[A case of penile necrosis in a patient with diabetic nephropathy]

The patient was a 63-year-old male. He was diagnosed as having diabetes mellitus in 1987, and hemodialysis was begun in October 1991 for diabetic nephropathy. He complained of glans pain from the middle of May 1992. Although he was administered antibiotics, a small ulcer arose on the glans penis at the end of May. The lesion became progressively black and carbonized on the whole glans penis by the first of June and involved the prepuce by the end of June. Partial penectomy was performed in July. Histopathological examination showed marked stenosis with calcification in the terminal branches of the dorsal penile artery and thickened wall of the small arteries due to vascular lesions as a result of diabetes mellitus. The patient was in generalized deterioration of clinical condition postoperatively and died of gastrointestinal bleeding in September. Penile necrosis in patients with diabetes mellitus is very rare and only ten cases including our own case have been reported. We reviewed the literature with special reference to the relationship with chronic renal failure.

[True hermaphrodite with ipsilateral vas deferens and intrascrotal ovary]

A 15-year-old, legally male patient came to our department with chief complaint of gynecomastia. Serum testosterone was at a low level of 1.6 ng/ml, and prolactin a high level of 23 ng/ml. Blood type was a mixed type of both type A and type B, and a chromosomal analysis with peripheral blood lymphocytes demonstrated a mosaic of 46, XX/46, XY. During the follow-up, he complained a painful swelling in his right scrotum, and received an emergent surgery. A large amount of blood was noted in the right scrotum. Unicorn uterus, Fallopian tube and finbriae were observed, and a thumb-sized gonad with hemorrhage and fissure was also seen in the upper part of the scrotum. The right gonad was an ovary and no testicular tissue was confirmed in the right scrotum, whereas the right vas deferens was noted. The left testis was accompanied by an induration on its upper pole which was histologically found to be ovarian tissue. The patient was diagnosed as a true hermaphroditism with 46, XX/46, XY chimera that had an ovary with inguinal uterus hernia and an unusual vas deferens in the right scrotum and an ovotestis in the left. It was considered that an adequate amount of testosterone secreted from the left testis during the early embryonal period might have affected the descent of the right ovary into the scrotum and on the development of the right vas deferens.

[Experimental and clinical studies on anal submucosal injection of methotrexate for bladder cancer]

The experimental and clinical studies were performed to investigate the efficacy of the anal submucosal injection (ASI) of methotrexate (MTX) for bladder cancer. In the experimental study, MTX was administered to male Wistar rats each weighing from 200 to 250 gm in a dosage of 2 mg/kg body weight through two different routes, one of which was intravenous injection (IV group) and the other of which was anal submucosal injection (ASI group). The concentrations of MTX in serum and bladder tissue after injection were estimated in both groups. Serum MTX levels in ASI group were significantly higher than those in the IV group from 30 minutes through 120 minutes after injection, while the IV group was higher than the ASI group at 5 minutes after injection. Tissue MTX levels in ASI group were significantly higher than those in the IV group from 60 minutes through 120 minutes after injection. However, tissue MTX levels in IV group were significantly higher than those in ASI group from 5 minutes through 15 minutes after injection. We started clinically to use ASI for bladder cancer as a preliminary random trial in November, 1988. Between November, 1988 and September, 1989 ASI was performed in 9 patients with various bladder cancer. The dose of MTX was 50 mg every week for 5 consecutive doses. The course was repeated at 3-week intervals.(ABSTRACT TRUNCATED AT 250 WORDS)

[Absent pulmonary valve syndrome: surgical approach for the worst group included in symptomatic neonates]

Absent pulmonary valve syndrome (APVS) has been classified to two groups. One is severely symptomatic infant group and the other no or slightly symptomatic. But we think that severely symptomatic group should be divided into the worst neonate group and the other. This worst group, that contains neonates who can not be weaned from the respirator after surgical intervention including corrective surgery because of severe bronchomalacia and/or peripheral bronchial stenosis, has already severe respiratory distress and needs ventilatory support while high pulmonary vascular resistance is maintained. Three patients of this group were operated on at 2, 13 and 2 days of age and there were two late hospital death. The last patient underwent ligation of main pulmonary artery (mPA) and left modified Blalock-Taussig shunt (MBTS) with phi 4 mm polytetrafluoroethylene graft and was extubated on the next day. The management of this group should aim at controlling the pulmonary regurgitation as early as possible to decrease the progressive airway obstruction and minimize pulmonary tissue damage. Ligation of mPA and MBTS can be performed without cardiopulmonary bypass and eliminates pulmonary regurgitation and controls the pulmonary blood flow less than the total correction. In the point of protecting bronchi and lung and reducing the risk of surgical intervention in critical neonatal period, ligation of mPA and MBTS can be safer and more effective operation for the worst APVS neonate than the total correction with insertion of artificial valve.

Delayed thoracic closure after cardiac surgery in infants

We report 4 cases of delayed thoracic closure after cardiac surgery in infants: 3 cases with transposition of the great arteries and one with hypoplastic left heart syndrome. Sternal and skin closure in the primary operation sometimes causes haemodynamic cardiac compression. Postoperative correction of haemodynamic and haemostatic functions are allowed by delayed sternal and skin closure. No complications were encountered.

[Clinical experience of adjustable pulmonary artery banding]

Pulmonary artery banding has been a useful palliative procedure for infants with congenital cardiac anomalies associated with excessive pulmonary blood flow. We have experienced some cases that the band was not sufficient enough to reduce the pulmonary artery pressure in complex cardiac anomalies. Therefore, we developed a new adjustable pulmonary artery banding system which can be re-adjusted extrathoracically without reoperation. We used this system in seven infants with congenital cardiac lesions and obtained good results.

[Right ventricular outflow tract reconstruction in two neonates with pulmonary atresia and intact ventricular septum]

Two neonates, aged 8 and 18 days, with pulmonary atresia and intact ventricular septum underwent right ventricular outflow tract reconstruction with an autologous pericardial transannular patch. Preoperative cardiac catheterization revealed a tripartite right ventricular morphology with suprasystemic right ventricular morphology with suprasystemic right ventricular systolic pressure (right ventricular to left ventricular peak pressure ratio was 1.2 in case 1 and 2.0 in case 2). Right ventricular volume was 73.5% of normal and 115% of normal respectively. Generous resection of the infundibular myocardium was done and a patch was inserted with the heart kept beating as the perfusate temperature of 32 degrees C. In case 1 a modified Blalock-Taussig shunt was added on the postoperative day 21, because of the insufficient growth of the right ventricle, but in case 2 prostaglandin E1 could be discontinued on the postoperative day 9.

[Delayed midsternal wound reconstruction for infants without secondary sternal closure]

Three infants, aged 11 days, 19 days and 48 days, underwent two Jatene operations and one modified Norwood operation. The sternum was left open and the skin defect was covered with a silicon sheet in all three patients. Delayed sternal closure was impossible because of hemodynamic deterioration in all three patients. Consequently delayed midsternal wound reconstruction was applied. One rectus abdominis muscle flap was turned up and the defect between the split sternum was filled with this muscle flap. Bilateral axillary incision was made to decrease the skin tension and the midsternal wound was closed with cutaneous advancement flaps. Bilateral axillary defects were covered with mesh skin implantation. All three patients recovered after this procedure. We propose this technique for the cases in which the delayed sternal closure is impossible.

[Successful treatment by using a pedicled omental flap for mediastinal infection in the presence of a external valved conduit]

Mediastinal infection is one of serve and fatal complications after cardiac surgery, especially in the presence of an artificial graft. A case of successful treatment by using a pedicled omental flap for mediastinal infection in the presence of an external valved conduit is reported. a 10-year-old girl who had implanted the 12 mm porcine valved conduit for truncus arteriosus at age 9 months, underwent replacement of the old conduit with a 18 mm valved conduit. On the 9th postoperative day, as soon as mediastinal infection was proved by positive culture of the drainage from the chest tube, a reoperation was performed to debride and irrigate the mediastinum. Irrigation with povidone-iodine and antibiotics was continued for 3 weeks until improvement of CRP levels and negative drainage cultures. Then the heart and the valved conduit were wrapped with the pedicled omental flap and the skin was closed. She was without any evidence of infection for 3 months after operation. Use of a pedicled omental flap might be an effective method for treatment of mediastinal infection in the presence of an external conduit.

[Clinical evaluation of patients with relapsed prostatic carcinoma]

A retrospective clinical study of 41 patients with prostatic carcinoma relapsing after endocrine therapy at Wakayama Medical College from 1972 to 1987 was reported. Patient's age was from 51 to 80, with an average of 69.8 years. Initial clinical stage was A in 2 patients, C in 12, D in 26 patients and unknown in one. Pathological grade at the first visit was well-differentiated cell type in 4 patients, moderately differentiated in 13, poorly differentiated in 23 patients and unknown in one. Of 41 patients, 32 had a local progression and 26 had an appearance or progression of metastasis. Several factors which might be related to the interval between initial endocrine therapy and relapse were analysed. Following factors such as poorly differentiated cell type, stage D, high Gleason score and increase in acid phosphatase level were revealed to be related to the short interval. Chemotherapy consisting of various agents and their combination has not been able to improve the survival of the patients with relapsed prostatic carcinoma. 1-year survival rate of all cases after relapse was 41.3% and none of the patients survived over 3 years.

[Renal cell carcinoma associated with tuberous sclerosis: a case report]

Renal angiomyolipoma associated with tuberous sclerosis is well known. On the other hand, few cases of renal cell carcinoma in connection with tuberous sclerosis have been reported. We report a patient with tuberous sclerosis whose kidney was involved with renal cell carcinoma. A 18-year-old woman was first admitted in August 1987 for evaluation of left renal tumor. Diagnosis of tuberous sclerosis was made when she was 11 years old on the basis of mental retardation, papules on her face, seizures, white leaf-shaped macules and periventricular calcifications. Computerized tomographic scan demonstrated a large mass arising from the left kidney and small masses in the right kidney. Angiography confirmed bilateral hypervascular renal tumors. On these bases, a clinical diagnosis of bilateral renal angiomyolipomas was made and surgical treatment of the left kidney was recommended because of its large size. However, her parents did not permit treatment until March, 1988. Finally, left nephrectomy of 4,750 g was performed and histological examination revealed renal cell carcinoma with clusters of spindle cells. In the literature available to us, we found twelve reports of malignant renal tumors associated with tuberous sclerosis including five renal cell carcinomas in Japan.

[Transcatheter arterial embolization in patients with renal arteriovenous malformation: a report of two cases]

We report two cases of renal arteriovenous malformation (AVM) with chief complaints of macroscopic hematuria, and treated with transcatheter arterial embolization (TAE) using Gelfoam. Although hematuria disappeared after TAE in both cases, recanalization of AVM was revealed by follow-up renal arteriography one and three months later respectively. TAE were repeatedly performed at the same time. At the follow-up, the partial infarction in the normal parenchyma of the treated kidney was demonstrated on CT scanning in one case. We suggest that if the residual or recanalization of AVM after the initial TAE is observed, careful follow-up should be preferred without repeated TAE unless some deriving symptoms have appeared.

[An anterior longitudinal aortotomy with a distal aortic transection for the arterial switch operation]

There are several methods of aortic transection of the ascending aorta and removal of coronary buttons in the arterial switch operation for the transposition of the great arteries. After transecting the aorta as far distally as possible, we place an additional aortotomy which runs longitudinally on the anterior aspect of the ascending aorta. This incision facilitates removal of the coronary buttons in a good operative field, avoids distortion of the Valsalva's sinuses and makes reconstruction of the neopulmonary artery easier after Lecompte maneuver with a anterior patch finally if needed, especially in the neonatal arterial switch operation. Consecutive 4 patients ¿the 1st is neonatal TGA I with single coronary artery (Shaher 3a), the 2nd is neonatal TGA II, the 3rd is neonatal TGA I with singal coronary artery (Shaher 3c), 4th is infantile (48 days) TGA II with single coronary artery (Shaher 3c)¿ have been operated upon this technique with good results recently.

An anterior longitudinal aortotomy with a distal aortic transection for the arterial switch operation

An additional longitudinal aortotomy on the anterior aspect of the old ascending aorta after distal aortic transection is very effective for removal of the coronary buttons, prevention of deformation of the neopulmonary arterial ring, and reconstruction of the neopulmonary arterial trunk after the Lecompte maneuver, especially for the neonatal arterial switch operation.

Atresia of the coronary sinus orifice. Fatal outcome after intraoperative division of the drainage left superior vena cava

A case of atresia of the coronary sinus orifice in a patient with transposition of the great arteries is reported. Inadvertent division of a drainage left superior vena cava during the arterial switch operation was fatal.

[Basal studies on combination of Chinese medicine in cancer chemotherapy: protective effects on the toxic side effects of CDDP and antitumor effects with CDDP on murine bladder tumor (MBT-2)]

Effects of oral administration of Juzentaihoto, a herb drug, on the toxic side effects of cis-diammine dichloroplatinum (CDDP) and combination effects with CDDP on murine bladder tumor (MBT 2) were studied using C3H/He male mice. The following results were obtained; 1. When the mice were treated with the mixture diet of 1% or 0.5% Juzentaihoto before 2 weeks, adverse effects of high dose CDDP (15 or 17.5 mg/kg) which were included with lethal toxicity, renal and hepatic toxicity, and myelosuppression were protected significantly. The administration of 0.5% Juzentaihoto mixture diet markedly shifted the LD50 to the right. Furthermore, the effects of Juzentaihoto were clearly revealed on the histological findings of testis and kidney. 2. On murine bladder tumor, when the mice were treated with the mixture diet of 1% or 0.5% Juzentaihoto and injected CDDP (2.5 mg/kg/week) for 8 weeks, significantly greater inhibition of the tumor growth and prolongation of the survival rate were observed than those in the group of CDDP alone. These results indicates that Juzentaihoto lessens the toxic side effects of CDDP and that it enhances the effects of CDDP experimentally. Juzentaihoto, a kind of Chinese herb medicine, might come under the category of biological response modifiers.

Intravesical Bacillus Calmette-Guérin treatment for superficial bladder tumours

Intravesical instillations of Tokyo 172 strain BCG were given to 56 patients with superficial bladder cancer during the 24-month period after transurethral tumour resection as a prophylaxis against tumour recurrence. The recurrence rate of tumours was compared with that of historical controls. Results were estimated by the person-years method and there were statistically significant decreases in recurrent tumours following BCG therapy. Our results suggest that the intravesical Tokyo 172 strain BCG is effective and safe as a prophylaxis against the recurrence of superficial bladder tumours.

[Axillary vertical incision thoracotomy sparing pectoralis major muscle and latissimus dorsi muscle: an approach for patent ductus arteriosus]

The technique of an axillary vertical incision thoracotomy sparing pectoralis major muscle and latissimus dorsi muscle for a closure of patent ductus arteriosus is presented. After an mid-axillary vertical incision, serratus anterior muscle is incised on the third intercostal space between pectoralis major muscle and latissimus dorsi muscle. The space between serratus anterior muscle and rib cage (Spatium intermusc. thoracale) is dissected with a finger, through this space the 3rd intercostal thoracotomy is performed in the axillary and dorsal portion. The ventral part of intercostal muscle is incised from inside of the thoracic cavity for sparing the pectoralis major muscle. We performed this technique in two patients aged 1 year, and secured equally good operative fields as could be secured by the original axillary vertical incision thoracotomy described by Browne.

[Pulmonary hypertensive crisis after open heart surgery]

Three patients with pulmonary hypertensive crisis (PHC) after open heart surgery for ventricular septal defect are reported. These patients ranged in age from 2 to 47 months, with Rp from 7.0 to 10.6 U.m2, Pp/Ps from 0.67 to 1.0, and Qp/Qs from 1.6 to 1.79. Intraoperative lung biopsy showed pulmonary vascular obstructive disease of Health-Edwards grade 2 in each patient. Atelectasis or pleural effusion on their chest-XP films was found when PHC occurred. The PHC course of the last case was recorded continuously on ABP, PAP and LAP. Administration of prostaglandin-E1 directly through the pulmonary arterial catheter was effective on PHC. Continuous recording of ABP, PAP and LAP during the episode was useful to differentiate PHC from acute left heart failure and/or acute right heart failure.

[Foreign body in the kidney: report of a case]

A 49-year-old man was admitted with the suspicion of renal foreign body. A fragment of wire rope was penetrated from his right lumbar region while working. Drip infusion pyelography and computed tomography films revealed a linear metallic object in the region of the right kidney. The foreign body was successfully extracted from the right renal parenchyma. The 38 cases of foreign bodies in the upper urinary tract including 12 in the renal parenchyma found in the literature are reviewed.

Prolonged aortic cross-clamping in early infancy and method of myocardial preservation

A cardioplegic solution containing blood with a low level of ionic calcium was prepared independent of pump-oxygenator perfusate blood, so as to contain a constant concentration of each component at any given time. Using this solution, Jatene's anatomic repair under prolonged periods of aortic cross-clamping ranging from 117 to 184 minutes (mean: 149 min) was performed on seven young infants with simple complete transposition. The ages of the patients ranged from 34 days to 3 months, with a median age of 2 months. Four patients, aged 39 days, 41 days, 2 months and 3 months, survived and showed uneventful postoperative hemodynamics. Two of the three non-survivors were considered retrospectively to have been unsuitable candidates for Jatene's anatomic repair due to their low left ventricular pressure (LV/RV pressure ratio less than 0.60 in both). The remaining infant who died had TGA with a large ventricular septal defect of the muscular type and developed a postoperative residual shunt. It was considered unreasonable to attribute the cause of death in this case to inadequate myocardial protection. Judging from our experience with these four survivors who underwent prolonged aortic clamping ranging from 117 to 160 minutes, our cardioplegic solution and the technique of its administration were considered to be effective and promising for heart surgery in young infants and neonates.

[Adrenal incidentaloma: report of eight cases]

Since 1983, eight cases of adrenal incidentaloma were experienced at the Department of Urology, Wakayama Medical College and affiliated hospitals. Six adrenal masses were incidentally detected by computed tomography, and two were first noted by either ultrasonography or intravenous pyelography. Surgical exploration was performed in all cases as the final diagnostic measure. Of them, three had adrenocortical adenomas, three had adrenal cysts, one had adrenal metastasis and one had pheochromocytoma. Preoperative evaluation revealed that all patients except one with pheochromocytoma had no endocrinological abnormality. The management of the adrenal incidentaloma, which will be discovered more frequently accompanied with the increasing use of computed tomography, was discussed with special references to its precise indication of surgical treatment.

The Blalock-Taussig shunt for simple complete transposition of the great arteries followed by later anatomic correction. Report of 2 cases with conflicting postoperative courses

The Blalock-Taussig (BT) shunt was performed in two infants with simple transposition of the great arteries (TGA) after poor response to septostomy not only to improve hypoxia but also in expectation of preparing the left ventricle for later anatomic correction. One patient had adequate muscle mass and pressure of the left ventricle after the shunt and underwent successful anatomic correction. The other patient developed intractable heart failure following the shunt. Anatomic correction was performed with success in this patient after pulmonary artery banding and takedown of the BT shunt. Based on these experiences, if heart failure does not develop or is controllable after BT shunt, there may be a possibility of later anatomic correction. However, if uncontrollable failure occurs, the shunt should be taken down and arterial or venous switch correction should be performed as soon as possible.

Modified Blalock-Taussig shunt following long-term administration of prostaglandin E1 for ductus-dependent neonates with cyanotic congenital heart disease

In the treatment of cyanotic heart diseases in neonates who are ductus dependent, the small size of the pulmonary artery and/or subclavian artery often precludes construction of a sufficient Blalock-Taussig shunt. To avoid an emergency operation and to obtain pulmonary and subclavian arteries of adequate size (3 mm), a low dose of prostaglandin E1 was given to 16 neonates for a mean of 47 days (range 26 to 65 days), and a modified Blalock-Taussig shunt operation was performed in neonates whose mean age was 50 days. The pulmonary artery grew significantly (mean 4.5 mm) and the mean diameter of the subclavian artery was 3 mm, which was large enough for a good shunt at the time of operation. There were two late deaths and one operative death. All surviving patients shunts at the mean follow-up period of 22 months. The shunt was constructed on the same side as the ductus arteriosus so that the ductus could be ligated at the same operation in selected cases; the ductus may not close after discontinuation of prostaglandin E1 infusion and may cause uncontrollable congestive heart failure because of excessive pulmonary blood flow, particularly in patients with a univentricular heart. The ductus, dissected in nine patients, was enlarged and elongated in all and was ligated in four patients without complication.

Left ventricular volume as a predictor of postoperative hemodynamics and a criterion for total correction of tetralogy of Fallot

The effect of preoperative left ventricular end-diastolic volume on hemodynamics after repair and the safety limit of left ventricular end-diastolic volume for total correction of tetralogy of Fallot were studied. Preoperative left ventricular volume was determined in 38 patients according to the area-length method from biplane cineangiocardiograms. The mean left ventricular end-diastolic volume of the 38 patients was 83% +/- 23% of normal. The left ventricular end-diastolic volume of 20 corrected patients (90% +/- 22% of normal) was significantly larger (p less than 0.05) than that of 18 with a systemic-pulmonary shunt (75% +/- 22% of normal). In the corrected patients, the total amount of dopamine required in the postoperative period showed an excellent inverse exponential correlation with the preoperative left ventricular end-diastolic volume (r = -0.826); it showed a poor inverse correlation with the ratio of pulmonary artery to aortic diameter (r = -0.587) and with myocardial ischemic time (r = -0.487); and it showed no correlation with postoperative right to left ventricular systolic pressure ratio (determined at the time of the chest closure) and residual right ventricular-pulmonary arterial pressure gradients. The patients with a left ventricular end-diastolic volume under 70% of normal had severe low-output syndrome after total correction. We recommend a left ventricular end-diastolic volume of 60% of normal as a safety limit for total correction in patients under 2 years of age. In patients over 2 years of age, the safety limit may be larger because there are more collaterals with increasing age.

Extrathoracically adjustable pulmonary artery banding

A new technique of adjustable pulmonary artery banding is presented. A tourniquet system has been used in eight consecutive infants with complex congenital cardiac anomalies during the past 2 years. They had severe congestive heart failure, and six of them required inotropic support preoperatively. All survived the banding procedure and there were no hospital deaths. Four of the eight infants required additional adjustment of the band to improve hypoxemia or persistent congestive heart failure 3 hours to 4 months postoperatively. Each adjustment was made easily via a small skin incision without thoracotomy. This technique allows fine adjustment by gentle and delicate tightening and loosening of the band during and after operation, so that the technique avoids most mortality and morbidity related to an inappropriate banding and brings satisfactory symptomatic palliation.