Koei Muguruma

SEMINAL TRACT OBSTRUCTION CAUSED BY CHILDHOOD INGUINAL HERNIORRHAPHY: RESULTS OF MICROSURGICAL REANASTOMOSIS

PURPOSE Childhood inguinal herniorrhaphy is a frequent causes of seminal tract obstruction. We investigate the characteristics of this obstruction, surgical techniques for reanastomosis and outcomes in patients with bilateral or unilateral obstruction caused by inguinal herniorrhaphy in childhood. MATERIALS AND METHODS We treated 22 men an average of 30.5 years old in whom average duration of obstruction was 27.1 years. Obstruction was bilateral in 9 patients and unilateral in 13, and 14 had azoospermia preoperatively. Microsurgical 2 layer vasovasostomy and/or specific tubule epididymovasostomy was performed. RESULTS Inguinal and crossed vasovasostomy was done in 18 and 4 patients, respectively. The distal end of the vas was found at the internal inguinal ring or in the pelvic cavity in 57.1% of the vasa and more than 3 cm. of the vas had been resected in 37%. Sperm was noted in vasal fluid in 45.2% of the vasa during the operation and the patency rate of inguinal vasovasostomy was 88.9%. Ipsilateral epididymovasostomy performed after patent inguinal vasovasostomy in 5 patients with secondary epididymal obstruction resulted in normal sperm density and 3 pregnancies. In 7 men more than 2 procedures were done. There was sperm in the ejaculate in 12 of the 14 patients who had had azoospermia preoperatively and apparently increased sperm density postoperatively in 4 of the 8 who had not had azoospermia preoperatively. Pregnancy was achieved by 7 of the 21 married men (33.3%). CONCLUSIONS Microsurgical reanastomosis of the seminal tract resulted in high patency and pregnancy rates in cases of seminal tract obstruction caused by childhood inguinal herniorrhaphy. Patients should elect seminal tract reanastomosis or assisted reproductive technology using epididymal or testicular sperm after receiving sufficient information on each treatment modality.

Quantitative Analysis of Testicular Histology in Patients with Vas Deferens Obstruction Caused by Childhood Inguinal Herniorrhaphy: Comparison to Vasectomized Men

PURPOSE We investigated the effects on spermatogenesis of lifelong vas deferens obstruction caused by childhood inguinal herniorrhaphy. MATERIALS AND METHODS Testicular histology was analyzed quantitatively in 15 post-herniorrhaphy patients with vasal obstruction for a mean of 28.5 years (group 1). The results were compared to those of 19 vasectomy patients with obstruction for a mean of 8.2 years (group 2). RESULTS There were significantly fewer total germ cells per tubular cross section in group 1 than in group 2 (p < 0.05). There was a significant negative correlation between the duration of obstruction and total germ cells per tubule (r = -0.389, p < 0.03, 34 patients). The tubular diameter was significantly larger in group 2 than in group 1 (p < 0.01). CONCLUSIONS Patients with vas deferens obstruction caused by childhood inguinal herniorrhaphy have decreased spermatogenesis compared to post-vasectomy patients, probably due to the longer obstruction period.

Microsurgical epididymovasostomy for obstructive azoospermia: factors affecting postoperative fertility.

Azoospermia due to epididymal obstruction can be treated by microsurgical epididymovasostomy with high patency rates. Twenty-four azoospermic patients with epididymal obstruction due to a variety of causes underwent 26 microsurgical epididymovasostomies. The overall patency rate following surgery was 80.8% and impregnation was achieved by 10 patients (41.7%). Factors affecting the postoperative impregnation rate were etiology and duration of obstruction. Patients with an obstruction for < or = 15 years, caused by epididymitis or post-vasectomy epididymal blow-out, achieved a higher impregnation rate than the others (8 of 9 vs. 2 of 11, p = 0.0019). The motility of epididymal sperm or the presence of serum antisperm antibodies had no apparent effect on postoperative fertility. Microsurgical epididymovasostomy is particularly effective in patients with epididymitis or vasectomy patients with a short-term obstruction.

Laparoscopic ureterolysis for idiopathic retroperitoneal fibrosis.

Ureterolysis and subsequent intraperitonealization were performed laparoscopically in 2 patients with unilateral idiopathic retroperitoneal fibrosis. The operative procedure was easily accomplished, and the outcome was excellent in the patient who had a ureteral stricture of 2 cm in length, whereas the operation was technically more complicated with a prolonged operation time in the other patient who had a stricture more than 5 cm in length. The convalescence period after the operation was short in both cases. Laparoscopic ureterolysis is a less invasive alternative to conventional open surgery, particularly in patients with involvement of a unilateral ureter of short length.

Retroperitoneoscopic pyeloplasty : Using reconstructive methods based on intraoperative findings

Aim: Reconstructive laparoscopic procedures have been recognized as a less invasive treatment than conventional open procedures. However, although the laparoscopic pyeloplasty has also been accepted as useful, few findings have been reported relevant to the retroperitoneal approach. To elucidate its effectiveness and safety, laparoscopic surgery via the retroperitoneal approach was examined in our institution. Furthermore, the importance of laparoscopic observation for ureteropelvic junction and urine passage ureteropelvic junction without indwelling ureteral stent.

Impact of the Inclusion of a Nephrologist on the Surgical Team for Peritoneal Catheter Insertion

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Failure of a gonadotropin-releasing hormone analogue to lower serum testosterone in patients with prostate cancer

Abstract We report 3 patients with prostate cancer who showed an unexplained failure to lower their serum testosterone levels despite monthly treatment with gonadotropin-releasing hormone analogues. We recommend assessing the serum testosterone levels when gonadotropin-releasing hormone analogue treatment is ineffective, before the diagnosis of hormone-refractory cancer is established.

CLINICAL OUTCOMES OF EXTERNAL-BEAM RADIOTHERAPY COMBINED WITH NEOADJUVANT ANDROGEN DEPRIVATION THERAPY FOR HIGH-RISK PROSTATE CANCER

(Purpose) We investigated the outcome of external-beam radiotherapy (EBRT) with neoadjuvant androgen deprivation therapy (NeoADT) for high-risk prostate cancer defined by National Comprehensive Cancer Network (NCCN) guideline. (Patients and method) From 2002 to 2013, 70 patients with high-risk prostate cancer (PSA ≥20 ng/ml or clinical T stage ≥T3a, Gleason score ≥8) were treated with NeoADT and EBRT. EBRT consisted of three-dimensional conformal or intensity modulated radiotherapy with or without whole-pelvic radiation. Biochemical failure was defined according to the Phoenix definition. Biochemical progression-free survival (bPFS) and overall survival (OS) were calculated by Kaplan-Meier method, and prognostic factors for bPFS were analyzed by using the Cox proportional hazard model. (Result) The median age and initial prostate-specific antigen (PSA) level were 72 years old and 25.2 ng/ml, respectively. 43 patients had PSA level ≥20 ng/ml, 51 patients had clinical stage ≥T3a, 27 patients had Gleason score ≥8. The number of risk factors patients possessed was 1 (RiskN-1) in 31 patients, 2 (RiskN-2) in 27 patients and 3 (RiskN-3) in 12 patients. Median EBRT dose and duration of Neo ADT were 74 Gy and13.0 months, respectively. Whole-pelvic radiation was administered in 7 patients. After median follow-up of 4.8 years, biochemical and clinical failure occurred in 23 and 2 patients, respectively. No patients died of cancer. Five-year/8-year bPFS and OS were 63%/54% and 100%/91%, respectively. In multivariate analysis, three high-risk factor of NCCN guideline (PSA, clinical stage, Gleason score) did not predict outcome after EBRT independently, but RiskN (-1 vs -2, 3, HR 35.35, 95%CI 2.51-498.05, p<0.01) and pre-EBRT PSA (continuous, hazard ratio 1.31, 95%CI 1.01-1.71, p<0.05) were the significant predictors of bPFS. Five-year/8-year bPFS in RiskN-1 group and RiskN-2 or -3 group were 89%/79% and 47%/39%, respectively. Grade 3/4 adverse events (CTCAE ver4.0-JCOG) occurred in 2 patients. (Conclusion) Median dose of 74 Gy EBRT with intermediate-term NeoADT was safe and beneficial for high-risk prostate cancer. The number of risk factors and pre-EBRT PSA level were the independent prognostic factors for biochemical progression-free survival.