Ryusuke Watanabe

Retroperitoneal Laparoscopic Adrenalectomy for Functioning Adrenal Tumors: Comparison With Conventional Transperitoneal Laparoscopic Adrenalectomy

PURPOSE We attempted to confirm the possibility and feasibility of laparoscopic adrenalectomy via the retroperitoneal approach, and to compare results of the transperitoneal and retroperitoneal approaches. MATERIALS AND METHODS Three men and 8 women (mean age 39.6 years) with functioning adrenocortical tumors (primary aldosteronism in 5 and Cushings syndrome in 6) underwent laparoscopic adrenalectomy via the retroperitoneal approach using a balloon dissection technique and a newly developed ultrasonic aspirator. Results were compared to those of 27 cases of transperitoneal laparoscopic adrenalectomy. RESULTS Although the retroperitoneal approach was successful in all 5 patients with primary aldosteronism, it succeeded in only 2 of the 6 cases of Cushings syndrome. In 3 Cushings syndrome cases the retroperitoneal approach was changed to the transperitoneal laparoscopic approach due to difficulty in exploration. Open laparotomy was required in 1 case of left Cushings syndrome because of an inadvertent pancreatic injury. Subcutaneous emphysema developed in 6 patients without hypercapnia or prolonged postoperative symptoms. Mean operative time and blood loss, and time to oral intake and ambulation were 248.3 minutes, 151.4 ml., and 1.55 and 2 days, respectively. There was no difference between retroperitoneal and conventional transperitoneal laparoscopic adrenalectomy in regard to these factors or to convalescence. CONCLUSIONS Retroperitoneal laparoscopic adrenalectomy is feasible for primary aldosteronism. However, Cushings syndrome is presently a much more difficult indication than primary aldosteronism for this new operative technique.

Loss of human E-cadherin (ECD) correlated with invasiveness of transitional cell cancer in the renal pelvis, ureter and urinary bladder

Loss or decreased expression of E-cadherin (ECD), which forms an epithelial junction complex that includes several other proteins and triggers signal transduction, may contribute to tumor progression. In the present study, we examined 90 transitional cell cancers (TCCs), 47 urinary bladder cancers and 43 ureteral or renal pelvic cancers, as well as TCC and papilloma cell lines to determine whether they express ECD. We classified ECD expression into normo-expression (like normal epithelial), decreased and loss of ECD staining on TCCs (urinary bladder, renal pelvic or ureteral). We found that low-stage TCCs expressed normal ECD in 68%, decreased of ECD in 20% and loss of ECD in 12%, whereas high-stage TCCs expressed 29%, 41% and 30% of ECD staining, respectively (P < 0.01). Furthermore, grade 1 TCCs were all estimated to show normo-expression, grade 2 TCCS expressed normal ECD in 49%, decreased of ECD in 41% and loss of ECD in 10% grade 3 TCCs classified as 20%, 30% and 50%, respectively (P < 0.01). Staining for cultured cell lines showed positive membranous staining for ECD in a benign papilloma cell line, RT4 and a TCC cell line, HT1376, but not in a TCC cell line, T24. Reverse-transcription polymerase chain reaction showed the presence of ECD and alpha-catenin mRNA in RT4 and HT1376, and only alpha-catenin in T24. Thus, it is more likely that decrease or loss of ECD might contribute to the malignant character of tumor cells and result in tumor progression.

Correlation of p53 protein expression in human urothelial transitional cell cancers with malignant potential and patient survival.

The p53 gene product has been detected frequently in various human malignancies. We have studied the expression of p53 protein in urothelial transitional cell cancers (TCCs) and examined its correlation with pathologic grade, stage(pT) and patient survival. Specimens from 69 surgically‐resected TCCs (38 cases of urinary bladder cancer, 17 cases of ureteral cancer and 14 cases of renal pelvic cancer) were examined by immunohistochemical staining, using two anti‐p53 monoclonal antibodies, PAb1801 and PAb240, and a polyclonal antibody, CM‐1. Twenty‐six TCCs (37.6%) were positively stained by at least one of the three antibodies. Statistical analysis showed a significant correlation between p53 expression and high pathologic grade (p less than 0.05, p less than 0.001) or progressive pathologic stage (p less than 0.01). In addition, in 51 of the patients who were available for follow‐up (23 cases of urinary bladder cancer, 13 cases of ureteral cancer, and 15 cases of renal pelvic cancer), the correlation between p53 protein expression and prognosis was examined. The survival of patients exhibiting positive p53 protein expression was significantly worse than those with p53‐negative tumors (p less than 0.05). These results suggest that an immunohistochemical test for p53 protein may be a useful method of evaluating the malignant potential of TCCs. Additionally, expression of p53 protein in TCCs is an indicator of a poor prognosis which should be considered in drawing up treatment strategies.

mRNA and protein expression of p53 mutations in human bladder cancer cell lines

We investigated mRNA and protein expression in p53 gene mutations in four human bladder cancer cell lines using polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) and Northern blot and Western blot analyses. The following mutations were identified in three of the four cell lines: a missense transversion at codon 110, a missense transition at codon 250 and a non-sense transversion at codon 126. These mutations were located outside previously identified hot spot codons and have rarely been reported in bladder cancer tissues or other neoplasms. Positive intranuclear p53 immunostaining in neoplastic cells in the two missense mutations and the premature stop codon in the non-sense mutation suggested the presence of structural and functional alterations in the p53 protein. Northern and Western blot analyses revealed either an intense or a weak p53 mRNA band together with an intense p53 protein band in the missense mutations, but no p53 mRNA or protein band in the non-sense mutation. A weak p53 mRNA band, but no distinct p53 protein band was observed in the cell line without a mutation and in normal control bladder cells. Our findings suggest that regulation of p53 expression in these cell lines differs at the post-transcriptional and/or post-translational level between the wildtype and the mutant p53 genes and also among different mutant p53 genes. The three cell lines with mutations were derived from high-grade carcinomas; the cell line without mutation was derived from a low-grade carcinoma.

Expression of E-Cadherin and Catenins on Testis Tumor

E-cadherin (ECD) is a homophilic Ca2+-dependent adhesion molecule associated with cell-to-cell interactions and normal growth. Recent reports have suggested that decrease or loss of ECD facilitates tumor progression and/or metastasis. ECD functions in a complex called an adherens junction, which includes several other proteins including α- and β-catenin. In the present study, fresh-frozen sections from 32 testis cancers, 16 seminomas and 16 non-seminomatous germ cell tumors (NSGCT), were examined immunohistochemically. E-cadherin was not expressed on normal germ cells, but expressed on 3 (18.8%) of 16 seminomas and 10 (62.5%) of 16 NSGCTs, mainly on the epithelial component of teratoma cells. α-Catenin was detected on 0 (0%) of 13 seminomas and 4 (25%) of 16 NSGCTs. β-Catenin was detected on 10 (71.4%) of 14 seminomas and 13 (81.2%) of 16 NSGCTs. ECD was detected significantly more frequently on NSGCTs than on seminomas. Immunoblot analysis confirmed the expression of ECD and β-catenin in NSGCTs. Expression of ECD and catenins may reflect the degree of differentiation and provide some information on the character of the tumor.

Primitive neuroectodermal tumor of the adrenal gland

Abstract  We report a rare case of primitive neuroectodermal tumor arising from adrenal gland in adulthood, diagnosed preoperatively as having non‐functional adrenocortical adenoma. Laparoscopic adrenalectomy was performed. Immunohistological examination revealed the definite diagnosis as primitive neuroectodermal tumor of the adrenal gland. Although primitive neuroectodermal tumor is a highly malignant neoplasm, there is no evidence of local recurrence and distant metastasis 16 months after surgery.

Obstruction of the ileal ureter by mesenteric vessels occurring 5 years after total ureteral substitution for bilateral ureteral stenosis due to systemic lupus erythematosus

Abstract  We previously reported a case of bilateral ureteral stenosis accompanied by systemic lupus erythematosus, which was successfully managed by total ureteral reconstruction using a segment of the ileum. Herein, we describe an unusual complication in the same patient, which we experienced 5 years after the ileal–ureteral substitution. Left‐sided back pain repeated together with transient obstruction of the ileal ureter interposed between the right and left renal pelvis. Consequently, exploratory laparotomy revealed that left colic vessels oppressed and caused obstruction, and the obstructed ileal ureter was released by reconstitution of these vessels instead of re‐anastomosis of the ileal ureter. Left hydronephrosis and related back pain disappeared postoperatively. The number of patients with an indication of ileal–ureteral substitution is increasing for various disorders, and thus, the present report gives additional suggestions for the follow up of patients with ileal ureter.

Gasless laparoscopy-assisted live donor nephrectomy.

(Purpose) We evaluated both efficacy and feasibility of laparoscopy-assisted live donor nephrectomy. (Materials and Methods) Since September 2000, 11 living kidney donors (2 males and 9 females) underwent laparoscopy-assisted live donor nephrectomy. All of sides were left. Gasless surgery was performed with a 7 cm pararectal upper abdominal incision and three trocars via a retroperitoneal approach, After creating the working space using balloon dissection technique, the abdominal wall was lifted using a metal retractor attached to the margin of the abdominal incision. Additionally, a metal plate, which was attached to the abdominal wall inside, was raised. The surgeon dissected left kidney from the skin incision under both direct vision and magnificated view on the monitor. (Results) The operating time, estimated blood loss and warm ischemic time were a mean of 209 minutes, 219g, and 4. 2 minutes, respectively. The mean times for the return to a normal diet and unassisted ambulation were 1. 3 and 1. 8 days, respectively. One case required blood transfusion due to subcutaneous hematoma at trocar entry site on the second day after surgery, in the remaining 10 cases there were no complications. All of donated kidneys achieved immediate function after engraftment. (Conclusions) Gasless laparoscopy-assisted donor nephrectomy is recommended and advantageous for healthy kidney donors as a minimally invasive method.

Bladder Neck Suspension Using Percutaneous Bladder Neck Stabilization to the Pubic Bone with a Bone-Anchor Suture Fixation System:A New Extraperitoneal Laparoscopic Approach

A 39-year-old woman with type 1 genuine stress urinary incontinence was treated using a novel extraperitoneal laparoscopic bladder neck suspension procedure with a bone-anchor suture fixation system. Operative time and blood loss were 2.5 and 50 g, respectively. The patient showed a remarkable improvement on chain cystography and in subjective and objective well-being with no complications, even 12 months after surgery. Extraperitoneal laparoscopic bladder neck suspension using the bone-anchor suture fixation system is an easy and feasible procedure.

Endoscopic renal biopsy in pediatric patients: comparison of retroperitoneoscopy-assisted and retroperitoneoscopic methods.

Accessible online at: www.karger.com/journals/nef Dear Sir, Laparoscopic surgery including retroperitoneoscopy has been widely used in various urological disorders because of its advantage of being less invasive than open surgery [1– 3]. We have already reported our experience with laparoscopic renal biopsy via the retroperitoneal approach [4]. In this paper, retroperitoneoscopy-assisted renal biopsy (ASSIST) and retroperitoneoscopic renal biopsy (RETRO) were reported and compared. Eleven pediatric patients with the nephrotic syndrome or hematoproteinuria were included. The inclusion criteria were difficulties with needle renal biopsy because of poor detection of the kidneys by ultrasonography. Six (cases 1–6) underwent RETRO, and the other 5 (cases 7–11) underwent ASSIST. The patient’s age was between 2 and 15 years (mean: 6.17 years for RETRO and 4.4 years for ASSIST; table 1). The backgrounds of the two groups were comparable. Regarding RETRO, the method was similar to Gaur’s retroperitoneoscopic approach [5]. After full induction of a general anesthesia with endotracheal intubation, a 2-cm transverse skin incision was made at two-finger breadths below the tip of the 12th rib, and a small retroperitoneal space was created by blunt finger dissection. A dissecting balloon was inserted into the retroperitoneal space and was fully inflated. After removal of the dissection balloon, a 10-mm trocar was inserted by the initial wound, and CO2 insufflation with a pressure of not more than 8 mm Hg was begun. Then, a second trocar was inserted under endoscopic monitoring about 3 cm below the first trocar port. The lower pole of the kidney was easily identified, and renal biopsy was performed by a single stroke of a laparoscopic cup forceps through the second trocar port. Hemostasis was obtained using the Argon-Beam-Coagulator (Kobayashi Medical, Osaka Japan). For ASSIST, retroperitoneal space was dissected by the same procedure as for RETRO. Then, retractors for open surgery were inserted to widen the wound space, and a 0 or 12° urethrocystoscope was inserted into