Resection of bulky chromophobe renal cell carcinoma resolved severe idiopathic thrombocytopenic purpura: A case report

Idiopathic thrombocytopenic purpura associated with renal cell carcinoma is relatively rare. We report the case of a 48-year-old woman with massive renal cell carcinoma, measuring approximately 20 × 14 × 14 cm, who presented with severe thrombocytopenia: platelet count, 2000 cells/μL. After confirming normal bone marrow, she received high-dose dexamethasone and intravenous gamma globulin, which raised the platelet count to normal levels. She then underwent left radical nephrectomy. The pathological examination showed chromophobe renal cell carcinoma. After the resection, the platelet count was maintained within the normal range without any treatment. The current case is the first report of chromophobe renal cell carcinoma causative of severe idiopathic thrombocytopenic purpura.

Contracted bladder developing after prostate brachytherapy

This report describes an extremely rare case of severely contracted bladder developing after prostate brachytherapy. In April 2001, a 76-year-old man initially presented to our hospital for weak urinary stream. The patient was diagnosed with and treated for benign prostatic hyperplasia. During follow up, prostate-specific antigen level was elevated. In November 2005, the patient underwent transrectal prostate biopsy. Pathology showed adenocarcinoma, Gleason score 3 + 4 = 7. The patient was diagnosed with stage cT1cN0M0 prostate cancer. In January 2006, he underwent brachytherapy for prostate cancer. The procedure of brachytherapy was uneventful and the patient was discharged without any problems. Four months after the implant, the patient was admitted to our hospital for deterioration of kidney function as a result of a contracted bladder. Urinary culture of tuberculosis was negative and urinary cytology was class II. A urethral catheter was indwelled and the patient has been followed every month for catheter replacement. Bladder capacity is now less than 5 mL.

Swelling of the prostate gland by permanent brachytherapy may affect seed migration

OBJECTIVE

The purpose was to monitor implanted seeds and to determine factors contributing to seed migration after permanent prostate brachytherapy.

METHODS

Sixty-two consecutive patients with Stage 1 prostate cancer who underwent brachytherapy with (125)I seeds between February 2008 and May 2009 were studied prospectively. On post-operative days 1, 7 and 30, scintigraphy was added to conventional radiography to monitor the migration of the implanted seeds. The prostate volume was measured during the pre-planning stage using ultrasound and during the post-planning stage using computed tomography on post-operative days 0 and 30. Magnetic resonance imaging was performed on day 30.

RESULTS

Of the 4843 seeds implanted in the prostates of 62 patients, 108 seeds (2.2%) in 43 patients (69.4%) exhibited seed migration. Thirty-five seeds could not be identified using any of the imaging modalities and were likely passed during urination (0.7% of the total number of seeds). The maximum number of migrated seeds in one patient was 10 of the 85 implanted seeds. The fraction of patients with seed migration or loss increased from 27.4% on day 1 to 69.4% on day 30. The number of seeds that had migrated from the prostate increased from 48 (0.1% of the total number of seeds) on 1 day to 78 (1.0%) on day 7 and 108 (2.2%) on day 30. Of the seeds lost from the prostate, 38.9% embolized to the lungs. The seed loss during the first post-operative month was closely correlated with the swelling of the prostate gland between the pre-planning measurement and the post-planning measurement performed on day 0 (P < 0.0001).

CONCLUSIONS

Prostate swelling between the pre-planning and post-planning (day 0) measurements was significantly associated with seed migration, and adequate attention should be given to this issue.

Primary aldosteronism associated with severe rhabdomyolysis due to profound hypokalemia

A 55-year-old Japanese man was admitted to our hospital with severe weakness. Without measurement of serum electrolyte concentrations, diuretic therapy for hypertension was started 2 weeks prior to admission. Laboratory findings showed profound hypokalemia (1.4 mEq/L), and extreme elevation of the serum creatinine phosphokinase levels (15,760 IU/L), suggesting that the patient had hypokalemic paralysis and hypokalemia-induced rhabdomyolysis. Further evaluations, including adrenal venous sampling strongly suggested that he had primary aldosteronism. He was treated successfully by laparoscopic adrenalectomy. This case provides an important lesson that serum electrolyte concentrations should be measured in hypertensive patients before the administration of antihypertensive agents.

Factors associated with variation in utility scores among patients with prostate cancer

OBJECTIVE

We aimed to assess the effects of age, comorbidity, and disease-specific functions on utility scores derived from three methods on prostate cancer.

METHODS

A total of 330 Japanese prostate cancer patients were asked to answer self-administered questionnaires. Community-weighted utility scores were derived from the EuroQoL-5D (EQ-5D) and the Short Form-36 (SF-36), while the patient's directly elicited utility score was derived from time trade-off technique. Univariate and multivariate analyses were performed to examine the relation between covariates and utility scores. We assigned age, the Index of Co-existent Disease, and disease-specific functions including sexual, urinary, bowel, and hormonal function as covariates.

RESULTS

Bowel and hormonal function were related to utility scores, while age and sexual function were not. Comorbidities were more closely related to utility scores derived from EQ-5D and SF-36.

CONCLUSIONS

These results contribute to an understanding of which factor has an impact on utility scores in patients with prostate cancer.

Decision analyses in consideration of treatment strategies for patients with biochemical failure after curative therapy on clinically localized prostate cancer in the prostate-specific antigen era

BACKGROUND

The introduction of prostate-specific antigen (PSA) testing has not only shortened the time required to make diagnosis but changed the treatment strategies of localized prostate cancer. We conducted the decision analysis on its treatment focusing on patients with biochemical failure.

METHODS

We developed a Markov model to calculate life expectancy (LE) and quality-adjusted life expectancy (QALE) stratified by age, comorbidity and tumor characteristics in patients with newly diagnosed prostate cancer or biochemical failure after curative therapy. For newly diagnosed patients, three treatment strategies were considered as primary managements: radial prostatectomy (RP), external beam radiotherapy (EBRT) and watchful waiting (WW). Managements considered for biochemical failure were: after RP, salvage radiotherapy (SRT), salvage hormonal therapy (SHT) and WW; and after EBRT, SHT and WW. Transition probabilities in the Markov model were derived from published studies. Quality of life (QOL) data to estimate QALE score were derived from 323 patients with prostate cancer.

RESULTS

For patients with Gleason 2-6 cancer at diagnosis, WW yielded the greatest number of QALE. For patients with Gleason 7 cancer, it was controversial whether curative therapy was the preferred strategy. For patients with Gleason 8-10 cancer, curative therapy yielded the greatest number of QALE in younger patients without severe comorbidity. Patients' benefit from salvage therapy for biochemical failure after curative therapy depended on age, comorbidities, tumor characteristics and QOL effect.

CONCLUSIONS

Our findings support the need for various treatment options, taking into consideration the patient's age, comorbidity and the QOL effect in the aging society.

Novel germline mutations in the SDHB and SDHD genes in Japanese pheochromocytomas

The SDHA, SDHB, SDHC, and SDHD genes code for subunits of succinate dehydrogenase (SDH), which forms part of the mitochondrial respiratory chain. Germline mutations in the genes encoding SDHB and SDHD have been reported in familial paragangliomas/pheochromocytomas and in apparently sporadic pheochromocytomas. SDHB and SDHD mutations are widely distributed along the genes with no apparent hot spots. SDHB mutations are often detected in malignant and extra-adrenal pheochromocytomas. SDHD mutations are also detected frequently in head and neck paragangliomas. We sequenced the entire coding regions of the SDHB and SDHD genes in 17 pheochromocytomas. We identified novel heterozygous G to A point mutations at the first base of intron 3 of the SDHB gene in a malignant extra-adrenal abdominal pheochromocytoma patient, and at the first base of codon 111 of the SDHD gene in an adrenal pheochromocytoma patient. Further, we confirmed the SDHD mutation by DHPLC. The prevalence of SDHB and SDHD mutations in pheochromocytomas we examined was 12% (2/17). Thus, we identified two novel SDH mutations in Japanese pheochromocytomas. Further studies will investigate the oncogenic potential of these mutations.

Acute pericarditis as a result of unusual metastasis of the visceral pleura in a patient with testicular seminoma

A 30-year-old man with a left testicular swelling was referred to our hospital. We performed a left high orchiectomy based on a diagnosis of clinical stage II testicular cancer. Pathological specimens of the left testis showed seminoma. The patient underwent three courses of combined chemotherapy. The retroperitoneal lymph nodes were dissected and there were no viable cancer cells. Twelve years later a right testicular tumor was discovered. The patient underwent a right high orchiectomy. Pathological specimens of the testis showed seminoma, and the patient was treated with prophylactic irradiation. One year after discharge a metastasis was found at a left supraclavicular fossa. The patient was treated with combined chemotherapy and irradiation. Six months after the treatment he complained of dyspnea. We diagnosed the condition as pleuritis carcimatosa. Two days after irradiation to the left thorax the patient suffered a sudden and fatal cardiac arrest. Autopsy survey revealed pericarditis as a result of a direct invasion of visceral pleural metastasis.

Different transformation of mature teratoma in a patient with mixed germ cell tumor of the testis

A 44-year-old male was referred with a left supraclavicular lymphadenopathy. A biopsy of the lymph node showed metastatic embryonal carcinoma. Tumor markers were present at high levels: alpha-fetoprotein 253.9 ng/mL, beta-human chorionic gonadotrophin 62 ng/mL. Computed tomography (CT) showed retroperitoneal adenopathy. High orchiectomy was done. The patient was treated with three cycles of etoposide plus cisplatin, achieved normalization of the serum tumor markers and underwent retroperitoneal lymph node dissection. Pathological findings of multiple lymph nodes showed teratomatous glands without viable cells. At follow-ups performed every 3 months, tumor markers remained within normal limits and no evidence of recurrence was observed. Eight years after first admission a CT scan revealed a cystic tumor 1 cm in diameter in the para-aortic region. The cystic tumor continued to slowly grow, expanding by 1 cm in diameter per year without elevation of tumor markers. The para-aortic tumor had grown to 4 cm in diameter and a left supraclavicular lymphadennopathy recurred. A resection of the supraclavicular cystic tumor showed mucinous cystadenocarcinoma, but a cystic tumor in the para-aortic region revealed mature teratoma. Here we report a case of mature teratoma with metastases at supraclavicular and para-aortic lymph nodes which had different transformations in spite of both regions consisting of cystic tumors.

Hemiresective reconstruction of a redundant ileal conduit with severe bilateral ileal conduit-ureteral reflux

A 58-year-old man was referred to our hospital with high fever and anuria. Since undergoing a total pelvic exenteration due to bladder-invasive sigmoid colon cancer, urinary tract infections had frequently occurred. We treated with the construction of a bilateral percutaneous nephrostomy (PCN), and chemotherapy. Although we replaced the PCN with a single J ureteral catheter after an improvement of infection, urinary infection recurred because of an obstruction of the catheter. Urological examinations showed that an ileal conduit-ureteral reflux caused by kinking of the ileal loop was the reason why frequent pyelonephritis occurred. We decided to resect the proximal segment to improve conduit-ureteral reflux for the resistant pyelonephritis. After the surgery, the excretory urogram showed improvement and the urinary retention at the ileal conduit disappeared. Three years after the operation, renal function has been stable without episodes of pyelonephritis. Here we report a case of open repair surgery of an ileal conduit in a patient with severe urinary infection.

Secondary IgA nephropathy presenting as nephrotic syndrome with glomerular crescentic changes and acute renal failure in a patient with autoimmune hepatitis

Patients with end-stage liver disease are prone to hemodynamic and immunologic renal injury, the latter at times manifesting as glomerulonephritis. Elevated serum immunoglobulin A (IgA) levels and mesangial IgG-IgA deposits are common in these patients, but are often clinically silent. We report a patient with autoimmune hepatitis and secondary IgA nephropathy (IgAN) who presented with nephrotic syndrome, acute renal failure (ARF), with 30% of the renal glomeruli having undergone crescentic change, and with IgA2 deposits in the glomerular mesangium. This article discusses secondary IgAN pathogenesis and its therapeutic management.

Clinical assessment and mutation analysis of Kallmann syndrome 1 (KAL1) and fibroblast growth factor receptor 1 (FGFR1, or KAL2) in five families and 18 sporadic patients

We report on the clinical and molecular findings in 25 males and three females with Kallmann syndrome (KS) aged 10-53 yr. Ten males were from five families, and the remaining 15 males and three females were apparently sporadic cases. Molecular studies were performed for Kallmann syndrome 1 (KAL1) and fibroblast growth factor receptor 1 (FGFR1, also known as KAL2) by sequence analysis for all the coding exons, by PCR-based deletion analysis, and by fluorescence in situ hybridization (FISH) analysis, showing six novel and two recurrent intragenic KAL1 mutations in seven familial and four sporadic male cases and two novel intragenic FGFR1 mutations in two sporadic male cases. In addition, submicroscopic deletions at Xp22.3 involving VCX-A, STS, KAL1, and OA1 were identified in three familial cases and one sporadic male case affected by a contiguous gene syndrome. Clinical assessment in the 15 males with KAL1 mutations showed normal and borderline olfactory function in two males and right-side dominant renal lesion in seven males, in addition to variable degrees of hypogonadotropic hypogonadism (HH) in all the 15 males and olfactory dysfunction in 13 males. The two males with FGFR1 mutations had HH and anosmia and lacked other features. Clinical features in the remaining 11 cases with no demonstrable KAL1 or FGFR1 mutations included right renal aplasia in one female, cleft palate in one male, cleft palate and perceptive deafness in one male, and dental agenesis and perceptive deafness in one male, in addition to a variable extent of HH and olfactory dysfunction. The results suggest the following: 1) KAL1 mutations might be more prevalent in the Japanese patients than previously estimated in the Caucasian patients and can be associated with apparently normal olfactory function; 2) FGFR1 mutations account for approximately 10% of KS patients, as previously reported in the Caucasian patients, and can result in HH and olfactory dysfunction-only phenotype; and 3) renal aplasia, which is characteristic of KAL1 mutations, and cleft palate and dental agenesis, which are characteristic of FGFR1 mutations, can occur in patients without KAL1 and FGFR1 mutations.

Computed tomography-guided percutaneous acetic acid injection therapy for functioning adrenocortical adenoma

We reported the outcomes of computed tomography (CT)-guided percutaneous acetic acid injection therapy for functioning adrenocortical adenomas. With the patient in a prone position, the puncture needle was inserted vertically downward into the adenoma with frequent CT scanning. After confirmation by pilot injection with contrast medium, a small aliquot of 40-50% acetic acid was injected and repeated. Between 1997 and 2002, 18 sessions of CT-guided injection therapy, including one session of ethanol injection, were performed on 10 patients (five patients with primary aldosteronism and five patients with Cushing's or subclinical Cushing's syndrome) without any complications except transient upper abdominal pain during the acetic acid injection. The follow-up period ranged from 5-69 months. The treatment resulted in almost an extirpation of the adrenocortical hyperfunction in seven patients after one or two sessions. CT-guided percutaneous acetic acid injection might be a simple, cost-effective, and far less invasive treatment for small functioning adrenocortical adenomas.

[Surgical outcomes of nephron-sparing surgery for renal tumors]

PURPOSE

We retrospectively assessed the surgical outcomes of nephron-sparing surgery (NSS) for patients with renal tumors.

PATIENTS AND METHODS

From 1985 to March 2001, a total of 99 NSSs were performed on 94 patients with renal tumors. The patients were divided into three groups. Group I comprised of 22 patients who underwent imperative surgeries for renal cell carcinoma (RCC). The tumors were found in 18 patients bilaterally (including 8 patients with von Hippel-Lindau disease), in 3 with solitary kidney, and in 1 with chronic renal failure. The mean +/- standard deviation of patient age and tumor diameter was 46 +/- 23 years and 36 +/- 23 mm, respectively. Twenty-three in situ NSSs were performed on 18 patients in Group I, and the remaining 4 patients were treated with 3 simultaneous operations for bilateral renal tumors with or without 2 ex vivo surgeries. Group II consisted of 49 patients who had small RCCs with the normal contralateral kidney and underwent NSSs (elective indication). The mean age and tumor diameter was 54 +/- 10 years and 28 +/- 11 mm, respectively. Group III consisted of 23 patients with non-RCC tumor (10 angiomyolipomas, 8 cystic tumors, 2 adenomas, 2 metastatic tumors, and 1 degenerative lesion), all of whom were treated with NSS. The mean age and tumor diameter was 47 +/- 14 years and 41 +/- 29 mm, respectively.

RESULTS

In Group I, 3 patients died of cancer including 2 patients who had had multiple lung metastases preoperatively. The five-year tumor specific survival rate was 87.3% with a postoperative follow-up of 49 +/- 36 months. In Group II, there were few peri-operative complications or no local recurrence at follow-up of 52 +/- 38 months. A patient developed lung metastasis, which was removed surgically with no evidence of recurrence at 159 months after NSS. Postoperative renal scintigraphy on 35 patients showed well-preserved renal function of the operated kidney. Improvement in surgical techniques resulted in less-invasive surgery in 22 operations during the last 4 years. The patients of Group III were also operated uneventfully, although 1 experienced postoperative bleeding. In 12 patients with solitary kidney (11 in Group I and 1 in Group III) serum creatinine level increased transiently, decreased to 1.3 times of preoperative values within 3 months, and almost recovered at 1-year follow-up.

CONCLUSION

Excellent outcomes in cancer control and preservation of renal function support the validity of nephron-sparing surgery to treat renal tumors. The candidate patients may include those with bilateral kidney tumors, tumor occuring in the solitary kidney or small renal cell carcinomas with the normal contralateral kidney. Earlier detection of small lesions and less invasive surgical techniques will facilitate a wider indication of NSS.

Multidisciplinary treatment of advanced testicular tumor with bulky liver metastasis

A 21-year-old man with far-advanced nonseminomatous germ cell tumor of the left testis is presented. He had multiple bulky metastases in the liver and retroperitoneum with an extraordinarily elevated serum alpha-fetoprotein (23,500 ng/ml). He received multidisciplinary treatment consisting of systemic chemotherapy, cytoreductive left hepatic lobectomy, percutaneous ablation therapy, transarterial chemoembolization, and external beam irradiation for median segments of the liver. The efficient combination treatment normalized the tumor markers within 6 months and has maintained complete serological remission for 4.7 years.

Effects of intracavernous administration of adrenomedullin on erectile function in rats

We have reported that adrenomedullin (AM)-induced vasodilation is at least in part nitric oxide (NO)-cGMP-dependent in the rat. Although it is well known that NO is much involved in the erectile function, it is controversial as to whether AM influences the erectile function. Thus, we examined the effects of AM on intracavernous pressure (ICP) during penile erection. The left carotid artery of rats was cannulated to monitor of mean arterial pressure (MAP). Bipolar electrodes were positioned on the cavernous nerve. The right cavernous body was cannulated with a needle connected to a pressure transducer to monitor ICP. Electrical stimulation (ES) increased ICP in a voltage-dependent manner. Elevation of ICP continued during ES. The intracavernous injection of 0.5 nmol AM significantly potentiated ES-induced increases in both maximal developed ICP/MAP and area under the curve (ICP trace; AUC). Since AM slightly lowered MAP, ICP was normalized by MAP. i.v. administration of N(omega)-nitro-L-arginine, a NO synthase inhibitor, markedly decreased AM/ES-induced ICP elevation. However, in the presence of E-4021, a cGMP-specific phosphodiesterase inhibitor, AM further increased both ICP/MAP and AUC. These results suggest that a NO-cGMP pathway is involved in the regulation of AM-induced rat cavernous vasorelaxation.

Long-term outcome of endoscopic biopsy and subsequent nephroureterectomy for upper urinary tract tumor

BACKGROUND

Upper urinary tract tumors can be biopsied using a flexible ureterorenoscope. This study examined retrospectively possible adverse effects of this procedure on patient outcome.

METHODS

The study subjects consisted of 16 consecutive patients with renal pelvic tumor (n = 13) and upper ureteral tumor (n = 3). All subjects underwent endoscopic biopsy of their tumor and subsequent total nephroureterectomy between 1989 and 1995. The follow-up period ranged from 4.1 to 9.5 (mean 5.2) years.

RESULTS

The overall 5-year survival rate was 87.0%, being 100% in 12 patients with tumors of grade 1 or 2. In contrast, of four patients with grade 3 tumor, three (75%) developed systemic lymphogenous and/or multiple lung metastases within 1 year postoperatively.

CONCLUSIONS

The excellent patient outcomes deny any adverse effect of endoscopic biopsy on patients with grade 1 or 2 tumor. However, the endoscopic procedure should be performed prudently when a high grade tumor is suspected.

CT-Guided acetic acid injection therapy for aldosterone-producing adrenocortical adenoma: a preliminary report of three cases

We reported the preliminary outcomes of CT-guided percutaneous injection therapy for aldosterone-producing adrenocortical adenoma (APA). Five sessions of injection therapy, 4 percutaneous acetic acid injections (PAI) and 1 percutaneous ethanol injection (PEI) were performed in 3 patients with APA. A small amount of acetic acid or ethanol solution was injected via a needle placed precisely inside the tumor. The procedure was frequently monitored by repetitive CT scanning. The follow-up period ranged from 5 to 27 months. After the treatment, hypertension was normalized or controlled by a low dose of conventional anti-hypertensive drug. In 2 of 3 cases the plasma aldosterone levels were normalized. Although temporary symptoms of alcoholic intoxication were observed in the single session of PEI, the 4 sessions of PAI were associated with no adverse symptoms or complications. Although this study covers only short-term results in 3 patients, CT-guided PAI appears to be a safe and effective treatment and may be a promising alternative as a simple and far less invasive therapy for APA.

[A case of ureterocalicostomy for refractory renal calculi]

We have sometimes encountered intractable cases of nephrolithiasis, even though ESWL and endourology have dramatically developed at the present time. We could obtain satisfactory result in the treatment of intractable right nephrolithiasis with ureterocalicostomy.

CASE

The patient was a 39-year-old man having undergone PNL, ESWL, pyelolithotomy for right nephrolithiasis. Ten-odd stones, measuring 5-20 mm in diameter, were detected, and his IVP revealed mild hydronephrosis with the ureteropelvic junction stenosis. Pyeloplasty was thought to be difficult to perform. Thus the stones were removed through an incision made on the lowermost portion of the kidney followed by ureterocalicostomy on September 9, 1993. After clamping of the renal artery, the lowermost portion of the renal parenchyma was resected, and the lower calyx was sufficiently exposed. Adequate hemostasis of the cut surface was made, and the renal artery was then declamped. Many stones, measuring 20 mm or less, were removed through the lower calyx, and the lower calyx and the ureter were anastomosed. After operation, ESWL was additionally performed for residue stones. The IVP in July 1997 demonstrated the sufficiently patent anastomosed site without hydronephrosis or recurrence of nephrolithiasis.

DISCUSSION

Anastomosis between the lower calyx and the ureter is an effective therapeutic method because it dose not interfere urine stream or small stone passage. However, it is not easy to make anastomosis in this site because the calyceal wall is very fragile. Several cases have been reported to have stenosis in the anastomosed site. We supposed that it is an excellent method for the treatment of refractory nephrolithiasis if the procedure is selected only for appropriate candidates.

[A case of primitive neuroectodermal tumor of the kidney]

A primitive neuroectodermal tumor (PNET) is a solid tumor originating from the neural crest. This tumor is known to occur in the central nervous system and soft tissue, but recently determined to also invade the kidney. Although primary renal PNET is very rare, we encountered a case of primary renal PNET with multiple lung metastasis. This case was a 35-year-old man with a chief complaint of macroscopic hematuria, which he noticed in January 1996. He was hospitalized because of right renal tumor detected with ultrasonography. On CT scan, a low-density solid tumor with a maximum diameter of 8 cm was visualized in the right kidney. Low-signal and high-signal tumorous lesions were demonstrated in the same region on T 1-weighted and T 2-weighted MR images, respectively. Then right radical nephrectomy was performed on Feb. 5, 1996. On histopathological observation, the tumor was composed of small tumor cells with solid growth. Immunohistochemical staining revealed that the tumor was positive for CD 99. Thus our final diagnosis was primary right renal PNET. Although 2 metastatic lesions with a diameter of about 1 cm were observed in the right lower lung before the time of surgery, pulmonary metastatic lesions markedly increased in number 3 months after surgery. Thus we initiated CAP chemotherapy with cyclophosphamide, doxorubicin, and CDDP. After 3 cycles, pulmonary metastatic lesions disappeared at CT scan, indicating complete remission. However, a tumor with a maximum diameter of about 10 cm recurred in the retroperitoneum 7 months after complete remission. Although 2 cycles of CAV/PE therapy with cyclophosphamide, doxorubicin, vincristine, CDDP, and VP-16 were performed following resection of the retroperitoneal tumor, he showed no response and decreased 24 months after surgery.

[Endocrinological mechanism of puberty in men]

Puberty is a developmental stage during which endocrinological, physical and psycho-social changes proceed. During prepubertal period, hypothalamic-pituitary-gonadal axis is maintained in an inactive state by negative feedback regulation or inhibitory function of central nervous system. The onset of puberty and sexual maturation are gained by the alternation of these inhibitory system. In recent years, highly sensitive techniques for evaluating the hormones of hypothalamic-pituitary-gonadal system have been developed. And many explorations of the hormonal mechanisms of puberty have been achieved. In this chapter, hormonal changes in puberty is reviewed, and mechanism of puberty in men is discussed.

Adenovirus-mediated transfer of tissue-type plasminogen activator gene to human endothelial cells

BACKGROUND

Seeding of vascular grafts with genetically engineered human endothelial cells (hECs) secreting antithrombogenic or fibrinolytic agents has considerable clinical potential.

METHODS

An adenoviral vector was used to transfer the human tissue-type plasminogen activator (htPA) gene to hECs, and the ability of the transduced hECs to secrete htPA was examined. Cultured hECs on plates were incubated with various concentrations of recombinant adenoviruses containing the htPA or LacZ gene for various times to determine the optimal transfer conditions. Transduced hECs were seeded onto fibronectin-coated expanded polytetrafluoroethylene grafts (4 mm in diameter), some of which were exposed to pulsatile flow in vitro.

RESULTS

Effective transduction of the htPA gene into hECs (htPAhECs) was achieved with viral soup at a multiplicity of infection of 30 after incubation for 1 day, which yielded 4.8 +/- 0.20 x 10(3) ng/10(6) cells/6 hr htPA antigen on plates (n = 3), 2.2 +/- 2.0 x 10(3) ng/10(6) cells/6 hr on grafts (n = 6), and 6.8 +/- 1.7 x 10(2) ng/10(6) cells/6 hr on perfused grafts (n = 6). The retention of htPAhECs by perfused grafts was 84.0% +/- 3.0%, comparable with the noninfected (82.1% +/- 8.0%) and mock-infected (94.2% +/- 0.4%) hEC values.

CONCLUSIONS

By adenoviral vector-mediated gene transfer, 10(2-3)-fold enhancement of htPA secretion was demonstrated, which did not affect cell retention by grafts.

Sling operation for male urinary incontinence after ileal neobladder reconstruction: a case report

In July 1992, sling surgery was performed on a 62-year-old male patient with urinary incontinence following ileal neobladder reconstruction. Incontinence ceased immediately after this procedure which was conducted using five nylon sutures and two dacron tubes to protect the posterior urethra.

Increased incidental detection and reduced mortality in renal cancer--recent retrospective analysis at eight institutions

A retrospective survey of renal cell carcinoma between 1975 and 1993 at eight collaborating institutions was conducted with special reference to the incidental detection and mortality of renal cancer. The analysis demonstrated a recent dramatic increase in the frequency of incidental renal cancer, which now comprises two-thirds of all renal cancers, and a simultaneous recession in non-incidental or suspected renal cancer. Incidental renal cancer has remained unchanged during the last decade as far as patient demographics, occasion and method of detection, and the degree of tumor extension are concerned. On the other hand, the annual number of deaths from renal cancer has significantly decreased, and kidney-sparing surgery has been more frequently performed. These results indicate that incidental renal cancers are now in the majority, and earlier detection may contribute to improving the mortality and morbidity from the disease as a whole.

PCR analysis of the Y chromosome long arm in azoospermic patients: evidence for a second locus required for spermatogenesis

We analyzed DNA from 63 Japanese men with either azoospermia or severe oligospermia whose Y chromosomes were cytogenetically normal. A total of 16 loci were examined: 15 loci on the long arm between DYS7E and DYZ1, and the YRRM1 locus, a candidate gene for the azoospermic factor, AZF. One patient with a pericentric inversion of the Y chromosome was also included. We detected micro-deletions in ten individuals. The YRRM1 gene was involved in only three of them. The remaining seven patients showed deletion between DYS7C and DYS239 in common, indicating the presence of at least one additional gene, deletion of which causes azoospermia.

Transurethral ultrasound-guided laser-induced prostatectomy (TULIP) for benign prostatic hyperplasia: clinical utility at one-year follow-up and imaging analysis

OBJECTIVE

The clinical utility of transurethral ultrasound-guided laser-induced prostatectomy (TULIP) for benign prostatic hyperplasia (BPH) and the laser effect on prostatic tissue were investigated.

METHODS

TULIP was carried out under epidural anesthesia on 30 patients with symptomatic BPH (aged 63-92 years; mean, 73.9 years).

RESULTS

Excluding 4 cases that were lost to follow-up, the mean modified Boyarsky symptom score significantly improved (P < 0.001) from a preoperative level of 22.2 +/- 5.3 to 7.7 +/- 4.3 at three months and 6.2 +/- 4.1 at one year. Maximum flow rate increased from 7.9 +/- 3.4 mL/sec to 14.5 +/- 5.9 mL/sec at three months and 14.7 +/- 6.3 mL/sec at one year (P < 0.001). A decrease in residual urine volume from 72 +/- 65 mL to 10 +/- 18 mL at three months and 16 +/- 17 mL at one year was also noted (P < 0.005). Transrectal ultrasonography revealed that estimated prostate volume was decreased from 39.7 +/- 20.4 mL to 26.9 +/- 20.3 mL at three months (P < 0.05) but it regrew to 32.2 +/- 26.2 mL at one year. Magnetic resonance imaging clearly showed less enhanced area to a depth of approximately 10 mm in the periurethral region, which could be attributable to coagulation necrosis in the prostatic tissue. Adverse effects were limited to epididymitis in 2 cases and no sexual dysfunction was associated with the procedure.

CONCLUSIONS

TULIP is an effective and safe alternative procedure to induce long-lasting relief of prostatic obstruction by coagulation necrosis in the periurethral region.

[A clinical study on renal pelvic and ureteral tumor associated with bladder tumor]

Of 65 cases of renal pelvic and/or ureteral tumor treated at Department of Urology, The University of Tokyo, during the period from January 1975 through December 1991, 26 had bladder tumors as well. These cases were divided into three groups; 1) bladder tumor preceding upper urinary tract tumor, 2) bladder tumor found simultaneously with upper urinary tract tumor, and 3) bladder tumor following upper urinary tract tumor. In group 1 (nine cases), the last bladder tumor preceded renal pelvic and/or ureteral tumors by 3 to 42 months (mean 14.6 months), and in seven cases, bladder tumor recurred 3 to 29 months (mean 9.0 months) after nephroureterectomy. The interval between the diagnosis of preceding bladder tumor and upper urinary tract tumor was highly correlated with the latent period of postoperative recurrence of bladder tumor (r = 0.948). Highly malignant pathological grade of bladder tumor featured seven cases of group 2, with the survival rate being significantly (p < 0.01) lower than that of other groups. In the group 3 consisting of ten cases, bladder tumors subsequently developed 6 to 37 months (mean 15.0 months). The latent period of bladder tumor was significantly (p < 0.01) longer than that in group 1. These results indicated that the bladder tumors associated with renal pelvic and/or ureteral tumors have distinct characteristics depending on the sequence of association.

[Clinical observations of advanced renal cell carcinomas--the chronological change between 1975 and 1991]

An analysis has been undertaken to determine chronological changes that have occurred in the clinical features and treatments of advanced renal cell carcinomas. To accomplish this, 96 renal cell carcinoma cases, handled by the authors' department and at the branch hospital, were divided into two groups: 48 patients treated between 1975 and 1983 (group 1) and 48 patients treated between 1984 and 1991 (group 2). Between the two groups, no differences were seen in the sex ratio, the mean age, and the ratio of those who were found to be advanced cases at the time of diagnosis and those whose cancers had advanced after undergoing a nephrectomy. Concerning treatment, interferon (IFN) and UFT were more frequently used in treating group 2 than group 1, and chemotherapy, radiotherapy, and endocrine therapy less frequently used. No differences were seen in the prognosis between the two groups; however, in those who had advanced after nephrectomy, group 2 cases survived for a significantly longer period than did group 1 cases. Patients who survived for 5 years or longer accounted for two cases in group 1 and 5 cases in group 2 and combination therapies involving surgery, IFN, UFT, or similar medications were used for their treatments. These results suggest that adjuvant therapies, such as surgery, IFN, and UFT, have possibly contributed to prolonging survival, especially for cases that advanced after nephrectomy.

Successful gonadotrophin treatment of hypogonadism in postoperative patients with macroprolactinoma and persistent hyperprolactinaemia

We report on two males with prolactinoma in whom hyperprolactinaemia and hypogonadism persisted for several years postoperatively despite the administration of a dopamine agonist or bromocriptine. In these patients, a GnRH test revealed no response in the levels of serum LH or FSH. An hCG stimulation test provoked no response in the serum levels of testosterone. Case 1, who was 28 years old at the first visit, received parenteral testosterone and appreciable virilization of the genitalia was noted within a few months. When he married and desired to father a child, the treatment was switched to hCG/hMG combined therapy and spermatozoa appeared subsequently in the ejaculate, although their numbers were low. His wife conceived and delivered a healthy baby girl. Case 2 was a single young man who presented with hypogonadotrophic hypogonadism and hyperprolactinaemia. He was started on hCG injections three times per week and the maturation of his genitalia was advanced rapidly. Semen analyses showed sperm concentration and motility to be within the normal range. Post-treatment GnRH test revealed no improvement in gonadotrophin responses for LH or FSH. In both cases, the hCG test repeated after the gonadotrophin treatment showed normal basal and stimulated testosterone levels. During the course of gonadotrophin treatment in these cases, serum prolactin levels remained elevated, and it is suggested that, in the two cases, the hypothalamo-pituitary function was disturbed by the tumour or its manipulation and the capacity of the pituitary gland to secrete gonadotrophin was impaired. Under such circumstances with persisting hyperprolactinaemia, hCG and/or hCG/hMG combination treatment can induce normal virilization and advance spermatogenesis sufficiently to achieve fertility.

Laparoscopic adrenalectomy: the initial 3 cases

Laparoscopic adrenalectomy was performed on 3 patients with primary aldosteronism. Traction with 2 steel skewers placed subcutaneously over the costal arch was combined with conventional intraperitoneal carbon dioxide gas insufflation. This combination provided a good operative field at 8 mm. Hg insufflation pressure. The laparoscopic approach to the adrenal gland requires neither a large skin and muscle incision nor resection of rib(s), and offers lower morbidity and rapid convalescence. Laparoscopic adrenalectomy is a new minimally invasive operation for the treatment of adrenal adenoma.

[Transurethral resection of papillary tumor in the lower end of the ureter: report of two cases]

Two cases of papillary ureteral end tumors, treated by transurethral resection are presented. Case 1: A 71-year-old female visited us for asymptomatic macroscopic hematuria. Cystoscopy revealed a papillary pedunculated tumor in the bladder protruding from the right ureteral orifice. Under a diagnosis of superficial tumor at the right ureteral end, transurethral resection was performed using a rigid ureteral resectoscope. Pathological examination revealed transitional cell carcinoma, grade 2 without muscular invasion. There is no evidence of recurrence after 25 months of follow up postoperatively. Case 2: On a routine cystoscopy after transurethral resection of bladder tumor in a 68-year-old male, papillary pedunculated tumors protruding from the right ureteral orifice were found. Under a diagnosis of superficial tumor at the right lower ureter, transurethral resection was performed using cold cup forceps and loop electrocoagulation. The tumor was transitional cell carcinoma, grade 1 without invasion. No evidence of recurrence was detected 15 months postoperatively. Transurethral resection of the ureteral tumor at the lower end appeared to be useful for the selected cases. The indications, complications and follow up for this procedure were discussed.

[A survey of postoperative steroid replacement in 40 patients with Cushing's syndrome]

Adrenalectomy for Cushing's syndrome due to adrenocortical adenoma was performed on 40 patients at Tokyo University Hospital between 1960 and 1990. There were 32 women and 8 men aged 2 to 59 (mean 35.7) years. Three different operative approaches to the adrenal gland were employed: lumbar approach in 24 cases, dorsal in 8, and transabdominal in 8 of whom 7 patients were operated before 1970 without definite preoperative localization of the lesions. Postoperative administration of cortisone and hydrocortisone as a steroid replacement has been reduced in duration and dosage in recent 10 years. Average treatment period was 3 years and 1 month in the 1970's, and 9.5 months in the 1980's, respectively. The mean daily dosage of steroid hormone was 517.5 mg (mean) on the operative day and 43.1 mg after three weeks in the 1970's, while 187.5 mg and 18.4 mg in the recent five years, respectively. Nonetheless, even in the recent 6 patients, metabolic alkalosis and hypopotassemia because of steroid excess were observed in a few days after the surgery. These observations indicate that period and dosage of steroid replacement have been reduced in these years and could be further shortened by means of rapid tapering in the early postoperative phase.

[A case report of laparoscopic adrenalectomy]

Laparoscopic left adrenalectomy was performed on a 47 years old male patient with primary aldosteronism. Subcutaneous steel traction method was utilized in addition to intraperitoneal CO2 insufflation method. The combined use of steel traction method reduced CO2 insufflation pressure below 12 mmHg and might reduce possibility of CO2-related complications. A left adrenal gland was approached by a resection of phrenic colic ligament and a traction of a transverse and descending colon. Laparoscopic adrenalectomy has distinct advantages over open adrenalectomy in terms of avoidance of skin and muscle incision and rib resection, and early convalescence. This less invasive method might prevail in near future.

[Implantation of self-contained non-inflatable penile prosthesis in patients with organic impotence]

Between April, 1988 and August, 1990, the OmniPhase penile prosthesis, a non-inflatable self-contained penile prosthesis, was implanted in 34 patients, aged from 37 years to 79 years, averaging 54.2 years. The etiologies of the impotence were radical surgery for bladder cancer or rectal cancer in 17 patients, diabetes mellitus in 7 patients, vascular abnormality in 3 patients, spinal injury in 2 patients, penile disorders in 2 patients and others in 3 patients. Penile prosthesis was implanted by subcoronal incision under spinal or general anesthesia. Clinical results were evaluated 12 weeks after surgery. Thirty-two patients (94.1%) could have intercourse postoperatively. Eighteen patients (52.9%) were completely satisfied and 14 patients (41.2%) were satisfied, whereas one patient (2.9%) had no improvement and another patient (2.9%) deteriorated. There was no serious complication. However, prosthesis was explanted because of skin erosion in one patient. Pain, which lasted for more than 10 days, was seen in 3 patients (8.8%), penile edema in 11 patients (32.4%), and acute epididymitis in one patient. The obtained results showed that implantation of OmniPhase penile prosthesis is a safe and useful procedure for treatment of organic impotence.