[Consideration on transfusion in urologic surgery--a retrospective study on homologous and autologous transfusions]

To obtain data for promoting autologous transfusion in urologic surgery, the cases of perioperative homologous transfusions in the past 5 years are reviewed. Although the mean perioperative homologous blood transfusion rate was not so high (10.2%), the rate in common urological surgery was comparatively high (eg. radical nephrectomy 39.4%, simple or palliative nephrectomy 21.6%, total nephroureterectomy 33.3%, renal allotransplantation 82.8%, total cystectomy 96.2%). Mean homologous transfusion volume in these surveys was 982 ml. Two successful cases of autologous blood transfusion by the predeposit method or intraoperative collecting method are presented. Transfusion-associated adverse effects, especially viral infection and immunosuppression, were discussed and the value of autotransfusion was stressed.

Clinical and immunohistochemical studies of subependymal giant cell astrocytomas associated with tuberous sclerosis

Two cases of TS associated with brain tumors had severe psychomotor retardation and early onset of long-term intractable convulsions, compared with cases without tumors. In one case, the tumor was partially cystic and progressed rapidly. Immunohistochemical studies of neuron specific enolase, glial fibrillary acidic protein and myelin basic protein revealed differences in positivity between cell types and between cases. These results suggested that the origin of the tumor cells could be variably differentiated cells.

[Prevalence of Rett syndrome in Tokyo]

Prevalence of Rett syndrome (RS) was studied in Tokyo. Based on the experience of our pilot study, we chose schools to identify the cases. We visited forty-four schools for mentally/physically handicapped children. The population of girls aged 6-14 years in the area was 598,000 and the number of girls examined at the schools was 1,311. We identified 24 cases with "classical" RS and 6 cases with "variant" RS. About one-third of the cases had not been diagnosed properly. The prevalence of RS was 0.50/10,000 girls age 6-14 years in metropolitan Tokyo, 1 April, 1988, including variants. The rate showed no statistical difference compared to those reported from European countries.

[Lithotomy of bile duct stones by flash-lamp-pumped dye laser]

Laser therapy for bile duct stones, such as the non-contact beam treatment using continuous wave of Nd:YAG laser or contact beam treatment using ceramics rod, has been done in our institution from 1980. As a result, the ratio of complete lithotomy has been increased from 31/47 (66%) to 66/71 (93%). Recently, we had a opportunity to use the Lasertripter by Candera Corp., which was devised for urinary stones. It beams pulse wave to crush stones. The effectiveness of this new laser lithotripsy is different according to the kind of the stones, but it is better than that of conventional YAG laser. Furthermore, as this method can be used with thin fiberscope, this method is more effective to peripheral intrahepatic stones than YAG laser.

[Clinical statistics on outpatients, inpatients and operations in 1987]

Statistical studies were made on 1,859 outpatients, 587 inpatients and 601 operative procedures at our department in 1987. The most frequent diseases among the outpatients were urogenital infections followed by anomalies, tumors and stones. The major diseases among the inpatients were hypospadias, vesicoureteral reflux, congenital urethral stenosis, benign prostatic hypertrophy and bladder tumor. A total of 601 operations were performed. The five major operations were hypospadias repair, optic internal urethrotomy, transurethral resection of prostate, ureterocystoneostomy and transurethral resection of bladder tumor.

Partial characterization of an unusual 185 kDa protein synthesized by dermal fibroblasts from patients with Marfan syndrome: identification of the protein as type IV collagen

Production of an unusual collagenous protein was observed in culture of dermal fibroblasts from four patients with Marfan syndrome. The apparent molecular weight of the protein was about 185 kDa after reduction with 2-mercaptoethanol and 175 kDa after limited pepsin treatment. The 185 kDa protein was susceptible to the bacterial collagenase but resistant to the animal collagenase. Immunoprecipitation revealed the specific interaction of the pepsin-treated 175 kDa collagenous protein with monoclonal and polyclonal antibodies to human type IV collagen. From the patterns of CNBr peptide mapping the 185 kDa band was identified as alpha 1 (IV) chain. Type IV collagen in the skin is generally considered to be of non-fibroblastic origin. However, in "diseased" condition, dermal fibroblasts might produce type IV collagen. The clinical manifestation in relation to production of type IV collagen by cultured skin fibroblasts from Marfan patients is discussed.

[Renal dysfunction in children with vesicoureteral reflux]

It is well recognized that reflux nephropathy is one of the commonest causes of end-stage renal failure (ESRF) in children. We made a retrospective study of 28 children with vesicoureteral reflux (VUR) who showed impaired renal function, as defined by either the serum creatinine of more than 1.0 mg/dl or BUN of more than 20 mg/dl. There were 20 boys and 8 girls, and the incidence of both sexes was 4.8% and 1.9% respectively. Of patients, proteinuria was detected in 22, and hypertension in 7. Five patients progressed to ESRF during his or her clinical course. About half of the patients in this series presented proteinuria or growth retardation which had led to urological check-up. Bilateral reflux was demonstrated in 24 patients, and all of the remaining 4 with unilateral reflux had hypoplastic or dysplastic contralateral kidney. Micturition cystourethrography revealed moderate or severe reflux in 86% of the ureters either at the first examination or during the follow-up periods. Urographic findings which suggested renal dysfunction included bilateral small kidney, unilateral small kidney with contralateral renal scarring, and bilateral generalized renal scarring. According to the pattern of the progression of renal dysfunction, patients were subdivided into 3 groups. Group I; patients showed bilateral renal hypoplasia on urography, and renal dysfunction progressed to ESRF before the age of 10 years despite surgical treatment. In patients of group II, gradual decrease of renal function led to ESRF at the age of puberty, although SCr was around 1.2-1.5 mg/dl when they were about 10 years old. In group III, renal function was stable at about 1.0 mg/dl of SCr during childhood. Temporary improvement of renal function was observed in only 3 of 21 children who were followed for more than 1 year after antireflux surgery. Deterioration of renal function was caused within 6 months to one year. Antireflux surgery had only little influence on the improvement of renal function in this series. We emphasize the need for early detection and management of reflux to prevent progression of renal dysfunction.

[Progression of CT scan findings in Rett syndrome]

Progression of the lesions revealed by CT scan was observed in five girls with Rett syndrome. The most distinct and common finding was progressive dilatation of Sylvian fissures, frontal extracerebral space, interhemispheric fissure, and sulci mainly in frontal lobe. It may indicate progressive lesion in the frontal and the temporal lobes. In addition, dilatation of the anterior horns of the lateral ventricles and the third ventricle was noted in some cases. Brainstem and cerebellum were small at any age with some morphological development as the patients became elder. Neither malformations nor abnormalities in density were found in any case. It is concluded that the main lesion of Rett syndrome on CT scan is progressive and localized in the frontal and the temporal lobes.

Positron emission tomography using pyruvate-1-11C in two cases of mitochondrial encephalomyopathy

Positron emission tomography (PET) using pyruvate-1-11C was carried out to investigate the in vivo metabolism of pyruvate in the brains of patients with mitochondrial encephalomyopathy and Leigh's disease. Two epileptic patients were studied as control subjects. Radioactivity was eliminated from the brain tissue of the epileptic patients soon after injection of pyruvate-1-11C. PET images of mitochondrial encephalomyopathy patients showed an increase in radioactivity in the cerebral cortex, basal ganglia and thalamus, with elimination of radioactivity being slower than that of epileptic patients. One patient with Leigh's disease showed similar PET images. PET using pyruvate-1-11C is useful for the evaluation of mitochondrial energy metabolism in the brain.

[Treatment of congenital urethral stenosis (urethral ring) in children. Optic internal urethrotomy in the congenital bulbar urethral stenosis in boys]

Congenital urethral stenosis in boys occurs at the junction of the entodermal primary urethra and ectodermal secondary urethra. Endoscopically this lesion is recognized as a ring-form stenosis just distal to the external urethral sphincter. It has been considered as rare congenital anomaly in American literature. But in our experience congenital urethral stenosis is an important cause of recurrent urinary tract infections, enuresis, pollakisuria or hematuria in pediatric urological practice. It also disturbs spontaneous healing of vesicoureteral reflux. The most effective treatment of this lesion is optic internal urethrotomy under direct vision. We would like to report our experience of optic internal urethrotomy for congenital urethral stenosis in boys. From 1974 to 1986, 226 boys with congenital bulbar urethral stenosis were treated in our clinic. Optic internal urethrotomy was performed using a Sachse urethrotome with a 10 or 13 Fr. sheath. Of the 176 ureters with vesicoureteral reflux, spontaneous disappearance of reflux after optic internal urethrotomy was noted in 62.5% of Grade I-II, 65.0% of Grade III, 28.9% of Grade IV and 16.7% of Grade V ureters. These spontaneous disappearance rates were significantly higher than those of primary vesicoureteral reflux in Grade III, IV and V ureters. Of the drug-resistant enuretic boys with a congenital bulbar urethral stenosis, enuresis disappeared or ameliorated in 69.4% after optic internal urethrotomy. Furthermore, urinary tract infections were mostly prevented by optic internal urethrotomy, irrespective of the presence or absence of vesicoureteral reflux. Our results support the view that congenital urethral stenosis (urethral ring) is an important clinical entity in pediatric urology.

Purification and characterization of neutral and acid sphingomyelinases from rat brain

Neutral and acid sphingomyelinases were copurified from a rat brain P2 fraction by extraction with 1% Triton X-100, followed by (NH4)2SO4 fractionation, acetone powdering, extraction with 1% Triton X-100, (NH4)2SO4 fractionation, Sepharose CL-6B chromatography, and chromatofocusing. The neutral sphingomyelinase was eluted with buffer containing 0.4 M NaCl after the acid sphingomyelinase had been eluted with Polybuffer at pH 5.3. The neutral sphingomyelinase exhibited specific activity of 48,300 nmol/h/mg of protein, with 254-fold purification; the corresponding value for acid sphingomyelinase was 25,300 nmol/h/mg protein, with 668-fold purification from the P2 fraction. The purified neutral sphingomyelinase had no acid sphingomyelinase activity, and vice versa. The properties of the two enzymes were examined. A single band corresponding to a molecular weight of 67,000 was obtained on sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) for both enzymes. The pI was estimated to be 5.5 for both on isoelectric focusing. The native molecular weights of the neutral and acid sphingomyelinases were found to be 434,000 and 284,000, respectively, on gel filtration with Sepharose CL-6B. The single band obtained for each enzyme on SDS-PAGE was identified as an antigen with antibody raised against the purified neutral sphingomyelinase. Their amino acid compositions were very similar. The neutral and acid sphingomyelinases probably consist of common polypeptides and are immunologically cross-reactive.

Increased deposition of types III and V collagen in neurofibroma tissue from patients with von Recklinghausen disease

Collagen components in neurofibroma tissue from patients with von Recklinghausen disease were investigated, in comparison with those in normal skin and peripheral nerve tissue. Biochemical analysis of collagen isolated from the tissues by limited pepsin digestion indicated that the neurofibroma tissue contained type I collagen as the major constituent and increased amounts of types III and V collagen. The relative ratios of alpha 1(III)/alpha 1(I) and alpha 1(V) + alpha 2(V)/alpha 1(I) in the tissue were 0.87-0.92 and 0.16-0.17, respectively, while in normal skin, these ratios were 0.36-0.45 and less than 0.024, respectively. Amino acid analysis and circular dichroism studies of types I, III and V collagen purified from the tissue showed that these collagens were essentially the same as the corresponding types of collagen isolated from fetal human skin and placenta. The increased deposition of types III and V collagen suggested that alternation of collagen metabolism had occurred in the neurofibroma tissue.

[Transurethral ureterolithotripsy under hydraulic ureteral dilatation]

Transurethral ureterolithotripsy was performed in 32 patients with ureteral stones. A rigid ureteroscope was used and for the purpose of ureteral dilatation a hydraulic ureteral dilator (Ureteromat) was used. In total 39 stones were treated and of these 30 stones (77%) were successfully extracted or disintegrated. The success rate according to the location of the stone was as follows; 50% for the upper ureteral stone, 55% for middle ureteral stone and 96% for lower ureteral stone. As a complication of the procedure a lower ureteral stricture was noted in one patient. Hydraulic ureteral dilatation is a useful method of ureteral dilatation in transurethral ureterolithotripsy.

Tuberous sclerosis: aberrant proline sensitivity of skin fibroblasts

Cultured skin fibroblasts from patients with tuberous sclerosis were analyzed as to their sensitivities to proline, glutamic acid and arginine, and their analogues by means of a cell growth study. A difference was observed between tuberous sclerosis and normal cells when proline was added. Skin fibroblasts derived from normal-appearing skin of tuberous sclerosis patients exhibited sensitivity to proline. Skin fibroblasts derived from tumorous skin of tuberous sclerosis patients exhibited resistance to proline in the cell growth study and was found to be rather sensitive to proline in a colony formation study. This aberrant sensitivity to proline of tuberous sclerosis cells may indicate abnormal proline metabolism in tuberous sclerosis patients.

[Clinical statistics on outpatients, inpatients and operations in 1986]

Statistical studies were made on 1,637 outpatients, 568 inpatients and 563 operative procedures at our department in 1986. The most frequent diseases among the outpatients were urogenital infections followed by anomalies, tumors and stones. The major diseases among the inpatients were hypospadias, vesicoureteral reflux, benign prostatic hypertrophy, bladder tumor and congenital urethral stenosis. A total of 563 operations were performed. The five major operations were hypospadia repair, optic internal urethrotomy, transurethral resection of prostate, ureterocystoneostomy and percutaneous nephrolithotripsy.

Renal growth and progression of reflux nephropathy in children with vesicoureteral reflux

We analyzed renal growth and development of renal scars in 754 children with primary and 169 with secondary vesicoureteral reflux. The incidence of a small kidney was 15.5 per cent in the primary and 24.1 per cent in the secondary groups. About three-fourths of the small kidneys remained small from the first examination through followup. Catch-up renal growth was only exceptional. New scars or progression of previous scarring was observed in 7.4 and 30 per cent of the primary and secondary groups, respectively. Factors that promote formation of new scars are high grade vesicoureteral reflux, recurrent urinary tract infections and abnormal bladder function that results in high pressure reflux. We emphasized the importance of precise examination of the lower urinary tract. An early antireflux operation should be performed on children with severe reflux or recurrent urinary tract infections.

Effects of dimethylsulfoxide on sphingomyelinase activities in normal and Niemann-Pick type A, B and C fibroblasts

The effects of dimethylsulfoxide (DMSO) on sphingomyelinase activity measured at pH range 3.5-8.0 were examined in normal and Niemann-Pick disease type A, B and C fibroblasts culture. In normal cells, a minor activity was observed at pH 7.5, which was 3- to 4-fold lower than a major one at pH 5.0. Both activities at pH 5.0 and 7.5 were Mg2+-independent and localized to lysosomes. Niemann-Pick type C cells had 30-50% residual sphingomyelinase activity at both pH 5.0 and 7.5, as compared to normal control cells, whereas type A and B cells exhibited virtually no activity over the entire pH range examined. Treatment with 2% DMSO caused a marked increase in sphingomyelinase activities at pH 5.0 and 7.5 in normal and Niemann-Pick disease type C cells, while in type A and B cells, both activities remained virtually unchanged after DMSO treatment. The increase in sphingomyelinase activity at pH 5.0 induced in normal cells by DMSO resulted in an increase in the Vmax without a substantial change in the Km and was inhibited by the simultaneous addition of 10 micrograms/ml of cycloheximide. By comparison, a less than 2-fold increase in other lysosomal hydrolase activities was observed after DMSO treatment in all cell lines examined.

Clinical analysis of the small kidney associated with VUR

Analysis was performed on the clinical features of children with VUR who had one or two kidneys that were at least -2 SD smaller than normal for age of its renal ratio. The prevalence of the small kidney was 15.6% (97/623 children). Of 107 small kidneys, 87 (82%) were associated with moderate (grade IV) to severe (grade V) reflux and renal scarring was evident on 95 kidneys (88%). About half of the kidneys were diagnosed as scarred atrophy and 40% as congenital hypoplasia. The renal growth after antireflux surgery was evaluated by the change of the renal ratio and it was found that about three-fourths remained small during the pre- and postoperative periods. Accelerated growth was only exceptional.