Yuichiro Shinno

Three-Dimensional Arrangement of Collagen and Elastin Fibers in the Human Urinary Bladder: A Scanning Electron Microscopic Study*

To clarify the arrangements of collagen and elastin fibers of the urinary bladder, we examined 9 human (male, aged 42 to 72) urinary bladders by scanning electron microscopy with chemical digestion methods. The mucosal layer was divided into 3 portions according to the collagen arrangement: the superficial portion interwoven densely by collagen fibrils, the middle portion layered by flat bundles of collagen fibrils and the deep portion made of a loose network of twisted collagen bundles. In the muscular layer, the smooth muscle fascicles were firmly covered with collagen sheets, while each muscle cell in a fascicle was accommodated by a thin sheath of collagen fibrils. The serosal layer consists of wavy collagen bundles piled up in a sheet, which was intercalated by clusters of adipose cells. Elastic fibers were, on the other hand, sparse throughout the bladder wall, except for denser networks around the blood vessels and muscle fascicles and beneath the peritoneal mesothelium. The arrangements of these components were discussed in relation to the mechanical function and compliance of the urinary bladder.

Peri-operative morbidity and mortality related to radical cystectomy: a multi-institutional retrospective study in Japan.

Study Type – Therapy (outcomes) Level of Evidence 2b Whats known on the subject? and What does the study add? Radical cystectomy remains associated with comparatively high perioperative morbidity and mortality, despite improvements in surgical techniques and perioperative care. At present, most studies on the complications associated with open radical cystectomy were derived from Western academic high‐volume centres, and data from Japan and other Asian countries were very limited. Using the modified Clavien grading system and 11 category grouping reported from MSKCC, we observed that 68% of patients experienced at least one complication within 90 days of surgery, and 17% of patients experienced major complications (90‐day mortality rate = 2%), which were compatible with reports from Western high‐volume centres. As far as we know, our report is the largest one regarding perioperative morbidity and mortality in Asian patients who underwent radical cystectomy.

Impact of Diagnostic Ureteroscopy on Intravesical Recurrence and Survival in Patients With Urothelial Carcinoma of the Upper Urinary Tract

PURPOSE We determined whether diagnostic ureteroscopy for upper urinary tract cancer affects intravesical recurrence and cancer specific mortality. MATERIALS AND METHODS In a retrospective, multi-institutional study we evaluated 208 patients undergoing nephroureterectomy for upper urinary tract cancer who had no perioperative systemic chemotherapy, history of invasive bladder cancer, distant metastasis or incomplete followup data. Of these 208 patients 55 who composed the study group underwent diagnostic ureteroscopy before nephroureterectomy while 153 serving as controls did not. We analyzed intravesical recurrence and cancer specific survival using the Kaplan-Meier method with the log rank test used to assess significance. RESULTS There was no significant difference between the 2 groups in patient characteristics or upper urinary tract cancer stage and grade while followup, and the proportion of multiple tumors and lymphovascular invasion positive tumors were significantly greater in controls. The 2-year bladder recurrence-free survival rate was 60.0% in the study group and 58.7% in controls. There was no significant difference in the intravesical recurrence rate between the 2 groups (log rank test p = 0.972). Estimated Kaplan-Meier cancer specific survival was 88.3% and 78.1% at 5 years in the study and control groups, respectively (log rank test p = 0.0687). CONCLUSIONS Diagnostic ureteroscopy did not affect intravesical recurrence or cancer specific survival in patients with upper urinary tract cancer undergoing nephroureterectomy.

Role of lymph node dissection in the treatment of urothelial carcinoma of the upper urinary tract: Multi-institutional relapse analysis and immunohistochemical re-evaluation of negative lymph nodes

AIM To determine the role of lymph node dissection (LND) in the treatment of urothelial carcinoma (UC) of the upper urinary tract (UUT). PATIENTS AND METHODS [Study-1] A retrospective multi-institutional study evaluated 293 patients undergoing predominantly nephroureterectomy for UC of the UUT. Of 293 patients, 267 patients had pure UC and 26 demonstrated other histological components. Regarding the pathological node status, 130 patients had pN0 disease, 141 patients had pNx disease and 22 patients had pN+ disease. The sites of initial recurrence and time to first recurrence were reviewed. The sites of recurrence were classified as locoregional or distant recurrence. The relationship between node status and future recurrence was analyzed. [Study-2] Fifty-one patients treated by nephroureterectomy at Hokkaido University Hospital were included. All had LND and all LNs were negative on hematoxylin and eosin staining. We re-evaluated the presence of micrometastasis in LND specimens by anti-cytokeratin immunohistochemistory. RESULTS [Study-1] Of 293 patients, 76 developed disease relapse. Regional lymph node recurrence was the most common site (34 patients). On multivariate analyses that adjusted for the effect of tumor stage and tumor grade, pNx (skipping LND) was an adverse factor not only for locoregional recurrence, but also for distant relapse. [Study-2] Immunohistochemistry identified micrometastases in 7 (14%) of 51 patients. Regarding survival, 5 of these 7 patients with micrometastases were alive at last follow-up. CONCLUSIONS On relapse analysis, skipping LND was an adverse factor not only for locoregional recurrence, but also for distant relapse. Immunohistochemistry detected micrometastases in about 14% of patients previously diagnosed as pN0. These findings further support a potential therapeutic benefit of LND by eliminating micrometastases.

Fascial Sling for the Management of Urinary Incontinence Due to Sphincter Incompetence

The surgical management of urinary incontinence due to sphincter incompetence is still a challenging issue for urologists to date. We reviewed our experience with the fascial sling performed in 10 male and 3 female patients 3 to 72 years old (median age 13 years) with sphincter incompetence, including 11 with a neurogenic bladder (8 with myelodysplasia, 2 after pelvic operation and 1 after spinal cord injury), 1 after transurethral resection of the prostate and 1 after surgical injury to the bladder neck. Patient selection for a sling procedure was based on cystography (an open bladder neck) and urodynamic findings (underactive external urethral sphincter on electromyography and low maximum urethral closure pressure). A free graft of fascia was harvested from the rectus fascia in 8 patients and from the fascia lata in 5, and the fascial sling was placed around the bladder neck in 11 and the bulbous urethra in 2. Augmentation cystoplasty was performed concomitantly in 9 patients with poor bladder compliance (8 ileocystoplasty and 1 gastrocystoplasty). Postoperative followup ranged from 4 to 63 months (mean 36). Nine patients became continent and 3 improved significantly but remain damp. Of these 12 patients 10 with a neurogenic bladder were placed on intermittent catheterization, while the 2 without a neurogenic bladder are able to void normally. The remaining patient with surgical failure due to inadvertent wound infection received an indwelling urethral catheter. In all but this patient preoperative and postoperative maximum urethral closure pressures were 34.3 +/- 5.7 and 37.2 +/- 3.8 cm. water, respectively, without a significant increase. However, postoperative simultaneous measurements of intravesical and intraurethral pressure demonstrated a dramatic increase in intraurethral pressure during coughing or straining because of the action of the sling. Postoperative upper urinary tract deterioration has not been documented to date. Although various surgical options have been available, the fascial sling seems to be promising in the management of refractory urinary incontinence due to sphincter incompetence.

THE ROLE OF LYMPH-NODE DISSECTION IN THE TREATMENT OF UPPER URINARY TRACT CANCER: A MULTI-INSTITUTIONAL STUDY

To determine the role of lymph‐node (LN) dissection in patients undergoing surgery for upper urinary tract (UUT) cancer.

Role of lymph node density in predicting survival of patients with lymph node metastases after radical cystectomy: a multi-institutional study.

Objectives:  To evaluate the prognostic role of different clinico‐pathological parameters in node‐positive patients treated by radical cystectomy.

Preexisting neurogenic voiding dysfunction in children with imperforate anus: problems in management.

We evaluated 22 boys and 2 girls 1 month to 8 years old with imperforate anus to determine the relationship between neurogenic voiding dysfunction and bony sacral or spinal cord anomalies. Lower urinary tract function before anorectoplasty was normal in 12 children (group 1), abnormal (detrusor-sphincter dyssynergia) in 9 (group 2) and not evaluated in 3 (group 3). High lesions of imperforate anus were present in 22% of the patients in group 1 and in 100% of those in group 2. Plain radiography revealed partial sacral agenesis in 1 child in group 1 and 4 in group 2. Magnetic resonance imaging detected occult spinal dysraphism in 1 patient in group 1 and 2 in group 2. (Occult spinal dysraphism included sacral lipoma, tethered cord, syringomyelia and thick filum terminale.) Seven children in group 2 had vesicoureteral reflux before anorectoplasty. All children in group 2 were placed on clean intermittent catheterization for the management of neurogenic voiding dysfunction. Normal upper urinary tract function was maintained in all patients in group 1 and 6 in group 2. The remaining 3 children in group 2 had high grade reflux at presentation associated with severe renal damage or noncompliance with clean intermittent catheterization. These findings indicate that in children with imperforate anus lower urinary tract function should be evaluated before anorectoplasty because of the high incidence of associated congenital neurogenic voiding dysfunction and the potential risk for renal deterioration. When possible, neurogenic voiding dysfunction should be managed with clean intermittent catheterization to prevent renal damage.

Relevance of Detrusor Hyperreflexia, Vesical Compliance and Urethral Pressure to The Occurrence of Vesicoureteral Reflux in Myelodysplastic Patients

Bladder pressure in the storage phase is considered to be relevant to the changes in the upper urinary tract. We analyzed retrospectively detrusor hyperreflexia, vesical compliance and maximum urethral closing pressure to determine which is the most significant factor relevant to the incidence of vesicoureteral reflux in 91 myelodysplastic patients. Vesicoureteral reflux was demonstrated in 29 of 91 patients. Cystometry and urethral pressure profilometry were performed in 69 and 27 patients, respectively. Vesicoureteral reflux was observed in 43% of the female patients, which was significantly greater than in the male patients (20%). Detrusor hyperreflexia was noted in 43 patients. Average vesical compliance was 11.3 +/- 8.3 ml./cm. water in 58 evaluable patients. Maximum urethral closing pressure was 56.7 +/- 25.8 cm. water. Vesical compliance in the patients with vesicoureteral reflux was 10.2 +/- 7.5, which was not significantly lower than in those without vesicoureteral reflux (12.2 +/- 8.8). The incidences of vesicoureteral reflux were 38% in the patients with vesical compliance of less than 10, 40% in those with vesical compliance of greater than 10 but less than 20 and 36% in those with vesical compliance of more than 20. The differences were not significant among these patients. Urethral pressure in the patients with vesicoureteral reflux was significantly higher than in those without vesicoureteral reflux (73.8 +/- 23.5 versus 48.2 +/- 23.0, p less than 0.05). The incidence of vesicoureteral reflux was 53% in the patients with urethral pressure of greater than 50, while it was only 8%, significantly less (p less than 0.05), in the lower urethral pressure group. Vesicoureteral reflux was noted in 44% of the patients with detrusor hyperreflexia, which was not significantly greater compared to 31% in the patients without detrusor hyperreflexia. These results suggest that in myelodysplastic patients maximum urethral closing pressure is highly relevant to the incidence of vesicoureteral reflux, while vesical compliance and detrusor hyperreflexia are not. The incidence of vesicoureteral reflux was significantly greater in female patients (43%, p less than 0.05) than in male patients (20%), although urethral pressure values showed no difference between them, indicating that female patients may be another risk factor for vesicoureteral reflux.

Radical Transurethral Resection of the Prostate in Male Paraplegics Revisited: Further Clinical Experience and Urodynamic Considerations for its Effectiveness

We report our experience with radical transurethral resection of the prostate performed on 89 male spinal cord injury subjects. The over-all success rate of modified sphincterotomy was 90 per cent, although there was a 14 per cent recurrence rate with time. Urodynamically, success was characterized by a statistically significant reduction in the degree of detrusor-sphincter dyssynergia, an increase in vesical compliance and a reduction in detrusor hyperreflexia. These results suggest an effect on the distal sphincteric area by the adrenergic system in the genesis of detrusor-sphincter dyssynergia. It is suggested that radical transurethral resection of the prostate exerts this effect via a surgical sympathectomy, while continence is preserved by the activity of the untouched external urethral sphincter.