Tomomi Ushiyama

Efficacy of an Ultrasonic Surgical System for Laparoscopic Adrenalectomy

PURPOSE We determine the value of an ultrasonic surgical system for laparoscopic adrenalectomy. MATERIALS AND METHODS We analyzed 16 patients who underwent laparoscopic adrenalectomy using the ultrasonic surgical system and compared the results with those of patients undergoing laparoscopic adrenalectomy without the system. RESULTS The system simplified exposure of the renal pedicles and inferior vena cava, and facilitated adrenal separation from the perinephric fat as well as dissection and identification of the adrenal vessels. Operating time was shorter and blood loss was also less with use of the ultrasonic surgical system. CONCLUSIONS The ultrasonic surgical system simplified laparoscopic adrenalectomy and made the operation much safer.

Can persisting detrusor hyperreflexia be predicted after transurethral prostatectomy for benign prostatic hypertrophy

Detrusor hyperreflexia (DH) is frequently found in patients with benign prostatic hypertrophy (BPH) and persists in 30–50% of patients after successful removal of bladder neck obstruction by transurethral prostatectomy (TUR‐P) or surgical enucleation of the prostate. It would be beneficial for surgeons to be able to identify patients who are at risk of persistent post‐operative urinary irritation symptoms and DH. Twenty‐three patients who showed DH pre‐operatively were included in this study. Of these 23 patients, four had neurogenic bladder because of previous cerebrovascular disease. The other 19 patients were considered to have DH because of BPH. These 19 patients were classified according to their cystometry chart patterns. Pattern 1 was the continual sporadic onset and offset of DH, pattern 2 was a single episode of DH at a bladder volume of <160 mL, and pattern 3 was a single DH episode at a bladder volume >160 mL. Preoperative single‐photon emission computed tomography (SPECT) was performed on 14 patients. Cystometric findings at 3 to 6 months after surgery were compared with the pre‐operative findings. Four of the six patients with pattern 2 (67%) and all patients with pattern 3 (100%) showed an absence of DH after surgery. In contrast, all five patients with pattern 1 and all four patients with neurogenic bladder showed persistent DH. Compared with pattern 3 patients, pattern 1 patients more frequently complained of urgency before surgery, and their symptoms and uroflowmetry parameters did not improve afterward. Among 14 patients who had pre‐operative SPECT, all eight patients with low cerebral blood flow in the frontal region showed persisting DH. Conversely, all six patients with normal SPECT results showed no DH after surgery. When DH occurs repeatedly (pattern 1) or occurs at a bladder volume of <160 mL (pattern 2), there is a greater risk of post‐operative irritation symptoms. Abnormal SPECT findings can also predict the post‐operative persistence of DH. Combing these two pre‐operative examinations allows us to predict better post‐operative DH in patients with BPH. Neurourol. Urodynam. 19:233–240, 2000.

Clinical application of an in vitro chemosensitivity test, the Histoculture Drug Response Assay, to urological cancers: wide distribution of inhibition rates in bladder cancer and renal cell cancer

Abstract To investigate the variations in chemosensitivity of individual cancers, we performed an in vitro chemosensitivity test, the Histoculture Drug Response Assay (HDRA), on fresh biopsied or surgical specimens. They were 26 bladder cancers and 19 renal cell cancers. Ten anticancer drugs were tested. By prolonging the drug exposure time to 7 days, we obtained reliable results. The mean inhibition rates (IRs) were higher for bladder cancer than for renal cell cancer, and the difference was significant for cisplatin, carboplatin, vinblastine, mitomycin C, and adriamycin. There was no significant correlation between the histological grade of the tumor and HDRA sensitivity. IR values showed a wide distribution and cancers could be classified into two groups of sensitive and resistant. This was especially true for 4-hydroxy-ifosfamide. Three bladder cancer patients with evaluable lesions were treated with drugs selected on the basis of the results of the HDRA. One patient achieved a complete response and the other patients showed a partial response. Our results suggest that chemosensitivity is independent of the clinicopathological classification of cancer, and that the HDRA may be useful for selecting the effective anticancer drug for patients with urological cancer.

Laparoscopic Nephrectomy, Ex Vivo Repair, and Autotransplantation for a Renal Artery Aneurysm : Report of a Case

A 57-year-old woman was hospitalized with a left renal artery aneurysm (RAA). The aneurysm measured 35 mm in diameter and was located at the renal artery bifurcation. We performed a laparoscopic nephrectomy using a retroperitoneal approach and performed an ex vivo repair of the renal artery. The reconstructed kidney was then autotransplanted at the left iliac fossa. The patients postoperative course was uneventful. A laparoscopic nephrectomy and ex vivo repair are both considered to be effective for treating complex RAA.

Cyclosporine concentration-dependent increase in concentration ratio of mycophenolic acid acyl and phenol glucuronides to mycophenolic acid in stable kidney transplant recipients

OBJECTIVES The aim of this study was to evaluate the influence of cyclosporine (CyA) and tacrolimus (Tac) on the pharmacokinetics of mycophenolic acid (MPA) and its glucuronides. DESIGN AND METHODS Kidney transplant recipients treated with mycophenolate mofetil and CyA (n=18) or Tac (n=17) in the stable phase were enrolled. The dependence of the trough concentration (C(0)) ratios of MPA acyl glucuronide (AcMPAG) to MPA (AcMPAG/MPA) and MPA phenol glucuronide (MPAG) to MPA (MPAG/MPA) on CyA C(0) or Tac C(0) was evaluated. RESULTS AcMPAG C(0) and MPAG C(0) were significantly higher in CyA- than Tac-treated recipients (P=0.04 and 0.02, respectively). AcMPAG/MPA and MPAG/MPA were significantly correlated to CyA C(0) (r=0.75, P<0.01 and r=0.81, P<0.01, respectively), but not to Tac C(0). CONCLUSIONS CyA increased AcMPAG/MPA as well as MPAG/MPA in a concentration-dependent manner, suggesting that higher CyA may cause AcMPAG-related adverse reactions. Tac did not alter pharmacokinetics of MPA and its glucuronides.

Complicating risk factors for pyelonephritis after extracorporeal shock wave lithotripsy

Purpose : The score to predict the risk of post‐extracorporeal shock wave lithotripsy (ESWL) pyelonephritis was evaluated. The score was based on the multivariate analysis of risk factors available pre‐operatively. Stone size, pyuria, bacteriuria, previous pyelonephritis and other adjunctive procedures had been selected and scored.

Transition Zone Volume-Adjusted Prostate-Specific Antigen Value Predicts Extracapsular Carcinoma of the Prostate in Patients with Intermediate Prostate-Specific Antigen Levels

Objective: The aim of the present study was to examine the efficacy of the volume-adjusted prostate-specific antigen (PSA) density as a predictor of pathological stage. Among patients who underwent radical prostatectomy for clinically organ-confined prostate cancer, we selected patients with PSA levels of 4–10 ng/ml. In these patients with borderline PSA value extent of disease is most difficult to predict. Using the transition zone (TZ) volume instead of the total prostate volume, we compared the ability of PSA to predict the tumor extent. Methods: From April 1992 to November 1996, we examined 61 consecutive patients who underwent radical prostatectomy. Their age ranged from 52 to 78 years. The PSA densities for the total prostate volume (PSAD) and for the TZ volume (PSAT) were calculated by transrectal ultrasound examinations. To compare the usefulness of PSA, PSAD, and PSAT, the area under the receiver-operator characteristic (ROC) curve was calculated for each parameter. Results: The final pathological stage was pT2N₀M₀ in 34 patients, pT3N₀M₀ in 20 patients, and pT3N1M₀ in 7 patients. Accordingly, 34 patients (55.7%) had organ-confined prostate cancer. In patients with capsular perforation, the areas under the ROC curve were 0.686 for PSA, 0.665 for PSAD, and 0.860 for PSAT, while in those with seminal vesicle invasion the respective values were 0.712, 0.703, and 0.882. Thus, PSAT was superior to PSA and PSAD in differentiating extracapsular disease. Conclusion: PSAT provides superior preoperative prediction of extracapsular tumor invasion, which appears to be useful in treatment selection (e.g. total prostatectomy).

Impact of calcineurin inhibitors on urinary excretion of mycophenolic acid and its glucuronide in kidney transplant recipients.

Concomitant cyclosporine interacts with mycophenolic acid (MPA) through inhibition of the biliary excretion of its glucuronide (MPAG). The aim of this study was to evaluate the influence of calcineurin inhibitors on the plasma disposition and urinary excretion of MPA and MPAG in kidney transplant recipients. Twelve recipients treated with tacrolimus and 18 treated with cyclosporine at 30 days after transplantation were enrolled. AUC from 0 to 12 hours (AUC0–12) of MPA was significantly higher in tacrolimus‐treated than in cyclosporine‐treated recipients. In contrast, there was no significant difference in MPAG AUC0–12 between calcineurin inhibitor medications. Unbound fractions of MPA and MPAG did not change significantly in a comparison between the tacrolimus and cyclosporine treatments (0.90% vs 1.27% in MPA; 20.0% vs 19.3% in MPAG). The ratio of renal clearance to creatinine clearance (CLR/CLCr) of MPA was significantly lower in tacrolimus‐ than in cyclosporine‐treated recipients (0.054 vs 0.100). In contrast, no significant difference was observed in the CLR/CLCr of MPAG between the tacrolimus and cyclosporine treatments (0.19 vs 0.18). In conclusion, concomitant calcineurin inhibitors influenced the urinary excretion of MPA but not MPAG in kidney transplant recipients. The results suggest the presence of renal tubular secretion in the urinary excretion process of MPA.

Laparoscopy-assisted radical nephrectomy without pneumoperitoneum.

A small renal cell carcinoma of the right kidney was completely removed from a 59-year-old women by laparoscopic radical nephrectomy without requiring a pneumoperitoneum. A 5-cm midline laparotomy incision was made and 3 small retractors were used for suspending the abdominal wall. Under laparoscopic observation, we safely positioned three trocars. The kidney was then removed en bloc together with the adrenal gland, perinephric fat and Gerotas fascia. The resected mass was enclosed in an entrapment sac and removed via the 5-cm abdominal incision without morcellation of the tissues. Three trocars could be positioned safely under direct observation and there were no adverse hemodynamic or ventilatory effects because the operation was performed without intraperitoneal carbon dioxide insufflation. There were no significant operative or postoperative complications. This procedure appears to be advantageous for the treatment of small renal cell carcinomas.

Thymidine Phosphorylase and Dihydropyrimidine Dehydrogenase in Renal Cell Carcinoma: Relationship between Histological Parameters and Chemosensitivity to 5-Fluorouracil

OBJECTIVES Thymidine phosphorylase (TdR-Pase) and dihydropyrimidine dehydrogenase (DPD) are thought to be key enzymes in the metabolic pathway of 5-fluorouracil (5-FU). Theoretically, cancer cells which have high TdR-Pase activity and/or low DPD activity should be sensitive to 5-FU. TdR-Pase is also known to have angiogenic activity which helps tumor progression and metastasis. On the other hand, little is known concerning the relationship of DPD activity with clinical malignant potential in renal cell carcinoma (RCC). In this study, we measured both TdR-Pase and DPD activities in surgically obtained RCC tissues and examined the relationship between these enzymatic activities and histological parameters. In addition, the results of in vitro chemosensitivity testing were also analyzed to determine whether TdR-Pase and/or DPD activity in carcinoma cells can predict the efficacy of 5-FU. METHODS RCC tissues from 53 patients were obtained. TdR-Pase and DPD activities were measured by ELISA and radioenzyme assay, respectively. Sensitivity to 5-FU was assessed by histoculture drug response assay (HDRA), an in vitro chemosensitivity test, for 20 of the 53 specimens. RESULTS Both TdR-Pase and DPD activities of RCC increased with histological grade. There was a significant positive correlation between the TdR-Pase activity and 5-FU sensitivity. In addition, a stronger positive correlation was found between TdR-Pase / DPD ratio and 5-FU sensitivity. DPD exhibited no correlation with 5-FU sensitivity. CONCLUSIONS The activity of both enzymes increased with malignant potential of RCC. TdR-Pase appeared to be the enzyme regulating activation of 5-FU in RCC.