Mizuya Fukasawa

Self-reversed parallel wire balloon technique for dilating unyielding strictures in native dialysis fistulas.

Editor: For patients undergoing hemodialysis treatment who have a rigid stricture of an arteriovenous fistula, it is extremely difficult to achieve sufficient dilation even if a highpressure resistant balloon catheter is used. In such cases, the parallel wire technique (1,2) has been a better alternative to achieve arteriovenous fistula dilation. The effectiveness of the parallel wire technique has been explained as being a result of the guide wire indwelling between the balloon and the stricture causing a cracked or cut intima, by which the vessel is extended. In other words, the cutting balloon’s blade is replaced with the guide wire. Eventually, the intimal injury is limited to the cracked area. It is speculated that the recurrence of strictures at these points will be less frequent. In the parallel wire technique, there are three alternative ways to indwell the guide wire, as shown in Figure 1: the conventional method passes another wire through the sheath of larger size (Fig 1a); the wire can also be passed through another puncture (Fig 1b); and finally, the selfreversed parallel wire technique, described herein, can be used (Fig 1c). Disadvantages of the conventional technique are that the sheath is required to be thicker than the optimum size and that blood is lost from the point at which the sheath is applied (2). It was reported that 200 mL of blood is generally lost with this method, and use of a Y-shaped connector was recommended (2). The disadvantage of the second method is that a new vein puncture is required and another guide wire is needed. To improve upon these techniques, we chose the method illustrated in Figure 1c: the self-reversed parallel wire technique. In this method, only one guide wire is passed through the sheath, so a sheath of appropriate size is sufficient and a connector preventing blood loss will not be needed. In our hospital, initial implementation of this method used two wires for conventional parallel wire technique (1,2), but this method presented problems such as blood loss from the sheath and required the use of an oversized sheath. Self-reversed parallel wire technique is a simple modification of the conventional one. Details of its implementation and effectiveness are reported herein. Between January 1999 and September 2001, blood access intervention therapy was carried out in 163 patients undergoing hemodialysis treatment. All these patients also had native arteriovenous fistulae. For these cases, we usually used noncompliant balloon catheters (balloon diameter: 4–6 mm) with a rated burst pressure of 15 atm and inflation times of 2 minutes for each dilation. Ultra-short braidedtype sheaths were used (5 F, 3 cm long; Medikit, Tokyo, Japan). In our experience, insufficient dilation was achieved in 22 cases (13%) in which only the high-pressure resistant balloon was used. The self-reversed parallel wire technique was applied in these cases. Figure 2 shows the self-reversed parallel wire technique procedure. A sheath of the required size (5 F) was inserted, through which a flexible-tipped guide-wire with an angleshaped tip (Radifocus; Terumo, Tokyo, Japan) was passed. The tip was then turned in a 180° curve by pushing the tip Figure 1. There are three alternative parallel wire techniques. (a) The conventional method requires an oversized sheath; (b) another puncture can be made to insert the guide wire; or (c) the self-reversed parallel wire technique can be employed.

Real-time quantitative analysis for human telomerase reverse transcriptase mRNA and human telomerase RNA component mRNA expressions as markers for clinicopathologic parameters in urinary bladder cancer

Aim:  The expression of the telomerase subunits such as human telomerase reverse transcriptase (hTERT) and human telomerase RNA component (hTR) may be associated with tumor development and progression. We evaluated the relationship between mRNA quantification of both hTERT and hTR and clinicopathologic parameters in bladder cancer.

INTRAPERITONEAL RUPTURE OF GIANT HYDRONEPHROSIS DUE TO URETERAL CANCER ACCOMPANIED BY RENAL CELL CARCINOMA

Intraperitoneal rupture of hydronephrosis is rare. We report a case of hydronephrosis caused by ureteral cancer accompanied by ipsilateral renal cell carcinoma. CASE REPORT A 72-year-old man complaining of general weakness and a tumor in the left upper abdomen without tenderness presented at our hospital. Abdominal ultrasonography and computerized tomography (CT) revealed a giant renal cystic mass and a solid mass at the lower end of the ureter (fig. 1, a to d). Diagnosis was tumor of the left ureteral stump, and a series of operations was scheduled. However, the patient complained of sudden reduction of the mass and resolution of the sensation of abdominal fullness. CT revealed a marked decrease in hydronephrosis and a large amount of ascites in the peritoneal cavity (fig. 1, e and f). Intraperitoneal rupture of left hydronephrosis was diagnosed, and an emergency procedure was performed. When the intraperitoneal cavity was entered through a midline incision there was approximately 1,000 ml. of dark brown ascites and an approximately 5 mm. foramen, from which bloody liquid was excreted into the descending colonic mesentery. Total nephroureterectomy was performed. Extirpated weight was 2,900 g. (including 1,900 ml. of dark fluid). There was a large amount of clotted blood within the renal pelvis, which revealed marked wall thickening. Papillary tumors were noted along the entire ureter. Cytological evaluation of the ascites and renal pelvic urine revealed class IV. Pathological diagnosis regarding the ureter was transitional cell carcinoma, grade 2 greater than 1, pT1, interferon-, pR0, pN0. An induration 3.5 cm. in diameter (fig. 2, a) was noted in the totally destroyed renal tissue (fig. 2, b). Pathological diagnosis was renal cell carcinoma, clear cell subtype, grade 2, interferon- ,V (), pT1a, pN0. Also, the ruptured portion of the kidney comprised necrotic

Differential impact of lower urinary tract symptoms on generic and disease-specific quality of life in men and women.

Introduction: We investigated how generic and disease-specific measures differ in estimating the quality of life (QoL) impact of lower urinary tract symptoms (LUTS). Materials and Methods: A total of 172 men and 67 women ≧40 years old who attended the public lectures completed the questionnaire comprising the International Prostate Symptom Score, benign prostatic hyperplasia impact index and SF-36 Health Survey. The multiple regression analysis was performed to evaluate the QoL impact of LUTS. Results: Both storage and voiding symptoms showed significant correlations with disease-specific QoL. Among men, voiding symptom correlated more closely with disease-specific QoL than storage symptom did, and this finding was reversed among women. Storage but not voiding symptoms showed a significant correlation with generic QoL. Among men, storage symptom correlated more closely with mental health than physical health, and the reversed finding was obtained among women. Generic QoL, especially physical health, was significantly influenced by some comorbid diseases, but disease-specific QoL was not. Conclusions: The QoL impact of LUTS was differentially estimated by disease-specific and generic measures with sex differences.

Multifocal metastases of recurrent renal cell carcinoma successfully treated with a combination of low dose interleukin‐2, α‐interferon and radiotherapy

Abstract  A 59‐year‐old man presented with a 2‐month history of left flank pain and a possibility of gross hematuria. Left renal cell carcinoma stage II was diagnosed and radical left nephrectomy was performed. Twenty‐two months postoperatively, lung metastases were demonstrated and 6 × 106 units of α‐interferon (IFN‐α) were administered for 9 months, only to keep the sizes of the metastases unchanged. Thirty‐four months after the operation, liver metastases and bone metastasis in the left sacroiliac joint were revealed. The combination cytokine therapy was performed with 1.4 × 106 U of interleukin‐2 (IL‐2) and 3 × 106 U of IFN‐α for 16 weeks, and the left sacroiliac joint metastasis was treated with radiation therapy of 4 Gy per day for 7 days. Six months after the 16 weeks of immunotherapy, computed tomography and bone scintigraphy revealed that the metastases of the lung, liver and bone substantially disappeared and this complete response is still kept after 16 months.

Practice of peritoneal dialysis access education using the new hybrid simulator in Japan.

Introduction To promote the increase in patients undergoing peritoneal dialysis (PD) in Japan, the Japanese Society for Dialysis Access started offering workshops on peritoneal access (PA) preparation procedures for doctors with less experience. Since the transfer of technology used in surgical procedures is difficult in small communities such as individual hospitals, a specialist group such as a society should take the initiative and fulfill this responsibility. Methods Here we used a hybrid simulator developed by Terumo Medical Pranex that uses the abdominal wall of an edible pig (a lump from the peritoneum to skin) and a mannequin. Since the structure of the porcine abdominal wall is similar to that of humans, the PA procedure can be simulated in this actual procedure. With three-dimensional reproduction of the Douglas pouch and other features of the pelvis using human computed tomography images, we created a system in which even drainage is possible if the catheter is well placed. Results Using this simulator, students were able to experience the PA access preparation procedure 2-4 times and easily observed the catheter position after insertion by peeling the abdominal wall from the mannequin. Conclusions In the future, by leveraging the advantages of the hybrid simulator, we aim to promote the training of medical staff interested in PD health care and increase the number of patients able to benefit from the many advantages of PD.