Outcomes of robot-assisted versus conventional laparoscopic low anterior resection in patients with rectal cancer: propensity-matched analysis of the National Clinical Database in Japan.

BACKGROUND: Robot-assisted laparoscopic surgery has several advantages over conventional laparoscopy. However, population-based comparative studies for low anterior resection are limited. This article aimed to compare peri-operative results of robot-assisted low anterior resection (RALAR) and laparoscopy. METHODS: This retrospective cohort study used data from patients treated with RALAR or conventional laparoscopic low anterior resection (CLLAR) between October 2018 and December 2019, as recorded in the Japanese National Clinical Database, a data set registering clinical information, perioperative outcomes, and mortality. Of note, the registry does not include information on the tumour location (centimetres from the anal verge) and diverting stoma creation. Perioperative outcomes, including rate of conversion to open surgery, were compared between RALAR and CLLAR groups. Confounding factors were adjusted for using propensity score matching. RESULTS: Of 21 415 patients treated during the study interval, 20 220 were reviewed. Two homogeneous groups of 2843 patients were created by propensity score matching. The conversion rate to open surgery was significantly lower in the RALAR group than in the CLLAR group (0.7 versus 2.0 per cent; P < 0.001). The RALAR group had a longer operating time (median: 352 versus 283 min; P < 0.001), less intraoperative blood loss (15 versus 20 ml; P < 0.001), a lower in-hospital mortality rate (0.1 versus 0.5 per cent; P = 0.007), and a shorter postoperative hospital stay (median: 13 versus 14 days; P < 0.001) compared with the CLLAR group. The CLLAR group had a lower rate of readmission within 30 days (2.4 versus 3.3 per cent; P = 0.045). CONCLUSION: These data highlight the reduced conversion rate, in-hospital mortality rate, intraoperative blood loss, and length of postoperative hospital stay for rectal cancer surgery in patients treated using robot-assisted laparoscopic surgery compared with laparoscopic low anterior resection.

The long-term outcome of transvaginal anterior levatorplasty for intractable rectovaginal fistula.

AIM: Several procedures have been described for rectovaginal fistula with a wide range of success, but there is little information on the long-term outcome. The aim of the present study was to investigate the long-term outcome after transvaginal anterior levatorplasty (ALP) for intractable rectovaginal fistula. METHOD: Data of 16 consecutive patients undergoing transvaginal ALP with fistulectomy and closure of the rectum and vagina between 1998 and 2011 were prospectively recorded and retrospectively investigated to study the long-term outcome. RESULTS: Birth injury (n = 7), low anterior resection for rectal cancer (n = 3), pouch surgery for ulcerative colitis (n = 2) and a procedure for prolapse and haemorrhoids (n = 2) were the main causes of the fistula. Nine patients had a covering stoma before surgery. All patients underwent ALP, with a covering stoma in two patients. Infection occurred in one patient and wound rupture after surgery in another patient. These patients underwent reoperation by ALP. All fistulae had healed at a median follow-up of 84 (8-193) months after initial surgery or stoma closure. CONCLUSION: Transvaginal ALP is effective for the treatment of mid or low rectovaginal fistula. The results show that a graft is not necessary regardless of whether or not previous surgery has been performed.

Short-term outcomes of local correction of stoma prolapse with a stapler device.

BACKGROUND: The aim of the present study was to classify the short-term outcomes of local correction of stoma prolapse with a stapler device. METHODS: The medical records of 11 patients undergoing local correction of stoma prolapse using a stapler device were retrospectively reviewed. RESULTS: No mortality or morbidity was observed after the surgery. Median operative time was 35 min (range 15-75 min), and blood loss was minimal. Median duration of follow-up was 12 months (range 6-55 months). One of the 11 patients had a recurrent stoma prolapse. CONCLUSIONS: This technique can be a feasible, safe and minimally invasive correction procedure for stoma prolapse.

Engineered synthetic pathway for isopropanol production in Escherichia coli.

A synthetic pathway was engineered in Escherichia coli to produce isopropanol by expressing various combinations of genes from Clostridium acetobutylicum ATCC 824, E. coli K-12 MG1655, Clostridium beijerinckii NRRL B593, and Thermoanaerobacter brockii HTD4. The strain with the combination of C. acetobutylicum thl (acetyl-coenzyme A [CoA] acetyltransferase), E. coli atoAD (acetoacetyl-CoA transferase), C. acetobutylicum adc (acetoacetate decarboxylase), and C. beijerinckii adh (secondary alcohol dehydrogenase) achieved the highest titer. This strain produced 81.6 mM isopropanol in shake flasks with a yield of 43.5% (mol/mol) in the production phase. To our knowledge, this work is the first to produce isopropanol in E. coli, and the titer exceeded that from the native producers.

A new technique of laparoscopic surgery for rectal disease.

Laparoscopic rectal surgery is a technique that has to be done in a narrow space: the pelvis. If an immoderate operation is performed with a difficult view, for example in female where the field is disturbed by uterus, it is possible to produce organ trauma or an unexpected bleeding. Taking these problems in mind, we performed laparoscopic surgery in 44 cases of rectal disease with several techniques which we have invented. In these cases either the uterus or the rectum was retracted in the narrow space, and if an anterior resection was to be done, the tape was tied tightly around the rectum below the tumor to avoid touching the tumor and leaving adequate vascular irrigation to the remnant rectum. With the use of our techniques, we did not have female intestinal injury or unexpected bleeding. In addition laparoscopic anterior resection of rectum did not cause any intestinal injury, or unexpected bleeding or anastomotic leakage; also we did not have any local tumor recurrence. It is our belief that these techniques can decrease complications that traumatize the grasping intestine with intestinal forceps and prevent implantation in the anastomosis. This technical report validate that our technique modifications for rectal laparoscopic surgery are useful when a surgeon has to work in a narrow space.

Transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele.

BACKGROUND: We evaluated functional and morphological outcomes of transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele. METHODS: Ten women (median 68 years) underwent transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele. Symptoms and continence were monitored before and after surgery. Manovolumetric study and defecography were performed in 9 of 10 patients before and 3-6 months after surgery. Twenty-one females without anorectal diseases were used as controls in manovolumetric study. The patients were followed up after a median of 89 months (range, 3-103). RESULTS: Main symptoms (defecatory disorders in 9 patients, vaginal mass in 6, perineal discomfort in 2) disappeared after surgery. Six patients performed digitation preoperatively and gave up digitation on defecation after surgery. Stool incontinence disappeared in 4 of 5 preoperatively incontinent patients (Cleveland clinic score, 5-12) and continence score improved from 5 to 2 in the remaining patient. Three patients with urinary cough incontinence preoperatively did not experience incontinence after surgery but cough incontinence occurred occasionally in an 81-year-old patient postoperatively. Rectocele demonstrated on defecography disappeared postoperatively in all 9 patients who underwent defecography. High threshold volume and maximum tolerable volume, which were observed preoperatively, decreased to control levels after surgery. CONCLUSION: Transvaginal anterior levatorplasty with posterior colporrhaphy might be an option for symptomatic rectocele to improve anorectal and urinary dysfunctions with morphological disorders.

Postrenal acute renal failure during pregnancy 20 years after antireflux surgery.

We report that a 27-year-old woman with bilateral severe hydronephorosis during pregnancy 20 years after antireflux surgery. The patient developed postrenal acute renal failure due to obstruction of the lower ureter. This patient could safely give birth after bilateral percutaneous nephrostomy through joint management with the obstetrics and gynecology staff. We describe that stenosis of the lower ureter is a late complication of antireflux surgery.

[A case of tumor-forming chronic pyelonephritis that was difficult to be differentiated from renal cell carcinoma].

We experienced a rare case of tumor-forming type of chronic pyelonephritis that could hardly be differentiated from renal cell carcinoma. A 62-year-old man was admitted to our department with right renal tumor which was discovered when he underwent examination for gastric cancer. Abdominal ultrasound sonography and computed tomography revealed a mass in the middle portion of the right kidney, measuring 3.8 x 3.5 cm in diameter, with irregular surface and isoechoic and isodense inner mass. Renal angiography demonstrated a hypervascular area in the middle portion. Radical nephrectomy and subtotal gastrectomy were performed under a tentative diagnosis of right renal cell carcinoma and early gastric cancer. The excised specimen macroscopically demonstrated a yellowish mass in the middle portion and microscopically revealed many lymphocytes and few neutrophils, macrophages or foam cells. The patient was diagnosed as tumor-forming type of chronic pyelonephritis. Such obvious inflammatory findings very rarely exist in the tumor-forming type of chronic pyelonephritis. Therefore, caution should be exercised in the differential diagnosis between this disease and renal cell carcinoma.

Fuzzy neural network-based prediction of the motif for MHC class II binding peptides.

Characterizing the interaction between major histocompatibility complex (MHC) molecules and antigenic peptides is critical for understanding immunity and developing immunotherapies for autoimmune diseases and cancer. To identify the peptide binding motif and predict peptides that bind to the human MHC classII molecule HLA-DR4(*0401), we applied a fuzzy neural network (FNN) capable of extracting the relationship between input and output. Analysis of the peptide binding motif revealed that the hydrophilicity of the position 1 residue located on the N-terminal side of the nonamer (9mer) was the most important variable and that the van der Waals volume and hydrophilicity of the position 6 residue and the hydrophilicity of the position 7 residue were also important variables. The estimation accuracy (A(ROC) value) was high and the binding motif extracted from the FNN agreed with that derived experimentally. This study demonstrates that FNN modeling allows candidate antigenic peptides to be selected without the need for further experiments.

[A study of the clinical effect of estradiol transdermal therapeutic system alone on pollakisuria and urinary incontinence in postmenopausal woman].

PURPOSE: Our purpose of this study was to evaluate the effect of a transdermal estradiol delivery system in postmenopausal women with confirmed pollakisuria and urinary incontinence. PATIENTS AND METHODS: We investigated 10 postmenopausal women, age 54-83 years, with pollakisuria and urinary incontinence but did not show distinct urological and/or neurological abnormalities. In this study, estradiol transdermal therapeutic system (Estraderm TTS 2 mg) alone were administrated for total of 8-week and this is observational, not randomized, blinded or controlled. A clinical evaluation were performed two times at before and after administration. RESULTS: In seven eligible cases, the severity of urinary incontinence was graded down in almost of them and the therapeutic effect on urinary incontinence was evaluated as "very effective" in 3 cases, "improved" in 2, "slightly improved" in 1 and "no change" in 1, respectively. In three eligible cases, the severity of pollakisuria was no change in all of them. CONCLUSION: Thus, the estrogen supplement therapy was considered effective for postmenopausal urinary incontinence.

[Vesicovaginal fistula due to a vaginal foreign body: a case report].

An 18-year-old female consulted a clinic complaining of pollakisuria and urinary incontinence. She was referred to our department for operation under the diagnosis of vesicovaginal fistula due to a vaginal foreign body confirmed by intravenous pyelography and cystoscopic examination. About 7 months earlier, she inserted a hair spray can into the vagina but could not remove its cap. The vaginal foreign body was transvaginally removed. After 2 months, transabdominal repair of the vesicovaginal fistula was performed. After operation, dysuria and urinary incontinence were not observed. Few cases of vesicovaginal fistula due to a foreign body in the vagina have been reported, and there have been only 6 reported cases in Japan including ours.

[A case of pedunculated hepatoma suspected of adrenal tumor].

A case of pedunculated hepatoma which was preoperatively diagnosed as non-functioning adrenal tumor is reported. A 48-year-old man presented to our hospital for further examination of remittent fever and leg edema. Abdominal ultrasonography, computed tomographic scan and magnetic resonance imaging showed a right suprarenal mass, its continuity of liver was uncertain. Tumor vessels were visualized on selective right adrenal arteriography and right adrenal function and serum alpha-fetoprotein were normal. Preoperative diagnosis was non-functioning right adrenal tumor. On operation, the dissection between the tumor and the inferior part of liver was easy. Pathological diagnosis was hepatocellular carcinoma with sarcomatous change. Difficulty of preoperative diagnosis of pedunculated hepatoma is discussed.

Why is transurethral microwave thermotherapy (TUMT) positively effective?

Between 1992 and 1994, 157 patients with benign prostatic hyperplasia were treated with transurethral microwave thermotherapy (TUMT). In evaluating the efficacy of TUMT with the International PrOstate Symptom Score (I-PSS) in 121 patients, 18 (15%) showed excellent and 42 (35%) showed good response. In evaluation of QOL, the result was 43 patients (33%) excellent and 42 patients (35%) good response. In objective evaluation of uroflow in 93 patients, 12 (13%) showed excellent and 13 (14%) showed good response. The prostatic volume did not show a significant decrease after treatment. In terms of overall improvement, according to the criteria proposed at the 2nd International Consultation on BPH, the treatment was considered effective in 53 of 108 patients (48%). Histological examination of the prostate enucleated from a patient 7 months after TUMT revealed degenerative changes of nerve fibres on S-100 protein immunohistochemical staining, which were more extensive than those in smooth muscle cells on HE staining. In in vitro tests the isometric contraction force of the rabbit prostatic tissue was measured after exposure to different temperatures, ranging from 37 to 50 degrees C. No significant change was observed up to 45 degrees C vs. 37 degrees C. After exposure to 48 degrees C, the nerve mediated contractions became completely depressed, although phenylephrine or KCl induced contractions were only partially suppressed. After exposure to 50 degrees C, no contraction was induced by any type of stimuli. In conclusion, it is suggested that good symptomatic improvement after TUMT results from both neural and muscular damage to the prostate. As TUMT is not aiming at a relief of anatomical obstruction, 50 degrees C is thought to be a sufficient thermal condition to cause an irreversible damage to prostatic tissue, which will provide a relief from functional obstruction and urethral instability.

[Investigation of long-term follow up after endoscopic operation for vesicoureteral reflux].

BACKGROUND: Results with respect of the state of the infused agent and the cause of unsuccessful outcome were examined in patients who were followed for more than 5 years after endoscopic surgery for vesicoureteral reflux (VUR). METHODS: Of 259 ureters treated by TUI (Transurethral injection) after 1988, 41 ureters (29 patients) that were followed for more than 5 years postoperatively were investigated. In all patients, teflon paste had been infused. The intervals between surgery and study enrollment ranged from 5 to 10 years, with a mean of 5.1 years. RESULTS: After TUI was performed once, reflux disappeared in 30 (73%) of 41 ureters. The intervals between the detection of relapse and additional surgery ranged from 1 to 18 months, with a mean of 6.5 months. In 10 of 11 ureters with relapse, relapse was detected within one year after the initial surgery. When the presence or absence of reflux was examined at the final evaluation, there was no relapse in 34 of 39 ureters, with a mean postoperative follow-up of 5.9 years. Teflon paste could be sufficiently confirmed in 34 of 39 ureters excluding patients in whom TUI was changed to invasive surgery. However, this agent could not be confirmed in 5 ureters during follow-up. CONCLUSION: Teflon paste was not confirmed by bladder echo in any patient showing an unsuccessful outcome, suggesting that success or failure in this procedure depends on the persistence of paste.

[A case of renal cell carcinoma in a nonfunctioning kidney caused by staghorn calculus].

A 62-year-old man was referred to our clinic with a chief complaint of gross hematuria. He had bilateral renal staghorn calculi at the age of 50 years and had undergone left nephrolithotomy. However, no treatment had been given to the right staghorn calculi associated with nonfunctioning kidney. Imaging diagnosis demonstrated no mass lesions in the bilateral kidneys. Right nephrectomy revealed renal cell carcinoma, tubular type, mixed subtype, G2, INF-beta with lymph node metastasis to the renal hilum. Cancer cells infiltrated diffusely throughout the entire renal parenchyma. He died of progressive metastases 15 months postoperatively.

[Surgical management of intractable epilepsy in patients with ganglioglioma].

Long-standing intractable seizures are common manifestation of cerebral gangliogliomas. There is much controversy regarding the most appropriate surgical treatment (lesionectomy vs resection of the epileptogenic cortex with the lesion) for patients with intractable epilepsy associated with gangliogliomas. We reported 2 cases, in which the favorable seizure outcome was obtained following lesionectomy alone. (Case 1) Nine-year-old female developed attack of abnormal sensation in her left upper limb followed by motor seizure in her left limbs since 5 years old. MRI revealed hyperintense tumor in the right medial frontal lobe. Chronic invasive subdural recording showed that ictal onset zone was located in the hand motor area. Following lesionectomy alone, she became free from seizures. (Case 2) Eight-year-old girl had intractable generalized seizure since 6 years old. MRI revealed a cystic tumor in the right parietal lobe. She had multiple spike foci on electroencephalography and magnetoencephalography, and intraoperative electrocorticography failed to reveal the paroxysm. Following lesionectomy, she had good relief with less than one minor seizure per 1-3 months. Thus, lesionectomy, even without resection of the epileptogenic cortex, may improve seizure outcome in patients with ganglioglioma-associated epilepsy.

The Relation between Superoxide Dismutase in Cancer Tissue and Clinico-pathological Features in Breast Cancer.

The localization of Cu/Zn- and Mn-superoxide dismutase (SOD) in breast cancer tissue (12 papillotubular carcinomas, 21 solid-tubular carcinomas, 16 scirrhous carcinomas, 1 medullary carcinoma, 1 secreting carcinoma, 1 lobular carcinoma, 1 Paget's disease) was investigated via an immunohistochemical technique using antihuman Cu/Zn- and Mn-SOD antibodies in 10%formalin fixed-paraffin embedded thin sections. Both SODs stained strongly in the normal breast gland, but not clearly in many cancer tissues. Furthermore, Cu/Zn-SOD stained more strongly in well differentiated tubular carcinomas than in poorly differentiated tubular carcinomas. It tended to stain less in tumors which recurred or had a poor outcome, and in tumors with a diploid pattern on DNA flow cytometry. Mn-SOD staining was similar to that of Cu/Zn-SOD, but no significant differences among subgroups was found, since the incidence of positively staining tumors was too small in all groups. The intensity of SOD staining seems to change in relation to cell proliferation and differentiation in breast carcinoma, and may be a prognostic indicator, since SOD decreased in poorly differentiated carcinoma and in tumors which developed distant metastasis. Thus, the localization of SOD in breast cancer tissue can provide useful information for cancer treatment.

Increase in lectin binding sites on epithelial cells by chronic bladder infection in rats.

Using lectin histochemistry we assessed whether chronic bladder infection modifies carbohydrate residues of glycoconjugates on uroepithelial cells in rats. The bladder infection was produced by implanting a knotted silk thread with Escherichia coli into the bladder. One or 4 weeks after the implantation the bladder was excised, incubated with sixteen biotinylated lectins and stained. The bladder epithelia as a whole stained more strongly positive for eight lectins in the infected rats than in the control rats having a sterile silk thread in the bladder. In the infected rats, the superficial epithelial layer that stained negative for Arachis hypogaea (PNA) in the controls became strongly positive for PNA, whereas the middle and deep epithelial layers increased in staining for Canavalia ensiformis and six other lectins. These results indicate that chronic bladder infection increases carbohydrate residues on uroepithelial cells and may facilitate bacterial adherence to uroepithelial cells.