Microsurgical vasoepididymostomy with sperm cryopreservation for future assisted reproduction

BACKGROUND

Although obstructive azoospermia is treatable with microscopic seminal reconstruction, the number of patients who choose to undergo vasoepididymostomy is limited because of recent advances in assisted reproductive technology (ART). We attempted to define the outcome of surgical reconstruction in patients with suspected epididymal obstruction and no previous history of vasectomy.

METHODS

We described 40 eligible end-to-side vasoepididymostomy procedures performed on 24 azoospermic patients who had either bilateral or unilateral epididymal obstruction.

RESULTS

The overall patency rate following surgery was 54% (13/24) and for four patients (17%), natural intercourse resulted in pregnancy. Two pregnancies were initiated with intracytoplasmic sperm injections using frozen sperm collected during vasoepididymostomy.

CONCLUSIONS

In the era of modern ART, microsurgical vasoepididymostomy with cryopreservation of sperm collected during the operation is recommended for patients with epididymal obstructions.

Intractable pediatric chronic sinusitis with antrochoanal polyp

It has been reported that pediatric chronic sinusitis with antrochoanal polyp is difficult to cure because it tends to recur easily even with surgery. Therefore, in order to improve its cure rate, aggressive treatment combining polypectomy, intra-maxillary intubation through the inferior meatus, macrolide administration, etc., was attempted. Thirty-seven sides of pediatric chronic sinusitis with antrochoanal polyp and 44 sides of chronic sinusitis without polyp were evaluated after the same treatments. The mean age of patients was 9.7 years, and the mean intubation period was 20 months. Since subjective improvements in children are questionable, the efficacy was evaluated strictly on the basis of X-ray alone focusing on the maxillary sinus. Twenty-four percent of the group with antrochoanal polyp showed 'excellent' effect, i.e. almost complete resolution of the sinus findings, while 45% of the group without polyp showed 'excellent' effect, with a mean follow-up period of 3 years and 6 months. This difference was significant (P<0. 01, chi(2)-test). These results further document the intractableness of chronic sinusitis with choanal polyp in children.

Edematous swelling of the facial nerve in Bell's palsy

Surgical decompression of the intratemporal facial nerve from the geniculate ganglion to the stylomastoid foramen was carried out in 91 patients with Bell's palsy. All of the patients had denervation exceeding 95%, and a suprastapedial lesion. Edematous swelling of the nerve was assessed using the following three grades: + +, nerve swells beyond the bony facial canal; +, nerve swells beyond the nerve sheath, but within the bony canal, and -, no notable swelling observed. Varying degrees of swelling of the nerve were noted in all of the patients from onset to the end of the ninth week. The incidence of + + swelling was highest within 3 weeks of onset and then declined. + + swelling was most often noted in the vicinity of the geniculate ganglion, and was thought to be a manifestation of inflammation due to herpes simplex virus infection. There was a clear time dependency of the swelling in the horizontal and pyramidal segments, but not in the mastoid segment. After the ninth week, the incidence of swelling decreased sharply and no swelling of the nerve was observed in about one-third of the patients. Considering the etiology and the analysis of edematous swelling, we propose that the course of Bell's palsy be differentiated into an acute phase (the first 3 weeks after onset), a subacute phase (from the fourth to ninth weeks) and a chronic phase (after the tenth week).

Ramsay Hunt syndrome in children

In a retrospective study, 52 children were diagnosed with Ramsay Hunt syndrome. The facial palsy was milder and complete recovery of the function was achieved in 78.6% of patients. Associated cranial neuropathies were less common in children than in adults. The timing of vesicle appearance tended to be delayed in children. In preschool children, Ramsay Hunt syndrome was rare, although the frequency has recently increased. The syndrome is relatively common in older children. This study suggested that vaccination can prevent or reduce the occurrence of Ramsay Hunt syndrome.

New initiation system for resin polymerization using metal particles and 4-META

Fifteen kinds of metal particles were examined to establish whether they could induce the setting of UDMA-based monomer containing BPO without amine under the presence of 4-META at room temperature. FT-IR spectra of the resultant set samples and the monomer were analyzed to see if the setting was caused by the polymerization. The effects of 4-META and BPO concentrations on the setting time were also studied using the metal particles that induced the setting very effectively. As-received Cu, Zn, Mo, Sn, Co, and In particles could initiate the polymerization of the monomer in combination with BPO and 4-META when they were moistened with water. All the three kinds of silver alloy particles examined also could initiate the polymerization, although pure silver metal particles could not. The presence of 4-META drastically shortened the setting time of the mixture of Cu particles and the monomer containing BPO, while higher concentration of BPO in the monomer significantly shortened the setting time.

[Clinical application of 133-Xe ventilation scintigraphy]

Xenon-133 ventilation scintigraphy provides three sets of scintigrams: wash-in, equilibrium, and washout images. Krypton-81m or 99mTc-Technegas can be used as alternatives depending on their physical characteristics and the purpose of scintigraphy. Xenon-133 scintigraphy is compatible with SPECT when a multi-detector gamma camera is used. Ventilation images are analyzed by the height/area method to calculate regional lung volume and the mean transit time of the posterior planar view. If perfusion scintigraphy is done during the same examination, a ventilation/perfusion ratio image is also obtained. Factor analysis is applicable to the washout phase and permits a more detailed depiction of uneven ventilation. Series of consecutive SPECT during washout (dynamic SPECT) visualize ventilation in cross section and provide three-dimensional images of regional lung volume and poorly ventilated areas. A major indication for 133Xe scintigraphy is acute pulmonary thromboembolism (PTE) when used in combination with perfusion scintigraphy. The scintigraphic diagnosis of PTE is not inferior to that of contrast-enhanced helical CT, although the latter was initially reported to have higher sensitivity and specificity than scintigraphy. Other important indications are differentiation between primary pulmonary hypertension and chronic pulmonary thromboembolism, and the prediction of postoperative pulmonary function. Ongoing trials are attempting to create functional images of ventilation by CT or MRI, both of which may become rivals of scintigraphy because of their higher image resolution.

Cluster of proliferating cells in rat vomeronasal sensory epithelium

We investigated the properties of small cells in the vomeronasal sensory epithelium of adult rats. The sensory neurons in the sensory epithelium were stained by antibodies to G(i2alpha) and G(oalpha) in their cell bodies and dendrites, while the small cells, which formed a cluster in the epithelium, were not stained at all. Voltage-activated inward currents were not detected by patch-clamp recordings, but outward currents were induced by the application of voltage step pulses. These results suggest that the small cells are different from the vomeronasal sensory neurons. Bromodeoxyuridine (BrdU) labeling indicated that dividing cells existed in the cluster of small cells.

[Treatment of Bell's palsy with acyclovir and prednisolone]

Many current studies have suggested that herpes simplex virus is a probable cause of Bell's palsy, and that treatment with antiviral agents such as acyclovir might benefit the patients. In the present study, 69 patients with Bell's palsy were treated with oral administration of acyclovir (2000 mg/day) and prednisolone (60-40 mg/day) at Ehime University Hospital between Oct. 1995 and Dec. 1998. Patients enrolled in this study met the following criteria: 1) severe or complete paralysis with a score lower than 20 by the 40-point Japanese grading system, and 2) treatment started within 7 days of onset. The overall recovery rate was 95.7% (66/69). The rate in patients who started this treatment within 3 days after disease onset was 100%, and this early treatment was highly efficacious in the prevention of nerve degeneration and resulted in a significantly better recovery. By comparison, the recovery rate in patients whose treatment was started 4 days or more after onset was only 84.2%. All patients who were given a diagnosis of zoster sine herpete and treated with acyclovir-prednisolone had a good outcome. These results suggest that early treatment, within 3 days after palsy onset, is necessary for effective acyclovir-prednisolone therapy of Bell's palsy.

Noninvasive, continuous evaluation of peripheral vascular resistance in humans

We sought a noninvasive alternative method of monitoring peripheral vascular resistance continuously in humans, based on the analysis of arterial pressure waveforms. Radial arterial pressure waveforms were recorded noninvasively with a tonometer and analysed using a neural network method. To test the accuracy of this method, the peripheral vascular resistance was also determined by an invasive thermodilution method using a Swan-Ganz catheter in 20 subjects. To test the method in a clinical application, peripheral vascular resistance was determined by the noninvasive method before and after administration of nifedipine in 6 patients with essential hypertension. Neural network analysis of waveforms reliably yielded values between 0.00 and 1.00. Peripheral vascular resistance determined by neural network analysis and according to the invasive method showed a significant (p< 0.005) positive linear correlation. The peripheral vascular resistance measured by neural network analysis showed a significant (p< 0.05) decrease 30 min after administration of nifedipine, paralleling a decrease in blood pressure. Neural network analysis of tonometric radial artery waveforms provides an accurate, noninvasive, and continuous index of peripheral vascular resistance in human subjects. This simple method should permit more extensive homodynamic studies and larger epidemiological surveys in contrast to those undertaken using invasive techniques.

Holmium laser incision technique for ureteral stricture using a small-caliber ureteroscope

BACKGROUND AND OBJECTIVES

The holmium laser has a short absorption depth in tissue and possesses excellent properties both in ablation and hemostasis. We have performed endoscopic incision for ureteral stricture using the holmium laser through a small-caliber ureteroscope.

METHODS

This method was used on five patients and seven ureters. The etiology of the stricture was stone scar in two patients, ureteroenteroanastomosis of Indiana urinary pouch in two, and primary in one. We used an 8F semi-rigid or 6.9F flexible ureteroscope. No prior procedures, such as balloon dilation, were necessary in any of the cases. The stricture was incised with the holmium laser using a 365-microm fiber through the working channel of the ureteroscope. The holmium laser operated at a wavelength of 2100 nm, with an output of 1.0 J/pulse at a rate of 10 Hz. After completion of the incision, a 12F Double-J catheter was left in for six weeks.

RESULTS

The mean operative time was 89 minutes. The stricture resolved completely in all cases at an average follow-up of 8.6 months.

CONCLUSIONS

The holmium laser incision for ureteral stricture using a small-caliber ureteroscope is an easy-to-perform, safe and effective procedure.

Mesonephric adenocarcinoma of the urinary bladder: a case report

We report a very rare case of mesonephric adenocarcinoma of the urinary bladder, the origin of which is still uncertain. A non-papillary and broad-based tumor was located in the trigone and bladder neck on cystoscopic examination. Pelvic magnetic resonance imaging in T2-weighted images revealed a mass invading into the muscular layer of the bladder wall. Histologic examination of bladder cup-biopsy specimens showed adenocarcinoma. She underwent total cystectomy and pelvic lymph node dissection. Histologically, the tumor was chiefly composed of cells with eosinophilic cytoplasm and partly of cells with clear cytoplasm or hobnail-shaped cells, arranged in tubular or papillary structures, and infiltrated peri-vesical fat tissues. She died of metastatic disease 22 months after surgery. To the best of our knowledge, the present case is the 19th reported in the literature.

Microsatellite instability and hMSH2 gene mutation in a triple cancer (colon cancer, endometrial cancer, ovarian cancer) patient in hereditary non-polyposis colorectal cancer (HNPCC) kindred

A patient who had triple cancer (colon cancer, endometrial cancer, and ovarian cancer) in HNPCC kindred is reported. Her family history revealed the occurrence of colon cancer in her paternal aunt and in two cousins, fulfilling the minimum HNPCC criteria. Microsatellite instability analysis revealed replication error (RER)+ in all cancer lesions at 2 microsatellite loci (D1S191, BAT 40). SSCP analysis suggested germline mutation in exon 2 of the hMSH2 gene. This case showed the importance of complete family-history investigations to identify HNPCC patients. In the near future, definitive diagnosis of HNPCC will be possible on the basis of DNA studies.

Analysis of segregation and aneuploidy in two reciprocal translocation carriers, t(3;9)(q26.2;q32) and t(3;9)(p25;q32), by triple-color fluorescence in situ hybridization

Meiotic segregation patterns of chromosomes 3 and 9 were analyzed in sperm of two translocation carriers (t(3;9)(q26.2;q32) and t(3;9)(p25;q32)) by triple-color fluorescent in situ hybridization (FISH) with a telomeric DNA probe in addition to two centromeric probes. The frequencies of each sperm product resulting from alternate or adjacent I, adjacent II and 3:1 segregation in a t(3;9)(q26.2;q32) translocation carrier were 88.35%, 5.44% and 5.94%, respectively. On the other hand, the frequencies of each sperm product in a t(3;9)(p25;q32) translocation carrier were 89.23%, 6.02% and 4.48%, respectively. Of all the sperm products, the frequency of normal or chromosomally balanced sperm in a t(3;9)(q26.2;q32) and a t(3;9)(p25;q32) were 52.49% and 47.25%, respectively. The frequencies of each sperm product resulting from various segregations were different between both carriers and significantly deviated from the expected frequencies. Additional dual-color and triple-color FISH were performed to analyze aneuploidy rates for chromosomes 12, 17, 18, X and Y in order to detect any interchromosomal effect; no evidence of an interchromosomal effect was found.

Advantage and disadvantage of KTP-532 laser tonsillectomy compared with conventional method

OBJECTIVE

The purpose of this prospective study is to define the advantages and disadvantages of KTP laser tonsillectomy compared with those of the conventional method.

METHODS

Eighteen adult patients (ten male and eight female, ranging in age from 14 to 44 years) underwent KTP-532 laser tonsillectomy on one side and standard dissection surgery on the other side under general anesthesia.

RESULTS

By KTP laser tonsillectomy, there was a reduction in intraoperative blood loss and average time for removing one tonsil. On the second day of tonsillectomy, subjective pain on the KTP laser surgery side was less than that on the conventional surgery side. By the days 5-8, however, this effect disappeared and many patients indicated the laser side was more painful. There was no postoperative bleeding after KTP laser tonsillectomy. Laser surgery appeared to lead to slow wound healing during the whole post-operative course with significant difference compared with the conventional method. Disadvantages of postoperative pain and the possibility of secondary infection due to slow wound healing could be prevented by application of antibiotics and an anodyne.

CONCLUSION

Considering safety and reliability during surgery, KTP laser was considered useful for adult tonsillectomy.

Delayed facial palsy after middle-ear surgery due to reactivation of varicella-zoster virus

Viral reactivation is thought to be an important cause of post-operative facial palsy of delayed onset. We present an unusual case of Ramsay-Hunt syndrome that occurred as a consequence of middle-ear surgery by triggering varicella-zoster virus reactivation. As a pathognomonic auricular eruption was not seen, the patient was initially misdiagnosed as iatrogenic facial palsy. Clinical features, diagnosis and management are discussed.

Development of a highly sensitive enzyme immunoassay for human calcitonin using solid phase coupled with multiple antibodies

We have developed a highly sensitive chemiluminescent enzyme immunoassay for human calcitonin using three different mouse monoclonal antibodies that recognize the N-terminal, C-terminal and central portions of a human calcitonin molecule. The assay signal in a two-step sandwich enzyme immunoassay for human calcitonin using a solid phase coupled with a mixture of monoclonal antibodies. CT08 and OCT1, was 3.7-fold higher than when using either or both solid phases coupled with CT08 or OCT1, respectively. This enhancement is the result of improved avidity of immobilized antibodies and greater stability of the complex of immobilized antibodies and calcitonin in the first reaction, which resulted in greater reactivity of the immunocomplex with alkaline phosphatase-conjugate in the second reaction. The present assay showed a linear response up to 2.5 micrograms/L of human calcitonin and a high specificity for human calcitonin, but not for rat calcitonin, human calcitonin gene-related peptide and rat calcitonin gene-related peptide. The detection limit of human calcitonin was estimated to be 0.29 ng/L at zero (assay blank) + 3 SD. Interbatch coefficients of variation ranged from 2.2-26.7%.

Clinical study on recurrence in bladder cancer patients undergoing total cystectomy--statistical analysis of factors related to recurrence

A clinico-pathological study was performed retrospectively for 77 patients undergoing total cystectomy for primary transitional cell carcinoma of the urinary bladder between 1981 and 1995 to clarify the mode of recurrence, the risk factors which may affect recurrence following cystectomy and prognostic factors. Postoperative recurrence was recognized in 27 (35.1%) out of 77 patients and the one-, two- and three-year non-recurrent rates by the Kaplan-Meier method were 75.3, 64.9% and 63.3%, respectively. The duration from cystectomy to recurrence was 1 to 102 months with a mean of 12.1 months, and approximately 92.6% of recurrence occurred within two years. Among 27 patients with recurrence, pelvic recurrence, distant metastasis, both of them and urethral recurrence were recognized in 6 (22.2%), 18 (66.7%), 1 (3.7%) and 2 (7.4%), respectively as the first site of recurrence. The overall one-, three- and five-year cause-specific survival rates of the 77 patients were 84.7, 71.1% and 65.6%, respectively. Of the 27 patients with recurrence, 25 (92.6%) died of bladder cancer. Of the factors related to recurrence or prognosis, pathological stage, lymphatic invasion, venous invasion, type of infiltration and lymph node metastasis but not pathological grade or adjunctive chemotherapy were significant risk factors for recurrence and prognostic factors in univariate analysis. However, lymphatic invasion was the only significant risk factor for recurrence and prognosis in multivariate analysis using Cox's proportional hazard model.

Mouse C2 myoblast cells resist HVJ (Sendai virus)-mediated cell fusion in the proliferating stage but become capable of fusion after differentiation

To investigate the mechanism of myoblast fusion, we attempted to prepare artificial myotubes of mouse C2 myoblast cells using the hemagglutinating virus of Japan (HVJ, Sendai virus). Proliferating C2 cells showed strong resistance to HVJ-mediated cell fusion and remained morphologically unchanged even though massive numbers of virions adsorbed onto their surface. They showed no membrane disruption, which occurs in the early stage of cell fusion induced by HVJ. These observations suggest that proliferating C2 cells are resistant to HVJ-mediated cell fusion. However, upon induction of differentiation, C2 cells gradually became capable of fusion induced by HVJ and then even generated heterokaryons with Ehrlich ascites tumor cells. When differentiated C2 cells that had become fusion-sensitive were treated with HVJ in the presence of EDTA, they did not fuse but degenerated, suggesting that their cell membranes were transiently disrupted by interaction with HVJ. These results suggest that the cell membranes of myoblasts change to a fusion-capable state during the process of differentiation.

Ultracompact, completely implantable permanent use electromechanical ventricular assist device and total artificial heart

An ultracompact, completely implantable permanent use electromechanical ventricular assist device (VAD) and total artificial heart (TAH) intended for 50-60 kg size patients have been developed. The TAH and VAD share a miniature electromechanical actuator that comprises a DC brushless motor and a planetary roller screw. The rotational force of the motor is converted into the rectilinear force of the roller screw to actuate the blood pump. The TAH is a one piece design with left and right pusher plate type blood pumps sandwiching an electromechanical actuator. The VAD is one half of the TAH with the same actuator but a different pump housing and a backplate. The blood contacting surfaces, including those of the flexing diaphragm and pump housing, of both the VAD and TAH were made of biocompatible polyurethane. The diameter, thickness, volume, and weight of the VAD are 90 mm, 56 mm, 285 cc, and 380 g, respectively, while those of the TAH are 90 mm, 73 mm, 400 cc, and 440 g, respectively. The design stroke volume of both the VAD and TAH is 60 cc with the stroke length being 12 mm. The stroke length and motor speed are controlled solely based on the commutation signals of the motor. An in vitro study revealed that a maximum pump flow of 7.5 L/min can be obtained with a pump rate of 140 bpm against a mean afterload of 100 mm Hg. The power requirement ranged from 4 to 6 W to deliver a 4-5 L/min flow against a 100 mm Hg afterload with the electrical-to-hydraulic efficiency being 19-20%. Our VAD and TAH are the smallest of the currently available devices and suitable for bridge to transplant application as well as for permanent circulatory support of 50-60 kg size patients.