Eiichi Ishizuka

TRANSARTERIAL EMBOLIZATION AND ABLATION OF RENAL ARTERIOVENOUS MALFORMATIONS: EFFICACY AND DAMAGES IN 30 PATIENTS WITH LONG-TERM FOLLOWUP

PURPOSE We evaluate the long-term efficacy and side effects of transarterial embolization and ablation for renal arteriovenous malformations. MATERIALS AND METHODS A total of 30 patients with cirsoid arteriovenous malformations causing massive hematuria underwent 34 procedures of embolization or ablation. We confirmed the ratios of occluded arteriovenous malformation areas on angiograms and those of infarcted areas on computerized tomography. All patients were followed for 4.1 to 15.0 years (mean 8.0 +/- 2.8) after the initial procedures. RESULTS Hematuria ceased in all patients after the initial procedures, including partial embolization or ablation of the arteriovenous malformations in 8. Massive hematuria recurred in 4 patients, who had undergone absorbable gelatin sponge (2), embolization, combined alcohol and subselective absorbable gelatin sponge embolization (1) and polyvinyl alcohol particles embolization (1). In these 4 cases total ablation of the arteriovenous malformations with alcohol was successful. In 29 patients, including aforementioned 4, no hematuria recurred after 5 years following total or partial ablation with alcohol. Large nontarget embolization with reflux of subselectively infused absorbable gelatin sponge caused a nonfunctioning kidney in 1 patient. The remaining 33 procedures caused 6.3 to 48.0% (mean 15.7 +/- 6.9%) areas of renal infarction. Polyvinyl alcohol embolization caused pulmonary embolism and renin dependent hypertension. CONCLUSIONS Partial or total transarterial ablation of arteriovenous malformations with alcohol proved effective for long-term cessation of hematuria. However, this procedure as well as transarterial embolization has the potential risk of nontarget infarction.

Cystoplasty by Regeneration of the Bladder

Herein we describe a new method for cystoplasty, making use of the regenerating ability of the bladder. The contracted bladder is opened with a crucial incision and enlarged by placing thin paper covered with liquid synthetic resin (nobecutane) like a cap over the opened bladder tissue. Within 3 to 4 weeks granulated tissue completely covers the artificial cap, which is then removed transurethrally. Thereafter, the bladder regenerates on its own. The operation has been done at our hospital from 1970 to 1975 on 13 patients with contracted bladders owing to various pathologic conditions. Excellent results have been obtained on 11 patients with tuberculous contracted bladders. These 11 patients have regained normal bladder capacity and are able to void normally through the urethra. The technique has not been effective in 2 patients with interstitial cystitis, caused by generalized collagen disease in 1.

Nephrolithotomy by one-layer interrupted parenchymal suture.

Since 1967, when Taguchi devised a method of closing renal incisions in nephrolithotomy in which the renal capsule, parenchyma and pelvic mucosa are sutured together as one layer without prior hemostasis, this method, with subsequent modifications of surgical technique, has been employed in 47 cases of staghorn or multiple large calculi. The simplified method of suture shortens the clamp-time of the renal pedicle during operation, minimizes injury to the parenchyma, while assuring adequate hemostasis. All the treated cases showed good results postoperatively, free from any serious complications such as secondary hemorrhage. Renal function tests after nephrolithotomy by this method showed decreases of 20 and 16% in glomerular filtration rate and renal plasma flow, respectively, which returned to preoperative levels in 2 weeks. Pre- and postoperative renal arteriograms indicated some changes in the intrarenal arteries and parenchyma due to the incision and method of suture. Occlusion of intrarenal arteries occurred in 91.7% of the cases, in fact at the level of interlobar or minor artery in 90%, and the average number of sites of arterial interruption per kidney was 4.7. The author considers the method to be irrevocably perfect for renal parenchymal suture.

A phase II study of prophylactic intravesical chemotherapy with 4′-epirubicin in recurrent superficial bladder cancer: comparison of 4′-epirubicin and Adriamycin

Since intravesical recurrence of superficial bladder cancer (Ta, T1) after transurethral resection (TUR) is frequent, adjuvant therapy to reduce the recurrence rate has been extensively investigated. Although intravesical chemotherapy has been employed for 30 years or more, neither the exact effect on the bladder epithelium nor the optimal dose and administration schedule has yet been clarified. In recent years, several derivatives of Adriamycin (ADR) have been developed, and 4′-epirubicin (FARM) is one of them. This drug has been shown to have antitumor effects almost equal to those of ADR and to produce less toxicity when given systemically as chemotherapy. In an attempt to clarify the effect of intravesical FARM in the prevention of recurrence of superficial bladder cancer, we conducted a prospective randomized trial to compare the effects of equal doses of FARM and ADR given by intravesical instillation after TUR in cases of highly recurrent superficial bladder cancer. A total of 73 patients with recurrent superficial bladder cancer were randomized to receive TUR and either 30 mg FARM or 30 mg ADR by intravesical instillation every 2–4 weeks for 1 year. The prophylactic effect on recurrence and the toxic effects of these drugs were investigated. The current results show that FARM provides efficacy almost equal to that of ADR in the prevention of recurrence in these patients. However, FARM also caused almost the same local toxic effects (bladder irritation, among others) as ADR. On the basis of these preliminary results, FARM is surmised to be one of the agents as beneficial as ADR in the prevention of recurrence of superficial bladder cancer.

A classification for intravaginal torsion of the testis

We have developed a new classification for intravaginal testicular torsion by comparing the testes in 36 cases of intravaginal torsion with those of 30 cases undergoing castration for prostatic cancer. The classification was made by our new criteria as follows: bell-clapper type (type III) in which torsion very easily occurs; intermediate type (type II), which can be further divided into two subtypes, type IIb in which torsion easily occurs and type IIa in which torsion hardly occurs, and normal type (type I) in which torsion never occurs. We believe that our new classification is simple and useful for definite clinical understanding.

Anatomic Comparison of the Ipsilateral and the Contralateral Testis in Intravaginal Torsion

Sixteen cases of intravaginal testicular torsion were studied to compare the intrascrotal anatomy with that of the contralateral testis and to determine possible anatomic predisposition to testicular torsion. The anatomy of the contralateral testis was not always similar to that of the ipsilateral testis, and four of the contralateral testes were judged to be without risk of torsion.

Continuous Intercostal Nerve Block for Pain Relief After Lumbar Incision

To relieve postoperative pain along a lumbar incision in 9 patients the intercostal nerves were blocked with catheters for continuous epidural anesthesia. The catheters were inserted near the intercostal nerves, above and beneath the incision, just before the wound was closed and 0.25% bupivacaine hydrochloride solution was infused periodically through the catheters. With this technique 5 of 9 patients had a satisfactory analgesic effect and could breathe deeply or cough without pain. The other 4 patients did not have satisfactory results and this was believed to be owing to inadequate insertion of the catheters. None of the patients had any complications. The technique is simple and can produce an analgesic effect repeatedly without causing pain for the patient.