Lower Dose of 5 mL of 1% Lidocaine is More Suitable than the Conventional 10 mL for Caudal Block in Transrectal Prostate Biopsy: A Retrospective Cohort Study

Objectives

In Japan, caudal block with 1% lidocaine is commonly used for transrectal prostate biopsy. Although 10 mL of 1% lidocaine is commonly used, the appropriate dosage of 1% lidocaine has not been studied. Our hospital routinely uses two different doses (5 or 10 mL) of 1% lidocaine for caudal block for transrectal prostate biopsy. Herein, we retrospectively evaluated the efficacy and safety of both doses of 1% lidocaine.

Methods

This retrospective study included 869 patients who underwent transrectal prostate biopsy with caudal block at our hospital. The amount of 1% lidocaine was determined by the day of the week on which the biopsy was performed, and the patient voluntarily chose the day of the biopsy, unaware of the dose of 1% lidocaine used on that day. Pain, anal sphincter tonus, cancer diagnosis rate, and early complications were compared.

Results

In total, 466 and 403 patients received 5 and 10 mL of 1% lidocaine for a caudal block, respectively. After propensity-score matching for patient characteristics, each group contained 395 patients. The pain score, anal sphincter tonus score, or prostate cancer diagnosis rate were not significantly different between the two groups. However, rectal bleeding was significantly more frequent and severe in the 10-mL than the 5-mL group (p=0.018 and p=0.0036, respectively). The incidence of other complications was not significantly different between the groups.

Conclusions

Our results suggest that 5 mL of 1% lidocaine may be more suitable than 10 mL for caudal block during transrectal prostate biopsy.

Adenocarcinoma in ectopic prostatic tissue at the trigone of urinary bladder

Introduction

Ectopic prostatic tissue is prostatic tissue located distant from the prostate gland. Although its existence is not uncommon, the occurrence of adenocarcinoma in ectopic prostatic tissue is rare.

Case presentation

A 68-year-old man was suspected to have a nodular-type tumor in the bladder trigone and a tumor in the prostate based on magnetic resonance imaging and cystoscopy results. Transurethral tumor resection and transrectal prostate needle biopsy revealed the coexistence of ectopic prostatic adenocarcinoma in the bladder trigone and low-risk orthotopic prostate cancer. Four years later, the tumor evolved to intermediate-risk prostate cancer during active surveillance, and the patient underwent prostatectomy with resection of the bladder trigone. Pathology indicated no residual ectopic prostatic tissue or adenocarcinoma at the bladder trigone.

Conclusion

Adenocarcinoma in ectopic prostatic tissue is very rare; however, when found, the possibility of concurrent cancer in the prostate gland should be considered.

Maintaining Serum Hemoglobin Levels Within the Physiological Range Prevented Bladder Tamponade Recurrence Due to Radiation-Induced Hemorrhagic Cystitis: A Case Report

Radiation-induced hemorrhagic cystitis is a refractory disease that can cause severe hematuria and bladder tamponade. Bladder tamponade due to radiation-induced hemorrhagic cystitis can often recur repeatedly and markedly reduce the quality of life. However, no blood test parameter has been studied yet regarding the prevention of bladder tamponade recurrence. An 84-year-old patient with a history of radiation therapy for cervical cancer was repeatedly hospitalized for bladder tamponade due to radiation-induced hemorrhagic cystitis. At each hospitalization, blood transfusions were performed to treat severe anemia as the first treatment, resulting in hematuria improvement, and the patient was discharged without invasive treatments such as transurethral coagulation. However, anemia developed gradually after each discharge. The anemia progression was obviously unrelated to macrohematuria because macrohematuria did not appear during that period. When the serum hemoglobin level decreased below the physiological range, bladder tamponade recurred. Based on these findings, we posited that the monitoring of the serum hemoglobin level could be useful to predict the occurrence of bladder tamponade. We hypothesized that if the serum hemoglobin level did not fall below the physiological range, bladder tamponade would not occur. We treated chronic anemia after determining its cause and kept serum hemoglobin levels within the physiological range. Since the treatment was initiated, bladder tamponade has not recurred in over 27 months. In this case, the monitoring of the serum hemoglobin level was useful to predict the occurrence of bladder tamponade due to radiation-induced hemorrhagic cystitis. By maintaining serum hemoglobin levels within the physiological range, we successfully prevented the recurrence of bladder tamponade due to radiation-induced hemorrhagic cystitis.

[A Case of Panperitonitis Due to Bladder Rupture Caused by Spinal Metastasis of Colorectal Cancer]

A 74-year-old patient was undergoing treatment for ascending colon cancer (cT4aN2M1a) in the Department of Surgery at our hospital. During treatment for increased lymph node metastasis and spinal metastasis, she complained of numbness in her dorsal thigh. Magnetic resonance imaging showed spinal canal stenosis due to L4 bone metastasis. Immediately after starting radiation therapy for L4 bone metastasis, bladder rupture occurred and led to generalized peritonitis. We performed emergency laparotomy and drainage. Later, the patient's general condition improved, but irreversible neurological symptoms remained, and activities of daily living decreased markedly. This was thought to be caused by weakening of the bladder wall due to chronic cystitis, and hyperextension of the bladder due to neurogenic bladder. Bacteriuria leaked into the abdominal cavity, resulting in generalized peritonitis.

Assessment of bone health in patients with prostate cancer using cancer staging computed tomography

PURPOSE

To evaluate the utility of vertebral Hounsfield unit (HU) values from computed tomography (CT) in cancer staging as a supplementary screening tool for bone health among prostate cancer (PCa) patients.

METHODS

T-scores of bone mineral density (BMD) in each lumbar vertebra (L1-L4) and hip for newly diagnosed PCa patients (N = 139) were measured using dual-energy X-ray absorptiometry (DXA). The degenerative changes in each lumbar vertebra were assessed, and the HU values of trabecular bone in axial CT images of each vertebral body (vertebral CT-HU value) were measured using staging CT.

RESULTS

556 vertebrae were analyzed. 326 of 556 (59%) lumbar vertebrae had degenerative changes. The vertebral CT-HU value was positively correlated with the lumbar BMD T-score, with higher correlation coefficients observed in vertebrae without degenerative changes (r = 0.655, N = 230) when compared to vertebrae with degenerative changes (r = 0.575, N = 326). The thresholds matching BMD T-scores of - 2.0 and - 1.5 set by cancer treatment-induced bone loss guidelines were 95 HU and 105 HU, respectively. Based on the intervention threshold (lumbar BMD T-score <  - 1.5), 15.1% of PCa patients required osteoporosis treatment; and, this value increased to 30.9% when L1-L4 CT-HU thresholds that corresponded to BMD T-score <  - 1.5 were used.

CONCLUSION

Lumbar BMD values from DXA may not reflect true bone health in PCa patients who often have lumbar degenerative diseases. Thresholds based on the vertebral CT-HU value can be used as a supplementary method to identify PCa patients who need anti-osteoporosis drugs.

[Case of Behcet's disease diagnosed by bilateral epididymitis]

A 24-year-old man visited our emergency room with testicular pain and left shoulder pain, and was admitted to our hospital for diagnosis of bilateral epididymitis. Antibiotics and anti-inflammatory medication were started, but the symptoms did not improve. During hospitalization, ulcerous lesions, erythema nodosum, folliculitis-like exanthema and multiple oral aphtha appeared. Then, we consulted the department of dermatology. As he had a combination of arthritis and epididymitis, he was diagnosed with the abortive form of Behcet's disease. After diagnosis, we began administering colchicine. Then, all symptoms improved in a few days, and he has remained free of the disease after the discontinuation of colchicine.

[A case of giant testicular tumor in a schizophrenic patient]

A 55-year-old man with schizophrenia presented with right scrotal enlargement. Clinical examination revealed a right adult -head-sized testicular tumor, multiple lymph node metastasis with marked elevation of serum lactic dehydrogenase (LDH) and β -human chorionic gonadotropin (β -HCG). Right high orchiectomy followed by chemotherapy with bleomysin, etoposide and cisplatin (BEP) for 4 cycles was performed. The tumor weighed 5,270 g, and was pathologically diagnosed as seminoma. After the treatment, the tumor markers were normalized, but he refused to undergo retroperitoneal lymph node dissection.

[Castleman's disease of the kidney: a case report]

Castleman's disease is a rare disorder characterized by benign proliferation of lymphoid tissue. A 61-year-old man was referred to our department for a renal mass incidentally detected by magnetic resonance imaging. Computed tomography showed a 18 × 20 × 14 mm mass in the upper pole of the right kidney, which enhanced at the early phase and washed out at the late phase. On the diagnosis of renal cell carcinoma, laparoscopic partial nephrectomy was performed. Pathological examinations revealed a hyaline-vascular type of Castleman's disease confined to the kidney.

[Successful treatment of spontaneous rupture of pheochromocytoma with laparoscopic adrenalectomy: a case report]

A 46-year-old man had sudden onset of severe left hypochondrial pain and went into shock following hospitalization. Computed tomography, echocardiography, and endocrinological tests revealed spontaneous rupture of a pheochromocytoma associated with catecholamine cardiomyopathy. After he underwent conservative management with fluid replacement, his blood pressure stabilized and cardiac function improved. Twenty-two days later, he was referred to our hospital. After admission, as his circulatory dynamics was stable, we performed elective laparoscopic left adrenalectomy. He was discharged on the tenth postoperative day. Spontaneous rupture of a pheochromocytoma is very rare : laparoscopic surgery for this condition has been reported only on 2 previous occasions worldwide.

[Panhypopituitarism caused by an intrasellar cystic mass in late-onset hypogonadism clinic]

A 74-year-old man who was referred to our late onset hypogonadism clinic presented with sweating and loss of appetite. His aging males' symptoms (AMS) and international index of erectile function (IIEF-5) scores were 59 and 2, respectively. His hormonal examination revealed extremely low free testosterone values. The patient was started on androgen replacement therapy, but his symptoms did not improve. Additional hormonal examinations revealed low values for other anterior pituitary hormones. Magnetic resonance imaging revealed an intrasellar cystic mass with suprasellar extension. We considered this mass caused hypothalamic hypopituitarism. A load test for anterior pituitary hormones revealed panhypogonadism. His symptoms improved after administration of adrenal and thyroid hormones and androgen. Five months after start of drug administration, his AMS score improved to 29, but IIEF-5 score showed little change. As a matter of course, not only androgen but all pituitary-related hormones are needed for hypopituitarism patients.

[Primary adenocarcinoma of the seminal vesicle difficult to differentiate from rectal carcinoma : a case report]

A 78-year-old man with urinary retention visited our hospital in June 2011. He presented with intestinal bleeding one month later and was admitted immediately. Contrast enhancement computed tomography revealed a lobulated intrapelvic tumor and liver metastasis. The prostate specific antigen level was normal, but his carcinoembryonic antigen level was elevated. Based on these results, his tumor was diagnosed as rectal carcinoma. On day 26, total pelvic exenteration and pelvic lymph node dissection to arrest bleeding were performed. We created an ileal conduit for urinary diversion and performed a sigmoid colostomy. The final histopathological assessment confirmed that he had primary adenocarcinoma of the seminal vesicle. The patient received the best supportive care because he rejected postoperative adjuvant chemotherapy and hormonal therapy. He died three months postoperatively. Primary adenocarcinoma of the seminal vesicle is very rare. The prognosis for this carcinoma is poor.

[A case of metabolic acidosis and tetany after ileal neobladder replacement]

A 64-year-old man visited our hospital with the complaint of macrohematuria and bilateral hydronephrosis. He had undergone total cystectomy and ileal neobladder replacement under the diagnosis of muscle invasive bladder cancer (cT2bN0M0). Tetany due to hyperventilation syndrome appeared on postoperative day 42. Blood gas analysis showed metabolic acidosis (pH 7.260, pO2 148.1 mmHg, pCO2 20.7 mmHg, HCO3 9.1 mmHg, BE -16.0 mmol/l). His condition was immediately improved after a urethral catheter was placed and sodium bicarbonate was administered. After re-removal of the urethral catheter, however, hyperventilation syndrome recurred. He was discharged from the hospital with the urethral catheter placed.

[Poor outcome due to spontaneous rupture of renal cell carcinoma : a case report]

A 54-year-old man experienced sudden onset of severe pain in his left lower back. Because the pain persisted for two days, he visited our hospital. Abdominal computed tomography revealed a hematoma around his left kidney, which was diagnosed as spontaneous rupture of a renal tumor. He was immediately admitted and was scheduled to undergo elective surgery. However, because his hemoglobin level decreased suddenly on Day 9 and rebleeding from the renal tumor was suspected, we chose to perform left radical nephrectomy following emergency transcatheter arterial embolization of his left renal artery. The resected specimen was a solid brownish-red mass surrounded by hematoma, and the histopathological findings revealed that it was a renal clear cell carcinoma (G3＞G2, INFα, pT1b, and pV0). On Day 51, he was found to have a local recurrence of carcinoma, and died five months after surgery. Spontaneous rupture of renal cell carcinoma is relatively rare : this is the 104th report on surgery for this carcinoma in Japan.

[IgG4-related idiopathic segmental ureteritis which was difficult to distinguish from ureteral cancer: a case report]

A 79-year-old woman was admitted with a chief complaint of gross hematuria, pollakisuria, lower abdominal pain. Urine cytology, intravenous pyelography, and cystoscopy were performed but showed no abnormal findings. About 6 months later, abdominal computed tomography (CT) revealed a 5cm long segment of ureteral narrowing with wall thickening, hydronephrosis, para-aortic lymph node swelling. Retrogradepyelography (RP) was done. Pelvic urine cytology was class IV. Under the clinical diagnosis of ureteral carcinoma and lymph node metastasis, a left nephroureterectomy with lymph node dissection was performed. The pathological diagnosis was IgG4-related idiopathic segmental ureteritis.

[A case of bladder cancer with metastasis to the bone of the hand]

Metastasis to the bone of the hand is rare. In addition, metastasis to the bone of the hand from bladder cancer is extremely rare. We herein report a case of distal phalanx metastasis from bladder cancer. A 64- year-old man who was diagnosed with bladder cancer (cT2bN0M0) received total cystectomy (pT3bN2). Two months after the surgery, a roentgenogram revealed lung metastasis. Then we administered 2 cycles of chemotherapy using gemcitabine and cisplatin. Computed tomography revealed a partial response. However, several months after chemotherapy, we noted that his left ring finger was swollen and showed erythema. We made a diagnosis of metastasis to the distal phalanx of the left ring finger and amputated the finger. Pathological findings showed no conflict with metastasis from bladder cancer. Postoperative course was good, but he died about three months after the diagnosis of metastasis.

[A case of chemical burn of the penis]

A chemical burn is not so common in the urological field. In addition, a chemical burn of the penis is quite rare. We experienced a case of chemical burn of the penis caused by resin for making fiber-glass reinforced plastics (FRP). He was a 41-year-old man and was referred to our hospital complaining of genital pain. He had sustained an injury to his penis induced by FRP at his workplace and had developed phimosis by the severe edematous foreskin. He underwent dorsal incision immediately and his postoperative course was favorable.

[Three cases of penile self-mutilation]

Penile self-mutilation is rare. We report our experience with 3 cases of penile self-amputation. One case was in a 48-year-old man who had no background history of mental disorders. He amputated his penis using a utility knife. He was referred to our hospital and underwent suture of the wound, but he took his own life one week after the surgery. Another case was in a 42-year-old man who had intelligence impairment. He amputated his penis using a kitchen knife. The other case was in a 41-year-old man who had schizophrenia. He amputated his penis using a piece of broken glass.

[A case of solitary epididymis rupture after blunt scrotal trauma]

Blunt trauma of the scrotum is sometimes associated with severe injuries such as testis rupture. However, there are few reports of traumatic rupture of the epididymis with blunt scrotal trauma. In addition, severe epididymis injuries after scrotal trauma are always associated with severe testis trauma. We experienced a case of solitary rupture of the left epididymis that occurred in a traffic accident. We report herein such a case and review the literature. To our knowledge, this case is the 4th case of solitary epididymis rupture by blunt scrotal trauma.

[Successful testicular sperm extraction in a non-obstructive azoospermic man with severe testicular microlithiasis : a case report]

A 45-year-old man was referred to our hospital for treatment of azoospermia. On physical examination, right testicular volume was 2 ml, left testicular volume was 3 ml, and pubic Tanner stage was 5. Scrotal ultrasonography revealed a high echoic lesion with acoustic shadowing at surfaces of bilateral testes. Semen analysis showed azoospermia and serum follicle stimulating hormone value was high (28.42 mIU/ml). He was diagnosed with non-obstructive azoospermia, and underwent microdissection testicular sperm extraction. Both testes were filled with shiny granular materials. In excised tissue of the testes, seminiferous tubules containing spermatozoa were found and motile spermatozoa were successfully retrieved. The histological examination revealed many small calcifications which had laminated structure. Spermatogenesis was slightly impaired, and Johnsen's score count was 9. Testicular microlithiasis has been reported to be an infrequent condition associated with conditions such as testicular tumors and testicular dysgenesis syndrome. Such a severe testicular microlithiasis has not been reported previously.

[Excellent growth following testosterone replacement therapy in identical twin with bilateral anorchia]

Bilateral anorchia is defined as the complete absence of testicular tissue with a normal male karyotype and phenotype. Although the precise etiology is not well understood, mechanical causes during or after testicular descent have been suggested, while genetic factors have also been reported. We treated a patient with bilateral anorchia who obtained excellent growth bytestosterone replacement therapyas compared with his normal identical twin. The patient was diagnosed with negative elevation of testosterone after hCG administration and surgical exploration confirmed the absence of a testicular structure. We began testosterone replacement therapyfrom 13 years old with the goal of matching the development of his brother. Four months after initiating therapy, the patient showed voice breaking and pubic hair growth. Thereafter, there were scant differences in height and secondarysexual characteristics as compared with his brother.

[An unusual case of cystic nephroma protruding into the renal pelvis]

Cystic nephroma is a relatively rare and benign renal lesion of uncertain etiology. Approximately 200 cases have been described, but only a few cases of cystic nephroma with prominent renal pelvis involvement have been reported. Here, we report an unusual case of cystic nephroma that protruded into the renal pelvis. A 45-year-old woman hospitalized because of a right renal mass detected on clinical examination. The diagnosis of a malignant or benign lesion was not clear. A right nephroureterectomy was performed. The characteristics of the resected specimen were consistent with those of cystic nephroma. Macroscopic examination revealed that the giant lesion originated from the upper renal pelvis and extended into the renal pelvis. The patient is currently free from disease at eight months after the surgery. In general, this tumor arises from the renal parenchyma. To our knowledge, this is the fifth case report on cystic nephroma with prominent renal pelvis involvement.

[A case of retroperitoneal myxofibrosarcoma]

A 63-year-old man presented to our hospital suffering from dull pain in his right flank and general malaise.Abdominal computed tomography (CT) revealed a 21X14 cm retroperitoneal tumor adjacent to the right kidney. He underwent extirpation of the tumor,which weighed 2,900 g. Histopathological diagnosis was high-grade myxofibrosarcoma. Six months after initial surgery,CT revealed isolated metastasis in the upper lobe of the left lung,which was surgically treated. Eleven months after the original tumor excision, CT revealed lymph node metastasis dorsal to the inferior vena cava,which was also removed. Because he refused to receive adjuvant chemotherapy,he was observed for 2 months until CT revealed multiple liver metastases and para-aortic lymph node metastasis. He underwent 1 cycle of combined chemotherapy with doxorubicin and carboplatin,but metastatic lesions grew larger rapidly and his general state became too poor to continue chemotherapy. He is under best supportive care 17 months after the initial surgery.

[Case report: collecting (Bellini) duct carcinoma during the follow-up for bladder cancer]

A 78-year-old man had undergone transurethral resection of bladder tumor (TUR-Bt) 6 times since he was diagnosed as having bladder cancer. Past histology was urothelial carcinoma, pTa, G1-G2. During the follow-up, recurrent bladder cancer was found. Enhanced computed tomography and drip infusion pyelography revealed pelvic cancer with tumor embolus in the inferior vena cava. Therefore, TUR-Bt and total ureteronephrectomy with removal of the thrombus from the vena cava was performed. The histopathological diagnosis was urothelial carcinoma of the bladder and Bellini duct carcinoma of the kidney, but in immunohistostaining surgical specimen of both bladder and kidney showed some similarities. This disease is rare. Several reports indicate an association between Bellini and urothelial carcinoma. We describe the case of the Bellini duct carcinoma of the kidney during the follow-up for bladder cancer with possibility of the association between Bellini and urothelial carcinoma.

[Experitoneal bladder perforation due to in-dwelling urethral catheter successfully treated by urethral drainage: a case report]

Perforation of the bladder related to long-term indwelling urethral catheter is a rare and serious complication. A 85-year-old man with an indwelling urethral catheter presented severe hematuria, abdominal pain with rebound tenderness and muscular tension over the suprapubic area after the exchange of the urethral catheter. Computed tomography and cystogram revealed experitoneal bladder perforation due to indwelling catheter. Three weeks after the indwelling urethral catheter had been placed, the perforation was closed. In most cases, laparotomy and suprapubic cystostomy are performed. We describe the case of experitoneal bladder perforation successfully treated by urethral drainage.

[Case report: a case of localized amyloidosis of the ureter]

A 78-year-old man visited our hospital with a chief complaint ofmacrohematuria in January 2006. Ultrasonography and computed tomography showed left hydronephroureter due to the enhanced tumor which was 10 mm in diameter in the lower ureter. Urine cytology was Class II. Retrograde pyelography could not be performed because of severe pain and hematuria. We considered the possibility of the malignant neoplasm and performed left total ureteronephrectomy in March 2007. The mucosa of the ureter was thickened and sclerosed. Microscopic appearance of the surgical specimen shows non-structural fibrosis and stained red with Congo-red stain. So amyloidosis of the ureter was suspected. After the systemic examination, the diagnosis was localized amyloidosis of the ureter. After 8 months, recurrence has not been pointed out.

[Case report: a case with small cell carcinoma of the bladder transformed from urothelial carcinoma]

A 69 year-old woman visited our hospital with a chief complaint of macrohematuria in April 2004. She was diagnosed with bladder tumor. She underwent transurethral resection ofbladdar tumor three times and right partial ureterectomy for ureteral tumor following primary bladder carcinoma. All pathological findings demonstrated that the tumor was urothelial carcinoma (UC), G1-G2, pT1 including right ureteral tumor. In spite of intravesical instillation of BCG, recurrent invasive bladder tumor was found in June 2006. In July 2006, we performed total cystectomy and construction of ileal conduit. Surgical specimen revealed small cell carcinoma and immunohistochemical staining with NSE and synaptophysin was positive. On day 67 after operation, the patient died of multiple metastases to liver and bone.

Elucidation of the mechanism of crystal-cell interaction using fibronectin-overexpressing Madin-Darby canine kidney cells

INTRODUCTION

Attachment of newly formed crystals to renal epithelial cells is considered to be a critical step in stone formation. Previously, we reported that exogenous fibronectin (FN; 220-240 kDa) had an inhibitory effect against renal tubular cell injury in Madin-Darby canine kidney (MDCK) cells. However, the exact mechanism of FN is not fully understood. To examine the role of FN in crystal-cell interaction, we generated stably transfected MDCK cells that overexpress FN.

MATERIALS AND METHODS

MDCK cells were transfected with rat FN cDNA. First, we assessed cell injury by addition of calcium oxalate monohydrate (COM) crystals. Next, we examined the effect of FN on the adhesion of COM crystals. Finally, we studied the association of COM crystals by scanning electron microscopy.

RESULTS

Cell injury was significantly reduced in the transfected cells relative to control MDCK cells. In the inhibitory assay, crystal adhesion decreased markedly as compared with control MDCK cells. Morphological study showed that few crystals were attached to the surface of the transfected cells.

CONCLUSIONS

We elucidated the relationship between crystal-cell interaction and FN by using FN-overexpressing MDCK cells. We suppose that FN inhibits the adhesion of crystals to cells by coating the renal tubular epithelial cells.

Fibronectin inhibits endocytosis of calcium oxalate crystals by renal tubular cells

BACKGROUND

Fibronectin (FN; 230 kDa) is a multifunctional alpha2-glycoprotein distributed throughout the extracellular matrix and body fluids. We recently reported that FN has a protective effect against injury of renal tubular cells by exposure to oxalate and calcium oxalate (CaOX) crystals and inhibits the adhesion of CaOX crystals to renal tubular cells. In the study presented here, we investigated whether FN has inhibitory effect on crystal endocytosis by renal tubular cells.

METHODS

The inhibitory effect of FN on endocytosis of CaOX crystals by MDCK cells was examined by using a radioactivity uptake assay. Also, crystal endocytosis by cells was morphologically assessed by means of transmission electron microscopy (TEM).

RESULTS

FN had inhibitory effects on CaOX crystal endocytosis by MDCK cells. The morphological TEM study showed that few crystals were taken into cells when FN was added compared to the number of crystals when FN was not added.

CONCLUSION

We found that FN had the inhibitory effects on the interaction between crystals and renal tubular cells, including the adhesion or endocytosis of crystals by cells.

Urinary macromolecules and renal tubular cell protection from oxalate injury: Comparison of normal subjects and recurrent stone formers

AIM

To determine whether urinary macromolecules (UMM), which are the high molecular weight substances in urine, can provide protection against the oxalate-associated injury to the renal tubular cells.

METHODS

UMM were extracted from 24-h urine of 12 healthy adult male volunteers and 13 recurrent-stone-former male patients. Urine parameters in relation to urolithiasis were measured, including the level of glycosaminoglycans (GAG) in the UMM. Madin-Darby canine kidney (MDCK) cells were used to evaluate the protective activity of UMM from oxalate-induced cytotoxicity by LDH release measurement and methyl-thiazolyl tertrazolium (MTT) assay.

RESULTS

Considering urinary parameters, citrate was significantly higher in urine from normal subjects than stone-former subjects; the other parameters show no differences between the groups. Total UMM and the level of GAG in the UMM were also significantly higher in the normal subject group. Compared with normal subject and stone-former subject UMM, after cells were treated with the UMM and then exposed to oxalate solution, LDH release was significantly higher in stone-former group. In the MTT assay, we found that more viable cells were observed after treatment with UMM compared to control in both groups. Moreover, UMM from the normal subjects showed higher protective activity against oxalate-related cytotoxicity than UMM from the stone-former subjects.

CONCLUSION

UMM protected renal epithelial cells from oxalate-related injury. This protective activity was found to be higher in normal subject UMM than stone-former UMM. Among other factors, a higher concentration of GAG and citrate in normal subject UMM might affect some parts in this finding.

Hepatocyte growth factor has protective effects on crystal-cell interaction and crystal deposits

OBJECTIVES

To investigate whether hepatocyte growth factor (HGF) has a protective role against crystal-cell interaction and crystal deposits in a stone-forming rat model kidney. Crystal-cell interaction is an important step during the early stages of stone formation. High oxalate levels induce cell injuries and increase adhesion of calcium oxalate monohydrate (COM) crystals to renal tubular cells. HGF was initially identified as the most potent growth factor for hepatocytes and is well known as a mesenchyme-derived pleiotropic factor for various types of cells. HGF has mitogenic, morphogenic, and anti-apoptotic effects on renal tubular cells.

METHODS

Madin-Darby canine kidney cells were exposed to potassium oxalate or COM crystals in the presence or absence of HGF. We measured lactate dehydrogenase activity in the medium and analyzed apoptosis by FACScan. COM crystal formation was induced by administration of 0.5% ethylene glycol in the drinking water and forced feeding of 0.5 microg of 1alpha-OH-D3 every other day to male Sprague-Dawley rats. Plasmid vector encoding HGF was transferred to stone-forming rats on day 1, and the kidneys were excised on day 8.

RESULTS

Exposure of Madin-Darby canine kidney cells to both potassium oxalate (KOX) and COM crystals resulted in an increase in lactate dehydrogenase release and the proportion of apoptotic cells, but these effects were reduced by HGF. HGF had inhibitory activity against the adhesion of COM crystals to Madin-Darby canine kidney cells. HGF gene transfer significantly reduced crystal deposits on the renal tubules in stone-forming rats.

CONCLUSIONS

These findings suggest that HGF might play an important role in stone formation.

Renal Tubular cell injury and fibronectin

We recently reported that fibronectin (FN: 230 kDa) was oversecreted from the renal tubular cells as a result of the stimulation of COM crystals, and inhibited the adhesion of COM crystals to renal tubular cells. In the study presented here, we investigated whether FN can prevent injury to renal tubular cells caused by oxalate and COM crystals and tried to identify the relation with inhibition of crystal adhesion. The protective effect of FN against renal tubular cell injury by exposure to oxalate and COM crystals was examined by measuring the lactate dehydrogenase (LDH) activity and using a non-radioactive proliferation assay. Moreover, crystal-cell interaction was morphologically assessed by means of scanning electron microscopy (SEM). LDH was reduced significantly by the addition of FN in a dose-dependent manner. Cell viability increased significantly with the addition of FN, also in a dose-dependent manner. Moreover, the morphological SEM study showed that few crystals were attached to the surface of cells when FN was added compared to the number of adhering crystals when FN was not added. FN was found to have an inhibitory effect on renal tubular cell injury caused by exposure to oxalate and COM crystals. We speculate that the inhibitory effect of FN on the adhesion of COM crystals is related to the inhibitory effect of exposure to COM crystals on renal tubular cell injury.

Experience with Laparoscopic Splenectomy for ABO-Incompatible Living Related Renal Transplantation

PURPOSE

To determine whether laparoscopic splenectomy for ABO-incompatible living related renal transplantation is safe and effective.

PATIENTS AND METHODS

From July 2000 to May 2002, laparoscopic splenectomy was performed on the day of transplantation in 10 patients undergoing ABO-incompatible living related renal transplantation. Perioperative and postoperative data, including operative time, blood loss, and complications, were evaluated.

RESULTS

The mean operative time was 79 minutes. Intraoperative blood loss ranged from 25 mL to 600 mL (mean 130 mL). Transfusion was not required in any case. One patient required open conversion because of bleeding from the splenic hilum. The serum amylase value was slightly elevated postoperatively in four patients but normalized with conservative treatment. One patient had bleeding from a trocar port wound, which was likewise treated conservatively. No complications, including postoperative renal dysfunction or fatal infections, that were considered attributable to the laparoscopic procedure were noted.

CONCLUSIONS

Laparoscopic splenectomy performed simultaneously with renal transplantation is a safe and efficacious procedure for ABO-incompatible living related renal transplantation.

[48XXYY Klinefelter's syndrome with recurrent foot ulcers: a case report]

A case of 48XXYY Klinefelter's syndrome diagnosed with foot ulcers, in a 43-year-old man, is reported. He presented to the Department of Dermatology in our hospital with the chief complaint of recurrent foot ulcers. He was referred to us because of atrophic external genitalia. The present condition and endocrinological examination suggested Klinefelter's syndrome. Chromosomal analysis revealed that his chromosomal type is 48XXYY. This is the 24th case of Klinefelter's syndrome with 48XXYY chromosome and is the 5th case associated with foot ulcers in Japan. Here we report this case together with a brief review of the previously reported cases.

[Three cases of metastatic renal tumor]

Since solitary metastatic renal tumors are not commonly diagnosed before death, the conclusive treatment of the metastatic renal tumor has not been established. We report three cases of metastatic renal tumors and discuss the indication of surgical therapy for metastatic renal tumors. The first case was in a 64-year-old male who underwent esophagectomy for squamous cell carcinoma. Seven months after the operation, a right renal tumor was found. The second case was in a 63-year-old male who underwent right upper pneumonectomy for adenocarcinoma with a right renal tumor, which seemed to be a solitary metastasis. The third case was in a 69-year-old male who underwent right pneumonectomy for adenocarcinoma. One month after the initial operation, a left renal cystic tumor was found. Since, in all cases, the tumors seemed to be solitary metastatic renal tumors without any other metastatic lesions, nephrectomy was performed. Unfortunately, however, the nephrectomy did not improve prognosis and all three patients did within 10 months after the nephrectomy. Nephrectomy may not be recommended in cases of metastatic renal tumors even if no other metastatic lesions can be found by various image examinations.

[A case of renal cell carcinoma associated with tuberous sclerosis]

Tuberous sclerosis is associated commonly with renal angiomyolipoma. On the other hand, the relation between tuberous sclerosis and renal cell carcinoma is not widely recognized. We report a case of renal cell carcinoma of the right kidney associated with tuberous sclerosis.

[A clinical study on renal pelvic and ureteral tumor associated with bladder tumor with special reference to risk factors of subsequently recurrent bladder tumor]

PURPOSE

The purpose of this report is to analyze the clinical feature of renal pelvic and/or ureteral tumor (RUT) associated with bladder tumor (BT) with special reference to risk factors of subsequently recurrent BT.

METHODS

Of the 49 patients with RUT who underwent surgery and were diagnosed pathologically as transitional cell carcinoma at the Department of Urology, Osaka National Hospital from April 1986 to October 1996, 20 patients (40.8%) had associated BTs. These patients were categorized to the following 4 groups, Group 1: 5 patients with BT preceding RUT, Group 2: 5 patients with concomitant BT, Group 3: 10 patients with subsequent BT following RUT operation and Group 4: 29 patients without any associated BT. The clinical course of these 4 groups were studied and compared with each other retrospectively.

RESULTS

In group 1, the first BTs preceded RUTs by 19 to 81 months (mean 54.6 months). And during this relatively long period, the preceding BTs were treated by TUR for each recurrence, 1 to 9 times (mean 5.2 times). Two of 5 were bilateral RUT cases, which were observed only in this group. In group 2, the prognosis were relatively poor (5-year survival rate: 0%), because all RUTs of this group were high stage. And also the concomitant BTs were showing invasive feature during the observation period, despite they were superficial at first. Thus 3 of 5 underwent radical cystectomy. On the other hand, in group 3, the subsequent BTs, which developed at 2 to 26 month (mean 13.4 month) after RUT operation, were all superficial and resectable by TUR. The 5-year disease specific survival rate was 50% in group 1, 0% in group 2, 63.5% in group 3, 64.9% in group 4. Group 2 had the most poor prognosis. However there was no significant difference in prognosis among the 4 groups. Incidence of preoperative urine positive cytology was significantly higher in group 3, than in group 4 (87.5% vs. 44.8%).

CONCLUSIONS

These results indicated that the RUTs with associated BTs have distinct clinical features depending on the sequence of association with the BTs. Especially the RUTs with concomitant BTs should be watched carefully as a high risk group with poor prognosis and possible development of invasive BTs. Positive urine cytology prior to RUT operation may reflect biological activity of tumor cell for dissemination in the lower urinary tract and we suggested preoperative urine cytology was possible predictor of subsequently recurrent BTs after RUT operation in this study.

[A clinical study on renal pelvic and ureteral cancer--with special reference to prognostic factors and adjuvant chemotherapy]

PURPOSE

This report focuses on the prognostic factors of the renal pelvic and ureteral cancer and on the treatment for advanced and/or recurrent cases.

METHODS

We reviewed the forty-nine patients with transitional cell carcinoma of the renal pelvis and/or ureter who underwent surgery at the Department of Urology, Osaka National Hospital from April, 1986 to October, 1996. Univariate and multivariate analysis was done on the pathological features from these patients.

RESULTS

The patients consisted of 34 males and 15 females and the mean age was 64.9, ranging from 27 to 83. Overall the 1, 3 and 5-year disease specific survival rates were 93.5%, 70.2% and 61.3% respectively by the Kaplan-Meier's method. The prognostic significance of the 6 pathological factors (pT, Grade, INF, pL, pV and pR) were evaluated statistically in terms of generalized Wilcoxon test and/or Cox-Mantel test. All the 6 factors effected on survival rates significantly. However, the grade, INF, pL, pV and pR factors were closely related to the pT factor. Moreover the pT factor was confirmed to be the most important and independent factor according to a multivariate analysis by the Cox's proportional hazard model. And the grade 3 factor with pT2 or higher stage was a high risk factor in recurrences significantly, in spite of curatively operated cases. Thirteen patients with high stage, metastasis or recurrences were treated after operation with the M-VAC or modified M-VAC regimen as preventive, adjuvant and/or salvage chemotherapy. The overall response rate was 72.7% in eleven cases with evaluable lesions, while these regimens could not be expected to improve long-term survival rate. The response rate of combined chemoradiation therapy was 66.7% for six cases with the localized recurrent cancer.

CONCLUSIONS

The pT factor was the independent predictor of disease-specific survival. Adjuvant chemotherapy for prevention of cancer recurrence should be considered in the case of pT2 or higher stage plus grade 3 factor, even if curatively operated cases. The M-VAC or modified M-VAC regimen was reconfirmed to be useful as first line chemotherapy of advanced renal pelvic and ureteral cancer. Combined chemoradiation therapy was useful for the localized cancer recurrences, especially as a second line therapy for relapsed cases after M-VAC chemotherapy in this series.

[Study on the duration of pyuria after transurethral resection of prostate]

A retrospective study was conducted on the duration of pyuria after transurethral resection of the prostate (TURP) and the factors affecting the duration in 273 patients, who were diagnosed as having benign prostatic hyperplasia (BPH) with postoperative resolution of pyuria among those who underwent TURP over the last ten years at our clinic. In the 273 patients, the mean (+/- SD) weight of the resected prostate was 13.2 +/- 10.2 g (range : 1-52 g), the mean operating time was 74.3 +/- 29.8 min (25-215 min), the duration of pyuria was 110.6 +/- 38.3 days (23-273 days), and the resected weight to operating time ratio was 0.172 +/- 0.093 g/min (0.018-0.500 g/min). There was a significant correlation between the duration of pyuria and the patient's age, resected weight, operating time, or resected weight/operating time ratio, resected weight being the most important factor. The surgeon, the postoperative antibiotics used, and the preoperative existence of pyuria did not have any significant effect on the duration of postoperative pyuria. Investigation after stratification by the resected weight in 10 g increments suggested that a shorter operating time was important to reduce the duration of postoperative pyuria, particularly in BPH patients with a resected weight of 20-29 g.

[Proliferating character of inverted papilloma of the urinary bladder]

BACKGROUND

Inverted papilloma (IP) of the urinary bladder is generally considered to be a benign lesion by histological examination. In recent years, however, there have been several cases of IP simultaneously accompanied with transitional cell carcinoma (TCC), elsewhere in the bladder or combined as a single urothelial lesion. So we investigated proliferating character of IP by DNA ploidy analysis and immunohistostaining with proliferating cell nuclear antigen (PCNA).

METHODS

Six cases of IP of the urinary bladder were analyzed and 12 cases of TCC of G1 and G3 grade were included in this study as a control. As DNA ploidy analysis, all specimens were feulgen stained using CAS DNA staining kit and examined by image cytometry (CAS 200R system). For the PCNA immunohistochemistry, all specimens were stained with anti-PCNA monoclonal antibody (Novocastra Lab.: PC10) according to ABC (avidin-biotin-complex) standard method. We determined that the DNA Index of the case under 1.20 was diploid and the others was aneuploid. PCNA staining were determined by only one pathologist as follows: negative (-) and positive (+), (2+) and (3+).

RESULTS

As DNA ploidy, 5 of 6 cases of TCC G3 group as a control were aneuploid. But in spite of all cases of TCC G1 group were diploid, among IP cases, only 1 out of 6 was aneuploid. As PCNA staining, 2 of 6 in TCC G1 group and 5 of 6 in G3 group were positive. And it was noted examination was positive.

CONCLUSION

There have been no recurrence since transurethral resection in all IP in the study including the case recognized as aneuploid and positive for PCNA staining. But the present results suggest that among IPs, considered generally as a benign tumor, the case which has high proliferating character exists.

A case of intraluminal duodenal diverticulum associated with congenital biliary dilatation: a review of the literature in Japan

A case of intraluminal duodenal diverticulum (IDD) associated with congenital biliary dilatation is reported. Patients with intraluminal duodenal diverticulum often have congenital anatomical abnormalities or acquired diseases. The treatment of the intraluminal duodenal diverticulum itself is easy, but it is important to detect and treat other disorders also present.

[Distribution of bleomycin in sesame oil suspension in organs of rat with mammary carcinoma induced by 7,12-dimethylbenz (a) anthracene and its effect on the tumors (author's transl)]

Distribution of the bleomycin A2 suspended in sesame oil (Oil Bleo Suspension) in rat organs and tumors after the intramuscular administration was investigated by bioassay, the effect of intratumor administration of the suspension on the growth of rat mammary carcinoma induced by 7, 12-dimethylbenz (a) anthracene was also studied. The oil suspension showed a protracted concentration in either tumor or organ tissues, but showed similar inhibitory effects on rat mammary carcinoma to those by regular bleomycin solution. Further studies should be performed on the effect of bleomycin A, in sesami oil on mammary carcinoma.

Inhibitory effect of L-arginine on growth of rat mammary tumors induced by 7,12-dimethylbenz(a)anthracene

The effect of L-arginine on growth of rat mammary tumors induced by 7,12-dimethylbenz(a)anthracene was studied. Growth of induced tumors was inhibited by feeding rats an arginine-enriched diet containing 5% L-arginine in addition to the necessary components for rats, including 15% milk casein. The diet significantly reduced both the rate of tumor induction and the number of tumors induced per rat. Histological examination showed that the tumors induced were more benign in rats fed the arginine-enriched diet than in those fed the control diet. A possible mechanism of the inhibitory effect of L-agrinine id discussed.

Urinary excretion of steroids and response to oophorectomy in premenopausal women with advanced breast cancer

Relationship between the urinary excretion of steroids in premenopausal Japaneses patients with advanced breast cancer and their response to oophorectomy was studied. The estrogen fractions were determined by radioimmunoassay and those who responded to oophorectomy showed higher levels of 17 beta-estradiol than the non-responders before surgery. The high levels of urinary 17 beta-estradiol of the responders dropped markedly after oophorectomy. On the contrary, the non-responders showed relatively low levels of urinary excretion of 17 beta-estradiol before oophorectomy and the levels appeared either unchanged or slightly elevated after surgery. No definite relation was found between changes in the urinary excretion of estrone or estriol and the clinical effect of oophorectomy. Excretion of 17-ketosteroids in the responders was lower than that of the non-responders.

Inhibitory effect of actinomycin D on the inductio of rat mammary tumors by in vitro exposure to 7,12-dimethylbenz(a)anthracene

The inhibitory effect of actinomycin D on the induction of tumors by in vitro exposure of mammary glands to 7,12-dimethylbenz(a)anthracene was studied. When actinomycin D was given i.p. 24 hr before excision of the mammary glands, the induction of tumors by in vitro exposure of the glands to 7,12-dimethylbenz(a)anthracene was significantly decreased. On the other hand, when actinomycin D was administered 24 hr after excision, it had no effect on the induction of tumors. In vitro exposure of excised glands to 7,12-dimethylbenz(a)anthracene and actinomycin D significant decreased tumor induction. However, the order of exposure to 7,12-dimethylbenz(a)anthracene and actinomycin D influenced the inhibitory effect of actinomycin D on tumor induction. Results indicated that this might be due to a difference in the amounts of 7,12-dimethylbenz(a)anthracene and actinomycin D bound to the mammary glands.