Nobuyuki Hinata

The significant immunological characteristics of peripheral blood neutrophil-to-lymphocyte ratio and Fas ligand expression incidence in nephrectomized tumor in late recurrence from renal cell carcinoma

OBJECTIVE In order to characterize the significance of immune system function in patients with advanced renal cell carcinoma (RCC), we investigated the interactive relationships among the following parameters: metastatic characteristics, expression of Fas ligand (FasL) in nephrectomized specimens, immunological parameters, and patients prognosis. MATERIALS AND METHODS Thirty-five patients with advanced RCC were stratified into 3 groups according to the characteristics of metastasis timing, at first presentation (mFP), within 5 years of nephrectomy (early-recurrence), after 5 years (late-recurrence). Immunological parameters [hemoglobin, lymphocyte count, neutrophil/lymphocyte ratio (NLR), serum albumin, Eastern Cooperative Oncology Group (ECOG) performance status (PS), and Charlson Comorbidity Index], FasL expression in RCC, and patient prognosis from occurrence of metastasis were compared among the groups. Thirty-five patients were also stratified into 2 groups according to FasL positivity and individual parameters. Patients prognosis and the remaining immunological parameters were compared between groups. RESULTS The NLRs of the late-recurrence group were significantly lower than those of the mFP (P = 0.0004) and early-recurrence (P = 0.013) groups. The FasL mRNA positivity of the late-recurrence group was significantly lower than those of the mFP (P = 0.001) and early-recurrence (P = 0.0277) groups. The prognosis of the late-recurrence group was significantly better than that of the early-recurrence group (P = 0.0255). NLRs were significantly lower in the FasL-negative group than in the -positive group (P = 0.0182). The cause-specific survival rates of the ECOG PS 0 group were significantly higher than that of the ECOG PS > 0 group (P < 0.0001). CONCLUSIONS Our results suggest the associations of the prognosis in advanced RCC with peripheral blood NLR and FasL expression in nephrectomized tumor. The characteristics of lower values of NLR and FasL expression positivity in late-recurrence compared with other metastatic timings suggest strong host immune activity, and may imply relatively long survival. On the other hand, elucidation of the patients general condition obtained not only by chemical data but also by ECOG PS is crucial in the management of patients with advanced RCC.

Quantitative detection of Escherichia coli from urine of patients with bacteriuria by real-time PCR.

AbstractIntroduction: Compared with the classical urine culture method, PCR is more rapid, and can detect smaller numbers of bacteria, however it is inferior for quantification. Because of the lack of quantification in routine PCR, the meaning of a positive PCR test result has not been validated for all infections. We report on the development of a novel quantitative detection system for the urinary tract infection (UTI) Escherichia coli using real-time PCR. Patients: We enrolled 200 patients with suspected bacteriuria. Methods: The gene encoding the universal stress protein (uspA) was found to be highly specific for E. coli. We quantified the copy numbers of E. coli in the urine of patients with UTI by using a real-time PCR assay (the TaqMan® system) targeting uspA genes in genomic DNAs isolated from urine samples (n = 200). To evaluate the feasibility of this method, the results were compared with those of a standard urine culture. Results: The incidence of positive urine cultures was 75% (150 of 200), and various doses of E. coli were detected in 84 of 150 specimens. The real-time PCR method also detected 84 cases of urinary infections of E. coli in the same specimens. Furthermore, the result of the quantification of E. coli using real-time PCR strongly correlated (r2 = 0.925) with the result of urine culture. Conclusion: Our results suggest that using quantitative-PCR means a faster and simpler diagnosis of E. coli urinary infection can be made compared with the traditional urine culture method.

Ambulatory movements, team dynamics and interactions during robot-assisted surgery

To analyse ambulatory movements and team dynamics during robot‐assisted surgery (RAS), and to investigate whether congestion of the physical space associated with robotic technology led to workflow challenges or predisposed to errors and adverse events.

Novel Telementoring System for Robot-assisted Radical Prostatectomy: Impact on the Learning Curve

OBJECTIVE To develop a Web-based audiovisual telementoring system for robot-assisted radical prostatectomy (RARP) and to assess the utility of this system. METHODS A telementoring system for RARP, consisting of a 3-dimensional high-definition view of the operating field, overview of the operating room, annotation function, and 2-channel audio feed with bidirectional connectivity between 2 institutions, was developed. The outcome of RARP performed for the initial 30 patients by 2 surgeons with telementoring was compared with that for 2 surgeons who received direct mentoring. RESULTS This system was shown to function properly with an acceptable latency. There were no significant differences in several parameters reflecting surgical outcomes, including the operating time, complication rate, early continence status, and positive margin rate between the telementoring and direct mentoring groups. CONCLUSION These findings suggest the usefulness of the telementoring system for promoting the spread of precise surgical techniques associated with RARP. To our knowledge, this is the first report concerning telementoring for robot-assisted surgery.

Evaluation and Impact of Workflow Interruptions During Robot-assisted Surgery

OBJECTIVE To analyze and categorize causes for interruptions during robot-assisted surgery. METHODS We analyzed 10 robot-assisted prostatectomies that were performed by 3 surgeons from October 2014 to June 2015. Interruptions to surgery were defined in terms of duration, stage of surgery, personnel involved, reasons, and impact of the interruption on the surgical workflow. RESULTS The main reasons for interruptions included the following: console surgeons switching (29%); preparation of the surgical equipment, such as cleaning or changing the camera (29%) or an instrument (27%); or when a suture, stapler, or clip was needed (12%). The most common interruption duration was 10-29 seconds (47.6%), and the least common interruption duration was greater than 90 seconds (3.6%). Additionally, about 14% of the interruptions were considered avoidable, whereas the remaining 86% of interruptions were necessary for surgery. CONCLUSION By identifying and analyzing interruptions, we can develop evidence-based strategies to improve operating room efficiency, lower costs, and advance patient safety.

Nerves supplying the internal anal sphincter: an immunohistochemical study using donated elderly cadavers

PurposeNerves serving the internal anal sphincter (NIAS) have been described as the lower rectal branches of the pelvic autonomic nerve plexus. However, their topographical anatomy and fiber components have remained unclear.MethodsUsing histological sections from ten elderly donated cadavers, we investigated the topographical anatomy and composite fibers of the NIAS using immunohistochemistry for S100 protein, neuronal nitric oxide synthase (nNOS), vasoactive intestinal polypeptide (VIP) and tyrosine hydroxylase (TH).ResultsAt the 2–3 o’clock position in the lower rectum, the NIAS originated from nerves at the posterolateral corner of the prostate in males or in the lower paracolpium in females. The nerves ran inferiorly along the internal aspect of the levator ani muscle, and joined branches of the myenteric plexus at a level slightly above the epithelial junction. The NIAS contained both nNOS-positive parasympathetic nerve fibers and TH-positive sympathetic fibers, but VIP-positive fibers were few in number.ConclusionsThe origin of the NIAS at the posterolateral corner of the prostate as well as in the lower paracolpium might be sacrificed or damaged during radical prostatectomy or tension-free vaginal tape insertion. Low anterior resection of rectal cancer will most likely render damage to the NIAS because of its intersphincteric course. Although the nerve composition of the NIAS is characterized by a higher proportion of sympathetic nerve fibers than the myenteric plexus in the large intestine, their role is unclear. However, evaluation of sphincteric function after surgery would appear to be difficult because of the complex control mechanism independent of nerve supply.

Fas expression in renal cell carcinoma accurately predicts patient survival after radical nephrectomy.

Objectives: To investigate Fas, Fas ligand (FasL) and Bcl-2 expression, which are considered to be important apoptotic regulatory factors in renal cell carcinomas (RCCs). Patients and Methods: mRNA quantification and immunohistochemistry allowed for the determination of the expression of these three factors in surgically resected tumors from 82 patients with RCC. The correlation of protein and gene expression with more than 10 years of survival data following nephrectomy (along with clinical and pathologic parameters) was analyzed using uni- and multivariate statistical models. Results: A significantly poorer outcome was observed in patients with tumors expressing high levels of Fas mRNA in the multivariate analysis (p = 0.0002). In addition, patient survival was significantly worse in FasL mRNA-positive tumor cases when compared with FasL mRNA-negative cases (p = 0.0345). Ten cases relapsed more than 5 years after nephrectomy. Among them, the tumors of 8 cases (80%) did not express FasL mRNA. Analysis of Bcl-2 did not show statistical significance of Bcl-2 expression as a prognostic indicator. Conclusions: The data suggest that pronounced Fas expression is a surrogate biomarker of active cancer cell proliferation. Given the FasL tumor counterattack theory, FasL overexpression in RCC may be one of the host immune deficiencies, consequently leading to poor prognosis.

Progress report on phase I/II clinical trial of Ad-OC-TK plus VAL therapy for metastatic or locally recurrent prostate cancer: Initial experience at Kobe University.

Abstract  There is no effective therapy for hormone‐refractory prostate cancer and a novel therapeutic modality, such as a gene therapy, should be actively pursued. Previously, Gardner and Chung conducted a phase I clinical trial of Ad‐OC‐TK (recombinant adenoviral vector containing osteocalcin promoter‐driven herpes simplex virus thymidine kinase gene) plus VAL (valacyclovir) for the treatment of hormone‐refractory prostate cancer at the University of Virginia. We report on our ongoing phase I/II clinical trial of Ad‐OC‐TK plus VAL for the treatment of advanced prostate cancer at the Kobe University Hospital, Japan.

The urethral rhabdosphincter, levator ani muscle, and perineal membrane: a review.

Detailed knowledge of the anatomy of the rhabdosphincter and adjacent tissues is mandatory during urologic surgery to ensure reliable oncologic and functional outcomes. To characterize the levator ani (LA) function for the urethral sphincter, we described connective tissue morphology between the LA and urethral rhabdosphincter. The interface tissue between the LA and rhabdosphincter area in males contained abundant irregularly arrayed elastic fibers and smooth muscles. The male rhabdosphincter was positioned alongside the LA to divide the elevation force and not in-series along the axis of LA contraction. The male perineal membrane was thin but solid and extends along the inferior margin or bottom of the rhabdosphincter area. In contrast, the female rhabdosphincter, including the compressor urethrae and urethrovaginal sphincter muscles, was embedded in the elastic fiber mesh that is continuous with the thick, multilaminar perineal membrane. The inferomedial edge of the female LA was attached to the upper surface of the perineal membrane and not directly attached to the rhabdosphincter. We presented new diagrams showing the gender differences in topographical anatomy of the LA and rhabdosphincter.

Detailed Histological Investigation of the Female Urethra: Application to Radical Cystectomy

PURPOSE We histologically examined the urethral anatomy to assess whether the surgical procedure for radical cystectomy should be modified in females. MATERIALS AND METHODS Anatomical and histological studies were performed on 20 adult female cadavers. Semiserial sections were processed for histological examination and immunohistochemistry. To assess the clinical value of the antegrade approach we examined blood loss and function in 12 consecutive patients who underwent radical cystectomy by this approach. RESULTS Vaginal wall smooth muscle contributed to urethral wall formation, in addition to a thin layer of proper urethral smooth muscle, particularly when the bladder detrusor was poorly developed or degenerated. The middle urethra was attached tightly to the vaginal smooth muscles with abundant veins running at the interface. The urethral sphincter and its inferoposterior continuation (urethrovaginal sphincter) were embedded in the elastic fiber rich perineal membrane. The membrane was U shaped, wrapping around the anterior aspect of the middle urethra and extending posterior along the distal vagina to end at the lateral extension of the perineal body near the external anal sphincter. Mean estimated blood loss was 965 ml. Of patients who received a neobladder hypercontinence was observed in 14.3% and 57.1% achieved continence. CONCLUSIONS There is topographical variation in the anatomy of tissues surrounding the female urethra. Care should be taken when dissecting the tissues dorsal or lateral to the urethra. The antegrade approach is useful since the urethra can be dissected under direct vision and traction can be applied to these structures.