Retroperitoneoscopic donor nephrectomy with a gel-sealed hand-assist access device.

BACKGROUND: The hand-assisted technique enables the rapid extraction of the graft, shortening the warm ischemia time (WIT), and the retroperitoneoscopic approach is potentially associated with a less incidence of postoperative ileus in donor nephrectomy for living kidney transplantation. The aim of this study was to assess the efficacy and safety of retroperitoneoscopic donor nephrectomy with a gel-sealed hand-assist access device (GelPort), which is a wound sealing device that permits the access of the hand to the surgical field, free trocar site choice within it, and rapid conversion to open surgery if necessary, while preserving the pneumoperitoneum/pneumoretroperitoneum. METHODS: Seventy-five consecutive donors receiving this procedure were retrospectively studied. A 2-cm skin incision was made at the midpoint between the tip of the 12th rib and superior border of the iliac bone in the midaxillary line, through which retroperitoneal space was made. Preperitoneal wound with a 6 - 7-cm pararectal incision in the upper abdominal region was connected to the retroperitoneal space. A GelPort was put inside the pararectal surgical wound. The principle was pure retroperitoneoscopic surgery; hand-assist was applied for retraction of the kidney in the renal vessel control and graft extraction. RESULTS: The mean operation time including waiting time for recipient preparation was 242.2±37.0 (range: 214.0-409.0) min, and the mean amount of blood loss was 164.3±146.6 (range: 10.0-1020.0) ml. The mean WIT was 2.8±1.0 (range: 1.0-6.0) min. The shortage of renal vessels or ureter was observed in none of the grafts. No donor experienced blood transfusion, open conversion, or injury of other organs. Blood loss was greater in patients with body mass index (BMI) of 25 kg/m2 or higher than in those with BMI of <25 kg/m2 (218.4±98.8 vs. 154.8±152.1 ml, P=0.031). No donor had postoperative ileus or reported wound pain leading to decreased activity of daily life or wound cosmetic problem. CONCLUSIONS: Retroperitoneoscopic hand-assisted donor nephrectomy with the mentioned approach was suggested to be a feasible option without compromising safety, although further improvement in surgical techniques is warranted.

Growing teratoma syndrome of the ovary after fertility-sparing surgery and successful pregnancy.

BACKGROUND: Growing teratoma syndrome (GTS) is rare and is defined as an enlarging mature teratoma that arises during or after chemotherapy for a malignant germ cell tumor, with normalization of previously elevated serum tumor markers. CASE: A 30-year-old nulliparous Japanese woman was diagnosed as having a stage IIIa immature teratoma. After fertility-sparing surgery, she received 4 cycles of chemotherapy consisting of cisplatin, etoposide and bleomycin. Thereafter, she successfully gave birth twice. Eight years after the initial surgery, a mass mimicking an adrenal tumor was resected laparoscopically. Surgical specimens revealed a mature teratoma, and she was diagnosed as having GTS postoperatively. CONCLUSION: Clinicians should consider that GTS may present late, even after pregnancy. Therefore, long-term follow-up of patients treated for ovarian immature teratoma should be mandatory.

Primary solitary fibrous tumor (SFT) in the retroperitoneum.

BACKGROUND: Solitary fibrous tumor (SFT) is an infrequent but distinct neoplasm, which generally arises from submesothelial connective tissue in the pleura. SFT is rarely recognized in extrathoracic sites, and histologically identical conditions have also been reported in the retroperitoneum, although their pathophysiology has not been extensively investigated. METHODS: We present four cases of primary SFT in the retroperitoneum, and review 37 similar cases in the previous literature. RESULTS: About 40% of patients were asymptomatic, and 19.2% and 15.4% presented with an abdominal mass and urinary symptoms, respectively. The tumor size ranged between 2 and 26 (mean 9.1) cm. Sixty-three percent of tumors showed nonspecific development with haphazard distribution of bland short spindle or polygonal cells with or without collagenous bundles and stromal hyalinization. In 22.0%, hemangiopericytomatous appearance was seen. About 15% of cases showed histologically malignant characteristics. The tumor cells were immunoreactive for vimentin in all cases, CD34 in 91% and Bcl-2 in 86%. All tumors were excised, and in 85.4% of cases, tumors did not recur postoperatively for 6 to 48 months. No significant difference was found between the recurrence rate of histologically benign and malignant cases. Cases positive for both CD34 and Bcl-2 had no recurrence. CONCLUSIONS: The identification of SFT in the retroperitoneum is of importance because histopathological indicators of malignancy are not necessarily associated with clinical malignant potential in many cases of retroperitoneal SFT. Retroperitoneal SFT showing typical pathological features with expression of CD34 and Bcl-2 is associated with a favorable outcome following excision.

[Persistent müllerian duct Syndrome in brothers].

Persistent Müllerian duct syndrome is associated with cryptorchidism and transverse testicular ectopia. Such gonads are at an increased risk of malignant transformation. Furthermore, most patients have azoospermia. Here in we report about two brothers with persistent Müllerian duct syndrome. The diagnosis was made during surgical operation for testicular cancer in younger brother. In the other one, persistent Müllerian duct syndrome was diagnosed during examination for infertility.

[The consequence after introduction of clean intermittent catheterization (CIC) in children with neurogenic bladder dysfunction secondary to spina bifida--the comparison of patients with and without upper urinary tract dilation at the time CIC was introduced].

PURPOSE: The aim of current study was to review the consequence after introduction of clean intermittent catheterization (CIC) in children with neurogenic bladder dysfunction secondary to spina bifida. PATIENTS AND METHODS: We retrospectively reviewed the records of 34 children (19 girls and 15 boys) presenting our clinic in a 18-year period. The patients were divided concentrating on the radiological upper urinary tract findings when CIC was introduced. 18 children had dilated upper urinary tract. In these patients, 10 children already had dilated upper urinary tract at first visiting to our clinic(group A). In remaining 8 patients, dilatation of upper urinary tract was found out in the course of followup (group B). 16 children had normal upper urinary tract when CIC was introduced. In 7 patients, CIC was applied for post-void residual and urinary tract infection (group C). In remaining 9 patients, CIC was introduced for urodynamically low compliance bladder (group D). RESULTS: In group A, 5 patients underwent enterocystoplasty and 3 patients underwent anti-reflux surgery consequently. Two patients, including 1 patient who underwent enterocystoplasty, have chronic renal dysfunction. In group B, 3 patients underwent enterocystoplasty and 2 patients underwent anti-reflux surgery. In group C, all patients have normal upper urinary tract. In group D, 8 patients have normal upper urinary tract. However, 1 patients underwent enterocystoplasty for low compliance bladder with vesicoureteral reflux (VUR). CONCLUSION: Some patients show the improvement of dilated upper urinary tract or VUR after introduction of CIC. However, enterocystoplasty or anti-reflux surgery was needed for many patients to prevent upper urinary tract deterioration. The patients whom CIC was introduced for postvoid residual and urinary tract infection have not shown any deterioration of upper urinary tract. The efficacy of CIC for incontinence was poor because many patients have urethral sphincter incompetence.