(Objectives) Appropriate management of renal trauma is still controversial. Many of the patients have minor injuries and conservative treatment can achieve excellent outcomes without any complications. For major injuries of deep lacerations or ruptures, we have been performing early surgical treatment to salvage the kidney in the selected cases after the precise evaluation of the injury. To obtain the optimal management options, we evaluated the clinical results of our procedures. (Patients and methods) We conducted a retrospective study, which included 106 cases of blunt renal trauma with evident etiology over the past 22 years and 9 months. The severity of the injury was evaluated mainly by CT scanning. The indication of renal exploration included persistent renal bleeding, large hematoma around the kidney, dislocated fragments, nonviable tissue, massive urinary extravasation and vascular injury. With the patients who required an operation, we first controlled the bleeding by clamping the hilar vessels. Then, the final decision whether to repair or remove the kidney was made based on the direct inspection of the injured kidney after the complete removal of the hematoma. The severity of renal trauma was classified by the classifications found in The Organ Injury Committee of the American Association for the Surgery of Trauma. (Results) Sixty-three patients were managed conservatively without any interventions, while 22 surgical repairs and 21 nephrectomies were performed. Of the 63 patients, 35 patients (81.4%) were operated on within 2 days after the injury. Judging from systolic blood pressure, red cell count, blood loss during surgery and transfusion requirements, surgically treated patients were more severely injured than conservatively treated patients. And nephrectomized patients than surgically repaired patients. All the surgically repaired cases were confirmed to have preserved renal functions postoperatively. In all of the 50 patients with Grade I injuries, conservative treatment was successful. Eight out of the 19 Grade II and III cases, who were indicated for kidney exploration because of multiple lacerations or considerable bleeding, were also successfully repaired. Localized hematoma with no urine leakage, even when it was large, settled spontaneously without complication. For the 37 Grade IV and V injuries, including 4 cases with hilar injuries, we implemented conservative procedures on 2 patients, surgical repair on 14 patients and nephrectomy on 21 patients. In the conservatively treated cases, one deep laceration with relatively large, but localized, hematoma, and minimal urine extravasation healed spontaneously. Atrophy of the segment and hypertension developed in the other ruptured kidney with dislocated fragments, large hematoma and urine leakage. This kidney, which also required later surgical exploration, did have good parenchymal blood flow. Hilar injury cases were all resulted in nephrectomy. (Conclusion) In most of our cases the indication for surgical exploration or nephrectomy based on our criteria seemed to be properly decided. Several cases, though, might have received overtreatment. Recent advances in evaluations and strategies of renal trauma have decreased the need for surgical exploration. This may have overreached the indication for conservative management. Severely injured kidneys may be managed conservatively because in most cases bleeding settles after the full formation of large hematoma within the Gerota' s fascia. In such cases, though, no one can predict whether the injury will heal spontaneously or not, and, moreover, whether a complication will develop or not. We think that the optimal management of the patient requires an accurate evaluation of the injured kidney. Therefore the indication for surgical exploration should be made based on the degree of the injury.
(Purpose) The efficacy and toxicity of two-drug therapy (etoposide and cisplatin, EP) in patients with metastatic germ cell tumors were investigated. (Patients and methods) Between December 1996 and November 1999, 18 patients with metastatic germ cell tumors (6 seminomas and 12 non-seminomas, Stage II 8, Stage IIIA 2, Stage IIIB 6, Stage IIIC 2) were treated by 3-5 cycles of induction chemotherapy regimen (EP). Etoposide and cisplatine were administrated in doses of 100mg/m2 and 20mg/m2, respectively, on days 1 to 5 and then repeated from day 21. After tumor markers obtained normal levels, one or two additional cycles of EP were continued. Patients showing evidence of residual tumor mass underwent debulking surgery as early as possible. (Results) At the end of EP therapy, 4 (22%) of the 18 patients achieved complete remission and 14 patients (78%) showed partial remission. Seven patients of partial remission were treated by excision of residual abnormalities: 6 had pathologically necrotic debris in the resected specimen and 1 had teratoma, and these 7 patients all achieved complete remission. Four other patients achieving partial remission were followed without surgical excision and have had no evidence of disease progression. Remaining three patients achieving partial remission received salvage chemotherapy with or without adjunctive surgery, resulted in complete remission in 2 patients and partial remission in 1 patient. EP demonstrated to have less treatment-related toxicity compared with that of EBP. Follow up studies ranging from 12 to 47 months (median, 29.6) showed that one patient experienced a relapse from complete remission at 13 months and was salvaged by chemotherapy and surgery. Finally, thirteen patients (72%) who achieved complete remission are alive and disease-free and 5 patients (28%) showing partial remission are alive with negative tumor markers and no evidence of relapse. (Conclusion) These results suggests that EP is an efficacious and less toxic first line regimen for good-prognosis patients with metastatic germ cell tumors.
(Purpose) We investigated the usefulness of the urinary red blood cell volume distribution curve (RVDC) for screening patients who are positive for asymptomatic urinary occult blood on mass examination. (Subjects and Methods) The subjects were 200 individuals over 40 years old (44 men with a median age of 53.4 years and 156 women with a median age of 57.2 years) who were positive for urinary occult blood on mass examination between January 1993 and December 1994. The subjects were classified into three groups based on the pattern of their RVDC. Group NG showed a nonglomerular pattern, group M showed a mixed pattern, and group G showed a glomerular pattern. The urological examinations performed included DIP, ultrasound of the kidney and urinary bladder and urethrocystoscopy. To investigate the prognosis, a questionnaire was sent to all subjects in September 1999 in which they were asked about the state of their disease during the period since the initial examination. (Results) Group G consisted of 192 patients, or almost all of the subjects (96%). There were five patients (2.5%) who had serious urological diseases, including two with bladder cancer, and all were found in Groups NG and M. During the period from initial examination until the prognosis survey (mean of 5.7 year), one patient in group G developed both bladder and ureteral cancer. The CVDC showed a mixed pattern when this patient was discovered. (Conclusion) RVDC was useful for screening patients who were found to be positive for urinary occult blood on mass examination. When the RVDC shows a non-glomerular or mixed pattern, detailed urological examination including endoscopy is necessary.
(Objectives) In this study, we investigated MHC-class I expression on both prostate cancer and normal prostate and compared those data with the number of CD8+ lymphocyte. Secondary, we investigated effect of IFN-γ to the MHC-class I expression on prostate carcinoma. (Materials and methods) Twenty cryo-preserved benign prostate samples (Seven normal prostates and five benign prostatic hypertrophy samples.) and fifteen prostate carcinoma samples were used for immunohistochemistry of CD8 and MHC-class I. Eleven fresh single cell suspensions of prostate carcinoma were used for IFN-γ study. After 24 hours IFN-γ stimulation, MHC-I expression was measured by FACs analysis. (Results) Interestingly, significant correlation was observed between MHC-class I expression and the CD8+ lymphocyte infiltrate (r=0.705, P<0.0001). After 24hrs IFN-γ stimulation, MHC-class I expression was up-regulated in all samples (p<0.05). (Conclusion) Reduced expression of MHC-class I was thought as one of the factor which is related to the reduced degree of TILs (tumor infiltratig lymphocytes) in prostate cancer. IFN-γ which is secreted mainly from CTL (cytotoxic T lymphocyte) might increase the degree of TIL through upregulated MHC-class I.
(Purpose) The chronic prostatitis syndromes are common disorders in urologic practice and present various clinical symptoms. The development of a chronic prostatitis symptom index appropriate for judgment of therapeutic effects is awaited since the pathophysiology and appropriate treatment are not well defined so far. We developed a Japanese version of the National Institutes of Health Chronic Prostatitis Symptoms Index (NIH-CPSI, Okayama version), and examined its usefulness. In addition, we evaluated clinical effects of Cernilton® for chronic nonbacterial prostatitis using this symptom index. (Subjects and methods) A total of 87 patients including 34 patients with NIH chronic prostatitis category III, 35 patients with BPH and 18 patients for control group who visited the Department of Urology at Okayama University Medical School filled in the questionnaire of our Japanese version of the NIH-CPSI to compare the NIH-CPSI scores among three groups. Twenty-four patients with NIH chronic prostatitis category III (IIIa 16, IIIb 8) were treated with Cernilton® and the NIH-CPSI scores were examined before and after its administration. (Results) The pain/discomfort domain score was 9.79 (mean) in the chronic prostatitis group, 1.66 in the BPH group and 0.39 in the control group; that of the urinary symptom domain was 3.82, 3.29 and 0.72, respectively; and that of the quality of life (QOL) was 8.21, 4.17 and 1.39, respectively. The pain/discomfort domain score was significantly higher in the chronic prostatitis group than in the other groups; the QOL domain score was higher in the order of the chronic prostatitis group, the BPH group and the control group. In the chronic prostatitis group, there was a significant, positive correlation between the pain/discomfort domain score and that of the QOL, and between the urinary symptom domain score and that of the QOL. These results suggested the usefulness of our Japanese version of the NIH-CPSI as a parameter of the severity of chronic prostatitis. Examination of changes in the NIH-CPSI scores revealed that scores of the items in all domains were significantly lower 4 to 6 weeks after the start of administration of Cernilton® than those obtained before the drug administration in patients with chronic prostatitis. (Conclusions) A Japanese version of NIH-CPSI (Okayama version) accurately reflects clinical symptoms and the QOL in patients with chronic prostatitis. It seemed to be a useful and appropriate system for scoring symptoms of chronic prostatitis, indicating further studies on translation, adaptation and validation of the NIH-CPSI in Japan.
(Background) To determine whether the immunosuppressive acidic protein (IAP) could be a useful marker for renal cell carcinoma (RCC), serum IAP levels were compared with clinicopathological features in RCC patients. Furthermore, IAP cutoff level to predict the recurrence was determined using receiver operating characteristics (ROC) curve analysis. (Patients and Methods) Between January 1994 and December 1998, pretreatment serum IAP was measured in 123 consecutive patients with PCC at Kitasato University Hospital. Ninety-eight patients were received radical surgery and 86 patients were performed as clinically curable renal cell carcinoma (pT1-pT3N0M0). ROC curve analysis was utilized to set the cutoff value of IAP for prediction of cancer recurrence. Significance of prognostic factors in RCC recurrence was analyzed by Cox proportional hazard model. (Results) The mean age of the 123 patients was 58.6 years (range 33 to 90, median 59). The mean follow-up period was 24.8 months (range 1 to 78, median 26). The median IAP levels were 447ug/ml in stage I, 629ug/ml in stage II, 588ug/ml in stage III and 1, 150ug/ml in stage IV (p<0.05). Tumor size and venous involvement were significantly associated with IAP concentrations (p<0.05). However, tumor grade did not correlate with IAP level. Of 86 patients with clinically curable tumor, 79 patients were disease-free after median follow-up of 27 months. Using ROC curve analysis, IAP cutoff level for prediction of cancer recurrence was set at 620ug/ml. Disease-free survival rate in patients with preoperative TAP levels of 620ug/ml or lower was 98.5% (67/68) at 27 months postoperatively, whereas that in patients with TAP greater than 620ug/ml was 75.0% (12/18). This difference was statistically significant (p<0.05). Results of multivariate analysis revealed that preoperative TAP and pT stage were statistically significant factors for tumor recurrence after radical surgery (p<0.05). (Conclusions) The present study indicates that preoperative IAP level is a useful prognostic marker in patients with RCC. In particular, patients with clinically curable tumors (pT1-3N0M0), whose preoperative IAP levels greater then 620ug/ml may have high risk for recurrence after radical nephrectomy.
(Purpose) We retrospectively assessed the surgical outcomes of nephron-sparing surgery (NSS) for patients with renal tumors. (Patients and methods) From 1985 to March 2001, a total of 99 NSSs were performed on 94 patients with renal tumors. The patients were divided into three groups. Group I comprised of 22 patients who underwent imperative surgeries for renal cell carcinoma (RCC). The tumors were found in 18 patients bilaterally (including 8 patients with von Hippel-Lindau disease), in 3 with solitary kidney, and in 1 with chronic renal failure. The mean±standard deviation of patient age and tumor diameter was 46±23 years and 36±23mm, respectively. Twenty-three in situ NSSs were performed on 18 patients in Group I, and the remaining 4 patients were treated with 3 simultaneous operations for bilateral renal tumors with or without 2 ex vivo surgeries. Group II consisted of 49 patients who had small RCCs with the normal contralateral kidney and underwent NSSs (elective indication). The mean age and tumor diameter was 54±10 years and 28±11mm, respectively. Group III consisted of 23 patients with non-RCC tumor (10 angiomyolipomas, 8 cystic tumors, 2 adenomas, 2 metastatic tumors, and 1 degenerative lesion), all of whom were treated with NSS. The mean age and tumor diameter was 47±14 years and 41±29mm, respectively. (Results) In Group I, 3 patients died of cancer including 2 patients who had had multiple lung metastases preoperatively. The five-year tumor specific survival rate was 87.3% with a postoperative follow-up of 49±36 months. In Group II, there were few peri-operative complications or no local recurrence at follow-up of 52±38 months. A patient developed lung metastasis, which was removed surgically with no evidence of recurrence at 159 months after NSS. Postoperative renal scintigraphy on 35 patients showed well-preserved renal function of the operated kidney. Improvement in surgical techniques resulted in less-invasive surgery in 22 operations during the last 4 years. The patients of Group III were also operated uneventfully, although 1 experienced postoperative bleeding. In 12 patients with solitary kidney (11 in Group I and 1 in Group III) serum creatinine level increased transiently, decreased to 1.3 times of preoperative values within 3 months, and almost recovered at 1-year follow-up. (Conclusion) Excellent outcomes in cancer control and preservation of renal function support the validity of nephron-sparing surgery to treat renal tumors. The candidate patients may include those with bilateral kidney tumors, tumors occurring in the solitary kidney or small renal cell carcinomas with the normal contralateral kidney. Earlier detection of small lesions and less invasive surgical techniques will facilitate a wider indication of NSS.
(Purpose) There are many reports about the usefulness of transrectal power-Doppler ultrasonography (PDUS) for detecting prostate cancer because of the high microvessel density in cancerous tissue in the prostate. The purpose of this study was to assess the role of PDUS and contrast-enhanced transrectal power-Doppler ultrasonography (enhanced PDUS) in the identification of prostate cancer. (Materials and Methods) One hundred forty-two cases (90 cases without enhancement, 52 cases with enhancement) of suspected prostate cancer found with digital rectal examination (DRE), transrectal ultrasound (TRUS) abnormal or prostate specific antigen (PSA) elevation were evaluated by PDUS and enhanced PDUS. (Results) Forty-three (30.3%) cases of cancer were detected, and there was a significant difference (p<0.05) between PDUS group (22 cases, 24.4%) and enhanced PDUS (21 cases, 40.0%). However, there were no significant statistical results about the usefulness of enhancement to detect prostate cancer although imaging was clear with contrast agent. The results of statistical analysis of PDUS use were almost the same as for PSA of more than 10.1ng/ml. Combination with PDUS was very helpful to detect prostate cancers. The positive predictive value of the combination with DRE, TRUS and PSA improved from 68.0% to 81.0% with the addition of PDUS. In particular, cancer was revealed frequently (65.8%) in peripheral hypoechoic lesions on gray-scale TRUS with hypervascular areas on PDUS. (Conclusions) We conclude that enhancement with contrast agent is not especially useful in the identification of prostate cancer although imaging was clear with contrast agent. However, PDUS is useful especially for hypoechoic peripheral areas. It is suggested that we should add PDUS to DRE, TRUS and PSA examinations.
We report two cases of priapism with metastases to the penis. The first case was a 52-year old man, diagnosed as suffering from gastric cancer by endoscopic biopsy five years previously, but for whom no treatment was performed. He visited our office due to priapism with a duration of 11 days. Physical examination showed two palpable mass lesions on the glans. A glansocavernosum shunt (Winter shunt) was performed, but this was not effective. Radiotherapy was also ineffective. Pathological analysis revealed gastric cancer metastasis to the penis and this was diagnosed as the cause of the priapism. He died of respiratory failure on postoperation day 28. The second case was a 64-year old man with kidney cancer. Hemodialysis had been performed due to chronic renal failure for 20 years and visited our office due to priapism from which he had suffered for 30 days. Computed tomography (CT) demonstrated a left renal cell cancer and metastasized to the retroperitoneal lymph nodes. A Winter shunt was performed on the penis and then a cavernosospongiosum anastomosis was done. The priapism improved about 40%. Pathological analysis confirmed that the renal cell cancer had metastasized to the penis and this was concluded to be responsible for the priapism.
A large calculus (6.0×4.5×7.0cm sized) in the continent urinary pouch was detected incidentally by computed tomography in a 7-year-old man with a gall bladder stone. He underwent a total cystectomy and Mainz pouch formation using appendix as the effernt limb for bladder cancer 7 years ago. Urine culture showed Proteus mirabilis and Escherichia coli, and urine pH was 8.5. The stone was removed successfully through a pouchotomy and composed mainly of struvite. The stone analysis was MAP; 88% and CaCO3; 12%. Convalescence was uneventful. This is the first case of in Mainz pouch using appendix as the effernt limb.
In Japan, freeze-dried live attenuated mumps vaccine has been used optionally since 1981. The effectiveness of mumps vaccination has been established by worldwide research since 1971. On the other hand, because of it's live activity several untoward effects have been reported. Vaccinationrelated mumps orchitis is a rare adverse effect of mumps vaccine. Only 9 cases of vaccination-related mumps orchitis have been reported in Japan. We describe a case of orchitis following mumps vaccination in adolescence. A 16 years-old male has admitted because of acute orchitis with high fever and painful swelling of right testis. The patient had received vaccination with freeze-dried live attenuated mumps vaccine 16 days before admission. After admission, the bed-rest had completely relieved the symptoms on 6th hospital day. The impaired testis has maintained normal size and consistency 6 months after discharge.
Bacillus Calmette-Guérin (BCG) immunotherapy is increasingly being accepted for management of some bladder transitional cell neoplastic lesions. Mild adverse reactions occur frequently. However, an unusual complication of tuberculous epididymitis is reported. A 64-year old man presented with bilateral epididymal mass. Four months earlier he had seven treatments with intravesical BCG instillation (Tokyo 172 strain) for a grade 2 transitional cell carcinoma in situ. Bilateral epididymectomy was performed. Microscopic examination of the epididymis revealed chronic inflammation and necrosis with granulomas and Langhans' giant cells. After the operation, there were no further complications.
A rare case of retroperitoneal bronchogenic cyst is presented. A 50-year-old man was referred to our hospital for an investigation of a retroperitoneal mass. Computed tomography and magnetic resonance imaging confirmed a retroperitoneal mass, about 4cm in diameter, adjacent to the left kidney and spleen. On the basis of these imaging modalities, a definitive diagnosis of this mass could not be made. So, resection of the mass was performed. The removed mass was an unilocular cyst and filled with mucinous fluid. Histopathologically, the cyst wall was composed of a fibrovascular connective tissue containing mucus-secreting glands and cartilages and was lined by ciliated pseudostratified columnar epitherium. Thus, a diagnosis of bronchogenic cyst was made. Bronchogenic cysts are rare congenital anomalies of the primitive foregut and usually develop in the mediastinum and lung.
A 28-year-old man visited our hospital complaining of the ulcerous lower extremity. An angiography showed the stenosis of the dorsal digital artery. The clinical diagnosis was Buerger's disease. The administration of prostaglandin I2 (PG I2) and antithrombotic drug were done. The ulcerous lower extremity improved. But a computerized tomographic scan of the abdomen showed the bilateral hydronephrosis incidentally. A retrograde pyelography (RP) revealed the bilateral ureteral strictures. We suspected the etiology was the retroperitoneal fibrosis associated with Buerger's disease.