Identification of the narrow lumen of the ureter using a Fogarty catheter during laparoscopic pyeloplasty.

It is difficult to identify the narrow sites of the ureter from the outside while carrying out laparoscopic pyeloplasty in patients with ureteropelvic junction obstruction. We developed and named a new method, the Fogarty test, to identify the narrow sites of the ureter using a Fogarty catheter. A 4- to 5-Fr Fogarty catheter was inserted through an incision in the pelvis to the proximal ureter, inflated with air and withdrawn gently to determine resistance. The narrow lumen of the ureter was identified under direct vision and spatulated by laparoscopic scissors. This procedure was carried out repeatedly until the ureter was fully spatulated. By using the Fogarty test, we can visualize the narrow position and length of the ureter under direct vision, and confirm whether it is fully spatulated or not. This technique is very simple and easy to carry out. We believe it is useful for sufficient spatulation of intrinsic ureteral stricture, especially in patients where multiple narrow sites exist.

[A case of giant renal angiomyolipoma treated by partial nephrectomy].

A 38-year-old woman visited our hospital complaining of decreased appetite and sensation of pressure on her abdomen. Computed tomographic scan revealed right giant renal angiomyolipoma. Partial nephrectomy was performed. The resected specimen weighed 970 grams. The histological diagnosis was consistent with angiomyolipoma. Partial nephrectomy was performed because the connection between the tumor and the kidney was in a small range and the tumor was detached easily from the surrounding tissue.

[Endoscopic trigonoplasty II for primary vesico-ureteral reflux].

PURPOSE: We report a technique and outcome of endoscopic trigonoplasty II (ET II), anti-reflux surgery via a transvesicostomy transurethral approach and discuss its usefulness. MATERIALS AND METHODS: Fifteen female patients, aged 5 to 64, with 23 refluxing ureters (grade I : 5, II : 2, III : 14, IV : 2) underwent the ET II. The principle of this surgery is tightening the muscular backing and elongating the intramural ureter. The operation consists of three steps: 1) two 5 mm locking trocars are placed into the bladder, 2) irrigating with 3% D-sorbitol solution, the bladder wall is incised upward along each side of the ureter using a resectoscope, to make a 2 to 3 cm U-shaped bladder flap including the ureter, 3) under a pneumobladder, the incised wall is sutured to make a muscular bed with a needle-holder via the urethra and forceps via the abdominal trocar. The U-shaped flap is fixed with two distal anchor sutures and four additional mucosal sutures. Urethral catheter is indwelled and the operation is finished. In recent four cases, we closed the tracts endoscopically. RESULTS: The average operative time was 144 minutes per ureter. In one patient with unilateral reflux, we switched to open surgery because of bleeding. Of 22 refluxing ureters, the reflux disappeared in 18 ureters (82%) and improved grade III to I in 1 ureter (5%) after 3 months and disappeared in 19 ureters (86%) after 12 months postoperatively. Ureteral injury was occurred in 3 patients during the transurethral incision of the bladder. Though we repaired it by placing a double-J stent in the 2 patients, reflux recurred in 12 months postoperatively in one of them. In the other patient cystoscopy revealed a vesicoureteral fistula in the injured portion. She subsequently underwent successful open Politano-Leadbetter ureteroneocystostomy. The average duration of indwelling catheter was shortened from 4.3 to 3.0 days by closing the tracts endoscopically. CONCLUSIONS: The overall cessation rate of the ET II was inferior to those of open anti-reflux surgeries or laparoscopic extravesical ureteral reimplantation. We do not recommend ET II for vesicoureteral reflux.

Does MICA influence acute rejection in kidney transplantation?

MHC class 1-related chain A (MICA) has been reported to be recognized by specific antibodies in the sera of transplanted patients, and it may be a target molecule in allograft rejection. MICA was originally pointed out to be an HLA-related polymorphic gene, the product of which may be recognized by a subpopulation of intestinal gamma delta T-cells and may play a role in the activation of a subpopulation of natural killer cells. Although their association with chronic rejection has been demonstrated before, there are few reports of any relation with acute rejection. We encountered a possible case of MICA-related acute early rejection. The recipient was a 25-year-old female; the original disease was IgA nephropathy, and the hemodialysis period was 12 months. She underwent ABO-compatible living-related renal transplantation from her mother. The HLA type was A24, A31, B7, B52, DR1, and DR15 in the donor and A31, A33, B7, B44, DR1, and DR12 in the recipient. A pre-operative direct cross-match was negative by a conventional cytotoxic test, and HLA class 1 and 2 antibodies were negative by LABScreen single antigen testing. Induction immunosuppressive therapy was started with TAC, MMF, MP, and BXM. The graft functioned at once, and SCr was 2.4 mg/dl on post-transplant day 1. SCr increased from post-transplant day 2, and oliguria progressed. Hemodialysis was restarted on post-transplant day 6. A biopsy revealed Banff 2b vascular rejection. The graft was finally rescued by steroid pulse and plasma exchange therapy. SCr went down to 1.07 mg/dl, and a re-biopsy showed improvement on post-transplant day 42. HLA class 1 and 2 antibodies were negative during this period, and MICA019 antibody was higher before transplantation retrospectively. Additionally, this antibody titer was decreased at the time of discharge. These data show that MICA may induce rejection in the early phase of renal transplantation. Further study is needed to evaluate this phenomenon.

[Prolonged complete remission of multiple organ metastases after radical nephrectomy induced by interferon-alpha therapy: a case report].

We experienced a case of advanced renal carcinoma that showed complete remission to interferon-alpha therapy. A 76-year-old male underwent radical nephrectomy for left renal cell carcinoma (pT3b pN0 M0, stage III). Two and a half months later, chest X-ray, computed tomographic (CT) scan and ultrasonography revealed multiple lung metastases and a hepatic metastasis simultaneously. We started the intramuscular administration of natural interferon-alpha (OIF, 5 MIU) combined with cimetidine everyday. It caused leukopenia, a possible side-effect of interferon-alpha. We reduced the dose to three times a week. The lung metastases and hepatic metastases disappeared after 5 and 12 months, respectively. After we reduced the dose to once a week, there was no evidence of disease for 21 months.

A new endoscopic ureteral reimplantation for primary vesicoureteral reflux (endoscopic trigonoplasty II).

PURPOSE: We describe a new technique of endoscopic antireflux surgery. The principle of the procedure is to make a reliable muscular backing and elongate the intramural ureter. MATERIALS AND METHODS: We performed this new endoscopic surgery in 8 female patients in whom 4, 1, 8 and 1 refluxing ureters (total 14) were diagnosed with grades I to IV reflux, respectively. The operation consists of 3 steps. Two 5 mm. locking trocars are placed into the bladder. Irrigation is done with 3% D-sorbitol solution and the bladder wall is incised upward along each side of the ureter using a resectoscope to make a 2 to 3 cm. U-shaped bladder flap, including the ureter. Under pneumobladder the incised muscle is sutured to make a muscular bed with a needle holder via the urethra and forceps via the abdominal trocar. The U flap is fixed with 2 distal anchor sutures on the embedded muscular layer and 4 additional sutures are placed to approximate the mucosa of the U-shaped flap and bladder. RESULTS: Mean operative time was 245 minutes. Ureteral injury occurred in 2 patients. A Foley catheter remained indwelling for 3 to 5 days (mean 4.1). Reflux resolved in 12 of the 14 ureters (86%) 12 months postoperatively. Vesicoureteral reflux persisted in 1 case because of insufficient fixation and recurred in 1 because of ureterovesical fistula. The patients were satisfied with better cosmesis and minimal postoperative discomfort. CONCLUSIONS: We believe that procedure is feasible for female patients with primary vesicoureteral reflux.