Testicular-sparing surgery for the prepubertal testicular tumor. Experience of two cases with large cell calcifying Sertoli cell tumors

PURPOSE

We review prepubertal germ cell tumors of testis in our institute and the Japanese registry and present 2 cases with a large cell calcifying Sertoli cell tumor (LCCSCT) and discuss the possibility of testis-sparing surgery.

MATERIALS AND METHODS

Incidence, age, pathology and clinical stages of prepubertal germ cell tumors are surveyed for 30 years at our department and 10 years of the malignant tumor registry of the Japanese Society of Pediatric Surgery. Two representative prepubertal boys with LCCSCT are presented. One of them was treated by partial orchiectomy.

RESULTS

The majority of testicular germ cell tumors in the prepubertal age were composed of embryonal cell carcinoma/yolk sac tumors or teratoma, occurred in preschool age, were limited to clinical stage I and did not metastasize irrespective of histology. Benign behavior which included recovery from hormonal derangement, no tumor recurrence and negative antisperm antigen was observed in 2 cases with LCCSCT who underwent either radical orchiectomy or partial orchiectomy.

CONCLUSION

Partial orchiectomy should be considered as a standard option in prepubertal schoolboys with a testicular mass if surgically feasible. This surgical treatment is safe and preserves fertility and is psychologically advantageous. It is not recommended for yolk sac tumors that may recur, however they are rare in prepubertal boys and can be differentiated preoperatively by prudent evaluation.

The centromere composition of multiple repetitive sequences on rice chromosome 5

The large-scale primary structure of the centromeric region of rice chromosome 5 was analyzed, the first example in a cereal species. The yeast artificial chromosome (YAC) and bacterial artificial chromosome (BAC) contigs aligned on the centromere of rice chromosome 5 (CEN5) covered a distance of more than 670 kb. Strong suppression of genetic recombination, one of the features of a functional centromere, occurred along the contig region. The most remarkable feature of CEN5 is the composition of the multiple repetitive elements. Oryza-specific RCS2 short tandem repeats were clustered along less than 100 kb at one end of the contig. At least 15 copies of the conserved domain of the 1.9 kb RCE1 centromeric repeats, which are similar to the long terminal repeats (LTRs) of gypsy-type retrotransposon RIRE7, were dispersed mainly in 320 kb stretches next to RCS2 tandem clusters. Many copies of the LTR-like sequences of RIRE3 and RIRE8, another gypsy-type retrotransposon, were also found throughout the contig. On the other hand, the gagpol region was less conserved in the contig. These results indicate that the rice centromere is composed of multiple repetitive sequences with the RCS2 tandem cluster probably being situated as the core of a functional centromere of some hundreds of kilobases to megabases in length.

Intravenous digital subtraction angiography and helical computed tomography in evaluation of living renal donors

OBJECTIVES

The present study was carried out to evaluate the accuracy of helical computed tomography (CT) and intravenous digital subtraction angiography (IV-DSA) on anatomical assessment of renal vasculature for living renal donors.

METHODS

Forty-two healthy potential renal donors were prospectively evaluated and 35 subsequently underwent donor nephrectomy after helical CT and IV-DSA evaluation. The vascular and non-vascular findings were compared between the findings on helical CT, IV-DSA and surgery.

RESULTS

Ten prehilar branches and five accessory renal arteries were found at nephrectomy. Overall, operative findings agreed with the findings by IV-DSA in 89% and by helical CT in 83%. In delineating accessory arteries, IV-DSA had a sensitivity of 60% and specificity of 97%, whereas helical CT had a sensitivity of 40% and specificity of 100%. In delineating prehilar branches, IV-DSA had a sensitivity of 90% and specificity of 100%, whereas helical CT had a sensitivity of 70% and specificity of 100%. Accessory arteries and prehilar branches that were not detected by helical CT or IV-DSA, were less than 2 mm in diameter and did not require vascular reconstruction. Renal veins were delineated in 63% by IV-DSA, whereas they were clearly imaged by helical CT in all cases, including a case with a circumaortic renal vein. Non-vascular findings were obtained in 64% by helical CT, including two renal tumors. None of these findings were obtained by IV-DSA.

CONCLUSION

Helical CT and IV-DSA provide comparably sufficient information on renal artery vasculature. However, helical CT provides significantly more information on venous and non-vascular findings as a single-imaging modality.

Pre-emptive renal transplantation in children

BACKGROUND

Renal transplantation is a definitive therapeutic modality in end-stage renal disease (ESRD). Most ESRD patients in Japan experience dialysis prior to renal transplantation. The present study was undertaken to examine the usefulness of pre-emptive renal transplantation (PET).

METHODS

Between 1987 and 1998, 255 renal transplantations were carried out by the authors. Among those consecutive cases, 10 were cases of PET. In nine pediatric cases, demographics, graft and patient survival, height growth and benefits from successful transplantation were studied and compared with age-matched dialyzed transplantation controls.

RESULTS

All transplantation was living-related. There was a disparity of causes of ESRD between the two groups. In PET, acquired renal deterioration due to a congenital lower urinary tract disorder was the major cause. Graft and patient prognosis was favorable in both groups. Growth retardation in PET patients under 15 years of age was significantly less apparent at the time of transplantation and after 3 years compared to the control. The benefits from transplantation were different in the two groups. Most PET patients felt an improvement of their physical condition; however, all of the control patients felt that the major boon was the freedom from the restriction of the daily diet and time for dialysis.

CONCLUSION

In pediatric renal transplantation, short-term preceding dialysis does not have a detrimental effect, but PET could benefit ESRD patients by maintaining their quality of life. Moreover, PET minimizes the production of renal dwarfism in prepubertal children. Thus, PET should be taken into consideration in the choice of renal replacement therapy.

Laparsocopic ureteroureterostomy for retrocaval ureter

Two cases of retrocaval ureter are reported that were successfully treated by a laparoscopic approach. Case 1 was a 20-year-old woman who presented with symptoms of a right ureter stone. Case 2 was a 23-year-old woman who had suffered from recurrent right flank pain with gross hematuria. A transperitoneal approach was used for case 1, and a retroperitoneal approach was used in case 2. Both were successfully treated with laparoscopic ureteroureterostomy using an intracorporeal suture technique. Laparoscopic surgery should be the first choice for retrocaval ureter not only because of the minimal invasiveness but also because of the cosmetic advantage compared to conventional open surgery. Further technical and instrumental advances are essential for intracorporeal suturing.

Neurosurgery at Fujita Health University, Japan

Neurosurgery at the Fujita Health University began in 1972 with Dr. Tetsuo Kanno. In 1973, he was joined by Dr. Kazuhiro Katada and in the year 1976, an independent neurosurgery department was established with Dr. Kanno as the Chief of Neurosurgery. Under his guidance the department continued to grow and by 1978, a neurosurgical residency program recognised by the Japanese Board of Neurosurgery was established. Integration of laboratory research and clinical experience is the hallmark of this program. The current philosophy is directed towards subspecialization and academic training. This article provides a brief overview of the rapid development of a Neurosurgical Centre to reach international acclaim under the guidance of Prof. Tetsuo Kanno.

Pharmacological properties of Y-27632, a specific inhibitor of rho-associated kinases

Y-27632 [(+)-(R)-trans-4-(1-aminoethyl)-N-(4-pyridyl)cyclohexanecarboxamide++ + dihydrochloride] is widely used as a specific inhibitor of the Rho-associated coiled-coil forming protein serine/threonine kinase (ROCK) family of protein kinases. This study examined the inhibition mechanism and profile of actions of Y-27632 and a related compound, Y-30141 [(+)-(R)-trans- 4-(1-aminoethyl)-N-(1H-pyrrolo[2, 3-b]pyridin-4-yl)cyclohexan-ecarboxamide dihydrochloride]. Y-27632 and Y-30141 inhibited the kinase activity of both ROCK-I and ROCK-II in vitro, and this inhibition was reversed by ATP in a competitive manner. This suggests that these compounds inhibit the kinases by binding to the catalytic site. Their affinities for ROCK kinases as determined by K(i) values were at least 20 to 30 times higher than those for two other Rho effector kinases, citron kinase and protein kinase PKN. [(3)H]Y-30141 was taken up by cells in a temperature- and time-dependent and saturable manner, and this uptake was competed with unlabeled Y-27632. No concentrated accumulation was found, suggesting that the uptake is a carrier-mediated facilitated diffusion. Y-27632 abolished stress fibers in Swiss 3T3 cells at 10 microM, but the G(1)-S phase transition of the cell cycle and cytokinesis were little affected at this concentration. Y-30141 was 10 times more potent than Y-27632 in inhibiting the kinase activity and stress fiber formation, and it caused significant delay in the G(1)-S transition and inhibition of cytokinesis at 10 microM.

Ectopic pheochromocytoma arising in the spermatic cord 5 years after removal of bilateral carotid body tumors and adrenal pheochromocytomas

A patient with ectopic pheochromocytoma that developed in the spermatic cord about 5 years after successive resections of bilateral carotid body tumors and bilateral adrenal pheochromocytomas is reported. This is thought to be the first case of pheochromocytoma of the spermatic cord in a setting of multiplicity.

Reappraisal of Tc-99m DMSA scintigraphy for follow up in children with vesicoureteral reflux

We reviewed Tc-99m DMSA scintigraphy in children with vesicoureteral reflux (VUR) in order to assess whether repeated Tc-99m DMSA scans are necessary for the follow up of these patients. Ninety-seven children who were followed up for more than one year (1-7.4 years, average 2.8 years) after the first DMSA scan were included in the study. Fifty-one patients had been diagnosed as primary VUR and 46 as secondary VUR. Age at the first examination ranged from 0 to 14 years (average 5.1 years). Planar images were taken 2 hours after injection. The % renal uptake per injected dose (%RU) was calculated from posterior images. Kidneys in 11 patients (11.3%) changed morphologically during the follow up. Of these, new photon deficient areas (PD) were detected in only 4 patients (4.1%). All of these 4 patients had neurogenic bladder and were managed with self-catheterization. Of the remaining 7 patients, cortical thinning progressed in 5 patients (5.2%) and PDs resolved in 3 patients (3.1%). In one of these 7 patients, PD resolved in one kidney and cortical thinning progressed in the contralateral kidney. Of 97 patients reviewed, % RU decreased more than 20% during the follow up in 6 patients (6.2%). All were diagnosed as secondary VUR due to neurogenic bladder. %RU decreased only in the contracted kidneys at the initial scan. Two of them underwent renal transplantation because of severe renal failure. In conclusion, new PD rarely developed and % RU decreased in only a few patients during the follow up of children with VUR. Repeated Tc-99m DMSA scintigraphy therefore seems to have little benefit in the follow up of children with VUR. It should be performed in selected patients with high risk of urinary tract infection or renal failure.

Impact of congenital narrowing of the bulbar urethra (Cobb's collar) and its transurethral incision in children

OBJECTIVES

We described the clinical manifestation and outcome after transurethral incision (TUI) of a congenital narrowing of the bulbar urethra (Cobb's collar).

MATERIALS AND METHODS

Over a period of 11 years a total of 74 boys, from 3 months to 16 years old with a mean age of 5 years, were subjected to TUI. A febrile urinary tract infection (UTI) was the most common symptom in 40 cases, enuresis in 15, urinary incontinence in 11, hematuria in 9, antenatally diagnosed dilated urinary tract in 4 and others in 9. Concurrent bladder instability was detected by cystometry in 27/31 boys older than 3 years with suspicious bladder urgency. When the bulbar narrowing was detected by cystourethroscopy under 8 Fr, the lesion was simultaneously incised by using an infantile resectoscope (Olympus 10 Fr with a knife electrode or Storz 10 F with a cold knife).

RESULTS

Vesicoureteral refluxes (VURs) occurred in 39 cases (53%) and it was diminished in 11 and improved in 25 after TUI. Of the 40 cases, 38 (95%) were free from UTI after TUI. For enuresis and urinary incontinence, 14/15 and all 11, respectively, thrived after TUI and the anticholinergic supplement. Although 61 cases were primarily cured with no complications, insufficient cutting and recurrence of the stricture required an additional TUI in 13 cases for whom the knife electrode was mostly used. Overall clinical improvement was obtained in 71/74 (93%) cases after TUI.

CONCLUSION

Meticulous cystourethroscopy is indispensable for detecting a clinically significant bulbar narrowing. TUI of the lesion is useful as a primary treatment in the majority of cases even with concurrent VUR and unstable bladder. A cold knife is preferable to electrocautery in incising this fine anterior urethral lesion.

Kidney transplantation in a child with posterior urethral valve from a hepatitis B virus-carrier mother. Report of a case with special reference to urinary tract reconstruction for dysfunctionalized uropathies and seroimmunological preparation against viral transmission

The case of a 7-year-old boy with posterior urethral valve (PUV) who underwent successful kidney transplantation for progressive renal failure is reported. He required complex reconstructive surgery for PUV-related disorders, and also specific serological preparation for hepatitis B (HB) as his living donor mother was a proven carrier. By carefully executing the principles of reconstructive surgery and with well-planned seroimmunological preparation, we have demonstrated that successful kidney transplantation can be done from an HB Ag-positive mother to an HB Ag- and HB Ab-negative son, even when his urinary tract is severely dysfunctional due to PUV.

Experience with kidney transplantation in children and adolescents

BACKGROUND

Paediatric kidney transplantation has different aspects in adults in terms of underlying primary renal disease, surgical technique, perioperative care and graft prognosis. Significant urological problems are present in a high percentage of paediatric recipients. This study was undertaken to characterize paediatric kidney transplantation as performed at our institutes.

METHODS

Twenty-eight patients (age range 4-17 years, 10 girls, 18 boys) were included in this study. We analyzed (1) urologic procedures performed prior to or simultaneously with transplantation, (2) intraoperative changes in haemodynamics, (3) postoperative complications and (4) acute allograft rejection and graft prognosis.

RESULTS

Of 4 patients with lower urinary tract abnormalities (neurogenic bladder in 3, posterior urethral valve in 1), 2 underwent augmentation ileocystoplasty prior to transplantation. The Mitrofanoff procedure as a diversion for neourethra was also performed in 2 of the 4 patients. All these 4 patients were managed with clean intermittent catheterization. Central venous pressure changes before and after graft vessel declamping were much greater in patients with body weight below 25 kg than in those above 25 kg. Five surgical complications and 6 infections were encountered postoperatively and hypertension was lasting in 6. Thirteen patients experienced 19 periods of acute allograft rejection. All of the 24 patients in the cyclosporin era (1986-) overcame rejections and they are all alive with good graft function.

CONCLUSIONS

As long as proper pretransplant patient evaluation and management, and intensive perioperative care are undertaken, good prognosis of renal allograft can be achieved in young patients.

Changes in renal blood flow in response to sympathomimetics in the rat transplanted and denervated kidney

BACKGROUND

Renal denervation and re-innervation may affect vascular responses to sympathomimetics, which may play a role in the maintainance of renal blood flow (RBF) following renal transplantation. The purpose of the present study was to elucidate pharmacological alteration of the renal sympathetic response following kidney transplantation. Using the rat kidney transplantation model, we focused on responses to various sympathomimetics in order to investigate the effects of sympathetic denervation and functional remodulation mechanisms in the transplanted kidney.

METHODS

Male isogenic rats underwent unilateral kidney denervation or kidney transplantation accompanied by unilateral native nephrectomy. Renal blood flow was evaluated using a laser Doppler flow meter following bolus injection of 50 microg/kg dopamine and continuous infusion of 60 microg/min phenylephrine (PE) at 0, 30, 60, 90 and 240 days after transplantation as well as at 30 days after denervation.

RESULTS

Bolus injection of dopamine (50 microg/kg) induced an initial reduction in RBF (that of alpha-adrenoceptors) followed by a long-lasting increase in RBF (that of beta-adrenoceptors) in the native kidney. In grafted or denervated kidneys, the dopamine-induced decrease in RBF mediated by alpha-adrenoceptors was markedly enhanced while the increase in RBF mediated by an action of dopamine on beta-adrenoceptors was blunted. The effects of the post-transplant period on vascular responses to dopamine were significant, but not completely synchronized with the native kidney, even at 240 days. Continuous infusion of PE (60 microg/min) produced a gradual increase in RBF in the native kidney, whereas a sudden reduction (i.e. breakthrough in autoregulation) was observed in the denervated and transplanted kidney.

CONCLUSIONS

The responses to sympathomimetics in the grafted kidney were shifted towards flow reduction (i.e. enhanced vasoconstriction via stimulation of alpha-adrenoceptors and blunted vasodilatation via stimulation of beta-adrenoceptors. This functional impairment was recovered in a time-dependent manner. In addition, the hemodynamic autoregulation system in the kidney deteriorated following transplantation or denervation.

Surgical repair of anterior hypospadias with fish-mouth meatus and intact prepuce based on anatomical characteristics

PURPOSE

A variant form of anterior hypospadias, called a megameatus and intact prepuce (MIP), is thought to be less amenable to conventional distal hypospadias repair. The feasibility of using the standard technique with a parameatal-based foreskin flap is described herein.

MATERIALS AND METHODS

Nine children with the MIP variant underwent repair. A foreskin flap for urethroplasty was harvested from either the ventral (Mathiew) or unilateral site. The glans was split along with the cleft glanular groove to create the glans wings. The flap was laid on the urethral plate to form a neourethra, and glanulomeatoplasty was completed by approximation of the glans wings. Sleeve reapproximation of the penile foreskin was performed for uncircumcised skin closure.

RESULTS

The functional and cosmetic results of the procedure were excellent in 8 cases including 1 with temporary postoperative edema of redundant foreskin. The last case underwent excision of the ventral excess foreskin for cosmetic reasons.

CONCLUSIONS

Although the etiology of the MIP variant remains obscure, the urethral plate distal to the meatus is uniformly pliable and healthy in this variant. Furthermore, the ventral portion just proximal to the meatus is well developed and not atretic so that the parameatal ventral foreskin is safely harvested for onlay urethroplasty.

Kidney transplantation in patients with neurovesical dysfunction

BACKGROUND

Five renal recipients with neurovesical dysfunction (NVD) were retrospectively reviewed focusing on anatomical and urodynamic abnormalities of the lower urinary tract and their management prior to kidney transplantation.

METHODS

The underlying anomalies in these 5 patients were a posterior urethral valve (1 with an imperforate anus; n = 2), meningomyelocele (n = 2) and a congenital short urethra with an imperforate anus (n = 1). Their urinary tracts were evaluated prior to transplantation with voiding cystourethrography, urethrocystoscopy, cystometrography and electromyography of the external urethral sphincter to identify a possible focus of urinary tract infection, urine storage and voiding function.

RESULTS

All 5 patients had NVD proven by urodynamic studies or by documentation of urinary retention in the absence of mechanical outlet obstruction. Bilateral high grade vesicoureteral reflux was noted in all patients, requiring ureteroneocystostomy. Clean intermittent catheterization (CIC) was ultimately employed for bladder emptying in all patients. Two patients with poor bladder compliance underwent augmentation cystoplasty before transplantation. The Mitrofanoff procedure was used in 2 patients with structural urethral abnormalities to access the bladder for catheterization. After eradication of possible sources of infection and establishment of a low-pressure urine storage system with bladder emptying by CIC, kidney transplantation was performed. Following kidney transplantation, all of the recipients were asymptomatic for urinary tract infections using CIC. Although 1 patient lost his graft due to chronic rejection, the other 4 other patients have good renal function.

CONCLUSION

Kidney transplantation in patients with NVD can be performed provided that their urinary tract problems are properly resolved.

Clinical features of vesicoureteral reflux in infants and outcome of conservative therapeutic approach

OBJECTIVES

We evaluated the clinical features of vesicoureteral reflux (VUR) detected in infants and the outcome of a conservative therapeutic approach.

METHODS

Consecutively 67 infants with VUR (55 boys and 12 girls) were enrolled in this study. Of the 67 patients, 34 had primary and 33 had secondary VUR. Underlying abnormalities in secondary VUR were: posterior urethral valve (PUV) in 7; bulbar urethral stenosis (Cobb's collar) in 16; neurovesical dysfunction (NVD) in 8, and others in 2. Transurethral incision was performed in patients with PUV or Cobb's collar. NVD was managed with intermittent catheterization. All patients were followed with antibiotic prophylaxis.

RESULTS

No significant difference was found in VUR grades between primary and secondary VUR. Spontaneous resolution of VUR was noted in 31% of primary and 54% of secondary VUR (p<0.02). VUR downgrading including VUR resolution was also noted more often in secondary than in primary VUR (80 vs. 48%; p<0.01).

CONCLUSIONS

The distribution of primary and secondary VUR in infants was almost equal in our study. Resolution of reflux is seen more often in secondary than in primary cases. Thus, early detection and proper management of underlying lower urinary tract abnormalities, either structural or functional, are crucial in the treatment of VUR in infants.

Early experience with real-time CT-fluoroscopy for an intracranial lesion

We have developed a real-time CT-fluoroscopy (CTF) system of which the initial trial was reported in 1993. This paper deals with the early clinical experience with this system. A third-generation scanner equipped with a slip-ring (Toshiba) was used. Images were reconstructed and displayed at a rate of 6/s with a 0.83-second delay time using a newly designed array processor. CTF was carried out in 12 cases (10 brain hemorrhages, 2 tumors). Good-quality fluoroscopic images were obtained in all cases. Real-time monitoring with CTF of needle placement and advancement was useful for accurate puncture needle biopsy and evacuation of the lesions. No serious complication was experienced in this series.

[Application and limitation of neoadjuvant hormonal therapy for prostate cancer]

Of 156 patients, 111 (clinical stage T1a-b; 21, T1c; 17, T2a-b; 36, T2c; 27, T3; 10) immediately underwent radical prostatectomy (surgery group), and 45 (clinical stage T1a-b; 8, T1c; 4, T2a-b; 10, T2c; 9, T3; 14) received neoadjuvant hormonal therapy (NHT group). NHT offered probability of increasing organ-confined cancer(OCC; pathological stage pT2 or lower N0M0) in the following group, which contains (a) patients who had moderately differentiated adenocarcinoma in the biopsy specimen and T2b or lower diseases, and (b) those who had well differentiated adenocarcinoma, T2c diseases and PSA levels of 10 ng/ml or higher, referred to as "OCC suitable criteria". Of 156 patients, 51 (33%) met OCC suitable criteria. In those cases, the proportion of OCC in NHT group was significantly higher than that in surgery group (11/12 (92%) vs. 16/39 (41%), p = 0.002). NHT is useful for increasing OCC in patients who meet OCC suitable criteria.

[One-stage-bilateral adrenalectomy by thoracoabdominal approach for bilateral large pheochromocytomas in men type IIa. A case report]

We experienced a case of MEN type 2a with bilateral and large pheochromocytomas. A 39-year-old man was admitted to the previous hospital with complaints of paroxysmal headache. hypertension and diabetes mellitus. Radiographic imagings showed thyroid tumors in both lobes and bilateral adrenal tumors. Thyroid tumors were histologically proved to be medullary thyroid carcinoma by needle biopsy and systemic investigations revealed an excessive secretion of plasma and urinary cathecholamines which suggested the presence of pheochromocytoma. The patient was diagnosed as MEN type 2a. He was admitted to our hospital for the treatment of bilateral adrenal tumors for which we performed one-stage bilateral adrenalectomy by thoracoabdmonal approach. Both adrenal tumors were histologically confirmed as pheochromocytoma. The patient's postoperative course was uneventful. He underwent uneventful total thyroidectomy approximately 2 months after bilateral adrenalectomy. Even in bilateral and large pheochromocytomas, one-stage bilateral adrenarectomyenables safe postoperative managements. We concluded that the thoracoabdominal approach is feasible in the patients with huge and cranially spreading adrenal tumor, which gives us a wide operative field for easy vascular control.

Structural changes of collagen components and diminution of nerves in congenital ureteropelvic junction obstruction

PURPOSE

Three-dimensional arrangements of smooth muscle cells, collagenous component and peripheral nerves of congenital ureteropelvic junction (UPJ) obstruction were studied in order to clarify the pathogenetic mechanism of interaction among these neuro-myo-stromal components.

MATERIALS AND METHODS

The UPJ and upper ureters were obtained from 14 patients with congenital hydronephrosis (7 intrinsic and 4 extrinsic obstruction) and 7 normal controls. Three-dimensional arrangement of each structural component was observed by scanning electron microscopy, and the nerve distribution was analyzed with immunohistochemistry for protein gene product 9.5.

RESULTS

The UPJ of intrinsic obstruction had structural features as follows. Muscle fascicles were sparse and thin. Each muscle cell was thin in diameter. Intercellular spaces were six to seven times wider than controls. Collagen fibrillar sheaths of smooth muscle cells (pericellular collagen fibrils attached to the basement membrane) were interwoven to form a dense felt-like structure against thin lace-like sheaths in controls. Interstitial collagenous component showed dense and compact structure against loose network of wavy collagen bundles in controls. In the muscular layer, nerve distribution was decreased to about one-third of controls. In contrast, non-stenotic portion of intrinsic UPJ obstruction as well as materials from extrinsic UPJ obstruction showed no structural difference as compared with controls.

CONCLUSIONS

In the intrinsic obstruction, nerve fibers were depleted in the muscular layers in the ureteric walls, resulting in dysfunction and atrophy of muscle fibers and an increase of collagen fibers in the muscle layers with abnormal accumulation of intercellular and interstitial collagen. These changes may disrupt the mobility of UPJ and lead to both mechanical and functional obstruction.

[Clinical evaluation of donor renal artery reconstruction in kidney transplantation]

This retrospective study describes the experience of arterial reconstruction of donor kidney in our institute since 1982.

MATERIALS AND METHODS

Of total 56 living related kidney transplantations 15 required renal arterial reconstruction or ligation of donor kidneys. Renal arterial reconstruction was employed for 11 cases (end to side anastomosis [4 cases], conjoined anastomosis [3], hypogastric artery graft interposition [3], other [1], while simple ligation was employed for 4. Bench surgery with microsurgical techniques was employed for the repair. Elective surgery was done for preoperatively defined multiple renal arteries [10] and aneurysm [1], while imperative surgery for intraoperatively detected accessory arteries [2] and surgical injuries [2]. Postoperative patency of arteries and renal function (GFR) and evaluated by 99mTc-DTPA renoscintigraphy.

RESULTS

The mean total ischemic time of reconstructed cases was 135 min., while that of ligated ones was 67 min. None of them required hemodialysis due to acute tubular necrosis. Postoperative graft arterial patency was impaired in 2 of 11 reconstructed cases (18%), while it was impaired in 3 of 4 ligated cases (75%). Two failure attempts of arterial reconstruction cases were all imperative ones. Postoperative GFR of the graft was well preserved in all cases.

CONCLUSION

We conclude that (1) Ligation and imperative surgery tend to be associated with renal infarction, although it does not affect GFR. (2) Renal artery reconstruction was highly successful in preserving renal mass (or normal cortical image), albeit longer ischemic time than simple ligation. (3) Considering importance of preserved nephron mass in clinical renal transplantation every attempt should be made to repair the donor arterial anomalies when expected (elective) or found (imperative). (4) Thorough preoperative evaluation of donor renal arteries is mandatory.

Normal perfusion pressure breakthrough syndrome in giant arteriovenous malformations

The treatment of large, high-flow cerebral arteriovenous malformations is one of the most difficult operations which neurosurgeons encounter because of the complex surgery and the post-operative effects on the brain. We have evaluated 10 patients with large, high-flow AVMs who underwent surgical resection. Patients were investigated with contrast-enhanced computed tomography and magnetic resonance imaging, 1231-IMP single photon emission computed tomography (SPECT) studies of cerebral flow and cerebral vasodilatory function, intraoperative Laser Doppler flowmetry (4 or 10 patients), and conventional angiography. The volume of the arteriovenous malformation nidi ranged from 32.8 to 210.5 cc. SPECT imaging performed on the first post-operative day showed marked hyperperfusion in the brain tissue surrounding the resected nidus, and these regions were normal on images on the 7th post-operative day. Laser Doppler flowmetry showed sudden, and marked increase in CBF immediately following placement of temporary clips on the main feeding artery. Angiograms done on 7-14 days following surgery showed a stagnating artery, fragile vessel, and a prolonged circulation time. Our results indicate that pre- and post-operative SPECT study, especially a dynamic SPECT study done on the first post-operative day, was the most useful examination for ascertaining the post-operative normal perfusion pressure breakthrough.