Osamu Ryoji

ETHANOL INJECTION THERAPY OF THE PROSTATE FOR BENIGN PROSTATIC HYPERPLASIA: PRELIMINARY REPORT ON APPLICATION OF A NEW TECHNIQUE

PURPOSE We evaluate the efficacy of a new technique of minimally invasive treatment for benign prostatic hyperplasia involving direct injection of dehydrated ethanol. MATERIALS AND METHODS Dehydrated ethanol was injected transurethrally with lumbar or sacral and urethral anesthesia in 10 patients with prostatic hyperplasia. Endoscopic injection was performed at 4 to 8 sites in the prostate and 3.5 to 12.0 ml. ethanol were used. RESULTS There were no intraoperative complications but postoperative urinary retention occurred transiently in all patients which required catheterization for a mean of 8.8 days. Mean symptom score plus or minus standard deviation was 12.2+/-5.8 at 3 months postoperatively, which was significantly improved from 23.1+/-7.0 preoperatively (p<0.01). Mean quality of life score also improved significantly from 5.1+/-0.6 preoperatively to 3.2+/-1.5 at 3 months postoperatively (p<0.01), mean peak urinary flow rate increased from 8.0+/-2.2 (9 patients) to 13.1+/-3.6 ml. per second (p<0.05) and mean residual urine volume decreased from 129.1+/-55.3 (9 patients) to 49.3+/-34.7 ml. (p<0.05). There was no significant change in prostate volume. Acute epididymitis and chronic prostatitis occurred in 1 patient each. CONCLUSIONS This technique can be performed as an outpatient procedure and appears to be safe and cost-effective. Retrograde ejaculation can be avoided.

Impact of arterial occlusion during partial nephrectomy on residual renal function: an evaluation with (99m)technetium-dimercaptosuccinic acid scintigraphy.

Background: Partial nephrectomy (PNx) has been performed with temporary renal arterial occlusion and in situ renal hypothermia (conventional PNx). However, the impact of temporary renal arterial occlusion on residual renal function has not been well assessed. To address this question, we performed renal scintigraphy with 99mtechnetium‐dimercaptosuccinic acid (DMSA) for the quantitative measurement of postoperative residual renal function after conventional PNx and partial nephrectomy without arterial occlusion (non‐clamping PNx).

Analysis of prognostic factors related to primary superficial bladder cancer tumor recurrence in prophylactic intravesical epirubicin therapy

Purpose: The aims of the present study were to examine the effects of intravesical instillation of epirubicin on tumor recurrence and to identify tumors that are at a high risk of recurrence.

Detection and quantification of soluble intercellular adhesion molecule-1 (sICAM-1) in the serum and urine of patients with bladder cancer.

Background: A possible role for intercellular adhesion molecules in tumor progression and metastasis has been strongly suggested. To investigate the effect of soluble intercellular adhesion molecule‐1 (slCAM‐1) on bladder cancer, slCAM‐1 serum and urinary concentrations were measured in patients with superficial or invasive bladder cancer and in patients with prostatic hypertrophy.

Cytokines accumulated in acquired renal cysts in long-term hemodialysis patients.

Background: Cytokines play a pivotal role in growth, differentiation, and apoptosis. In this study, we measured cytokine content in the renal cyst fluid of patients with acquired cystic disease of the kidney (ACDK) in order to elucidate the possibility that cytokines are related to the development of ACDK. Patients and Methods: All or some of 15 cytokines, IL-1a, -1b, -2, -4, -5, -6, -8, -10, IFN-α, -γ, G-, M-, GM-CSF, TNF-α, and vascular endothelial growth factor (VEGF) were analyzed in cyst fluid and serum of 12 patients on hemodialysis (HD) including 8 with ACDK and 8 with normally functioning kidneys by sandwich enzyme-linked immunosorbent assay. Results: Out of these cytokines, only IL-6, -8, M-CSF, and VEGF were detected in the cyst fluid of patients with ACDK. Moreover, IL-6, -8, and VEGF showed significantly higher concentrations in the cyst fluid than in the blood (194.9 ± 90.9 vs. 0.0 ± 0.0 pg/ml, 2,377.5 ± 602.9 vs. 0.0 ± 0.0 pg/ml, 5,167.8 ± 1,316.9 vs. 41.1 ± 14.7 pg/ml, respectively), while M-CSF showed comparable concentrations in the cyst fluid with those in the blood (3,519.4 ± 730.0 vs. 3,250.3 ± 319.1 pg/ml, p = 0.69). Additionally, IL-6, -8, and VEGF accumulated more abundantly in the cyst fluid of patients with ACDK than in that of patients with other cystic nephropathies including ADPKD patients on HD (194.9 ± 90.0 vs. 4.6 ± 3.2 pg/ml, 2,377.5 ± 602.9 vs. 76.8 ± 46.5 pg/ml, 5,167.8 ± 1,316.9 vs. 131.1 ± 63.1 pg/ml, respectively). However, there was no significant correlation between the intracystic concentrations of these cytokines and the corresponding cyst diameters. Conclusion: These results showed that in ACDK patients a local environment exists in which production or accumulation of certain cytokines is selectively enhanced compared with patients with other cystic nephropathies. They imply that these cytokines are closely related to pathogenesis particular to ACDK.

Case of IgG4-related retroperitoneal fibrosis with concomitant rheumatoid arthritis

A new clinicopathological concept of IgG4-related sclerosing disease affecting various organs has recently been proposed in relation to autoimmune pancreatitis. The present report describes a case of IgG4-related retroperitoneal fibrosis concomitant with rheumatoid arthritis independent of autoimmune pancreatitis. A 67-year-old Japanese man presented with left flank pain and high-grade fever. He had neither any previous medical history nor was there any family history. Abdominal computed tomography (CT) showed left hydronephrosis and urinary extravasation around the renal pelvis owing to a thick retroperitoneal soft tissue tumor surrounding the abdominal aorta (Fig. 1a). The tumor was visualized as a low or iso-intensity mass by T1 or T2 weighted image in magnetic resonance imaging (MRI) without gadolinium. Retroperitoneal fibrosis, a ureteral tumor or malignant lymphoma was suspected. Retrograde pyelography showed the left ureteral stricture wherein the retroperitoneal tumor caused the compression of the ureter without any filling defect. Urine cytology using a urine sample from the left renal pelvis and lower ureter was negative. Immediately after a double-J ureteral catheter was inserted into the left renal pelvis without resistance, through the ureter, his general condition and inflammatory reactions improved. Blood tests showed increased serum IgG-4 concentrations and soluble interleukin-2 receptor-alpha levels, but were negative for the anti-human T-lymphotropic virus type I (HTLV-I) antibody. To investigate the inflammatory activity, fluorodeoxyglucose positron emission tomography (FDGPET)/CT was implemented. However, it was difficult to confirm the precise diagnosis based solely on the FDGPET/CT findings, even though FDG-PET/CT had shown rapid intense FDG uptake in the region of the retroperitoneal tumor (Fig. 1b). The patient was finally diagnosed with IgG4-related retroperitoneal fibrosis after a retroperitonealopen tumor biopsy, which obtained adequate specimens, resulting in a correct histopathological classification (Fig. 1c). The presence of high serum IgG4 concentrations led us to consider a possible association with IgG4-related sclerosing disease affecting various organs. However, there were no clinical features to support the diagnosis of autoimmune pancreatitis. In contrast, he had experienced Reynaud’s symptoms and arthralgia for a several months prior. He was diagnosed with rheumatoid arthritis (RA) with high serum levels of rheumatoid factor (RF, 113 IU/mL) and positivity for anti-nuclear antibody (80-fold) after we had consulted a physician to examine the cause of those symptoms. After administration of oral prednisolone at an initial daily dose of 30 mg, regression of the retroperitoneal mass, as well as the reduction of Reynaud’s symptoms and arthralgia, were achieved. A prescription for 4 weeks induced decreases in serum IgG4 levels from 384.3 mg/dL to 74.8 mg/dL. These effects strongly suggested that the present case was an IgG4-related retroperitoneal fibrosis with concomitant rheumatoid arthritis, although the clinical significance remains unknown. Retroperitoneal fibrosis generally presents in a nonspecific manner with malaise, fatigue, fever and weight loss, and has many causes; although in approximately 70% of cases, the cause is unknown. A novel clinicopathological entity of IgG4-related sclerosing disease has been proposed. IgG4-related sclerosing disease is classified as a systemic disease, including autoimmune pancreatitis (AIP) itself, and is characterized by high serum IgG4 concentrations and extensive infiltration of IgG4-positive plasma cells into a variety of organs, such as the bile duct, salivary gland, retroperitoneum, kidney and lung. Currently, IgG4-related retroperitoneal fibrosis has been reported to develop

Inducible Nitric Oxide Synthase Localization in Acquired Cystic Disease of the Kidney

Accessible online at: http://BioMedNet.com/karger Dear Sir, Nitric oxide (NO) is a messenger molecule which may play a pivotal role in the physiological and pathophysiological regulation of various organ systems. Overproduction of NO can cause cell death by DNA damage and cytotoxicity [1]. A number of isoforms of NO synthase (NOS) have been confirmed, including one that is inducible NOS (iNOS). Cytokines are powerful inducers of iNOS that can result in a marked increase in NO synthesis [2]. Previous in vitro experimental studies demonstrated that expression of iNOS mRNA following NO production in isolated renal tubular cells was induced by stimulation of a variety of cytokines [3]. In human glomerulonephritis, an immunohistochemical study showed that the expression of iNOS was detected in infiltrating monocytes/macrophages alone [4]. However, the exact distribution of iNOS in normal and pathological states of the kidney has not been clarified. In the present study, we demonstrated immunohistochemical localization of iNOS in dialysis patients having, among others, acquired cystic disease of the kidney (ACDK). We examined 42 patients who underwent nephrectomy. They were divided into four groups according to their underlying renal diseases: group A included 17 patients with ACDK-associated renal cell carcinoma (RCC); group B 5 patients with RCC of the dialyzed kidney without ACDK; group C 7 patients with autosomal dominant polycystic kidney disease (ADPKD), and group D 13 patients with RCC or renal pelvic cancer in a normal-functioning kidney. The 29 patients in groups A–C all underwent maintenance hemodialysis therapy. The LSAB method (DAKO, Japan) was used to localize iNOS. After deparaffinization with xylene and ethanol, the sections (3.5 Ìm) were incubated with 0.3% hydrogen peroxide in methanol for 30 min. The slices were immersed with primary antibody (rabbit antimouse iNOS antibody, WAKO) at 1:500 dilution in phosphate-buffered saline containing 1% bovine serum albumin and incubated for 60 min at room temperature. The following procedures including the treatment with second antibody and visualization of immunoproducts were performed using the LSAB kit according to manufacturer’s instructions. The tissue specimens were scored as positive, if more than 10% of cells were stained for iNOS in the most intensely staining areas. Moreover, in order to determine the origin of the iNOS-positive cells, serial sections were also stained with antiCD68 antibody, KP-1 (DAKO), and anticytokeratin antibody, MNF116 (DAKO), as monocyte/macrophage and epithelial cell markers, respectively. In the renal tissues of ACDK, the iNOS immunoreactivity was localized in cystic epithelial cells and stromal cells (fig. 1). As summarized in table 1, the positive staining rate for iNOS was 82.4% (14 of 17) in patients with ACDK (group A) and 42.9% (3 of 7) in patients with ADPKD (group C; p = 0.0127, Fisher’s exact test). On the contrary, it was not stained in dialyzed kidneys without ACDK (group B) as well as Table 1. Immunohistochemical staining of ACDK, ADPKD, end-stage renal disease (ESRD), and normal kidney tissue by antiiNOS antibody

Nephron-sparing tumorectomy for a large benign renal mass : A case of massive bilateral renal angiomyolipomas associated with tuberous sclerosis

Abstract A case of massive bilateral angiomyolipomas (AML) associated with tuberous sclerosis in a 33‐year‐old woman is reported. She was hospitalized because she had been experiencing abdominal fullness and epigastralgia. Several imaging studies revealed massive bilateral renal tumors and she was diagnosed as having renal AML associated with tuberous sclerosis. Left nephrectomy was carried out after renal arterial embolization for intratumor hemorrhage. Two years after left nephrectomy, nephron‐sparing surgery (tumorectomy) for right AML was done because of an increase in the size of the right renal AML and she hoped for a future pregnancy. The left kidney with AML weighed 5700 g and the right AML weighed 1700 g. Postoperative serous creatinine did not differ from that before operation and an increase in the size of the residual tumor was not observed 8 months after operation. We consider that tumorectomy is an effective therapy in patients with a very large tumor involving a solitary kidney.

Electrovaporization using a rollerball electrode for flat or small papillary tumors of the bladder: basic study in dogs.

PURPOSE We investigated electrovaporization of flat bladder tumors with a rollerball electrode 3 mm in diameter as a substitute for conventional transurethral resection with a cutting loop. MATERIALS AND METHODS A basic study of the action of electrovaporization was performed in dogs. The bladder was exposed under general anesthesia in three mongrel dogs. The rollerball electrode was attached to the resectoscope and inserted into the bladder via a cystostomy. Then electrovaporization was performed with a low or high pressure on the electrode tip and a speed of about 1 cm/sec using a Force 40 generator. The cutting mode power was set at 100 W or 200 W. The effects of the rollerball and cutting loop electrodes were also examined in the coagulation mode (45 W) as a control. RESULTS A deeper vaporization zone was obtained by using a power of 200 W in the cutting mode than with a power of 100 W, and a desiccation zone was found below the vaporization zone (VZ). The VZ was thicker with a high contact pressure than with a low contact pressure. This VZ was deeper than the tissue defect and heat-affected zone obtained using a rollerball electrode or cutting loop electrode in the 45 W coagulation mode. CONCLUSION Although caution is required because the VZ can become too deep with excessive pressure, the rollerball electrode seems to be safer and more useful than the cutting loop electrode for resection of flat or small papillary bladder tumors.

A case of metachronous multiple urothelial cancer developing through out the whole urinary tract in a diabetic hemodialysis patient

症例は67歳, 男性. 糖尿病性腎症のため1997年1月, 血液透析導入となった. 同年2月に肉眼的血尿が出現し膀胱憩室内とその周囲に限局した膀胱癌と診断, 膀胱部分切除術を施行した. その後, 膀胱内に再発, 筋層浸潤があったため, 1998年4月, 膀胱全摘術を施行した. 両側尿管は結紮し尿路変更は行わなかった. 1999年3月, MR urographyにて右腎孟再発を認め, 右腎尿管摘出術を施行. 2か月後, 尿道出血より尿道再発を疑い, 尿道摘出術を施行した. 1999年11月, 腹部CTおよびMR urographyにてリンパ節転移, 左腎孟再発を認めたため, 放射線治療を行った. しかしながら癌は進行し, まもなく癌死した. 透析患者における膀胱癌はhigh stageでhigh gradeのことが多く, 膀胱全摘術が必要となるが, 通常, 尿路変更は行わず上部尿路はそのままで経過観察することがある. しかしながら, 本症例のように尿道を含めて全尿路に再発することもあり, 膀胱全摘術後の慎重な経過観察と再発時の迅速な治療が重要であると思われた.