Preservation of the right atrial appendage improves reduced plasma atrial natriuretic peptide levels after the maze procedure

OBJECTIVES

The present study was conducted to determine whether preservation of the right atrial appendage lessens the decrease of plasma atrial natriuretic peptide levels after the maze procedure and whether the increase of plasma atrial natriuretic peptides improves the ability of the kidneys to excrete the fluid load after the operation.

METHODS

We evaluated 42 patients who underwent the maze procedure. The right atrial appendage was preserved in 22 patients but not in 20. Blood samples were obtained before and after the operation for measurement of atrial natriuretic peptides. To evaluate the influence of atrial natriuretic peptides on the ability of the kidneys, we also measured body weight, fluid balance, and the doses of furosemide and dopamine administered after the operation.

RESULTS

The restoration to sinus rhythm at 1 month after was comparable in the two groups. Plasma atrial natriuretic peptide levels significantly increased after the operation in patients in whom the right atrial appendage was preserved (1 day after: 23.4 +/- 17.8 vs 3 days after: 42.7 +/- 23.6 and 7 days after: 36.3 +/- 23.7 pg/mL, P <.05) but not in patients in whom the right atrial appendage was not preserved (1 day after: 20.0 +/- 19.6, 3 days after: 28.5 +/- 19.3, and 7 days after: 23.0 +/- 16.1 pg/mL). Furthermore, plasma atrial natriuretic peptide levels were significantly lower in patients in whom the right atrial appendage was not preserved than in patients in whom the right atrial appendage was preserved at 3 and 7 days after the operation. The fluid balance during the first 7 days of the postoperative period was comparable in the two groups, although the total dose of dopamine used in the same period was significantly smaller in patients in whom the right atrial appendage was preserved than in patients in whom the right atrial appendage was not preserved (155.3 +/- 119.0 vs 244.9 +/- 129.0 microg/kg, P <.05).

CONCLUSIONS

The present study showed that preservation of the right atrial appendage lessens the decrease of plasma atrial natriuretic peptide levels after the maze procedure and that increased plasma atrial natriuretic peptides may improve the ability of the kidneys to excrete the fluid load after the operation.

Major racial differences in coronary constrictor response between japanese and caucasians with recent myocardial infarction

BACKGROUND

Enhanced coronary vasomotion may contribute to acute coronary occlusion during the acute phase of myocardial infarction (AMI). Japanese have a higher incidence of variant angina than Caucasian patients, but racial differences in vasomotor reactivity early after AMI are controversial.

METHODS AND RESULTS

The same team studied 15 Japanese and 19 Caucasian patients within 14 days of AMI by acetylcholine injection into non-infarct-related (NIRA) and infarct-related (IRA) coronary arteries followed by nitroglycerin. Incidence of vasodilation, vasoconstriction, spasm, and basal tone were assessed in proximal, middle, and distal segments after each drug bolus by quantitative angiography. Japanese patients had much lower cholesterol levels than Caucasians (183+/-59 versus 247+/-53 mg/dL, P<0.006) but showed a lower incidence of vasodilation (2% versus 9% of coronary segments) and a greater incidence of spasm after acetylcholine (47% versus 15% of arteries, P<0.00001). Incidence of spasm was higher in IRAs than in NIRAs in both populations (67% versus 39% and 23% versus 11%, respectively). Multivessel spasm was more common (64% versus 17%, P<0.02) and vasoconstriction of nonspastic segments was greater in Japanese patients (-23.4+/-14.9% versus -20.1+/-15.7%, P<0.02) in the presence of similar average basal coronary tone with respect to post-nitroglycerin dilation and of nonsignificant differences of coronary atherosclerotic score.

CONCLUSIONS

Soon after AMI, Japanese patients exhibited a 3-fold-greater incidence of spasm and greater vasoconstriction of nonspastic segments after acetylcholine than Caucasians. The causes of such differences warrant further investigation because they may have relevant pathophysiological and therapeutic implications.

Efficacy of maternal serum screening in the prenatal detection of fetal chromosome abnormalities in Japanese women

OBJECTIVE

This prospective study assesses the efficacy of maternal serum screening for use in prenatal diagnosis of fetal anomaly and chromosome imbalance in Japanese women.

METHODS

Maternal serum alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol were measured in 1,055 singleton pregnant women between 14 and 20 weeks of gestation. A calculated risk for trisomy 21 of >/=1/299 or alpha-fetoprotein >/=2.5 multiples of the median was adopted as positive.

RESULTS

Three hundred and seventy-eight of the 1, 055 women screened (35.8%) were identified as positive. Sensitivity, false-positive rate, and positive predictive value in women aged <35 years were 60.0, 10.6, and 6.8%, respectively, and these values were 87.5, 49.3, and 4.2%, respectively, in women aged >/=35 years. The false-positive rate in women aged <35 years was significantly lower than that for women aged >/=35 years (p < 0.001). Chromosomal abnormalities were identified in 21 cases, including 10 with trisomy 21, 5 with trisomy 18, 2 with trisomy 13, and 4 with other chromosomal disorders. Seventeen of the 21 cases (81.0%) showed screen-positive results, and among these all 10 cases with trisomy 21 were detectable. Two cases with trisomy 18, 1 with trisomy 13 and 1 with isochromosome X showed extremely low human chorionic gonadotropin levels (0.4 +/- 0.1 multiples of the median, mean +/- SE), although they were screen negative. Of the 264 women who did not undergo amniocentesis, none had any clinical findings consistent with aneuploidy after birth.

CONCLUSIONS

Our results suggest that the evaluation of each serum marker, as well as of the calculated risk, was significantly important in the prenatal detection of fetal aneuploidy.

Bacterial triterpenoids of the hopane series as biomarkers for the chemotaxonomy of Burkholderia, Pseudomonas and Ralstonia spp

Hopanoid fingerprints allowed to differentiate bacteria formerly connected to the genus Pseudomonas. Whereas all strains related to Pseudomonas and Ralstonia were devoid of any detectable hopanoid, these pentacyclic triterpenoids were found in the Burkholderia species and in related soil isolates, which contained as main hopanoid a bacteriohopanetetrol carbapseudopentose ether, accompanied by significant amounts of its novel Delta(6) unsaturated homologue. Unsaturated hopanoids represent an extremely rare feature in soil bacteria and the only known indication for a catabolism of this pentacyclic carbon skeleton in bacteria.

Insulin-like growth factor-I improves recovery of cardiac performance during reperfusion in isolated rat heart by a wortmannin-sensitive mechanism

Insulin-like growth factor-I (IGF-I) has been shown to produce a short-term positive inotropic effect (PIE) in the myocardium under nonischemic conditions. IGF-I also conferred cytoprotection against ischemia and reperfusion injury in various organs. IGF-I may, therefore, facilitate the recovery of postischemic cardiac function. Isolated and crystalloid-perfused rat heart was subjected to 25 min of normothermic ischemia followed by 30 min of reperfusion. IGF-I produced PIE in a dose-dependent manner at concentrations ranging between 1 and 100 nM under nonischemic conditions. Although 1 nM isoproterenol produced much greater PIE and myocardial energy conversion efficiency (MECE) than did 65 nM IGF-I in this condition, the same concentration of IGF-I administered during reperfusion conferred better recovery of left ventricular function and MECE compared with isoproterenol. The improved cardiac performance by IGF-I was associated with lower release of creatine kinase (CK). Wortmannin (100 nM), a specific inhibitor of phosphatidylinositol kinase (PI-3 kinase), abrogated IGF-I-induced improvement of contractile function and inhibition of CK release in the postischemic heart. We conclude that IGF-I administered during reperfusion accelerates recovery of cardiac performance and mitigates myocardial injury through a wortmannin-sensitive mechanism.

Redirection of hepatic venous drainage after total cavopulmonary shunt in left isomerism

BACKGROUND

Conversion from total cavopulmonary shunt (TCPS) to the Fontan circulation can improve cyanosis in patients with potential risks of development of pulmonary arteriovenous fistula (PAVF).

METHODS

Inclusion of the hepatic veins in the pulmonary circulation was employed using an intra-atrial tube graft in 5 patients with left isomerism previously undergoing TCPS. Prior to the conversion, abnormal communication was identified between the azygos vein and either the hepatic or the portal vein in all. PAVF was seen in 3.

RESULTS

All patients survived the procedure. Postoperative catheterization showed 13 +/- 2 mm Hg of superior caval venous pressure, and 2.3 +/- 0.4 L/min/m2 of cardiac index. Pulmonary arteriovenous fistula progressed markedly in the right lung even after the conversion in 2 patients, in whom the hepatic veins had been exclusively diverted to the left lung. Arterial oxygen saturation became below 65%, with exercise capacity reduced, in these 2 patients. The other patients remain asymptomatic.

CONCLUSIONS

Total cavopulmonary shunt can be efficiently converted to the Fontan circulation by appropriately redirecting hepatic venous drainage to perfuse both lungs in a balanced fashion.

A randomized comparative study of the Bandloop versus the standard loop for transurethral resection of the prostate

PURPOSE

The Bandloop is a new electroresection loop that is broader than the standard loop and thickens from front to back. We compared the safety and efficacy of the Bandloop to the conventional loop electrode for transurethral prostatectomy.

MATERIALS AND METHODS

A randomized prospective study was performed on 53 patients with lower urinary tract symptoms and estimated prostatic volume greater than 30 ml. on transrectal ultrasonography. The Bandloop was used in 25 cases (Bandloop group) and standard loop was used in 28 (standard group). Surgical outcomes, including International Prostate Symptom Score, resected prostatic weight, operative time, uroflowmetry, post-void residual urine, postoperative catheterization period, time to disappearance of macrohematuria, and serial changes of hemoglobin and urinalysis, between the 2 groups were compared.

RESULTS

A total of 23 Bandloop and 28 standard loop cases were evaluable. There was no difference in preoperative estimated prostatic volume (mean 44.7 versus 47.8 ml.), resected prostatic weight (36.5 versus 29.4 gm.) or operative time (61 versus 60 minutes) between the 2 groups. The ratio of resected weight-to-estimated prostatic volume was significantly greater in the standard group (81.4% versus 61.9%). There was no difference in postoperative catheterization period (3.3 versus 3.4 days) or time to disappearance of macroscopic hematuria (5.0 versus 5.0 days). Postoperative changes in symptom score (-15.1 versus -15.9), maximum flow rate (11.8 versus 16.3 ml. per second at 12 weeks) and residual volume (-31.6 versus -48.6 ml. at 12 weeks) demonstrated no significant difference between the 2 groups. There was no difference in intraoperative and postoperative bleeding estimated by serial changes in serum hemoglobin and urinalysis after surgery. No patient had major complications or required transfusion.

CONCLUSIONS

Transurethral prostatectomy using the Bandloop is as safe and effective in achieving subjective and objective improvements as standard transurethral prostatectomy. However, our randomized study indicates that the Bandloop offers no advantage compared to the standard loop electrode for transurethral prostatectomy.

[Maze procedure for a lone atrial fibrillation]

Between 1992. 2 and 1997. 12, the maze procedure for lone fibrillation or flutter (lone af) was performed in 8 patients including 2 patients with a sustained atrial fibrillation, 5 patients with a paroxysmal atrial fibrillation and 1 patient with a sustained atrial flutter. All patients had suffered from a drug resistance lone af which induced sever symptom that is the dyspnea, palpitation and fatigue. Therefore patients requested to receive the maze procedure, and they agreed with the informed concent. After the maze operation, the normal sinus rhythm was recovered in 7 of 8 patients (87.5%). In only 1 patient, a paroxysmal atrial fibrillation remained but his symptoms improved after surgery. So this operation is a good choice of a treatment for a drug resistance lone af.

A study on the lectin reactivity of alpha-fetoprotein produced by hepatoid adenocarcinomas and yolk sac tumors

The carbohydrate structure of glycoproteins is considered to be tissue-specific or cell type-specific, but there have been no reports on the differences of the carbohydrate structure of alpha-fetoproteins (AFPs) produced by histologically identical tumors in different tissues. The lectin affinity electrophoresis of hepatoid adenocarcinomas and yolk sac tumors from different organs suggested that either the tumor heterogeneity or the tissue specificity is possibly involved, the lectin reactivity of the AFP sugar chain structure produced by the tumors in different tissues.

Recent trends in the prevalence of Down syndrome in Japan, 1980-1997

The aims of the present study were to determine recent trends in the prevalence of Down syndrome (DS) in Japan, and to determine whether recent changes in demographic and social habits and access to prenatal diagnosis have influenced the livebirth rates of DS. Livebirth statistics indicate that the birth rate in Japan has decreased for women in their 20s and has increased for those in their 30s and 40s. During an 18-year period between 1980 and 1997, 1,299 consecutive DS infants were born among a total of 2,232,694 births, a rate corresponding to approximately 10% of all births in Japan over the same period. The increasing risk of DS with advancing maternal age was confirmed. The overall prevalence was 5.82 DS births per 10,000 livebirths (8.3-9.7 per 10,000 after correction according to the estimated ascertainment ratio: 60-70%). The prevalence rate by year of child birth represents a statistically significant increase (P = 0.001). In conclusion, recent trends in the prevalence of DS in Japan from 1980 to 1997 failed to show a consistent tendency to decrease, probably because of the concomitant increase in pregnancy in advanced maternal age.

Effects of aspirin and trapidil on cardiovascular events after acute myocardial infarction. Japanese Antiplatelets Myocardial Infarction Study (JAMIS) Investigators

Aspirin therapy confers conclusive net benefits in the acute phase of evolving myocardial infarction, but no clear evidence of benefit from the long-term use of aspirin after acute myocardial infarction (AMI) has been shown in any single study. This multicenter study, the Japanese Antiplatelets Myocardial Infarction Study, was performed to find out whether aspirin or trapidil would improve clinical outcome compared with no antiplatelets in postinfarction patients. The study was a multicenter, open-label, randomized controlled trial of aspirin 81 mg/day, trapidil 300 mg/day, and no antiplatelets in patients with AMI admitted within 1 month from the onset of symptoms. Seven hundred twenty-three patients were enrolled at 70 hospitals in 18 prefectures of Japan; 250 were randomly assigned to treatment with 81 mg aspirin (aspirin group), 243 to that with trapidil (trapidil group), and 230 were not given antiplatelet agents. The mean follow-up period was 475 days. This study demonstrated that long-term use of aspirin at the dose of 81 mg/day reduced the incidence of recurrent AMI compared with the group receiving no antiplatelets after AMI (p = 0.0045) and that trapidil also reduced the occurrence of reinfarction compared with the group receiving no antiplatelets, but the difference was not significant (p = 0.0810). The incidence of cardiovascular events including cardiovascular death, reinfarction, uncontrolled unstable angina requiring admission to hospital, and nonfatal ischemic stroke was reduced in the group receiving 300 mg trapidil daily compared with the group receiving no antiplatelets (p = 0.0039). The use of aspirin 81 mg/day provided almost no benefit over no antiplatelets therapy in the incidence of cardiovascular events. In conclusion, low-dose aspirin (81 mg) effectively prevented recurrent AMI in postinfarction patients after thrombolysis or coronary angioplasty when used over a long term. Furthermore, the long-term use of trapidil resulted in a significant reduction in the incidence of cardiovascular events.

Breastfeeding twins: guidelines for success

BACKGROUND

Although the frequency of twin births has increased in Japan, little information is available about breastfeeding twins. An intervention of breastfeeding support was implemented to promote breastfeeding for mothers of twins and to compare the factors related to breastfed and formula-fed twins.

METHODS

Eleven Japanese twins-mother pairs received breastfeeding support according to a breastfeeding protocol for twins, and a control group of seven pairs received routine care. Perinatal data were obtained from clinical records for analysis.

RESULTS

No significant differences were evident between the two groups in terms of maternal age, gestational age, birthweight, the age at which breastfeeding was initiated, amount of supplementary feeding in hospital, infants' age at discharge, or duration of mothers' hospital stay. At age 3 months, 13 infants in the intervention group were being exclusively breastfed and 9 were almost exclusively breastfed. In the control group 4 infants were almost exclusively and 10 were exclusively formula-fed. The mothers in the intervention group breastfed and expressed milk significantly more frequently than the mothers in the control group during their hospital stay.

CONCLUSIONS

Mothers of twins face many obstacles in breastfeeding, and health care professionals should offer individualized care and support.

Tissue factor pathway inhibitor-2 is a novel mitogen for vascular smooth muscle cells

A mitogen for growth-arrested cultured bovine aortic smooth muscle cells was purified to homogeneity from the supernatant of cultured human umbilical vein endothelial cells by heparin affinity chromatography and reverse-phase high performance liquid chromatography. This mitogen was revealed to be tissue factor pathway inhibitor-2 (TFPI-2), which is a Kunitz-type serine protease inhibitor. TFPI-2 was expressed in baby hamster kidney cells using a mammalian expression vector. Recombinant TFPI-2 (rTFPI-2) stimulated DNA synthesis and cell proliferation in a dose-dependent manner (1-500 nM). rTFPI-2 activated mitogen-activated protein kinase (MAPK) activity and stimulated early proto-oncogene c-fos mRNA expression in smooth muscle cells. MAPK, c-fos expression and the mitogenic activity were inhibited by a specific inhibitor of MAPK kinase, PD098059. Thus, the mitogenic function of rTFPI-2 is considered to be mediated through MAPK pathway. TFPI has been reported to exhibit antiproliferative action after vascular smooth muscle injury in addition to the ability to inhibit activation of the extrinsic coagulation cascade. However, structurally similar TFPI-2 was found to have a mitogenic activity for the smooth muscle cell.

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.

Staged reperfusion preserves the coronary flow reserve, especially in the regions not severely damaged by ischemic injury in the canine heart

The objective of this study was to determine the effects of staged reperfusion on the progressive reduction in coronary blood flow (CBF) and coronary flow reserve during reperfusion and on the infarct size in the canine heart. Fifteen dogs underwent 90 min of left circumflex coronary artery occlusion and 3 hr of reperfusion. In the abrupt reperfusion group, the occluder was released completely at the initiation of reperfusion. In the staged reperfusion group, CBF was maintained at 20% of preocclusion values for 10 min after initiation of reperfusion, then gradually released, and completely released 20 min after initiation of reperfusion. There was no significant difference in CBF between the staged (n = seven) and abrupt (n = eight) groups after 3 hr of reperfusion. The repayment of flow debt in the staged reperfusion group was significantly greater than in the abrupt reperfusion group after 3 hr of reperfusion (260+/-120% vs 100+/-60%, staged vs abrupt at 3 hr, p < 0.03). The ratio of peak reactive hyperemic flow to resting flow in the staged reperfusion group was significantly greater than in the abrupt reperfusion group throughout the reperfusion phase (4.4+/-1.0 vs 2.6+/-0.6 at 3 hr, p < 0.001), and had returned to the preocclusion values after 3 hr of reperfusion. This preservation of the coronary flow reserve in the staged reperfusion group was observed in the epicardium (4.1+/-0.6 vs 2.8+/-0.7, staged vs abrupt at 3 hr, p < 0.01), but not in the endocardium or midmyocardium. Infarct size did not differ significantly between the two groups. Staged reperfusion in this study did not appear to attenuate the reduction of CBF, or to reduce infarct size, however preserved the coronary flow reserve, especially in the regions not severely damaged by ischemic injury.

[Surgical treatment for mitral regurgitation associated with secundum atrial septal defect]

We reviewed 25 patients who underwent a mitral valvuloplasty, from 1984 to 1996, for mitral regurgitation (MR) associated with atrial septal defect (ASD). Mean grade of MR was 2.3 +/- 0.7. The locations of mitral valve lesion were as follows; Postero-medial side of the anterior leaflet (AML) (11 patients: 44%), posteromedial side to center of the AML (7 patients: 28%), whole of the AML (5 patients: 20%), center of the AML (1 patient: 4%), posteromedial side of the posterior leaflet (PML) (1 patient: 4%). In summary, the mitral valve lesion was located in the AML in 96% patients and were seen in the postero-medial side of 96% patients. Mitral valve repair was performed as follows; chordae shortening only (3 patients: 12%), chordae shortening + Kay's annuloplasty (9 patients: 36%), Kay's anuloplasty (10 patients: 40%), using artificial chordae only (1 patient: 4%), using artificial chordae + Kay's annuloplasty (1 patient: 4%), using artificial chordae + ring annuloplasty (1 patient: 4%). In 24 patients, the grade of MR was less than 2/4 in the early postoperative period. In one patient, the grade of 3/4 MR was still remained. Reoperation were required in 2 patients, because of gradual increase of MR, 9 years and 10 years after the initial operation, respectively. In another patient, the grade 3/4 MR recurrently occurred at 6 months after the operation. He has been well maintained medically. In all 4 patients who had more than the grade 3/4 MR postoperatively, the annuloplasty was performed with Kay's method and the cause of MR was poor coaptation around the center of the AML. The mitral valve lesion associated with ASD seemed to be the dislocation of the AML which cause the discrepancy of the coaptation zone between both leaflets, without any prominent prolapse and chordae elongation. We put a particular emphasis on that the mitral valve repair should be performed with the recognition of the etiology of the mitral valve lesion. Especially, if the lesion extends around the center of the AML, sufficient coaptation area of both leaflets at the center of the AML should be obtained by anuloplasty.

[Long-term results and quality of life of hemi-Kock orthotopic ileal neobladder after radical cystectomy]

We analyzed the long-term results and the quality of life in patients who received orthotopic lower urinary tract reconstruction using the Kock ileal neobladder. Between July 1990 and October 1993, 37 consecutive patients including 2 females received orthotopic hemi-Kock neobladder after radical cystectomy. In these patients, we analyzed the urinary continence, complications and urethral recurrence, and performed a questionnaire survey by mail. Good continence all day had been achieved in 71% of the patients 4 years after surgery. The rate of the pouch-related complications requiring reoperation was 27%. There was no urethral recurrence. Compared with preoperative conditions, 42% were not satisfied with urination. In these dissatisfied patients, the need to use pads in the daytime, sensation of residual urine and weak urine stream were significantly more frequent than in satisfied patients. In summary, the rate of complications was higher than that of other methods. However, the Kock orthotopic ileal neobladder is a stable procedure providing good function over the long-term.

Relation of electrocardiographic left ventricular hypertrophy with and without T-wave changes to systemic blood pressure, body mass, and serum lipids and blood glucose levels in Japanese men

Left ventricular (LV) hypertrophy, especially combined with an abnormal ST-T, is considered 1 of many coronary risk factors. Seven hundred forty-nine Japanese men were selected according to their electrocardiographic findings, i.e., normal electrocardiogram, LV hypertrophy without an abnormal ST-T segment, LV hypertrophy with a flat T wave, and LV hypertrophy with a negative T wave. Coronary risk factors were compared among these 4 age-matched groups. Groups with LV hypertrophy with negative or flat T waves had larger body mass index (24.9 vs 22.9 kg/m2), higher mean systemic blood pressure (111 vs 95 mm Hg), larger LV mass (265 vs 157 g), higher blood glucose (110 vs 100 mg/dl), higher serum triglyceride (148 vs 122 mg/dl), higher total cholesterol (206 vs 198 mg/dl), and lower high-density lipoprotein cholesterol (47 vs 54 mg/dl) than the normal group or the group with LV hypertrophy without T-wave change. Among these risk factors, blood pressure and glucose remained higher even after the adjustment by body mass index or by body mass index and blood pressure. Electrocardiographic LV hypertrophy with a changed T wave signified higher risk of coronary artery disease in Japanese men.

Expression of nitric oxide synthases and GTP cyclohydrolase I in the ventilatory and limb muscles during endotoxemia

Nitric oxide synthases (NOS) convert L-arginine to nitric oxide in the presence of tetrahydrobiopterin (BH4). Two constitutive isoforms of NOS exist in normal skeletal muscle fibers, however, the existence of a third, the inducible isoform (iNOS), has never been detected in these fibers in vivo. Therefore, we assessed the influence of in vivo endotoxemia on skeletal muscle expression of constitutive and inducible NOS isoforms and GTP cyclohydrolase I, the rate limiting enzyme of BH4 synthesis. Two groups of rats were infused i.p. either with E. coli endotoxin (20 mg/kg, LPS group) or saline (saline group). Animals were killed 6 h later and the ventilatory and limb muscles were quickly frozen. Endotoxin infusion elicited a significant rise in NOS activity of the diaphragm, intercostal, soleus and gastrocnemius muscles. Reverse transcription-polymerase chain reaction (RT-PCR) on muscle total RNA detected very low expression of iNOS and GTP cyclohydrolase I mRNA in the saline group, but significant upregulation of both enzymes was found in the ventilatory and limb muscles of the LPS group. Immunoblotting detected no iNOS protein in the saline group but a significant iNOS protein expression was found in the diaphragm, intercostal and soleus muscles and to a lesser extent, in the gastrocnemius of the LPS group. Endotoxemia was also associated with increased protein expression of constitutive NOS isoforms mainly in the diaphragm and to lesser extent in the intercostal, gastrocnemius and soleus muscles. We conclude that in vivo exposure to endotoxin leads to differential induction of both iNOS and GTP cyclohydrolase I in the ventilatory and limb muscles.

Advances in soil microbial ecology and the biodiversity

Recent studies on the colony formation of soil bacteria opened the way to categorize soil bacteria into colony forming curve (CFC) groups of different growth rates. A bacterial culture collection comprising organisms from every CFC group is called an ecocollection (EC). Outlines of ECs of paddy soil 1992 and grassland soil 1987 and 1992 were described. Phylogenetic studies by 16S rDNA sequencing showed a great diversity of culture strains of the ecocollections. A set of alternative concepts was proposed; the active and the quiescent forms of bacterial cells in soil. The former is able to be cultivated and thus counted by the plate method, while the latter is not unless it transforms into the former. Based on the results several points required for extensive cataloguing of soil bacteria were noted.

[Chronic expanding hematoma following pneumonectomy managed with a thoracic balloon: a case report]

A 64-year-old male was treated for a chronic expanding hematoma three years after pneumonectomy for left lung cancer (p T2N2M0, Stage IIIA). Two years prior to admission a left pleural effusion shadow was detected on a follow-up chest X ray, and since then there had been a progressive mediastinum shift to the right. The suspected diagnosis on referral was recurrent lung cancer or giant intrathoracic hematoma. Chest CT scans and thoracentesis led to a diagnosis of a chronic expanding hematoma developing after pneumonectomy. Surgery was performed because of the severity of symptoms and the progressive nature of the tumor. Histopathological examination confirmed the diagnosis of chronic expanding hematoma. During the operation, it was difficult to achieve hemostasis, but bleeding was effectively managed with a thoracic balloon.

Na+-induced structural change of a soil bacterium, S34, and Ca2+ requirement for preserving its original structure

A drastic change in the outer membrane structure of a salt-sensitive soil bacterium, S34, related to the genus Deinococcus was induced by 0.2 to 0.4% (wt/vol) NaCl. The change was relieved by 6 mM CaCl2 and induced by 1 mM EGTA. The results indicate the strong dependence of the organism on calcium.

Successful treatment of mediastinitis after cardiovascular surgery using electrolyzed strong acid aqueous solution

Dilute povidone-iodine solution has been widely used as an irrigant for the treatment of mediastinitis. However, its use is not without adverse effects and often causes poor growth of granulation tissues. To avoid the problems seen with the use of povidone-iodine solution, we applied electrolyzed strong acid aqueous solution (ESAAS) to mediastinal irrigation in 4 patients (2 infants and 2 adults) who developed mediastinitis after cardiovascular surgery. According to the "open" method, the mediastinal wound was left open and irrigated with ESAAS 1 to 3 times a day until the infection was eradicated. Satisfactory growth of granulation tissues was observed in all patients treated with no evidence of adverse effects attributable to ESAAS. Delayed primary sternum closure was performed for 2 patients, and musculocutaneous transposition of rectus abdominis for 1. Our experience suggests that irrigation with ESAAS is a safe and effective method of therapy for mediastinitis.

Expression of inducible nitric oxide synthase and its involvement in pulmonary granulomatous inflammation in rats

Two types of pulmonary granulomatosis were produced in rats by intratracheal instillation of zymosan or silica. In both models, immunostaining with anti-rat monoclonal antibody for inducible nitric oxide synthase (iNOS), ANOS11, showed that the intensity of iNOS immunoreactivity in the inflammatory lesions peaked at 3 days and declined thereafter. Immunohistochemical double staining and in situ hybridization demonstrated the expression of iNOS in neutrophils, monocyte-derived macrophages, and bronchiolar epithelial cells in the pulmonary lesions. Electron spin resonance spectroscopy revealed the production of an excessive amount of nitric oxide (NO) in the pulmonary lesions. Immunostaining with a polyclonal antibody against nitrotyrosine indicated the formation of nitrotyrosine residues in the granulomatous lesions, particularly in the periphery of the lesions, providing indirect evidence for the generation of peroxynitrite anion in the zymosan- or silica-instilled lungs. Administration of N omega-nitro-L-arginine methyl ester or S-methylisothiourea sulfate, which significantly suppressed NO production, resulted in marked reduction of monocyte/macrophage infiltration as well as in inhibition of induction of monocyte chemoattractant protein-1 in the lesions. These data indicate that NO and its more reactive product peroxynitrite anion may be important mediators of granuloma formation in the lung.

Oxygen uptake and its relation to physical activity and other coronary risk factors in asymptomatic middle-aged Japanese

PURPOSE

Low physical activity is considered to be an important risk factor for atherosclerotic coronary artery disease. However, few data are reported on the Japanese general population. The authors have studied whether oxygen uptake in physical fitness evaluation is a quantitative index for physical activity and whether or not it has a relation to coronary risk factors.

METHODS

Five hundred thirteen asymptomatic Japanese (40-64 years of age, 282 males and 231 females) were tested on a cycle ergometer for measurement of peak oxygen uptake (peak VO2) and oxygen uptake at anaerobic threshold (VO2AT). Physical activity was estimated by pedometer score. Data for oxygen uptake were adjusted by age or by age and body mass index (BMI), then its relationship to the following risk factors was investigated: physical activity, BMI, blood pressure, total cholesterol, HDL and LDL cholesterol, fasting blood glucose, and triglycerides.

RESULTS

Subjects in the highest peak VO2 quartile walked significantly more than those in the lowest quartile in both males and females. Those in the highest quartile showed lower BMI, lower blood pressure, lower triglyceride, and higher HDL cholesterol. The same relationship was observed for VO2AT.

CONCLUSIONS

Higher fitness level determined by peak VO2 or VO2AT is related to higher physical activity and lower coronary risk factors in the asymptomatic middle-aged Japanese. These data provide support for exercise prescription in the primary prevention of coronary heart disease in Japan.

[Laparoscopic pelvic lymphadenectomy for localized prostate cancer]

We report the clinical results and efficacy of laparoscopic pelvic lymphadenectomy for localized prostate cancer. This procedure was followed by radical prostatectomy, when metastasis was not found in the frozen section, and by optional treatment, such as transurethral resection (TUR) or castration, other than radical prostatectomy when metastasized nodes were found. We performed transperitoneal laparoscopic lymphadenectomy on 30 patients and extraperitoneal approach on 20 between April, 1992 and September, 1995. The patients were between 52 and 78 years old. Nineteen, patients had stage B1, 17 stage B2 and 14 stage C cancer. Bilateral obturator nodes were dissected. We could not perform laparoscopic lymphadenectomy on two patients because of adhesion. The average operation time and blood loss were 166 minutes and 151 ml, respectively, in the transperitoneal group, while 142 minutes and 126 ml in the extraperitoneal group. The average number of removed nodes was 12 in the transperitoneal group and 10 in the extraperitoneal group. The extraperitoneal approach is a safer and useful procedure. Nodal metastasis were found in 12 patients by frozen section. Additional positive nodes were found in 7 patients by a further study. Two were not harvested laparoscopically and 5 were ascertained only by permanent section. Therefore, the two-staged operation might be preferable. Nodal metastasis was likely to be found in localized prostate cancer patients with clinical stage C, poorly differentiated cancer, or prostatic specific antigen density (PSAD) over 0.5 ng/ml/ml. Laparoscopic pelvic lymphadenectomy might be indicated for these cases.

Effect of ebselen on bovine and rat nitric oxide synthase activity is modified by thiols

The inhibition of nitric oxide synthase (NOS) by ebselen, 2-phenyl-1,2-benzisoselenazole-3(2H)-one, was reversed by the addition of 10(-5) M dithiothreitol, suggesting that ebselen reacts with a critical thiol group of NOS in the inhibitory mechanism. In the presence of 10(-4) to 10(-3)M dithiothreitol, ebselen dose-dependently enhanced NOS activity, implicating another interaction of ebselen with NOS under these conditions. Thus, the effect of ebselen on the NOS activity is modified by thiols.

Increased neurons containing neuronal nitric oxide synthase in the brain of a hypoxic-ischemic neonatal rat model

We evaluated the temporal profile of the number of neurons containing neuronal nitric oxide synthase (nNOS neurons) in the brain of a neonatal hypoxic-ischemic rat model. Hypoxic-ischemic insults were produced in the brains of 7-day-old rat pups using a combination of unilateral carotid artery ligation and hypoxic (8% oxygen) exposure. Sections of brain from rats killed at 0-24 h after the onset of hypoxia were stained immunohistochemically using a polyclonal anti-nNOS antibody. Histological changes of neuronal injury were evaluated in the adjacent Nissl stained sections. The number of nNOS neurons in the hemisphere ipsilateral to the carotid ligation was significantly increased (P < 0.05) at 3 h, when the neuronal injury consisted of clusters of degenerating hyperchromic neurons. Neuronal degeneration and an increased number of nNOS neurons were seen only in the ipsilateral hemisphere and the increase was most prominent in the dorsolateral area of the striatum. The increase in the number of nNOS neurons continued at 6 h, when the area of neuronal injury continued to expand. At 24 h, the neuronal injury was diffuse, and the number of nNOS neurons on the ipsilateral side significantly decreased. The increase of the number of nNOS neurons in the early phase of neonatal neuronal injury suggests its possible involvement in the hypoxic-ischemic injury. The delineation of its role in neuronal injury may lead to an improvement in managing neonatal hypoxic-ischemic brain injury.

Lysophosphatidylcholine inhibits endothelium-dependent hyperpolarization and N omega-nitro-L-arginine/indomethacin-resistant endothelium-dependent relaxation in the porcine coronary artery

BACKGROUND

Oxidized LDL and lysophosphatidylcholine (LPC) have been reported to inhibit the endothelium-dependent relaxation (EDR) mediated by nitric oxide. Recently, a new vasorelaxing factor, endothelium-derived hyperpolarizing factor (EDHF), which hyperpolarizes and relaxes the porcine coronary artery in the presence of N omega-nitro-L-arginine (NNA) and indomethacin (IM), has been reported. We examined whether LPC also inhibits both the EDHF-mediated relaxation and membrane hyperpolarization of the porcine coronary artery.

METHODS AND RESULTS

EDHF was evaluated as the bradykinin- or A23187-induced relaxation of the porcine coronary artery contracted by prostaglandin F2 alpha in the presence of NNA and IM. We also directly measured the membrane potential of the porcine coronary artery. The effects of LPC on both relaxation and membrane hyperpolarization were investigated. At concentrations of 0 to 20 mumol/L, LPC dose-dependently inhibited the NNA/IM-resistant EDR induced by bradykinin and A23187, and the relaxation was reversible after the absorption of LPC with albumin. LPC also inhibited the bradykinin- and A23187-induced hyperpolarization of the porcine coronary artery.

CONCLUSIONS

In the present study, LPC was found to inhibit not only nitric oxide-mediated but also EDHF-mediated relaxation of the porcine coronary artery. Our findings suggest a new regulatory mechanism in the atherosclerotic coronary artery.

[Laparoscopic radical nephrectomy. Analysis of 10 cases and preliminary report of retroperitoneal approach]

PURPOSE

To examine the efficacy of laparoscopic radical nephrectomy (LPRNX) for patients with small renal cell carcinoma, the clinical result of 10 patients treated with this procedure was analysed.

MATERIALS

Ten patients with renal cell carcinoma measuring diameter less than 5 cm were treated by LPRNX between July 1992 and October 1994. Four cases had T1N0M0 disease and 6 had T2N0M0 disease. Of the 10 patients, seven had right sided tumor and three had left sided tumor.

METHOD

Trans-abdominal approach was employed for the initial 8 cases. Retroperitoneal approach was applied for the last 2 cases. Five trocars were placed through lateral abdominal wall. Intraperitoneal or retroperitoneal cavity was insffulated with CO2 at 12 mmHg. A kidney was dissected endoscopically with Gerota's fascia, peri renal fatty tissue and adrenal gland as en bloc fashion. It was trapped into the laparoscopy sack and pulled out of the body through a 4 to 5 cm incision without morcellation.

RESULTS

Average operation time was 331 minutes and average bleeding was 380 ml. All the kidneys were removed by endoscopic technique. As major complications, we experienced a cases of splenic injury and a cases of adrenal injury. The bleeding of both cases was successfully managed by endoscopical procedure, however, transfusion was needed for the last case. Pathological examination of specimens revealed renal cell carcinoma in all ten cases. Average hospital stay after surgery was 10.6 days and average duration to the convalescence was 20 days. There was no episode of recurrence in all 10 patients for 2 to 29 months (Mean: 15.2 months) followed up period.

CONCLUSION

Although further technical progress was expected, LPRNX is a potential operative procedure that realizes minimally invasive therapy for the patients with small volume of renal cell carcinoma.

[Clinical outcome of radical prostatectomy and pelvic lymph node dissection]

Between September, 1987 and September, 1993, a total of 44 consecutive patients had undergone radical retropubic prostatectomy and pelvic lymphadenectomy for the treatment of prostate cancer. The patients were between 56 and 77 years (mean, 68 years). Eleven patients had clinical state A2 disease, 21 had stage B disease, and 12 had stage C disease. Fourteen of the 44 patients (32%) had positive lymph node metastases. The 5-year survival rate for patients with pT1, pT2 and pT3 was 100%, 71% and 87%, respectively. It was 77% in patients with positive node disease and 90% in patients with negative node disease. The 5-year disease-free survival rate for patients with pT1, pT2 and pT3 was 82%, and 78%, respectively. It was 54% in patients with positive node disease and 88% in patients with negative node disease. In 14 positive node patients, metastases were located in obturater nodes in 8 patients (57%), hypogastric nodes, in 6 patients (43%), external iliac nodes in 6 patients (43%), common iliac nodes in 4 patients (29%) and presacral nodes in 2 patients (14%). We confirmed that radical retropubic prostatectomy is effective treatment for locally confined prostate cancer and removal of obturater, hypogastric lymph nodes and the internal chain of external iliac lymph nodes is important in detecting metastases.

Expression and localization of inducible nitric oxide synthase in anti-Thy-1 glomerulonephritis

To elucidate a possible involvement of nitric oxide in the development of a mesangial proliferative glomerulonephritis induced by anti-Thy-1 antibody administration, glomerular expression of three isoforms of NO synthase (NOS), inducible NOS (iNOS), brain NOS, and endothelial NOS, was examined at both mRNA and protein levels by ribonuclease protection assay and immunofluorescence microscopy. Light microscopy showed an accumulation of polymorphonuclear leukocytes at 1 hour, lysis of mesangial cells at 1 day, a mesangial proliferative lesion at 4 to 10 days, and minimal residual glomerular lesions by 28 days. Ribonuclease protection assay showed that the glomerular expression of iNOS mRNA peaked at 1 hour and decreased thereafter. No substantial expression of iNOS mRNA was observed in normal glomeruli or in the nephritic glomeruli obtained at different time points (1, 4, 10, or 28 days). By immunofluorescence microscopy with a specific monoclonal antibody, an intense reaction for iNOS was demonstrated in a few cells in the glomeruli at 1 hour. Most of the iNOS-positive cells were identified as polymorphonuclear leukocytes. iNOS-positive cells were found less frequently in the glomeruli on days 1 and 4. Endothelial NOS mRNA was constitutively expressed in normal glomeruli and increased biphasically with two peaks at 1 hour and at 4 days or later; however, the peak expression was much less than that of iNOS mRNA at 1 hour. Expression of brain NOS mRNA was not detectable in either normal or nephritic glomeruli. These results show that iNOS is predominantly expressed in polymorphonuclear leukocytes accumulating at 1 hour in the glomeruli of anti-Thy-1 glomerulonephritis and suggest an involvement of NO in the initiation of the disease.

Long-term prognosis after thrombolytic therapy for acute myocardial infarction

In order to clarify the relationship between the patency of the infarcted arteries and subsequent long-term prognosis after thrombolytic therapy, we evaluated 116 patients with acute myocardial infarction treated with intracoronary (112 patients) or intravenous (four patients) urokinase. Patients treated with angioplasty after thrombolysis were excluded. The infarcted vessel was recanalized in 52 patients (patent group) and was not in the remaining 64 patients (occluded group). Five-year and 8-year follow up was conducted in 91% and 81% of the patients, respectively. The 1-, 5- and 8-year survival rate for the patent and occluded group was 91.8 and 80.9%, 80.8 and 79.2%, and 75.9 and 75.6%, respectively. The survival rate in the patent group tended to be higher than that in the occluded group up to 4 years. However, after 5 years, both groups showed similar survival rates. Therefore, reopening of the infarcted arteries with thrombolysis was not an independent predictor for late cardiac death (Cox regression analysis).

[The efficacy of endopyeloureterotomy via a transpelvic extraureteral approach]

To evaluate the efficacy of endopyeloureterotomy via a transpelvic extraureteral approach for the treatment of ureteropelvic junction obstruction or upper ureteric stenosis, we analysed the results of 85 patients treated with this procedure between Aug. 1988 and June 1993. Eighty-five patients underwent 87 procedures. Each patient has been followed-up more than 6 months postoperatively. Of 87 procedures, 71 were performed in patients with ureteropelvic junction obstruction and 16 were in patients with stenosis of the upper third ureter. Primary disease was 59 and secondary disease was 28. Twenty-one procedures were performed in patients with the stenotic segment over 2 cm. The operative procedure was performed by first incising with a 22 Fr. urethrotome (ACMI Co.); the dilated renal pelvic or ureteral wall posterolaterally as long as 1-1.5 cm junction from the stenotic segment toward ureteropelvic junction, then bringing the urethrotome out retroperitoneally through the incision and finally incising the stenotic segment with the cold knife under direct vision. A 12-16 Fr. PTCS tube (Sumitomo Behkuraito Co.) was left in place for 3 weeks as a stent. Mean operative time was 101 min and average length of incised segment was 3.7 cm. Complication included pneumothorax (1 case), pseudo ureter (1 case) and renal arterial anexryma (1 case). Followed-up period ranged from 6 to 64 months with the average being 26 months. Of 87 procedures, 80 (92%) achieved a disappearance or improvement of the obstructive change and 7 failed.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunohistochemical expression of inducible nitric oxide synthase (iNOS) in reversible endotoxic shock studied by a novel monoclonal antibody against rat iNOS

An antirat monoclonal antibody (mAb) against inducible nitric oxide synthase (iNOS), ANOS11, was used for immunohistochemistry to examine the expression of iNOS in various organs and tissues of adult rats in experimental endotoxic shock induced by lipopolysaccharide (LPS) injection. The phenotype of iNOS-expressed cells was also examined immunohistochemically using various mAbs. In control rats, very few cells were positive for ANOS11 except in the thymus. After intravenous injection of LPS, the number of iNOS-positive cells increased rapidly in almost all organs, except the thymus and brain, peaked 6 h after the injection, and decreased slowly. Of the numerous inflammatory cells that infiltrated the lungs, liver, and spleen after LPS injection, many were positive for ANOS11. Besides inflammatory cells, hepatocytes and endothelial cells of the aorta were also positive for ANOS11 but only around 6 h after injection. The cellular composition of iNOS-positive infiltrated cells changed along with the progression of endotoxic shock. At 4 to 6 h after injection, most iNOS-positive cells were considered polymorphonuclear leukocytes judging by their positive reactivity to OX42 and their nuclear morphology. The population of iNOS-positive macrophages positive for ED1 or ED2 increased with time. After 24 h, many iNOS-positive macrophages were found around the focal necrosis in the liver and spleen. These results indicate that the expression of iNOS in neutrophils, endothelial cells, and hepatocytes precedes that of macrophages in experimental endotoxic shock. The expression of iNOS in various cells and organs is closely associated with the progress and pathological changes of endotoxic shock.

Long-term effects of niceritrol on serum lipoprotein(a) and lipids in patients with high levels of lipoprotein(a)

The long-term effects of niceritrol on lipoprotein(a) (Lp[a]), lipids, apolipoproteins, and fibrinogen and fibrinolytic factors were evaluated in 20 outpatients who had serum Lp(a) levels higher than 20 mg/dL. The mean ( +/- SE) levels of Lp(a) decreased from 33.6 +/- 2.3 mg/dL to 23.5 +/- 3.5 mg/dL after 12 months of niceritrol treatment (P < 0.01). Serum levels of triglycerides and apolipoprotein E decreased significantly and high-density lipoprotein cholesterol (HDL-C) increased significantly after 12 months (P < 0.05). There were no significant changes overall in fibrinogen and fibrinolytic factors, although fibrinogen concentrations showed a tendency to decrease with treatment. PAI-1 levels decreased significantly (P < 0.05) after 6 months of niceritrol treatment. A significant correlation of percent reduction between Lp(a) and apolipoprotein B levels (P < 0.01) was observed, suggesting that the Lp(a)-lowering effects of niceritrol may be due to niceritrol inhibition of apolipoprotein B synthesis, the major apolipoprotein of Lp(a). The ability of niceritrol to decrease Lp(a) levels and increase HDL-C levels, together with its tendency to lower fibrinogen levels, may help prevent coronary events in patients with high levels of Lp(a).

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.

Structure and function of nitric oxide synthases

Nitric oxide (NO), which accounts for the biological activity of endothelium-derived relaxing factor, is now thought to play a variety of roles in the nervous system and in immunologic reactions. NO is synthesized from L-arginine by nitric oxide synthase (NOS). There are three isoforms of NOS; type I (neuronal), type II (inducible), and type III (endothelial). The fundamental structure of the three isoforms, which contain calmodulin-, FMN-, FAD-, and NADPH-binding domains, is the same. Calmodulin is already bound to inducible NOS without requiring Ca2+, while the others are Ca2+/calmodulin-dependent. Endothelial NOS is bound to membranes by N-myristoylation, while the other isoforms are soluble. The human endothelial NOS gene has been cloned. It has several highly repetitive regions which could provide potential sites for DNA polymorphism. It might be of interest to examine the relationship between such polymorphism and cardiovascular disorders.

[Laparoscopic pelvic lymphadenectomy in prostate cancer]

We described the clinical results and efficacy of laparoscopic pelvic lymphadenectomy for localized prostate cancer. This procedure was followed by radical prostatectomy, if metastasis was not found in frozen section. In the presence of positive nodes, optional treatment, such as TUR or castration, other than radical prostatectomy was performed. We performed laparoscopic lymphadenectomy on twenty seven patients between April 1992 and September 1993. They range from 52 to 78 years in age and consist of 4 patients with stage A2, 17 with stage B, and 6 with stage C. We dissected the obturator lymph nodes on bilateral sides. The average operating time was 162 minutes (range 86 to 320 minutes). The average number of nodes removed from the right side was 7.1 +/- 5.9 and 6.1 +/- 4.5 from the left side, which was comparable to the number of lymph nodes obtained by open dissection. Colon injury occurred in one patient, which was managed by laparotomy procedure. Nodal metastases were found in 6 patients by frozen section, and in 10 patients by permanent section. This discrepancy suggested that two-staged operation might be preferable for the localized prostate cancer. Six patients were given suitable therapies besides radical prostatectomy. Laparoscopic pelvic lymphadenectomy is a safe and useful procedure for prostate cancer, especially for the patients who are likely to have nodal metastasis.

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.