Hideo Kiyokawa

DISTRIBUTION OF DOXORUBICIN IN THE BLADDER WALL AND REGIONAL LYMPH NODES AFTER BLADDER SUBMUCOSAL INJECTION OF LIPOSOMAL DOXORUBICIN IN THE DOG

PURPOSE Liposome-encapsulated doxorubicin (Lip-Dox) has increased therapeutic efficacy and reduced toxicity compared to free doxorubicin (Dox). To assess the utility of Lip-Dox for local control of bladder cancer, we examined the distribution of Dox in the bladder wall and the regional lymph nodes of dogs after bladder submucosal injection of Lip-Dox. MATERIALS AND METHODS In 8 dogs (group SM), Lip-Dox (2 mg.:1 ml.) was injected into the submucosal layer of each lateral bladder wall by using a flexible cystoscope. The other 8 dogs (group IV) underwent intravenous injection of free Dox (4 mg.). Both groups of animals were sacrificed at 1, 3, 5 or 7 days after the injections. The concentration of Dox was measured in both the mucosal and muscle layers of 5 bladder wall sites and also in the external iliac lymph nodes bilaterally. RESULTS The Dox-concentration in the lymph nodes of group SM was significantly higher (about 15-100 times) than that of group IV throughout the whole follow-up period. The Dox-concentration in the bladder wall for group SM was significantly higher than that in group IV (about 70-930 times at the lateral walls and 2-830 times at the other sites). CONCLUSION The present results demonstrate that Lip-Dox injected into the bladder submucosally distributes well, both in the whole bladder wall and in regional lymph nodes and remains at a high concentration in these tissues for at least one week after injection.

Radical retropubic prostatectomy through a minimal incision with portless endoscopy : Our initial experience

Abstract  Twenty‐one patients with clinically localized prostate cancer underwent minilaparotomy radical retropubic prostatectomy through a single 5‐cm midline or Pfannenstiel incision. A 30° laparoscope was usually positioned around the edge of the incision to facilitate the procedure. The mean operating time was 255 min. The mean blood loss was 859 mL, and no patient required an allogenic blood transfusion. Postoperative pain was noticeably reduced, especially in the Pfannenstiel incision group. Endoscope‐assisted minilaparotomy did not involve a learning curve, and could be useful for most urologic surgeons as minimally invasive surgery.

Anatomical reconsideration to renal area : Lessons learned from radical nephrectomy or adrenalectomy through a minimal incision over the 12th rib

Abstract Background: To perform radical nephrectomy or adrenalectomy through a minimal incision over the 12th rib and to compare this with the traditional supracostal or transcostal approach. We review and clarify the related surgical anatomy through close observation.

Hyperammonaemic encephalopathy associated with retention of urine in multiple large diverticula.

A 76-year-old woman had been aware of lower abdominal distension for several years and reported having no clear desire to void. The day before being admitted to a local hospital in a coma she had begun to vomit and became disoriented; she also had a lowgrade fever. An indwelling catheter was placed in the bladder and 1 L of urine was drained immediately, but the urine was not analysed or cultured. CT of the brain showed no manifest abnormalities. Serum creatinine levels and liver function tests were normal but the serum ammonia level was high, at 3.77 mg/L (normal <0.75 mg/L). Abdominal CT showed no evidence of liver cirrhosis or portal-caval shunt. Aminoleban1 (an amino-acid preparation for hepatic insuf®ciency; Table 1) and an antibiotic (cefotiam hydrochloride, 2 g/ day) were given intravenously. She became increasingly alert and the serum ammonia level decreased rapidly, reaching 0.52 mg/L on the second day after admission. An examination of serum amino acids showed a normal Fischer ratio (the molar ratio of [valine + leucine + isoleucine]/[tyrosine+phenylalanine]), which would be expected to decrease in hepatic encephalopathy. No cause for her hyperammonaemic encephalopathy was discovered. A month later she noticed asymptomatic gross haematuria; CT showed a cystic mass in the pelvis (Fig. 1) and she was referred to our department for further examination. Urine analysis revealed sterile urine and no malignant cells; excretory urography showed normal upper tracts. However, cystoscopy revealed many large diverticula of the bladder. The residual urine volume was 800 mL; an indwelling catheter was placed in the bladder, with intermittent catheterization being introduced later. The serum ammonia level remained normal.

Continent Ileal Pouch Using the Serous–Lined Principle

Objectives: The flap valve principle is not easily applicable to an ileal pouch since a submucosal tunnel is difficult to create. We attempted to construct an ileal pouch with an umbilical stoma applying the serous–lined principle for both ureteral implantation and construction of a continent valve.Methods: In 9 patients, a continent pouch with an umbilical stoma was created entirely from an ileal segment. Adopting the serous–lined principle, a continent valve was created by appendix in 2 cases, tapered ileum in 3 cases, and reconfigured ileum in 4 cases. These were implanted into the anterior suture line of the pouch and embedded into the serous–lined tunnel formed by the pouch wall.Results: Patients can catheterize the pouch easily with a 14–Fr catheter. Postoperatively, pouch capacity is over 400 ml with complete continence.Conclusion: This technique can provide a simple and effective continent ileal pouch facilitating umbilical anastomosis. As a continent valve, the reconfigured ileal segment seems most useful for application of the serous–lined principle.

Churg–Strauss syndrome presenting with eosinophilic prostatitis

Abstract  We report a patient with eosinophilic prostatitis associated with Churg–Strauss syndrome. A 74‐year‐old man, who had been treated for asthma, underwent transurethral resection of the prostate. After the operation he had a high temperature of approximately 40°C. The differential blood count revealed marked eosinophilia of 77.5%. The patient received 20‐mg prednisolone and dramatically became afebrile. The pathological diagnosis was eosinophilic prostatitis. These findings strongly indicate Churg–Strauss syndrome.

The serous-lined tunnel principle for urinary reconstruction: a more rational method.

Objective To examine the feasibility of using the serous‐lined‐tunnel principle for orthotopic neobladder, continent cutaneous diversion and ureteric replacement by an intestinal segment.

SIMPLE ANTI-REFLUX URETERO-ILEAL ANASTOMOSIS: AN EXPERIMENTAL STUDY IN DOGS

PURPOSE To develop more simple and effective anti-reflux techniques applicable to the ileal reservoir, we examined the usefulness of a novel anti-reflux uretero-ileal anastomosis creating a flap valve mechanism. MATERIALS AND METHODS Five dogs were used. A 4 cm. long ileal segment was isolated and its oral part (2.5 cm.) was detubularized. The detubularized ileal plate was anastomosed to the dome of the bladder. The left ureter was cut and its proximal end was spatulated and anastomosed end-to-side to the ileal plate. The end of the 1.5 cm. long afferent limb (non-detubularized part of the ileal segment) was closed and fixed down to the ileal plate to create an extramural tunnel. In this way, the reimplanted ureter was covered by the afferent limb. The dogs were evaluated between 3 and 4 months postoperatively. RESULTS None of the 5 dogs used showed vesico-ureteral reflux or hydronephrosis. Histological examination showed an intact ureter enclosed with a normal ileal wall. CONCLUSION Our proposed anti-reflux uretero-ileal anastomosis is simple and reliable. This technique may be suitable for applying to a urinary reservoir, especially as an alternative to the intussuscepted nipple valve.

Optimization of orthotopic colonic bladder: Implantation of tubularized mucosal flap from colonic segment into demucosalized urethra

If the urethral mucosa of a female could be replaced by another mucosa, one could augment the indication for orthotopic reconstruction of the bladder. A mucosal replacement technique for the female urethra is reported. A colonic mucosal flap formed from a colonic bladder was used in a patient with bladder cancer for whom cystectomy was indicated. For 3 years after the surgery, the patient has maintained satisfactory voiding and urethral function. There has been no evidence of a recurrence. The orthotopic bladder with the mucosal replacement technique can be applied to female patients who have a bladder cancer with a high risk of urethral recurrence.

A clinical and pathological study of radical prostatectomy for prostate cancer

BACKGROUND Thirty-one patients with prostate cancer underwent radical prostatectomy and simultaneous pelvic lymphadenectomy at Matsumoto National Hospital between 1988 and 1994. Prognostic factors are discussed from their clincopathological findings. METHODS The patients ranged from 54 to 80-year-old, with an average age of 69.9 years. The median follow-up period was 44 months. The diagnosis was confirmed by needle biopsy or transurethral resection of the prostate. All the patients received short-term endocrine therapy preoperatively, and only noncuratively resected patients underwent adjuvant therapy postoperatively. At initial diagnosis, the tumor grades were well, moderately, and poorly differentiated adenocarcinoma in 9, 12, and 10 patients, respectively. The clinical stage was defined as A2, B, C, D1, and D2 in 12, 4, 6, 3, and 6 patients, respectively. RESULTS A difference of tumor grade was found between the initial diagnosis and the final diagnosis based on the resected prostate in 8 patients (26%), with 7 of them (88%) showing an increase in grade in the final diagnosis. Also revealed was that 11 of the 25 patients (44%) in stage A2, B, C, or D1 had been understaged preoperatively. The five-year actuarial survival rates were 100%, 92%, and 51% for patients with well, moderately, and poorly differentiated adenocarcinoma, respectively, with a significant difference noted between well and poorly differentiated adenocarcinoma (p = 0.03). Recurrence only developed in patients with pathological stage D tumors. However, the presence or absence of lymph node metastasis did not affect the crude 5-year survival rate. Several stage D patients were successfully treated by radical prostatectomy and adjuvant therapy, achieving long survival. CONCLUSION These results indicate that patients in clinical stage C have tumors which exhibit differing biological behavior. These patients should be analyzed and classified more precisely so that the most appropriate therapy can be chosen.