(Purpose) We report the clinical results and efficacy of laparoscopic radical prostatectomy for localized prostate cancer. (Patients and methods) Between December, 1999 and June, 2000 we performed transperitoneal laparoscopic radial prostatectomy on 10 patients with T1 or T2 organ confined prostate cancer according to the techniques as described by Guillonneau et al. Different points were as follows: 1) We placed double J catheters during surgery to prevent ureteral injury. 2) We treated dorsal vein complex using an Endo-GIA-stapler. 3) We dissected the bladder neck from the prostate using an ultrasound scalpel in the manner to preserve the bladder neck. (Result) We could not completed laparoscopic prostatectomy on two patients because of massive bleeding from drosal vein and consuming too much time to suture urethra-bladder anastomosis. The average operating time in all cases was 8.1 hours including 1.8hours in laparoscopic pelvic lymphadenectomy. The average estimated blood loss in all cases was 859ml. There were 2 surgical complications with bladder injury and port site hernia. The histological examination revealed prostate cancer; pT2pNO in 8, pT3pNO in 2. The surgical margin and lymph nodes were negative in all patients. The duration of an indwelling catheter ranged from 5 to 40 days mean 17 days. The duration to recovery of normal micturition was 6 to 90 days, mean 40 days. (Conclusion) Long-term follow-up and extensive studies are necessary to evaluate the efficacy of this procedure. It might provide shorter duration of an indwelling catheter and earlier recovery of normal micturition as compared with the conventional open surgery.
(Purpose) We examined the usefulness of prostate specific antigen density (PSAD) for selection of biopsy candidate with prostate specific antigen levels between 4.1 and 10.0ng./ml. in prostate cancer screening retrospectively. (Materials and methods) The screening was conducted on male candidates in Natori city, aged 55 years or older, for 6 years from 1994 through 1999. We could analyze serum PSA levels and PSA density in 118 men with PSA levels between 4.1 and 10.0ng./ml. All of 118 men underwent ultrasound guided systematic prostate biopsy regardless of findings of digital rectal examination and transrectal ultrasound. Prostate volume was estimated by transrectal ultrasound measurements using the prolate ellipse formula (π/6×length×width×height). PSAD was calculated by dividing serum PSA level by prostate volume. Serum PSA levels were determined by Tandem-R assay. (Results) In 118men, twenty-five men had prostate cancer. There was no significant difference in mean PSA between those with prostate cancer and those without prostate cancer, but the difference was significant in the mean PSA density (mean 0.26 and 0.16. respectively, p<0.0001). Receiver operating characteristic curves for PSA and PSAD demonstrated superior benefit for PSAD in 118 men. A sensitivity, a specificity, a positive predictive value and a negative predictive value of PSAD cut-off of 0.15 were 88%, 52.7%, 33.3% and 94.2%. PSAD cut-off of 0.18 showed the highest sum of sensitivity and specificity, which gave a sensitivity of 80%, a specificity of 72%, a positive predictive value of 43.5% and a negative predictive value of 93.1%. PSAD cut-off of 0.15 would seem to be preferable to cut-off of 0.18 because of less cancer missing. (Conclusions) Although further studies are needed to determine optimal cut-off value to be used in clinical practice, PASD seems to be useful for the selection of biopsy candidates with PSA levels of 4.1 to 10.0ng./ml. in the prostate cancer screening.
(AIMS) To review our experience of neonates with unilateral multicystic dysplastic kidneys (MCDKs) and to plan how to manage this anomaly. (PATIENTS and METHODS) Forty-eight neonates (30boys, 18girls) with unilateral MCDK were referred to our institute between August 1991 and Februaly 1999. Urological evaluation was performed by USG, VCUG and radionuclide study. Follow-up period was 15 month to 106 months (Ave. 54months). (RESULTS) Forty-five of 48 (93.8%) MCDKs were found prenatally. No surgical procedure was performed in utero. Seven (14.6%) had low grade vesicoureteral reflux (ipsilateral 5, contralateral 2). Dilation of contralateral upper urinaly tract was detected in 16 (33.3%) neonates and diuretic renography revealed 4PUJ obstruction and 2mid-ureteral stenosis. Althouth 29 of 48 (60.4%) MCDKs were large, no neonate showed mass effect which caused vomiting or dyspnea. All MCDKs except two, which removed because of ipsilateral ureterocele or ectopic ureter, were followed conservatively. Two boys had nephrectomy when they became 5-year-old on their parent's request. Surgical correction of contralateral urinary tract anomaly, 3 pyeloplasty and 2 end-to-end ureteral anastomosis, was performed. All neonates but one with contralareral hypodysplastic kidney had good renal function. Neither hypertension nor malignant tumor had occurred. (CONCLUSION) These findings suggest that neonates with unilateral MCDKs can be treated conservertively only if they have no contralateral serious anomaly. Surgical intervention is not nessesery for unilateral MCDKs before and after birth but socially and/or economically it depends on patients' request.
(Objective) We evaluated the efficasy of betamethasone ointment in the treatment of childhood phimosis and determined the most effective concentration of betamethasone. (Material and Methods) Between August 1996 and May 2000, 69 patients (median age 3.0, range 0-12) presented to our department with severe phimosis (grade 4, Tsugaya's classification), and were enroled in this study and treated with betamethasone ointment for 4 weeks. The ointment was applied on the narrowed preputial skin twice a day by parents. During the first week, parents were asked not to retract the foreskin. After this period, parents were encouraged to retract the foreskin gently and without intense tension. The concentration of betamethasone were 0.12%, 0.05% and 0.025%. If the patients become to be able to retract foreskin satisfactory, we consider the state as complete response. If he become to be able to retract to allow partial exposure of the glans, we consider the state as partial response. We compared the efficacy among each of the concentrations, and at 3 months after the end of the treatment, we also assessed the adverse effects and recurrence. (Results) The overall success rate was 85.5%. Success rates with 0.12%, 0.05% and 0.025% ointment were 96.8%, 82.8% and 55.6%, respectively (p=0.0001). The 0.12% ointment was most effective. Recurrence was observed in 3 patients (4.3%). No adverse effects were observed in any of the patients. (Conclusions) Treatment with betamethasone ointment is very effective, easy and safe. We recommend betamethasone ointment as the first treatment of choice for childhood phimosis.
A 70 year-old male was seen at the hospital with the chief complaints of frequent miction and incomplete urinary retention. A hen's egg-sized firm mass was palpable in anterior wall of rectum by digital rectal examination. Intravenous urography showed severe bilateral hydronephroureter. Transrectal ultrasouud, CT scan and MRI revealed a mass with 5cm in diameter between prostate and rectum, and the margin of them were unclear. On needle biopsy of the tumor, leimyosarcoma of the prostate was suspected. We performed radical cytectomy and created continent urinary reserver. Because the tumor and rectum could not be lysed, part of the rectum was resected. Histological examination showed gastrointestinal stromal tumor (GIST) of rectum. GIST of rectum is a rare entity, and in case of contact with the prostate, it is difficult to differentiate from leiomyosarcoma of prostate.
Skin metastasis of internal carcinoma is a rare situation and its risk is reported as 0.7-9%. The site of skin metastais is more popular at upper part of the body such as neck and face. We report a case of perineal and penile skin metastases of gastric carcinoma associated with prostatic carcinoma. A 72-year-old man, who underwent total gastrectomy for gastric carcinoma 4 years ago, was found to have sclerotic change at perineal and penile skin. As his serum PSA level was 10.6ng/ml, trasrectal prostate biopsy and penile skin biopsy were performed. The prostate tissue pathologically demopnstrated moderately differentiated adenocarcinoma and it was positive for both anti-PSA and anti-CEA antibody by immunohistochemical staining. The skin tissue was found to be infiltrative adenocarcinoma, negative for PSA and positive for CEA, which was compatible with the primary gastric carcinoma specimen. The patient had been treated for 7 months with administration of Doxifluridine and injection of LH-RH agonist, but died for progression of gastric carcioma. A risk of skin metastasis of gastric carcinoma is reported as 6%, however, its metasyasis to perineal and penile skin is the first case reported in the literature.
Neuroblastoma, common in children, rarely develops in adults. We recently treated a patient with adult neuroblastoma. A 34-year-old man complained of a swelling in right inguinal region. CT scan showed swelling of retroperitoneal and inguinal lymphnodes, and bone scintigram by 99mTc-HMDP showed an abnormal uptake in the swollen lymphnodes. Chemotherapy with CDDP (cisplatinum), VP-16 (etoposide), BLM (bleomycin), ADM (adriamycin) was not effective. Histopathological examination of a biopsy speicmen revealed neuroblastoma. Another chemotherapy with CPM (cyclophosphamide), VCR (vincristine), ADM, DTIC (dacarbazine), CDDP, VP-16 was effective in decreasing the tumor size. Further high dose chemotherapy with CPM, ADM, CDDP, VP-16 combined with peripheral blood stem cell transplantation led to almost complete disappearance of the tumor and normalization of blood tumor markers (neuron specific enolase and immunosuppressive acidic protein). Retroperitoneal lymphnode dissection demonstrated well-differntiated neuroblastoma in the excised tissue. Six months postoperatively, the tumor recurred in the pelvic cavity. Although chemotherapy and radiotherapy were given, he died of the disease 12 months postoperatively.
We report a case with a large bladder diverticulum caused by the bladder outlet obstruction, which was successfully treated with laparoscopic extraperitoneal diverticulectomy. The patient was a 71-year-old man, who had had dysuria, mictrition pain and cloudy urine. We found the patient to have benign prostatic hyperplasia and a large diverticulum of the bladder. We removed the diverticulum by laparoscopic procedure and then the prostate by transurethral resection on September 24th, 1998. Before the diverticulectomy, we placed a ureteral stent in the left ureter and 8Fr Foley catheters in the diverticulum and bladder. A working space was made by dilation using a balloon dilator. After removing the diverticulum, we made 5 stitches to close the bladder wall. After the surgery, a 22Fr Foley catheter was placed and removed on the 9th postoperative day. Patient had a satisfactory micturition and was discharged on the postoperative 15th day. Laparoscopic diverticulectomy might be a modality for symptomatic bladder diverticulum, because it is minimally invasive and can completely remove bladder diverticulum.
We studied the renal transplant blood flow using an ultrasonic contrast agent. The contrast medium was injected intravenously and produced blood flow enhancement for at least 60 seconds. Measuremements were made from the recorded Doppler spectra. Fourteen renal transplant recipients were inverstigated by color Doppler echography. Blood flow in the interlobular artery could be analyzed in all patients using a contrast, agent, as compared with 2 patients (14%) by a conventional method. The average maximum and minimum flow velocity of the interlobular arteries were 0.15m/sec and 0.04m/sec. In conclusion, an ultrasonic contrast agent is useful to accurately evaluate peripheral blood supply in renal transplants.