(Purpose) Laparoscopic nephrectomy is being employed in renal transplantation because of its minimal invasiveness, and several modifications in surgical procedures have been proposed. We devised a new technique of retroperitoneoscopic hand-assisted nephrectomy (RHAN) for live donor. We report the early experiences with this technique in 5 cases of live renal graft donor. (Techniques and Subjects) The donors are placed in a modified decubitus position under general anesthesia, and all the laparoscopic surgical procedures were performed retroperitoneally using 3 port sites and a sealing device (LAP DISC™) under a pressure of 10mmHg. The LAP DISC™ is placed through a para-rectus abdominal skin incision of approximately 8cm in length into the retroperitoneal cavity and used as a rout for instrumental as well as hand-assisted manipulations during the surgery. The hand-assistance through the LAP DISC™ made the surgical manipulation considerably easier and allowed the immediate removal of the graft after the interruption of the renal blood flow. This procedure was applied to 5 subjects, 4 in the left and one in the right kidney. (Results) The operating data were 264-359min for operating time, 0.9-3.9min for warm ischemic time and 40-755ml for intra-operative blood loss, respectively. The serum creatinine level of the recipients at day 7 was 0.9-2.7mg/dl. These values, except for operating time, were at the same range as those of the open live donor nephrectomy in our clinic. The 5 donors discharged 7-9 days after RHAN without any surgical complications. (Conclusion) Our technique of RHAN will be a minimal invasive one in terms of both for the donors and the grafts, and be widely acceptable for donor nephrectomy on either side.
(Purpose) We investigated treatment results of IFEP chemotherapy in patients with advanced urothelial cancer (N2-3, M1) and the usefulness of measuring serum CEA, CA19-9 and SCC to evaluate the treatment response of chemotherapy. (Patients and methods) From March 1994 to May 2000, we treated 41 patients with IFEP therapy consisting of ifosfamide (2g/m2), 5-fluorouracil (750mg/m2), etoposide (100mg/m2) and cisplatin (20mg/m2), all of which were given daily for 3 consecutive days every 3 weeks. Before initiating the chemotherapy, serum CEA, CA 19-9 and SCC were measured. And in patients with high pretreatment serum concentration, they were serially evaluated and compared with the tumor response assessed by imaging studies and the patients' clinical course. (Results) The response rate of the chemotherapy was 53.7% (CR+PR), with a median survival period being 10.8 months and a median duration of response for the 22 responders being 7.5 months. One and three-year survival rates of all the patients were 59.3% and 16.5%. Respnse rates of primary tumors and metastatic lesions to the lymph node, bone, lung and liver were in 54% and 57%, 56%, 50% and 40%, respectively. Bone marrow toxicity was significant with 1 drug-related death. Before chemotherapy, tumor marker was elevated in 19 patients: CEA in 7, CA 19-9 in 13 and SCC in 10. Serum levels of the tumor markers were related neither to the primary and metastatic tumor sites nor to patient' s survival time. However, decline of serum tumor markers after chemotherapy was well related to response of the tumor assessed by imaging studies. (Conclusion) IFEP chemotherapy appears to be active in the treatment of advanced urothelial tumor and serial measurment of serum CEA, CA 19-9 and SCC may be useful in judgement of tumor response to the chemotherapy.
(Objective) Cost containment has become an important issue in medical practice because of recent bad economic conditions. We analyzed the cost of benign prostatic hypertrophy (BPH) patients and cost-effective analysis was carried out comparing transurethral resection of prostate (TURP), visual laser ablation of the prostate (VLAP) and transurethral microwave thermotherapy (TUMT). (Materials & Methods) Our series consists of 95 BPH patients treated with TURP, VLAP and TUMT between January 1, 1994 and March 31, 1997. The cost for each patient was caluculated (46 were treated with TURP, 31 with VLAP and 28 with TUMT). Considering the clinical outcome, costeffectiveness was compared in 3 groups retrospectively. (Results) The median level of total charges (insurance points) was 59, 395 points for the TURP group, 66, 784 points for the VLAP group and 14, 927 points for the TUMT group. The median follow-up period was 12.4 months, 46.7 months and 14.4 months, respectively. Several patients needed medication after operation in the VLAP group. In the TUMT group, 3 patients needed re-operation and 5 other needed an alternative surgical method (TURP or transurethral needle ablation) and 1 needed both methods. (Discussion) TUMT is the most cost-effective method, however the reccurent rate is highest in the follow-up period among the three groups. The costs of reccurent cases were most expensive. We should select surgical treatment for BPH very carefully.
(Purpose) Some reports suggest that the high level expression of thymidine phosphorylase (TP), which is known as one of angiogenic factors, is related to high malignancy and also poor prognosis in the field of gastrointestinal cancer. So the authors investigated the expression of TP in bladder cancer. (Materials and methods) The expression of TP in cancer tissues and normal tissues, which were obtained during transurethral resection of the tumor of 66 patients with initial primary bladder cancer, was examined by enzyme-linked immunosorbent assay (ELISA). And relationship of the TP expression and clinicopathologic factors was investigated. (Results) The level of TP expression was significantly high in cancer tissues compared with normal tissues (P<0.0001). About the level of TP expression of cancer tissues, there was a significant difference between G1 and G3 in grade (P=0.0099), Ta and T2 or greater (P=0.0059), Ta, T1 and T2 or greater (P=0.0157) in T stage, papillary and non-papillary in surface form (P=0.0056), pedunculated and sessile in tumor shape (P=0.0458), and 1cm or under and 3cm or greater in size (P=0.0267). The level was higher in latter, respectively. About the level of TP expression of normal tissues, the level was significantly higher in the cases with sessile tumor than the cases with pedunculated tumor (P=0.0078). (Conclusion) There is correlation between the level of TP expression of cancer tissues and their grade of malignancy, so we can expect that the level of TP expression of cancer tissues will be a prognostic factor. And what does it mean in the fact that the level of TP expression of normal tissues in patients with sessile tumor is higher? It should be clear after accumulation of the cases and collecting the episodes in the follow-up period.
(Objective) ESWL is now widely used for the treatment of renal stone disease. Although ESWL has many advantages for patients' quality of life, few reports have demonstrated the long-term outcomes of the alterations of renal morphology after ESWL. We reported renal scarring after ESWL monotherapy in patients with renal calyceal stones. In this study, we evaluated a large series of patients' cohort treated at our institution, and assessed the causal effect of ESWL on the late occurrence of renal scar formation. (Patients and methods) ESWL was performed with EDAP (LT-01, 02) that generates shock wave energy by piezoelectric discharge. We analyzed the records of 285 kidneys treated between Dec. 1986 and Nov. 1998. Renal scarring was noted in 44 kidneys and not in 241 kidneys with periodical ultrasonography. We compared the backgrounds of the two groups using chi-square or non-parametric analysis. The Kaplan-Meier method and Cox regression model determined the analysis of renal scar formation. (Results) Univariate and multiple regression analysis revealed that the total amount of ESWL emission and hyperuricemia independently affected the probability of renal scar formation. (Conclusions) Over-emission of ESWL (over 10000 shots) must be care for the prevention of renal scarring in patients with renal calyceal calculi, especially when associated with hyperuricemia. After ESWL, periodical checkups with ultrasonography will provide useful information for the clinical diagnosis of renal scarring.
We report a case of retroperitoneal gas gangrene, which was caused by cecal diverticulitis with perforation. A-57-year-old male was admitted to the Sado General Hospital with the chief complaint of right lateral abdominal pain. Roentogenogram and Computelized Tomography (CT) showed gas accumulation in the retroperitoneal space behind the ascending colon. Based on the clinical, labolatory, and instrumental examination findings gas gangrene was diagnosed. Since urolithiasis or urinary tract infection was suspected to be the cause of the lesion at that time, the patient was transferred to our department immediately. CT scan done on day 3 at our inpatient department provided data suspicious for the cecal perforation into retroperitoneal space due to appendicitis or diverticulitis. We performed an acute drainage of the abscess and intensive care including continuous hemodiafiltration (CHDF), oxygen under high pressure (OHP), and chemotherapy with antibiotics was carried out. However, in spite of the above mentioned measures, the patient's condition deteriorated and he died due to progression of gangrene and multiple organ failure in 23 days. The autopsy revealed that the cause of perforation was cecal diverticulitis. Retroperitoneal gas gangrene is an uncommon entity and has been rarely reported. It is supposed that laparotomy with diagnostic and therapeutic purpose should have been performed in this case.