The voiding parameters improved: mean peak flow rate increased from 7.1 to 16.5mL/s 2 weeks after operation and to 15.2mL/s 6 months after operation and residual volume decreased from 172 to 45mL 2 weeks after operation and to 43mL 6 months after operation. IPSS and QOL score improved significantly in Wilcoxon signed-ranks test. The ratio of excellent and good in efficacy criteria of Kawabe group was 71.4% 2 weeks after operation and that was 71.4% 6 months after operation. Mean catheterization term was 4.5 days. Only one patient showed transient urinary retention when the catheter was removed the third postoperative day. None had incontinence postoperatively. No other significant complications were recognized. The prostate volume was more than 50mL in 3 cases and the postoperative 6 months outcomes of the 3 cases were all poor in their symptoms in the efficacy criteria of Kawabe group. (Conclusions) KTP laser vaporization prostatectomy is safe and effective for obstructive prostates up to 50mL in volume and produces good results 2 weeks post operatively that are sustained for 6 months after operation.
(Purpose) In 1998 Guillonneau et al reported feasible and safe technique for laparoscopic radical prostatectomy. Herein we review initial 5 cases with using the Montsouris technique. (Materials and Methods) Between January and April 2000, 5 patients underwent transperitoneal laparoscopic radical prostatectomy. Clinical stages were T1c in 2, T2a in 1 and T2b in 2 patients. Preoperative PSA levels and Gleason grades in needle biopsies ranged from 7.9 to 39ng/ml and from 2 to 6, respectively. Under general anesthesia 5 to 6 trocars were introduced and the patient was placed in the exaggerated Trendelenburg position. In 2 patients bilateral obturator lymph nodes were dissected for frozen pathological examination. Antegrade prostatectomy was performed initiating with the transperitoneal dissection of seminal vesicles. A watertight vesicourethral anastomosis was made with 8 to 10 interrupted sutures. (Results) Operating time and blood loss ranged from 505 to 925 minutes and from 100 to 700gm, respectively. There were no intraoperative complications and one postoperative complication of prolonged urinary leakage, which was spontaneously closed. In other 4 patients Foley catheters were removed on postoperative day 6 to 10. (Conclusions) Laparoscopic radical prostatectomy provides better visualization, inducing meticulous surgical procedures and less blood loss. More sophisticated maneuver would be required in dissection between the prostate and the bladder neck.
(Purpose) To characterize age-related clinical and urodynamic features of patients with benign prostatic hyperplasia (BPH) treated by transurethral resection of the prostate (TUR-P). (Materials and Methods) Between July 1994 and March 2000, a total number of 451 patients underwent TUR-P in Nagoya Urology Hospital. Out of these 451 patients, 15 (3.3%) were diagnosed as having an incidental prostate cancer on pathological examination of resected prostate tissue. The remaining 436 patients (48-92 years, 69.8±7.4 years), in whom 196 (45.0%), 208 (47.7%) and 32 (7.3%) were ≤69, 70-79 and ≥80 years, respectively, were subjects for the present study. Their clinical features before and after TUR-P and the therapeutic effects of the treatment were evaluated in terms of aging. (Results) Among preoperative variables evaluated, IPSS in patients aged ≤69 years was significantly higher than in those aged 70-79 years (p<0.05). The QOL index was significantly higher in patients aged ≥80 years than in those aged 70-79 years (p<0.05). The maximum bladder capacity decreased with age from 276ml in patients aged ≤69 years to 211ml in those aged ≥80 years. Postoperatively, both maximum and mean flow rates were significantly lower in patients aged 70-79 and ≥80 years compared to those aged ≤69 years. There was, however, no significant age-related difference in IPSS and QOL index. The assessment of treatment effects at 3 months following TUR-P revealed that the outcomes in function as evaluated by uroflowmetry, anatomy and ultrasonic measurement of prostate volume were significantly worse in patients aged ≥80 years compared to those in younger patients. However, there was no significant age-related difference in outcomes in subjective symptoms and QOL. (Conclusions) TUR-P could be performed safely even in patients aged ≥80 years. It is concluded that although postoperative urinary condition might be worse in older patients, they would nevertheless be satisfied with the results of TUR-P in the same way as less aged patients. As long as subjects are selected properly based on the correct diagnosis of BPH and a sufficient evaluation of operation risks, TUR-P can be expected to be performed safely and be followed by satisfaction with the treatment effects.
(Purpose) We investigated the results of Le Duc-Camey procedure as a method of ureteroileal implantation on augmentation cystoplasty in patients with myelodysplasia. (Materials and Methods) A total of 14 patients (25 renal units) underwent ureteroileal implantation with Le Duc-Camey procedure on augmentation cystoplasty. The possible causes of complications concerning ureteroileal implantation that developed during the postoperative observation were classified as preoperative factors and postoperative factors.: The preoperative factors were the causative disease required ureteroneostomy, the grade of preoperative VUR, and the ureteral diameter at the anastomosis with the ileum.: The postoperative factors were the volume, and the compliance of the urinary bladder, and the maximum intravesical pressureled by the peristalsis of the utilized intestine. (Results) With the mean observation period of 31.6months, no complications developed but VUR observed in 4 renal units of 4 patients. The patients with VUR had a larger ureteral diameter at the anastomosis site to the ileum among the preoperative factors and a signific antly larger maximum in-travesical pressure led by the intestinal peristalsis among the postoperative factors when compared with the patients without VUR. (Conclusion) Regarding ureteroileal implantation with Le Duc-Camey procedure on augmentation cystoplasty in patients with myelodysplasia. It seems necessary to consider some countermeasures for the dilated ureters and for the unexpected 2 elevation of intravesical pressure due to the peristalsis of the utilized intestine.
A 62-year-old man was admitted to our hospital with the chief complaint of terminal macroscopic hematuria. He had a history of left tuberculous epididymitis in 1994. On digital rectal examination, the prostate was found to be a normal size and slightly hard with no elasticity. Transcrectal ul-trasound showed hypoechoic lesions in the peripheral zone. T1-weighted MRI demonstrated cavitary lesions and T2-weighted MRI demonstrated relatively low signal intensity in the same zone. Urethrography revealed various cystlike lesions in the prostatic urethra. Cystourethroscopy revealed cavitary change with many septa in the left lobe of the prostate. TUR-P was performed and histological findings of the specimen revealed tuberculosis of the prostate. The patient was treated with an antituberculous regimen of INH, RFP and EB.
A 69-year-old female was admitted to hospital with the complaint of high-grade fever and clouding of consciousness. Physical examination and laboratory data revealed septic shock, disseminated intravascular coagulation and multiple organ failure. Ultrasonography demonstrated left hydronephrosis and a cystic mass in pen-renal fatty tissue. KUB showed a left ureteral stone. A diagnosis of septic shock due to pyonephrosis-calculosa and peri-renal abscess was considered. A left nephrectomy, endotoxin removal therapy and continuous hemodiafiltration was performed. Thereafter all morbidities improved. A nephrectomy and intensive treatment are the good alternative method for such a case.
A 61-year old man visited our hospital with a painless swelling of right scrotal contents as the chief complaint. Transillumination test of the right scrotal contents was negative, and a quail's egg sized, elastic hard and smooth induration in the right testis was palpable. The laboratory data were normal except for slightly elevated E. S. R and CRP. Urine examination was normal. Although not only tumor marker, β-hCG, AFP and LDH but also Plain lung X-ray, DIP and CT were normal, ultrasonography and MRI revealed a well-defined nodule in the right testis. Under the diagnosis of right testicular tumor, right high orchiectomy was performed. A yellowish white nodule of 2.5cm in diameter was found in the slightly enlarged right testis. Pathologically, the patient was diagnosed as having tuberculotic granuloma with necrotic caseation. However, the epididymis was histologocally normal. After operation, an antitubercular medication was started. Subsequently, E. S. R and CRP became normalized. At present, 12 months after surgery, the recurrence is not found. Tuberculosis of testis which shows no lesion in the epididymis is very rare, and ours is the first reported case in the Japanese literature. The importance of tuberculosis as a revival infection should be recognized in social circumstance in which tuberculosis is begining to spread again.
An 82-year-old female presented with asymptomatic gross hematuria in June 1997. Urethrocystoscopy revealed a multiple papillary tumor of the bladder and posterior urethra. Histology of the punch biopsy specimens of the tumor revealed transitional cell carcinoma (TCC), grade 2 (G2). CT scan showed no distant metastasis and extravesical invasion. The patient was treated by intravesical instillation of adriamycin (ADM), drip infusion of low dose cisplatin (CDDP) and irradiation of the bladder. As the treatment caused a significant tumor shrinkage, transurethral resection of the tumor was performed. Histologically, the tumor revealed no invasion to the muscular layer of the bladder. In April 1998 she noticed genital bleeding, and a multiple papillary tumor was found on the vaginal wall. Histology of punch biopsy specimens of the vaginal tumor showed non-invasive TCC, G2. MRI and specimens of all layer needle biopsy showed no infiltration outside the bladder wall and the vaginal wall. Irradiation of the cavity of the vagina and uterus was made under the diagnosis of superficial vaginal TCC. We assume that vaginal implantation via irrigating fluid or urine has occurred.