Ryohei Hattori

Laparoscopic radical nephrectomy for renal cell carcinoma: a five-year experience

OBJECTIVES To evaluate the efficacy of laparoscopic radical nephrectomy for patients with small renal cell carcinoma by comparing the clinical results of patients treated laparoscopically with those of patients treated with traditional open radical nephrectomy. METHODS Of 100 patients with localized, small (less than 5 cm in diameter) renal cell carcinoma treated by the same surgical team between 1992 and 1998, 60 patients underwent laparoscopic radical nephrectomy and 40 underwent open radical nephrectomy. Of the 60 laparoscopically treated patients, the first 11 and the most recent 34 patients were operated on transperitoneally and the other 15 retroperitoneally. RESULTS The mean operative time of the laparoscopically treated patients was longer than that of the open nephrectomy patients (5.2 versus 3.3 hours, P<0.001). The mean blood loss of the laparoscopically treated patients was less than that of the open nephrectomy patients (255 versus 512 mL, P<0.001). One laparoscopically treated patient needed conversion to open surgery. The time to full convalescence of the laparoscopically treated patients was shorter than that of the open nephrectomy patients (23 versus 57 days, P<0.001). Two of the 59 laparoscopically treated patients and 1 of the 40 open nephrectomy patients had metastatic disease. The former 2 are alive with stable disease and the latter died of progressive disease 11 months after surgery. The 5-year disease-free rate was 95.5% in laparoscopy patients and 97.5% in open nephrectomy patients (P = NS). CONCLUSIONS Laparoscopic radical nephrectomy is a less invasive alternative to open surgery for patients with localized small renal cell carcinoma.

THE LONG-TERM OUTCOME OF LAPAROSCOPIC RADICAL NEPHRECTOMY FOR SMALL RENAL CELL CARCINOMA

PURPOSE To evaluate the efficacy of laparoscopic radical nephrectomy in patients with small renal cell carcinoma, we analyzed the long-term results in those treated with laparoscopy and those undergoing open surgery. MATERIALS AND METHODS A total of 149 patients with tumors less than 5 cm. in diameter enrolled in a radical nephrectomy program between January 1992 and March 2000. Of these patients 103 were treated laparoscopically and the remaining 46 underwent open surgery. Patient followup was until June 30, 2000. RESULTS Laparoscopy followup was from 3 to 95 months (median 29). A total of 100 patients survived, 2 died without any recurrent disease in months 34 and 45, respectively, and 1 dropped out in postoperative month 3. Seeding of the port sites did not develop in any of the patients. There were 3 patients who had metastatic disease in months 3, 19 and 61, respectively, and 1 had local recurrence in postoperative month 43. The 5-year disease-free and patient survival rates were 95.1%, and 95.0%, respectively. Except for 2 patients who dropped out in months 10 and 16, respectively, 44 who underwent open surgery were followed from 11 to 101 months (median). Of the 44 patients 41 survived without any recurrent disease, 1 also survived with metastasis and 2 died of metastatic disease in months 7 and 11, respectively. The 5-year disease-free and patient survival rates were 89.7% and 95.6%, respectively. CONCLUSIONS Laparoscopic radical nephrectomy can be an alternative to open nephrectomy in patients with localized small renal cell carcinoma.

Laparoscopic Radical Nephroureterectomy: A Multicenter Analysis in Japan

BACKGROUND Laparoscopic nephroureterectomy (LNUx) is prevalent in Japan and throughout the world, but long-term outcome data remain limited. OBJECTIVE To understand the present state of LNUx in Japan, we conducted a multicenter analysis of clinical outcome and long-term cancer control for patients who underwent the procedure. DESIGN, SETTING, AND PARTICIPANTS Between January 1995 and December 2005, 1003 patients with urothelial cancer in the upper urinary tract were treated with LNUx at 51 institutions in Japan, and patient data were collected retrospectively. MEASUREMENTS Patient profiles were gathered and analyzed for survival, intravesical recurrence, and risk factors influencing them. RESULTS AND LIMITATIONS Median operative time was 320 min. Median bleeding volume was 232 ml. Complications occurred in 93 cases (9.3%) intraoperatively and in 107 cases (10.7%) postoperatively. Overall survival rate was 70% at 5 yr. Grade 3, pT3 or pT4, multifocal tumor, lymph-node metastasis, and previous or coexistent bladder tumor were independent risk factors for overall survival. Intravesical recurrence rate was 43% at 5 yr. Intravesical recurrence occurred more frequently in males, in patients with multifocal tumors, in patients with previous or coexistent bladder tumors, and in patients who underwent the hand-assisted approach. CONCLUSIONS Our report represents the largest multicenter analysis of LNUx reported to date. Male sex and the use of the hand-assisted approach were shown for the first time to be risk factors for recurrence-free survival and intravesical recurrence. To further analyze the effectiveness of LNUx, a long-term outcome comparison with risk stratification must be made between LNUx and open nephroureterectomy.

Periurethral injection of autologous adipose-derived stem cells for the treatment of stress urinary incontinence in patients undergoing radical prostatectomy: report of two initial cases.

Objectives:  To report a novel cell therapy using autologous adipose tissue‐derived stem cells (ADSC) for stress urinary incontinence caused by urethral sphincteric deficiency and the outcomes in two initial cases undergoing periurethral injection of stem cells for the treatment of urinary incontinence after radical prostatectomy.

Ischemic Renal Damage after Nephron-Sparing Surgery in Patients with Normal Contralateral Kidney

BACKGROUND Although nephron-sparing surgery (NSS) has been reported not to affect total renal function, the functional damage of the operated kidney is masked by the contralateral kidney in elective indications. OBJECTIVE To determine ischemic renal damage after NSS. DESIGN, SETTING, AND PARTICIPANTS From August 2005 to October 2007, 32 consecutive patients with elective indications underwent NSS. The mean tumor diameter was 2.6 cm. INTERVENTION Of our patients, the open surgery was performed in 20 patients, and laparoscopic surgery was performed in 12 patients. NSS was performed by hilar clamping with a warm ischemic time of 24.3 min. MEASUREMENTS We analyzed effective renal plasma flow (ERPF) calculated from (99m)Tc-mercaptoacetyltriglycine ((99m)Tc-MAG-3) renal scintigraphy and renal parenchymal volume (RPV) measured from computed tomography (CT) scan. In addition, we analyzed (99m)Tc-MAG-3 uptake regionally in the surgically non-affected parts. (99m)Tc-MAG-3 and CT scans were performed preoperatively and 1 wk and 6 mo postoperatively. RESULTS AND LIMITATIONS One week after NSS, ERPF of the operated kidney decreased by 28.7% (from 158.9 to 113.3 ml/min per 1.73 m(2), p<0.001), and RPV decreased by 12.6% (from 149.8 to 131.0 cm(3), p<0.001). These changes were stable for 6 mo. Regional (99m)Tc-MAG-3 uptake of the operated kidney with an ischemic time of > or = 25 min decreased to 61.8% after 1 wk and 70.9% after 6 mo. In contrast, with ischemic times within 25 min, regional (99m)Tc-MAG-3 uptake was 87.4% after 1 wk and 94.4% after 6 mo. This is a relatively small study, and the follow-up period is short. A larger sample size and longer follow-up may be required. CONCLUSIONS Although total renal function was almost unaffected before and after NSS, a warm ischemic time of > or = 25 min caused irreversible damage distributed diffusely throughout the operated kidney.

Retroperitoneoscopic nephroureterectomy for transitional cell carcinoma of the renal pelvis and ureter: Nagoya experience

OBJECTIVES To evaluate the efficacy of our new retroperitoneoscopic nephroureterectomy for patients with transitional cell carcinoma of the renal pelvis and ureter, we present the operative procedure and analysis of the clinical outcome of retroperitoneoscopy in 23 patients. METHODS Twenty-three patients with transitional cell carcinoma of the upper urinary tract underwent retroperitoneal laparoscopic nephroureterectomy between February 2000 and February 2002. Patient age ranged from 44 to 83 years (mean 66.7). Each kidney was retroperitoneoscopically dissected en bloc, together with the perirenal fatty tissue, lymph nodes, and/or adrenal gland, without transecting the ureter. The lower ureter was resected with the bladder cuff transected using an ultrasonic scalpel and an endoscopic gastrointestinal automatic stapler. The dissected specimen was removed intact through a 6-cm-long original incision. RESULTS The mean operating time was 4.8 hours, including 0.7 hours for complete removal of the ureteral end with the bladder cuff. The mean estimated blood loss was 304 mL. The mean time to recovery to normal activity was 18 days. In the mean follow-up period of 15 months, 2 patients died of cancer progression in the sixth postoperative month, 2 died of other causes, and 4 had recurrent transitional cell carcinoma of the bladder after surgery. CONCLUSIONS Our retroperitoneal laparoscopic nephroureterectomy using an endoscopic gastrointestinal automatic stapler is a fast, low-risk, and minimally invasive procedure and might be an alternative to other laparoscopic techniques and open nephroureterectomy. However, long-term follow-up is necessary to confirm the efficacy for patients with transitional cell carcinoma of the renal pelvis and ureter.

Prognostic value of intraductal carcinoma of the prostate in radical prostatectomy specimens.

Intraductal carcinoma of the prostate (IDC‐P) is an adverse prognostic factor for radical prostatectomy (RP). The endpoint in most IDC‐P studies is increased prostate‐specific antigen (PSA) levels. The aim of this study was to evaluate whether IDC‐P in RP specimens is an adverse prognostic factor for progression‐free survival (PFS) and cancer‐specific survival (CSS).

Efficacy of Silodosin for Relieving Benign Prostatic Obstruction: Prospective Pressure Flow Study

PURPOSE We investigated the effect of the new sympathetic alpha1A-adrenoceptor antagonist silodosin for relieving benign prostatic obstruction by pressure flow study. MATERIALS AND METHODS In this open, nonblinded, prospective study we administered 8 mg silodosin daily for 4 weeks in 60 patients with lower urinary tract symptoms associated with benign prostatic enlargement. As a primary outcome measure, we assessed changes in bladder function and benign prostatic obstruction using pressure flow study. As secondary outcome measures, changes in subjective symptoms and quality of life were assessed by the International Prostate Symptom Score. Objective changes in urination status were also assessed by free uroflowmetry in terms of maximum flow rate and post-void residual urine volume. RESULTS A total of 57 patients were enrolled for analysis. In the storage phase of the pressure flow study bladder capacity at first desire to void increased significantly with no significant change in maximum cystometric capacity. Of 24 patients 14 (58.3%) with uninhibited detrusor contractions before administration showed apparent improvement in detrusor overactivity after administration, including 6 in whom uninhibited contractions disappeared. In the voiding phase mean detrusor pressure at maximum flow significantly decreased from 72.5 to 51.4 cm H(2)O. The mean bladder outlet obstruction index decreased significantly from 60.6 to 33.8. Obstruction grade assessed by the Schaefer nomogram improved in all except 1 patient. Total symptom and quality of life scores, maximum flow rate and post-void residual urine volume on free uroflowmetry significantly improved. CONCLUSIONS Silodosin improved lower urinary tract symptoms by improving bladder storage function and relieving benign prostatic obstruction.

TGF-β1 Promotes Lymphangiogenesis during Peritoneal Fibrosis

Peritoneal fibrosis (PF) causes ultrafiltration failure (UFF) and is a complicating factor in long-term peritoneal dialysis. Lymphatic reabsorption also may contribute to UFF, but little is known about lymphangiogenesis in patients with UFF and peritonitis. We studied the role of the lymphangiogenesis mediator vascular endothelial growth factor-C (VEGF-C) in human dialysate effluents, peritoneal tissues, and peritoneal mesothelial cells (HPMCs). Dialysate VEGF-C concentration correlated positively with the dialysate-to-plasma ratio of creatinine (D/P Cr) and the dialysate TGF-β1 concentration. Peritoneal tissue from patients with UFF expressed higher levels of VEGF-C, lymphatic endothelial hyaluronan receptor-1 (LYVE-1), and podoplanin mRNA and contained more lymphatic vessels than tissue from patients without UFF. Furthermore, mesothelial cell and macrophage expression of VEGF-C increased in the peritoneal membranes of patients with UFF and peritonitis. In cultured mesothelial cells, TGF-β1 upregulated the expression of VEGF-C mRNA and protein, and this upregulation was suppressed by a TGF-β type I receptor (TGFβR-I) inhibitor. TGF-β1-induced upregulation of VEGF-C mRNA expression in cultured HPMCs correlated with the D/P Cr of the patient from whom the HPMCs were derived (P<0.001). Moreover, treatment with a TGFβR-I inhibitor suppressed the enhanced lymphangiogenesis and VEGF-C expression associated with fibrosis in a rat model of PF. These results suggest that lymphangiogenesis associates with fibrosis through the TGF-β-VEGF-C pathway.

Laparoscopic radical nephrectomy for renal cell carcinoma: the standard of care already?

Purpose of review Laparoscopic radical nephrectomy has been developed and applied for patients with renal cell carcinoma since 1992. The number of patients undergoing laparoscopic radical nephrectomy has increased explosively worldwide in recent years, and laparoscopy is now extended to patients with advanced disease. It is very important to clarify the present status of laparoscopic radical nephrectomy among the treatment modalities for patients with renal cell carcinoma. Recent findings Laparoscopic radical nephrectomy has a minimally invasive nature as well as comparable long-term cancer control in patients with pT1-3a renal cell carcinoma to open surgery. It is technically applicable for N1-2 disease and T3b disease if the tumor thrombus is within the renal vein. Also, it is feasible as a cytoreductive surgery for patients with M1 disease. Summary Laparoscopic radical nephrectomy is a standard treatment modality for T1-3a renal cell carcinoma patients. It is also available for treating patients with N1-2 disease, and for patients with M1 disease as a cytoreductive surgery.