Successful renal transplantation for a patient with pyoderma gangrenosum.

Pyoderma gangrenosum (PG), a rare skin disease of unknown etiology, forms intractable skin ulcers at surgical or traumatic sites. This case is a 40-year-old woman with PG who experienced end-stage renal disease due to type 1 diabetes mellitus. Arteriovenous fistula (AVF) creation and peritoneal dialysis introduction were considered to be difficult, because this patient had a history of developing intractable aseptic ulcers at surgical sites. Therefore, she continued hemodialysis via a temporary catheter. With frequent catheter exchange, there was stenosis of both the femoral veins and the internal jugular vein. Therefore, a hemodialysis catheter that could be used for the long term was inserted into the left jugular vein as a final site. To prevent the patient not being able to continue hemodialysis, we performed a kidney transplantation to save her life. We performed a blood type-compatible, living donor kidney transplantation after confirming the absence of active skin lesions. The 69-year-old donor was her mother. Induction immunotherapy started with tacrolimus, mycophenolate mofetil, steroids, and basiliximab. Intravenous pulses of methylprednisolone were performed to prevent ulceration of the surgical site on days 0-2 (500 mg/d). The postoperative course was excellent. After the operation, ulceration of the surgical site was never observed. The serum creatinine value was 0.87 mg/dL at 6 months. To our knowledge, renal transplantations for a patient with PG has not been previously reported.

Conversion from mycophenolate mofetil to mizoribine for patients with positive polyomavirus type BK in urine.

It is known that administration of mycophenolate mofetile (MMF) is associated with BK virus (BKV) nephropathy in renal transplant recipients. To determine any inhibitory effect of mizoribine for BKV, seven patients with positive BKV in their urine who took MMF as immunosuppressive therapy were evaluated after MMF was changed to mizoribine. Baseline BKV DNA in urine, which ranged from 2.2 x 10(2) to 5.5 x 10(6) copies per milliliter, decreased in all cases (mean = 1.9 x 10(-1) times; median 2.8 x 10(-3) times). Four cases turned negative within 6 months and one within 12 months. No acute rejection or deterioration of graft function occurred during the administration of mizoribine. An inhibitory effect of mizoribine on BKV was suggested.

Use of marginal organs from non-heart-beating cadaveric kidney donors.

BACKGROUND: The severe shortage of cadaver donor kidneys for transplantation has prompted many centers to utilize older donor kidneys, which have been associated with lower graft survival rates. The aim of the present study was to examine the availability and feasibility of considering kidneys from donors over the age of 60. METHOD: We studied 252 cadaveric renal transplant recipients (156 males, 96 females) who received kidneys from uncontrolled non-heart-beating donors between 1987 and 1997. We performed in situ cooling with especially designed double-balloon catheters to minimize warm ischemic kidney damage. Recipients were classified according to donor age (age 60), and we examined graft survival rates. All patients were followed for a minimum of 1 year after transplantation. RESULTS: Graft survival rates for recipients of kidneys from the older donor group at 1, 5, and 10 years after transplantation were 77%, 37%, and 30%, respectively. Corresponding values for the younger donor kidney recipients were 87%, 64%, and 47%, respectively (P=0.0011). Improved survival rates were noted when older kidneys were used for lighter weight recipients (<54 kg). No other significant factors impacted on older donor graft survival rates. CONCLUSION: Older donor kidneys are associated with poorer graft survival rates. However, kidney transplants from older donors can be quite effective in lighter weight recipients (<54 kg).

Crossreactivity between human and canine Ia antigens using a mouse monoclonal antibody (CIA).

A mouse monoclonal antibody (CIA) produced against human Ia antigens that reacts with 20-30% of human peripheral blood lymphocytes was found to react with more than 90% of dog lymphocytes. Less than 41% of the Ia-positive dog lymphocytes expressed surface immunoglobulins. Immunoprecipitation studies with 125I-labeled cells precipitated heavily labeled Ia bands at 28K and 35K from human cells, but from dog cells the 29K beta chain of Ia was much more heavily labeled than the alpha chain.

Magnetic resonance images of hematospermia.

Seminal vesicles and their adjacent structures were studied using magnetic resonance imaging (MRI) in 7 normal volunteers and 15 patients with hematospermia. Normal seminal vesicles are depicted on T2-weighted images either as a mixture of high- and low-signal granules or as a convolution of tubules with a diameter of less than 0.5 cm. Fourteen of the 15 patients with hematospermia exhibited abnormalities on MRI. Dilatation or cyst formation in the seminal vesicle was observed in 13 patients, and a dilatation of the midline structure was seen in 3 patients. Abnormal signal intensity of the seminal vesicles was seen in 11 patients and was thought to be due to subacute hemorrhage.

Laparoscopic radical nephrectomy for renal cell carcinoma: a five-year experience.

OBJECTIVES: To evaluate the efficacy of laparoscopic radical nephrectomy for patients with small renal cell carcinoma by comparing the clinical results of patients treated laparoscopically with those of patients treated with traditional open radical nephrectomy. METHODS: Of 100 patients with localized, small (less than 5 cm in diameter) renal cell carcinoma treated by the same surgical team between 1992 and 1998, 60 patients underwent laparoscopic radical nephrectomy and 40 underwent open radical nephrectomy. Of the 60 laparoscopically treated patients, the first 11 and the most recent 34 patients were operated on transperitoneally and the other 15 retroperitoneally. RESULTS: The mean operative time of the laparoscopically treated patients was longer than that of the open nephrectomy patients (5.2 versus 3.3 hours, P<0.001). The mean blood loss of the laparoscopically treated patients was less than that of the open nephrectomy patients (255 versus 512 mL, P<0.001). One laparoscopically treated patient needed conversion to open surgery. The time to full convalescence of the laparoscopically treated patients was shorter than that of the open nephrectomy patients (23 versus 57 days, P<0.001). Two of the 59 laparoscopically treated patients and 1 of the 40 open nephrectomy patients had metastatic disease. The former 2 are alive with stable disease and the latter died of progressive disease 11 months after surgery. The 5-year disease-free rate was 95.5% in laparoscopy patients and 97.5% in open nephrectomy patients (P = NS). CONCLUSIONS: Laparoscopic radical nephrectomy is a less invasive alternative to open surgery for patients with localized small renal cell carcinoma.

Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience.

OBJECTIVES: Although laparoscopic radical nephrectomy is a safe and minimally invasive alternative to open surgery, the long-term disease-free outcome of this procedure has not been reported. We evaluated our experience with the laparoscopic management of renal cell carcinoma to assess the clinical efficacy of this surgical modality. METHODS: Between February 1991 and June 1997, 157 patients at five institutions were retrospectively identified who had clinically localized, pathologically confirmed, renal cell carcinoma and had undergone laparoscopic radical nephrectomy. Operative and clinical records were reviewed to determine morbidity, disease-free status, and cancer-specific survival. Of the patients followed up for at least 12 months (n = 101), 75% had an abdominal computed tomography scan at their last visit. RESULTS: The mean age at surgery was 61 years (range 27 to 92) and all patients were clinical Stage T1-2,NO,MO. Fifteen patients (9.6%) had perioperative complications. During a mean follow-up of 19.2 months (range 1 to 72; 51 patients with 2 years or more of follow-up), no patient developed a laparoscopic port site or renal fossa tumor recurrence. Four patients developed metastatic disease, and 1 patient developed a local recurrence. The 5-year actuarial disease-free rate was 91%+/-4.8 (SE). At last follow-up, there were no cancer-specific mortalities. CONCLUSIONS: The laparoscopic surgical management of localized renal cell carcinoma is feasible. Short-term results indicate that laparoscopic radical nephrectomy is not associated with an increased risk of port site or retroperitoneal recurrence. Longer follow-up is necessary to compare long-term survival and disease-free rates with those of open surgery.

Detection of muscle layer invasion with submillimeter pixel MR images: staging of bladder carcinoma.

Conventional magnetic resonance (MR) images used for the pelvic organs generally have a pixel size of 1.3 mm x 1.3 mm. We obtained images with a higher resolution than conventional images, and evaluated the usefulness of this type of image in staging urinary bladder carcinoma. Twenty-six patients having either transurethral resection of bladder tumor (TUR-BT) or cystectomy were retrospectively studied. T2-weighted images of the bladder were acquired with a 20 cm field-of-view, a matrix size of 224 x 224 (pixel size: 0.9 mm x 0.9 mm), and a slice thickness of 7 mm using a 0.5 T system. MR appearances of the carcinoma were divided into the following five categories: no abnormality found on the inner surface of the bladder wall (0), high signal layer or protrusion without breakage of the wall (I), partial disruption of the wall (II), transmural disruption of the wall (III), and complete disruption with mass formations in the perivesicular region (IV). These findings were correlated with the TNM pathologic staging determined from each tissue specimen. A prediction for muscle layer invasion was calculated by selecting pathologic stage pT2 and MR category III as a boundary measure. The accuracy was 96.2%, the sensitivity 100.0%, and the specificity 91.7%. The results obtained indicate that submillimeter pixel MR imaging shows promise as a noninvasive method for the preoperative staging of bladder cancers.

Laparoscopic radical nephrectomy for renal cell carcinoma: early experience.

We developed a laparoscopic radical nephrectomy for malignant disease of the kidney and successfully performed the operation in six patients between July 1992 and October 1993. This procedure is basically derived from that of Clayman and associates. A CO2 pneumoperitoneum is induced, and five trocars are introduced into the abdominal cavity through the lateral abdominal wall. The kidney is removed en bloc together with the adrenal gland, perirenal fatty tissue, and Gerota's fascia. The free kidney is put into a laparoscopy sack, and the sack is pulled out through a 5- to 6-cm incision in the abdominal wall without morcellation to allow complete pathologic examination. By this procedure, right nephrectomy was performed in four patients and left nephrectomy in two patients. The mean operative time was 6 hours and 13 minutes, and the mean blood loss was 430 mL. There were no severe complications. The average hospital stay was 11 days, and the average time to full convalescence was 21 days. Pathologic examination revealed renal cell carcinoma in five patients and nephroblastoma in one. Of the patients with renal cell carcinoma, the stage was pT1pN0pM0 in three patients and pT2pN0pM0 in two. There has been no recurrent disease in these six patients with a mean follow-up period of 9.5 months.

Exploration of the system for cadaver kidney transplantation with the non-heart-beating donor: efficacy of in situ cooling and low-dose cyclosporine.

To expand the indication for the cadaveric kidney donor, the reduction of prolonged warm ischemic damage is the most important factor. We believe that the restriction of warm ischemic damage will be decreased by using the ISC procedure and low-dose CyA regimen.

Laparoscopic radical nephrectomy for renal cell carcinoma.

PURPOSE: To estimate the efficacy of the laparoscopic radical nephrectomy we analyzed the clinical data of our series. PATIENTS AND METHODS: One hundred eighty five patients were enrolled in our laparoscopic radical nephrectomy program between July, 1992 and July, 2001. Of the 185 patients, 146 had small renal tumors (smaller than 5 cm in diameter) and 39 had large tumors (equal to or more than, 5 cm in diameter). Under a laparoscope the kidney, adrenal gland, and perirenal fatty tissue were dissected in an en bloc fashion. In case of taking out a small tumor, the specimen was fractionated within the sack to avoid an additional skin incision after entrapping in the laparoscopy sack in the working space. In case of a large tumor, regional lymph nodes dissection was done and the specimen was taken out intact in the sack through an enlarged incision. RESULTS: Our laparoscopic procedure was successful in 171 of the 185 cases; 14 patients required open surgery because of bleeding from an injured vessels or treatment for other injured organs. The mean operative time was 4.7 hours for both small and large tumors. Estimated blood loss was between 237 and 380 ml on average for small and large tumors, respectively. Full convalescence was achieved around 3 weeks after operation in both groups. Only one patient who had large tumor was found to have micrometastasis in 1 of 5 regional lymph nodes. Recurrences were observed in 4 cases of the small tumor group and in 2 cases of the large tumor group during 1 to 108 months of follow-up. CONCLUSION: Laparoscopic radical nephrectomy is a very useful and safe surgical procedure for renal cell carcinoma.

[A case of recurrent yolk sac tumor of testis in a 3-year-old child successfully treated by VAC (vincristine, actinomycin-D, cyclophosphamide) therapy].

A case of recurrent yolk sac tumor in a three-year-and five-month old child is reported. Left high orchiectomy was performed two years earlier at which time no evidence of metastatic disease was demonstrated. Twenty-four months postoperatively, serum alpha-fetoprotein (alpha-FP) was elevated and recurrent mass appeared in the left para aortic region. Treatment by VAC regimen consisting of vincristine, actinomycin D and cyclophosphamide was performed. Complete response was obtained after two courses of this therapy, which was confirmed by retroperitoneal lymphadenectomy. We believe that this chemotherapy is effective and safe for the treatment of yolk sac tumor of infantile testis.

[The treatment and prognosis of acute late rejection after kidney transplantation].

To examine the acute late rejection episodes (ALR) occurring 4 months after kidney transplantation, 330 cadaver kidney transplant recipients who were operated on between 1982 and 1996 and immunosuppressed by cyclosporine or tacrolimus were analyzed. In 213 recipients who were followed up for 5 years or longer, the frequency of ALR without an acute early rejection (AER) was 14% and ALR with AER was 16%, respectively. ALR was the strongest deteriorating factor for graft survival at the chronic stage. Judging from the renal function 1 month after an ALR episode, the complete and partial response rates were 22% and 62% with steroid treatment and 16% and 58% with DSG treatment, respectively. The 5-year graft survival after the treatment was 20% with steroid treatment and 45% with DSG treatment. Although the intensity of the rejection classified based on the Banff grading system was the strongest factor affecting the graft survival, the multivariate analysis by Cox proportional hazard model for non-pathological factors revealed that urine protein and hypertension 1 month before the episodes may also be important prognostic factors. The body weight of recipient (> 55 kg) and donor age (> 55 y.o) were slightly correlated to the graft prognosis. Due to incomplete immuno-suppressive methods for acute late rejection, the conservative nephron sparing policy after a rejection episode is inevitable to obtain better graft survival at the chronic stage.

[A case of ureteral complication following endopyelotomy].

A case of ureteral complication observed after endopyelotomy is reported. A 19-year-old female patient suffering from right hydronephrosis due to uretero pelvic junction stenosis was treated with endopyelotomy. The stenotic ureter was incised by cold knife for a distance of 5 cm through full thickness. The cut ureteral segment was intubated with a ureteral stent catheter of 10 Fr calibre. The top of the catheter was advanced 1 cm from the edge of the incised ureter. To prevent protrusion of the catheter tip, a flexible guide wire 0.038 inches in diameter was inserted into the catheter and the tip of the guide wire was advanced to the bladder. Antegrade pyelography performed 3 weeks after the operation revealed a lesion resembling a pseudo-ureter. It was made by the catheter that had slipped out of the incised ureter. The lumen of the true ureter was also preserved without stenosis. After removal of the stent catheter and safety guide wire, the true ureter was intubated with a double J catheter of 10 Fr calibre. One week later the pseudo-ureter was not demonstrated by excretory urography performed. Finally, hydronephrosis due to uretero pelvic junction stenosis was treated successfully.

[Indication of neobladder replacement in patients undergoing radical cystectomy for bladder cancer].

Neobladder replacement has become an important procedure in the patient undergoing radical cystectomy for invasive bladder cancer. It yields postoperatively excellent quality of life in these patients. The indications of the patients selection have not been established, since long-term clinical results have not been presented and some issues such as urethral recurrence of the original disease, growth of the cancer from the neobladder made of the gastrointestinal tract and influences arising from orthotopic micturition are still unclear. We reviewed the reports describing neobladder replacement in the patients undergoing cystectomy for the bladder cancer. At present the criteria of patients selection described by most authors can be summarized as follows, (1) male patients, (2) patients having an available gastrointestinal tract for reconstructing the neobladder, (3) patients having a good renal function and liver function and could tolerate for the surgery and (4) patients with no evidence of disease in their urethra and prostate (direct invasion of the disease). As to carcinoma in situ within the bladder, some authors included their indication and the others contraindication.

[Surgical removal of the staghorn calculi in the solitary kidney patients].

Seven patients undergoing surgical removal of extensive renal calculi involving a solitary kidney are reviewed. Problems arising from the surgery for the extensive renal calculi in a solitary kidney patient are demonstrated and indication of the surgery is also discussed. From January, 1978 to July, 1984, extensive renal calculi were removed in 7 solitary kidney patients. The operative technique for removing calculi consisted of anatrophic nephrolithotomy (in 2 patients) and ex vivo surgery (in 5 patients). There were 2 operative deaths and 2 major complications. Calculi were completely removed in 6 and 1 patient undergoing anatrophic nephrolithotomy, had a 3 X 4 mm residual calculus. The postoperative serum creatinine was improved in 5 patients. These major complications were observed in the patients who had severe renal dysfunction during the early postoperative period. It was indicated that good renal function should be maintained even during the early postoperative period in the surgery on a solitary kidney patient. Investigating injury to the operated kidney, the early postoperative serum creatinine level was analysed in these 7 patients and 3 patients undergoing ex vivo surgery for removal of aneurysm in a solitary kidney. The results indicated that nephrotomy was the most extensive damage to the kidney. However, pyelotomy and cold ischemia during ex vivo surgery, are not always harmful. In performing surgery for extensive renal calculous disease involving a solitary kidney, we should choose pyelotomy rather than nephrotomy in in situ operation. Ex vivo surgery can provide an effective treatment.

[Descent of right renal vein--a case report].

Renal descensus with the descent of right renal vein and ureteroureterostomy was carried out in a 61-year-old male patient. The patient had a 9 X 6 mm calculus in his right kidney and 2 cm long stricture in his right upper ureter that had been caused by the previous surgery for ureteral calculus. This operation, which was described by Gil-Vernet, provided excellent results without any complications.

[A case report of inverted papilloma of the posterior urethra].

Sixty-seven cases of inverted papilloma have been reported in many anatomical sites of urinary tract but only 9 cases involving the posterior urethra have been described in Japan. We report the 10th case of inverted papilloma of the posterior urethra in a 27-year-old male who complained of macroscopic hematuria. The lesion was diagnosed cystoscopically and treated by transurethral resection.

[Renal autotransplantation and ex vivo surgery in renal calculus disease].

Renal autotransplantation and ex vivo surgery in renal calculus disease are reviewed and their indications were discussed. In recent years, renal autotransplantation and ex vivo surgery have been applied in the management of renal calculus diseases. This technique has been believed to be a complete method for removing extensive renal calculi. However, this technique has some disadvantages such as technical difficulties and serious complications. Therefore, this technique should be indicated for cases carefully selected. At present, indications of this technique in the management of renal calculus disease are as follows; multiple or complicated calculi contained in a solitary kidney with narrow infundibla and dilated calices or in the kidney with history of previous surgery for calculus disease. This technique might not be chosen in those cases with perihilar inflammation, uncontrollable infection in the kidney or extensively damaged kidney (S-Cr 2.5 mg/dl, especially in solitary kidney).

[The residual calculi in conservative operation for renal calculi].

One hundred and three kidneys with calculi in 100 patients, were treated by conservative renal surgery from Jan., 1980 to Dec., 1982. The operative technique consisted of pyelolithotomy, extended pyelolithotomy, dismembered pyelolithotomy, nephrolithotomy (bivalve or anatrophic nephrolithotomy) partial nephrectomy and pyelo-nephrolithotomy. Intraoperative X-ray and coagulum lithotomy were employed when pyelolithotomy was performed. Thirty-five residual calculi in 20 kidneys were observed on postoperative X-ray film. The rate of residual calculi was 19.4%. Factors causing residual calculi, were analysed on these 103 kidneys. The factors were as follows; the shape of calculi: staghorn calculus with multiple small calculi, the shape of the renal collecting system: narrow pelvis with narrow caliceal neck and dilatated calices, and the operative technique: nephrolithotomy. These results suggested that it would be necessary to minimize residual calculi when performing nephrolithotomy.