Nobuaki Tanabe

The role of lymphadenectomy in the treatment of transitional cell carcinoma of the upper urinary tract.

PURPOSE We evaluated the efficacy of lymphadenectomy in conjunction with nephroureterectomy in patients with transitional cell carcinoma of the upper urinary tract. MATERIALS AND METHODS Data were evaluated retrospectively in 21 consecutive men and 15 women (mean age 67 years) who underwent total nephroureterectomy with lymphadenectomy between January 1985 and December 1993. RESULTS Of the 36 patients 11 (31%) had lymph node metastases. Of 20 patients with stages pT3 to 4 or pN+ tumors 12 received cisplatin based chemotherapy (11 postoperatively and 1 preoperatively). Followup ranged from 3 to 135 months (mean 55). Among 13 patients who died by May 1996 tumor was the cause of death in 8, while 5 died of unrelated causes. The probability of a cause specific survival at 5 years was 100% in patients with stages pTa to 1, 80% with stage pT2, 59% with stage pT3 and 0% with stage pT4 cancer. The probability of a cause specific survival at 5 years in patients with nodal metastasis was 21%. No patient without nodal metastasis died of tumor related causes. CONCLUSIONS Lymphadenectomy may provide therapeutic benefit in select patients with lymph node metastasis. It also may be a useful indicator of candidates for adjuvant chemotherapy if an effective regimen is established because lymph node metastasis is common in patients with carcinoma of the upper urinary tract and is critical in establishing the prognosis.

Angiontensin II Receptors in the Rat Urinary Bladder Smooth Muscle: Type 1 Subtype Receptors Mediate Contractile Responses

Angiotensin II (Ang II) receptors in the rat urinary bladder smooth muscle were investigated by in vitro responses of smooth muscle strips to exogenous Ang II stimulation and in radioligand binding assays. Ang II (10(-10) M. to 10(-5) M.) caused a potent contractile response in a concentration-dependent manner. Using the recently developed nonpeptide subtype-selective antagonists, the Ang II-induced contractile response was further characterized. The Ang II-induced contractile response was inhibited weakly by the type 2 subtype (AT2)-selective antagonist PD123319 but was potently inhibited by the type 1 subtype (AT1)-selective antagonist DuP 753 with a pA2 value of 9.03, suggesting that the response is mediated predominantly by AT1 receptors. [125I]Ang II was used to specifically label a single class of binding sites with a dissociation constant of 0.31 nM. and a maximal binding capacity of 41.5 fmol./mg. of protein. DuP 753 could completely antagonize the binding of Ang II in a particulate fraction of rat bladder (Ki = 14 nM), whereas PD123319 did not have any effect in the concentration range of 10(-9) to 10(-5) M. The results suggest that AT1 receptors rather than AT2 receptors predominantly mediate Ang II-induced contraction in the rat urinary bladder.

Retroperitoneoscopic Nephron-Sparing Surgery of Renal Tumor Using a Microwave Tissue Coagulator without Renal Ischemia: Comparison with Open Procedure

PURPOSE It is ideal to use not a transperitoneal but a retroperitoneal approach for both open and endoscopic partial nephrectomy. We compared the results of retroperitoneoscopic nephron-sparing surgery for small renal tumors using a microwave tissue coagulator without renal pedicle clamping with those of a retroperitoneal open procedure. PATIENTS AND METHODS Between 1996 and 2002, eight patients with small renal tumors underwent retroperitoneoscopic partial nephrectomy without renal ischemia, and nine patients with small renal tumors underwent open partial nephrectomy via a retroperitoneal approach. Both groups were operated on using a microwave tissue coagulator. RESULTS Retroperitoneoscopic partial nephrectomy without renal ischemia was performed without any major or minor complications in any patient. The mean operation time for retroperitoneoscopic surgery was significantly longer than that for open partial nephrectomy (221.9 minutes v 145.9 minutes; P = 0.0004). However, the mean estimated blood loss for retroperitoneoscopic surgery was less than that for open partial nephrectomy (137.5 mL v 334.8 mL; P = 0.012). In addition, the retroperitoneoscopic group seemed to recover more rapidly than the open surgery group. CONCLUSIONS Retroperitoneoscopic nephron-sparing surgery of small renal tumors using a microwave tissue coagulator without renal ischemia is feasible as minimally invasive procedure. It results in saving renal function, minimal blood loss, and rapid recovery.

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.

Right Adrenal Pheochromocytoma with Anterolateral Displacement of the Inferior Vena Cava: Skin Incision and Approach

We report a case of a right adrenal pheochromocytoma with prominent anterolateral displacement of the inferior vena cava. A right ipsilateral anterior subcostal incision extending from the xiphoid process to the 11th intercostal space allowed for wide upward retraction of the right costal arch. This incision is useful for easy mobilization of the liver and manipulation of the inferior vena cava without thoracotomy.

Ex Vivo Comparison of Radiological and Histological Evaluation of Early Metastatic Lesions of Pelvic Lymph Nodes from Carcinoma of the Bladder or Prostate

To study the limitations of lymphangiography in the detection of early lymphatic spread of pelvic malignancies, we evaluated 587 lymph nodes from 23 patients with stages pN0 to 2 carcinoma of the bladder or prostate. Pelvic lymphadenectomy was performed 5 to 10 days after bipedal lymphangiography. Excised lymph nodes were separated one by one and an x-ray of each node was taken (lymphnodegram). The individual lymphnodegram was compared to the histological findings. Interpretations of lymphnodegrams from all 17 nodes with metastases were positive in 5, suspicious in 1, negative in 9 and radiolucent in 2. False negative judgments occurred chiefly because metastatic foci were microscopic. Two lymph nodes without metastasis were interpreted as positive for disease because of fat replacement of the nodes. These results indicated that lymphangiography is not suitable for the detection of early lymphatic metastases of carcinoma of the bladder or prostate.

Modified endoscopic live donor nephrectomy: Retroperitoneoscopy followed by hand‐assistance

Abstract  We have developed a novel modification of previous approaches to donor nephrectomy and herein review our original operative procedure. First, the posterior aspect of the kidney was dissected retroperitoneoscopically and dissection of the renal artery, ureter and gonadal vein was almost completed. Second, the anterior aspect of the kidney was dissected with transperitoneal hand‐assistance, and dissection of the renal pedicle from the anterior surface was accomplished easily and safely. This operative procedure was successfully performed for two donors with no intraoperative or postoperative complications. Our modified endoscopic donor nephrectomy is feasible as a minimally invasive procedure because of its safety, and its ability to preserve renal function and establish an excellent operative field for both posterior and anterior aspects of the kidney.

[Benefits and adverse effects of post-operative radiation therapy after radical cystectomy for patients with advanced bladder cancer].

BACKGROUND The benefits and adverse effects of post-operative irradiation for advanced bladder cancer patients were investigated. METHODS Ten patients with pT3b, pT4 or pN+ bladder cancer who underwent radical cystectomy at Yamanashi Medical University hospital during 7 years and 3 months from October 1983 to December 1991 received adjuvant chemotherapy and radiotherapy (Group 1). During the same period, six patients with recurrent tumor after radical cystectomy were treated by radiotherapy (Group II). Stages of the primary tumors were pT2 in 1, pT3a in 2, pT3b in 6 and pT4 in 7 cases. In addition, 10 of 16 patients (63%) had positive nodes. RESULTS During the follow up period, seven patients died of cancer, and one died of other cause. As a result eight patients (5 in Group I, 3 in Group II) are alive. The cumulative 5-year survival rate is 50%. However, nine of the 16 patients (56%) suffered from the small bowel obstruction as an adverse effect of irradiation. Six patients required resection of the small bowel or bypass surgery. CONCLUSIONS Radiation after radical cystectomy seemed to be effective for the local control of the tumor, but the adverse effect to the digestive system was very severe and common.

Early Site of Lymphatic Involvement from Right Renal Cell Carcinoma: CT Demonstration and Method of Lymphadenectomy

The value of lymphadenectomy in the treatment of renal cell carcinoma remains controversial. The precise location of nodal metastasis and method of lymphadenectomy had seldom been mentioned. We report 2 patients with right renal cell carcinoma who had regional lymph node involvement without blood-borne metastasis. The involved lymph nodes were demonstrated by CT scan just behind the inferior vena cava at the level of renal hilus. These nodes seemed to be the first sites of nodal involvement from the right renal cell carcinoma. Elevation of the inferior vena cava by dividing its small branches, including a few lumbar veins, was necessary for complete removal of these nodes en bloc with the right kidney.