Failure of Costimulatory Blockade-induced Regulatory T Cells to Sustain Long-term Survival of High Ischemic Allografts

BACKGROUND

Costimulatory blockade-induced allograft tolerance has been achieved in rodent models, but these strategies do not translate well to nonhuman primate and clinical transplants. One confounder that may underlie this discrepancy is the greater ischemic inflammation imposed on the transplants. In mice, cardiac allografts subjected to prolonged cold ischemic storage (CIS) before transplant have increased ischemia-reperfusion injury, which amplifies infiltrating endogenous memory CD8 T-cell activation within hours after transplantation to mediate acute graft inflammation and cytotoxic lymphocyte-associated molecule-4 immunoglobulin-resistant rejection. This study tested strategies inhibiting memory CD8 T-cell activation within such high ischemic allografts to achieve long-term survival.

METHODS

A/J (H-2 a ) hearts subjected to 0.5 or 8 h of CIS were transplanted to C57BL/6 (H-2 b ) recipients and treatment with peritransplant costimulatory blockade. At 60 d posttransplant, regulatory T cells (Treg) were depleted in recipients of high ischemic allografts with anti-CD25 monoclonal antibody (mAb) or diphtheria toxin.

RESULTS

Whereas peritransplant (days 0 and +1) anti-lymphocyte function-associated antigen-1 mAb and anti-CD154 mAb prolonged survival of >60% allografts subjected to minimal CIS for >100 d, only 20% of allografts subjected to prolonged CIS survived beyond day 80 posttransplant and rejection was accompanied by high titers of donor-specific antibody. Peritransplant anti-lymphocyte function-associated antigen-1, anti-tumor necrosis factor-α, and anti-CD154 mAb plus additional anti-CD154 mAb on days 14 and 16 obviated this donor-specific antibody and promoted Treg-mediated tolerance and survival of 60% of high ischemic allografts beyond day 100 posttransplant, but all allografts failed by day 120.

CONCLUSIONS

These studies indicate a strategy inducing prolonged high ischemic allograft survival through Treg-mediated tolerance that is not sustained indefinitely.

[A Case of Strangulated Bowel Obstruction Caused by Barbed Suture Following Laparoscopic Sacrocolpopexy]

A 63-year-old woman underwent laparoscopic sacrocolpopexy for pelvic organ prolapse. Four days postoperatively, she underwent an abdominal computed tomography scan because she developed a stomachache, and a strangulated bowel obstruction was suspected. The patient then underwent an emergency laparotomy which revealed strangulation of the small intestine caused by a band formed between the stump of a barbed suture and the mesentery. The strangulation was released by resecting the stump, and intestinal resection was not necessary. Nine days following the re-intervention, the patient was discharged from our hospital. As of four months after the surgery, she has not experienced any recurrence of pelvic organ prolapse or other postoperative complications. We need some ingenuity when using barbed suture in situations where the thread and the intestine come into contact.

[A Case of Advanced Bladder Carcinoma Treated by Third-Line Gemcitabine and Paclitaxel Chemotherapy]

A 77-year-old man underwent robot-assisted laparoscopic radical cystectomy with pelvic lymph node dissection and ileal conduit for bladder carcinoma. Six months postoperatively, multiple lung metastases and a sacral bone metastasis were detected on computed tomography (CT). The patient then received gemcitabine-carboplatin (G-CBDCA) because he had renal dysfunction, which is a contraindication for cisplatin. After two courses of G-CBDCA, pembrolizumab was started because the lung metastases showed progression. The patient then underwent gemcitabine-paclitaxel (GP) chemotherapy (G : 1,000 mg/m² on days 1, 8, and 15 ; P : 180 mg/m² on day 1 ; every 4 weeks) as third-line treatment because of further progression after two courses of pembrolizumab. The lung metastases showed an almost complete response after two courses of GP. Additionally, after two courses, the lung metastases showed a complete response, and no abnormal fluorodeoxyglucose uptake in the sacral bone metastasis was seen on positron emission tomography-CT. The patient suffered neutropenia and anemia as adverse effects ; however, these disappeared after discontinuing gemcitabine. Chemotherapy was discontinued after the four courses in accordance with the patient's wishes, and he has remained free from recurrence for 2 months after discontinuing therapy.

Novel metastatic burden-stratified risk model in de novo metastatic hormone-sensitive prostate cancer

The metastatic burden is a critical factor for decision-making in the treatment of metastatic hormone-sensitive prostate cancer (HSPC). This study aimed to develop and validate a novel risk model for survival in patients with de novo low- and high-burden metastatic HSPC. The retrospective observational study included men with de novo metastatic prostate cancer who were treated with primary androgen-deprivation therapy at 30 institutions across Japan between 2008 and 2017. We created a risk model for overall survival (OS) in the discovery cohort (n = 1449) stratified by the metastatic burden (low vs high) and validated its predictive ability in a separate cohort (n = 951). Based on multivariate analyses, lower hemoglobin levels, higher Gleason grades, and higher clinical T-stage were associated with poor OS in low-burden disease. Meanwhile, lower hemoglobin levels, higher Gleason grade group, liver metastasis, and higher extent of disease scores in bone were associated with poor OS in patients with high-burden disease. In the discovery and validation cohorts, the risk model using the aforementioned parameters exhibited excellent discriminatory ability for progression-free survival and OS. The predictive ability of this risk model was superior to that of previous risk models. Our novel metastatic burden-stratified risk model exhibited excellent predictive ability for OS, and it is expected to have several clinical uses, such as precise prognostic estimation.

External validation of the albumin, C-reactive protein and lactate dehydrogenase model in patients with metastatic renal cell carcinoma receiving second-line axitinib therapy in a Japanese multi-center cohort

PURPOSE

To externally validate the utility of the albumin, C-reactive protein and lactate dehydrogenase model to predict the overall survival of previously treated metastatic renal cell carcinoma patients.

PATIENTS AND METHODS

The ability of the albumin, C-reactive protein and lactate dehydrogenase model to predict overall survival was validated and compared with those of other prognostication models using data from 421 metastatic renal cell carcinoma patients receiving second-line axitinib therapy at 36 hospitals belonging to the Japan Urologic Oncology Group.

RESULTS

The following factors in this cohort were independently associated with poor overall survival in a multivariate analysis: a low Karnofsky performance status, <1 year from diagnosis to targeted therapy, a high neutrophil count, and low albumin, elevated C-reactive protein, and elevated lactate dehydrogenase, and the Japan Urologic Oncology Group model was newly developed based on the presence/absence of these independent factors. In this cohort, 151 (35.9%), 125 (27.7%) and 145 (34.4%) patients were classified into the favorable, intermediate and poor risk groups, respectively, according to the albumin, C-reactive protein and lactate dehydrogenase model; however, the proportions of patients in the intermediate risk group stratified by the Japan Urologic Oncology Group, Memorial Sloan Kettering Cancer Center and International Metastatic Renal Cell Carcinoma Database Consortium models were >50%. The superiority of the albumin, C-reactive protein and lactate dehydrogenase model to the Memorial Sloan Kettering Cancer Center and International Metastatic Renal Cell Carcinoma Database Consortium models, but not the Japan Urologic Oncology Group model, was demonstrated by multiple statistical analyses.

CONCLUSIONS

The utility of the albumin, C-reactive protein and lactate dehydrogenase model as a simple and objective prognostication tool was successfully validated using data from 421 metastatic renal cell carcinoma patients receiving second-line axitinib.

Differential prognostic factors in low- and high-burden de novo metastatic hormone-sensitive prostate cancer patients

Metastatic burden is a critical factor for therapy decision-making in metastatic hormone-sensitive prostate cancer. The present study aimed to identify prognostic factors in men with high- or low-metastatic burden treated with primary androgen-deprivation therapy. The study included 2450 men with de novo metastatic prostate cancer who were treated with primary androgen-deprivation therapy at 30 institutions across Japan between 2008 and 2017. We investigated the prognostic value of various clinicopathological parameters for progression-free survival (PFS) and overall survival (OS) in patients stratified by low- or high-metastatic burden. Among the 2450 men, 841 (34.3%) and 1609 (65.7%) were classified as having low- and high-metastatic burden, respectively. Median PFS of the low- and high-burden groups were 44.5 and 16.1 months, respectively, and the median OS was 103.2 and 62.7 months, respectively. Percentage of biopsy-positive core, biopsy Gleason grade group, T-stage, and N-stage were identified to be differentially prognostic. M1a was associated with worse PFS than was M1b in the low-burden group, whereas lung metastasis was associated with better PFS and OS than was M1b in the high-burden group. Differential prognostic factors were identified for patients with low- and high-burden metastatic prostate cancer. These results may assist in decision-making to select the optimal therapeutic strategies for patients with different metastatic burdens.

[A Case of Bladder Cancer Treated with Arterial Stent-Grafting to Prevent Uretero-Arterial Fistula Due to Radiation Therapy for Metastasis]

A 66-year-old male with bladder cancer underwent radical cystectomy and ileal conduit construction. The pathological diagnosis was urothelial carcinoma with squamous differentiation (pT3b). Computed tomography (CT) 18 months postoperatively revealed a right external iliac lymph node metastasis. He was treated with systemic chemotherapy after placement of bilateral ureteral stents, but CT following chemotherapy revealed an increase in the size of the metastasis, and the patient was diagnosed with progressive disease. Radiotherapy to the metastasis was selected as local therapy, but the patient was at risk of an uretero-arterial fistula because the right external iliac artery and the right ureter adjacent to the metastasis were involved in the irradiated field. The right external iliac lymph node metastasis was irradiated with a dose of 50 Gy after stent grafting for the right external iliac artery to prevent an ureteroarterial fistula. He had no adverse events, including hematuria after radiotherapy, but died of cancer cachexia 12 months after radiotherapy.

Potential effectiveness of local radiotherapy for extending survival and reducing symptomatic local events in patients with de novo metastatic prostate cancer

Objectives

To evaluate the association between the use of local radiotherapy (RT) with the survival of patients with de novo metastatic prostate cancer and symptomatic local events (SLEs).

Patients and methods

Patients were initially diagnosed with metastatic prostate cancer between 2008 and 2017 at 30 institutes in Japan. Prostate‐specific antigen (PSA) progression‐free survival (PSA‐PFS) under initial androgen deprivation therapy and overall survival (OS) was compared between patients receiving local RT (RT group) and no RT (no‐RT group) by multivariate Cox proportional hazard analyses. The occurrence rate of grade ≥2 SLEs was compared by multivariate logistic regression analyses. Propensity score matching (PSM) analyses were performed to compare PSA‐PFS and OS of the groups in the high and low metastatic burden cohort.

Results

Two hundred and five (7%) of 2829 patients received RT before PSA progression. Median PSA‐PFS and OS were significantly longer in the RT group than in the no‐RT group and the difference was significant in multivariate analyses (HR = 0.44, 95% CI = 0.33‐0.57 and HR = 0.40, 95% CI = 0.27‐0.60, respectively). The occurrence rate of grade ≥2 SLEs was significantly lower in the RT group (2%) than the no‐RT group (9%) and the difference was significant in multivariate analyses (HR = 0.28, 95% CI = 0.10‐0.76). Using PSM analyses, PSA‐PFS and OS remained significantly different (HR = 0.64, 95% CI = 0.46‐0.89 and HR = 0.47, 95% CI = 0.30‐0.72, respectively), between the RT (n = 182) and the no‐RT (n = 182) groups. The difference in OS was significant in the high metastatic burden cohort (HR = 0.55, 95% CI = 0.37‐0.81).

Conclusions

Addition of local RT to standard treatment for de novo metastatic prostate cancer patients tends to have the potential to extend survival, even in patients with high metastatic burden, and to reduce SLEs.

Oncological outcomes of a multicenter cohort treated with axitinib for metastatic renal cell carcinoma

The present study aimed to evaluate the efficacy of the real-world use of axitinib and to develop a prognostic model for stratifying patients who could derive long-term benefit from axitinib. This was a retrospective, descriptive study evaluating the efficacy of axitinib in patients with metastatic renal cell carcinoma that had been treated with 1 or 2 systemic antiangiogenic therapy regimens at 1 of 36 hospitals belonging to the Japan Urologic Oncology Group between January 2012 and February 2019. The primary outcome was overall survival (OS). Using a split-sample method, candidate variables that exhibited significant relationships with OS were chosen to create a model. The new model was validated using the rest of the cohort. In total, 485 patients were enrolled. The median OS was 34 months in the entire study population, whereas it was not reached, 27 months, and 14 months in the favorable, intermediate, and poor risk groups, respectively, according to the new risk classification model. The following 4 variables were included in the final risk model: the disease stage at diagnosis, number of metastatic sites at the start of axitinib therapy, serum albumin level, and neutrophil : lymphocyte ratio. The adjusted area under the curve values of the new model at 12, 36, and 60 months were 0.77, 0.82, and 0.82, respectively. The efficacy of axitinib in routine practice is comparable or even superior to that reported previously. The patients in the new model's favorable risk group might derive a long-term survival benefit from axitinib treatment.

Small bowel obstruction due to internal hernia caused by the ureter after laparoscopic radical cystectomy and ileal conduit: A case report

A 74-year-old man presented at our hospital with complaints of abdominal pain, nausea, and vomiting. He had undergone laparoscopic radical cystectomy and ileal conduit for urinary bladder cancer 1 month earlier. The patient had abdominal distention, resonant sounds on percussion, and diffuse abdominal tenderness without rebound or guarding. Abdominal CT revealed dilated jejunal loops herniated through a cord-like structure. Based on these findings, emergency surgery was performed, and intestinal dilatation into the space between the ureter, the ileal conduit, and the sacral bone was detected. The loops were released manually and were not resected. To the best of our knowledge, this is the first case report of small bowel obstruction due to internal hernia caused by the ureter after laparoscopic radical cystectomy and ileal conduit. Retroperitonealization and the minimum required mobilization of the ureters may be necessary when urinary diversion is constructed, especially in laparoscopic or robotic surgeries.

Impact of relative dose intensity in gemcitabine-cisplatin chemotherapy for metastatic urothelial carcinoma

Objectives

To evaluate the impact of relative dose intensity for gemcitabine-cisplatin chemotherapy in patients with metastatic urothelial carcinoma.

Methods

We retrospectively reviewed the medical records of 18 patients with metastatic urothelial carcinoma, who received gemcitabine-cisplatin regimen as the first-line chemotherapy between 2009 and 2015. The doses of gemcitabine and cisplatin were reduced or the intervals between treatment cycles were prolonged according to the treatment efficacy and adverse events during the first and second cycles. The individually optimal relative dose intensity was set as the actual dose per the standard dose in the first and second cycles. From the third course onward, patients received the gemcitabine-cisplatin chemotherapy with the same relative dose intensity. Overall survival was compared with the groups according to the value of relative dose intensity.

Results

The median age was 72.5 (range, 56-79) years and 15 men and 3 women were enrolled in the study. The median number of cycles of first-line gemcitabine-cisplatin chemotherapy was 8 (range, 2-17), and the median survival time from initiation of first-line chemotherapy was 20.1 (range, 3.5-32.8) months. The total median relative dose intensity of gemcitabine-cisplatin chemotherapy was 56.1%. The median survival time of 10 patients in the group with the relative dose intensity of less than 60% was significantly longer than that of 8 patients in the group with the relative dose intensity of more than 60% (19.2 and 11.0 months, respectively, p = 0.04).

Conclusion

Individual low relative dose intensity management in the first-line gemcitabine-cisplatin chemotherapy may be an acceptable option for patients with metastatic urothelial carcinoma.

Supposed pituitary-production of human chorionic Gonadotropin induced by androgen deprivation therapy

INTRODUCTION

The main cause of slightly elevated human chorionic gonadotropin (HCG) after successful treatment of male germ cell tumors is considered to be pituitary-derived HCG. It is well known that pituitary-derived HCG is frequently detected in postmenopausal women. We evaluated the status of serum HCG in men with elevated gonadotropins, which were induced by androgen deprivation therapy, using commercially available assays.

MATERIALS AND METHODS

We enrolled 44 patients with prostate cancer, who underwent luteinizing-hormone releasing hormone agonist treatment. We measured serum follicle-stimulating hormone (FSH), serum luteinizing hormone (LH), serum total HCG, serum free HCG-β subunit, and urine total HCG 3 times per patient, on the day of treatment initiation, the next day, and 3 months after.

RESULTS

On the day after treatment initiation, serum and urine HCG was detected in 61% and 73% of patients, respectively. Markedly strong correlations were observed between serum/urine HCG and FSH/LH. In particular, receiver operating characteristic curve analysis indicated excellent area under the curve (0.977, 95% confidence interval 0.951-1.003)) for serum HCG-detectable LH. At the cutoff value of 21.07 mIU/mL for serum HCG-detectable LH, the sensitivity and specificity were 96.7% and 95.3%, respectively. Serum HCG-β was not detectable at any times in any patients.

CONCLUSIONS

Suggested pituitary-derived HCG can be frequently detected in patients with elevated gonadotropins, and there is a firm association between HCG detection and gonadotropin levels.

Aquaporin 4 blockade improves survival of murine heart allografts subjected to prolonged cold ischemia

Prolonged cold ischemia storage (CIS) is a leading risk factor for poor transplant outcome. Existing strategies strive to minimize ischemia-reperfusion injury in transplanted organs, yet there is a need for novel approaches to improve outcomes of marginal allografts and expand the pool of donor organs suitable for transplantation. Aquaporins (AQPs) are a family of water channels that facilitate homeostasis, tissue injury, and inflammation. We tested whether inhibition of AQP4 improves the survival of fully MHC-mismatched murine cardiac allografts subjected to 8 hours of CIS. Administration of a small molecule AQP4 inhibitor during donor heart collection and storage and for a short-time posttransplantation improves the viability of donor graft cells, diminishes donor-reactive T cell responses, and extends allograft survival in the absence of other immunosuppression. Furthermore, AQP4 inhibition is synergistic with cytotoxic T lymphocyte-associated antigen 4-Ig in prolonging survival of 8-hour CIS heart allografts. AQP4 blockade markedly reduced T cell proliferation and cytokine production in vitro, suggesting that the improved graft survival is at least in part mediated through direct effects on donor-reactive T cells. These results identify AQPs as a promising target for diminishing donor-specific alloreactivity and improving the survival of high-risk organ transplants.

Inhibition of Endogenous Memory CD8 T Cell Infiltration into Cardiac Allografts Subjected to Prolonged Cold Ischemic Storage is Required to Promote Long-Term Graft Survival Naoki Kohei, Hidetoshi

Endogenous memory CD8 T cells infiltrate MHC-mismatched cardiac allografts and produce IFN-γ in response to donor class I MHC within 24 hrs after graft reperfusion in mice. We have reported that prolonged cold ischemic graft storage (CIS) provokes intense inflammation within hours after allograft reperfusion and promotes CTLA-4Ig-resistant endogenous memory CD8 T cell rejection of the allograft by day 28 post-transplant (whereas CTLA-4Ig prolongs survival of allografts subjected to minimal CIS &gt; day 60). We tested strategies inhibiting endogenous memory CD8 T cell infiltration into cardiac allografts subjected to prolonged CIS to promote long-term allograft survival. Peri-transplant anti-LFA-1 mAb and anti-CD154 mAb treatment of recipients of allografts subjected to minimal CIS prolonged survival of 60% of allograft &gt; 100 days. In contrast, this treatment prolonged only 20% of allografts subjected to prolonged CIS beyond day 80 post-transplant, with rejection accompanied by the appearance of high titers of donor-specific antibody (DSA &gt;10,000 vs. &lt;100 in long-term survivors). Use of a new regimen: peri-transplant recipient treatment with anti-LFA-1 mAb, anti-TNFa mAb, and anti-CD154 mAb plus additional doses of anti-CD154 mAb on days 14 and 16 post-transplant promoted long-term survival of 60% allografts subjected to prolonged CIS past day 100 post-transplant. Recipients with surviving allografts accepted donor skin allografts, but rejected third-party skin allografts. These studies indicate long-term survival of allografts subjected to prolonged CIS by using strategies that include reagents inhibiting endogenous memory CD8 T cell infiltration into the allografts and reagents that inhibit the production of DSA.

NK Cells Play a Critical Role in Mediating Inflammation and Graft Failure During Antibody-Mediated Rejection of Kidney Allografts

The incidence of antibody-mediated kidney graft rejection has increased, but the key cellular and molecular participants underlying this graft injury remain unclear. We previously reported that kidney allograft rejection in CCR5−/− mice is dependent on donor-specific antibody (DSA). The current study determined if cells expressing cytotoxic function contributed to antibody-mediated kidney allograft rejection in CCR5−/− recipients. Wild type C57BL/6, B6.CCR5−/− and CD8−/−/CCR5−/− mice were transplanted with complete MHC mismatched A/J kidney grafts and intra-graft inflammatory components were followed to rejection. B6.CCR5−/− and CD8−/−/CCR5−/− recipients rejected the allografts by day 35 whereas 65% of allografts in wild type recipients survived past day 80 post-transplant. Allograft rejection in wild type recipients was associated with high titers of DSA, equivalent to those induced in CCR5-deficient recipients. Rejected allografts in C57BL/6, B6.CCR5−/− and CD8−/−/CCR5−/− recipients’ expressed high levels of VCAM-1 and MMP7 mRNA that was associated with high serum titers of DSA. At rejection in wild type and CD8−/−/CCR5−/− recipients, kidney allografts also expressed genes associated with NK cell (Sh2d1B1 and MYBL1) but not with T cell (CXCR6) activity during inflammation. High levels of perforin and granzyme B mRNA expression in kidney allografts peaked on day 6 post-transplant in all recipients. NK cell depletion in CD8−/−/CCR5−/− recipients reduced this expression to background levels and promoted long-term survival of 40% of kidney allografts. These results support a role for NK cells in increasing inflammation during antibody-mediated kidney allograft injury and rejection.

Aquaporin 4 blockade is a novel strategy targeting ischemia/reperfusion injury in heart transplantation (TRAN1P.942)

Aquaporin 4 (AQP4) is the major water channel in the brain and its absence reduces brain edema in murine models of stroke.Recently, human and mouse cardiomyocytes were shown to express AQP4. Our goal was to test whether therapeutic inhibition of AQP4 reduces IRI and improves cardiac allografts survival. B6 mice were transplanted with BALB/c heart allografts subjected to 8 h of cold ischemia. Donors received AQP4 inhibitor 0.5h before harvest; hearts were perfused with and stored for 8 h on ice with the inhibitor. Recipients were given AQP4 inhibitor every 6h for 5 days. In the absence of additional immunosuppression, treatment with AQP4 inhibitor significantly prolonged heart allograft survival (MST 2d, n=24 vs. 6 d, n=5), decreased early T cell infiltration and the intragraft expression of IFNγ, granzyme B, perforin, FASL, CXCR3, ICOS, and CXCL10 in comparison to untreated controls. The frequencies of donor-reactive spleen cells secreting IFNγ in recipients treated with AQP4 inhibitor were also four fold lower than those in untreated controls. Blocking AQP4 during allograft storage and early after transplantation prolongs the survival of fully MHC-mismatched heart allografts subjected to 8 h CIS. The graft prolongation is associated with the reduced early memory T cell infiltration into the graft and decreased anti-donor responses. Our data identify AQP4 as a promising therapeutic target to diminish the detrimental effects of prolonged CIS on transplant outcome.

Anti-huCD20 antibody therapy for antibody-mediated rejection of renal allografts in a mouse model

We have reported that B6.CCR5(-/-) mice reject renal allografts with high serum donor-specific antibody (DSA) titers and marked C4d deposition in grafts, features consistent with antibody-mediated rejection (AMR). B6.huCD20/CCR5(-/-) mice, where human CD20 expression is restricted to B cells, rejected A/J renal allografts by day 26 posttransplant with DSA first detected in serum on day 5 posttransplant and increased thereafter. Recipient treatment with anti-huCD20 mAb prior to the transplant and weekly up to 7 weeks posttransplant promoted long-term allograft survival (>100 days) with low DSA titers. To investigate the effect of B cell depletion at the time serum DSA was first detected, recipients were treated with anti-huCD20 mAb on days 5, 8, and 12 posttransplant. This regimen significantly reduced DSA titers and graft inflammation on day 15 posttransplant and prolonged allograft survival >60 days. However, DSA returned to the titers observed in control treated recipients by day 30 posttransplant and histological analyses on day 60 posttransplant indicated severe interstitial fibrosis. These results indicate that anti-huCD20 mAb had the greatest effect as a prophylactic treatment and that the distinct kinetics of DSA responses accounts for acute renal allograft failure versus the development of fibrosis.

Sequential analysis of donor-specific antibodies and pathological findings in acute antibody-mediated rejection in a rat renal transplantation model

Alloantibodies contribute significantly to renal transplant rejection by activation of complement and various cytokines with a variety of effector cells, and are a major cause of allograft loss. Although there is clinical evidence of antibody- and complement-mediated injury in renal transplantation, the mechanism of antibody-mediated rejection remains largely unknown. In order to understand the sequential production of antibodies and complement components, we presensitized recipient rats by skin transplantation. Anti-donor-specific IgG levels reached a maximum 2 weeks following presensitization after which the rats underwent renal transplantation from the same donor strain. We then evaluated sequential pathological findings based on the Banff classification and several factors related to graft rejection. In this presensitized model, peritubular capillaries were already dilated and stained for C4d. Neutrophil and mononuclear cell infiltration in these capillaries was detected beginning 2 h after transplantation. Donor-specific antibody IgG levels decreased rapidly and anti-IgG antibody stained glomerular and peritubular capillaries in the grafts beginning 2 h after transplantation. Additionally, several cytokines and complement components showed marked changes in the presensitized group. Thus, in the donor-specific presensitized recipient, alloantibodies and complement were activated immediately after transplant. C4d deposition in peritubular capillaries appears to be a key factor for the diagnosis of antibody-associated rejection.

Chronic antibody-mediated rejection is reduced by targeting B-cell immunity during an introductory period

Transplantation across blood group antigen and human leukocyte antigen (HLA) barriers are immunologically high risk. Both splenectomy and rituximab injection were developed to overcome those immunological barriers. The idea behind these treatments is to control B-cell immunity before and after renal transplantation and antibody production. Between January 2001 and December 2004, recipients underwent pretransplant double-filtration plasmapheresis (DFPP) and splenectomy at the time of transplantation in the ABO-incompatible group (ABO-I-SPX; n= 45). From January 2005 to June 2009, a low dose of rituximab was given as an alternative to splenectomy (ABO-I-RIT; n = 57). As a control group, we selected 83 cases of ABO-C living-donor kidney transplantation between January 2001 and December 2007 (ABO-C). We compared the graft survival rate and chronic antibody-mediated rejection (C-AMR) rate between ABO-C and ABO-I kidney transplantation with induction treatment. C-AMR rates 2 years after the operation were 8.8, 3.5 and 28.9%, and de novo donor-specific anti-HLA antibody (DSHA) positive rates were 2.2, 1.7 and 18.1% in the ABO-I-SPX, ABO-I-RIT and ABO-C groups, respectively. The ABO-C group showed the highest rate of C-AMR and de novo DSHA. B-cell depletion protocols, such as splenectomy or rituximab administration, reduced C-AMR after kidney transplantation.

[Comparison of intracytoplastic sperm injection outcomes with fresh and frozen-thawed testicular sperm]

Testicular sperm can be obtained from patients with non-obstructive azoospermia. However, there is not enough evidence concerning whether fresh or frozen-thawed sperm is better for successful pregnancy. We retrospectively compared initial treatment results of intracytoplasmic sperm injection using fresh and frozen-thawed testicular sperm in our institution. From August 1997 to May 2006, a total of 27 cases including 18 cases using fresh sperm (269 oocytes) and 9 cases using frozen sperm (97 oocytes) were evaluated. In the fresh and frozen sperm groups 33.4 and 32.9%, respectively, developed good quality embryo. There was no significant difference between the two groups in successful pregnancy and birth rates.

Late relapse of testicular cancer 21 years after first complete remission: a case report

We report here a case of very late relapse of a nonseminomatous germ cell tumor 21 years after first complete remission. A 42-year-old man, with a clinical history of right testicular cancer, was referred to our hospital with elevated serum alpha-fetoprotein (AFP) level. CT scan demonstrated a 5 x 5 cm retroperitoneal lymph node swelling compressing the inferior vena cava (IVC) extending from the right renal vein down to the bifurcation of the aorta. The patient received a total of four courses of combination chemotherapy consisting of cisplatin, etoposide, paxlitaxel, and ifosfamide. However, the retroperitoneal lymph node metastasis did not respond to chemotherapy, and the serum AFP level increased. Extended bilateral retroperitoneal lymph node dissection with right nephrectomy, partial duodenectomy, and vena cavectomy were performed. The patient has been followed up with no evidence of disease for 48 months after the operation without any further therapy.

Impact of Retraction of Vas Deferens in Postradical Prostatectomy Inguinal Hernia

OBJECTIVES

The incidence of inguinal hernia after radical retropubic prostatectomy (RRP) is high. We speculated that retraction of the vasa deferentia with a retractor might cause stretch injury of the myopectineal orifice and lead to inguinal hernia. In testing this hypothesis, we performed RRP with a modified technique and followed up patients prospectively.

METHODS

From 1993 to 2002, 171 patients underwent RRP with a retrograde approach, in which the vasa deferentia were cut after the prostate and seminal vesicles were finally exposed. From 2003 to 2005, 150 patients were followed up prospectively who had undergone RRP with a modified technique, in which the bilateral vasa deferentia and surrounding tissues were dissected before placing a retractor so as not to retract them and injure the myopectineal orifice. The incidence rates of inguinal hernia in the two groups were compared. In addition, for the entire group of 321 patients, we determined the risk factors for inguinal hernia after RRP using multivariate analysis.

RESULTS

Of the 150 patients in the modified method group, 22 (14.7%) developed an inguinal hernia during follow-up, and 42 (24.6%) of the 171 patients did so in the previous method group. No significant difference was noted between the two groups in terms of the hernia-free rate. Multivariate analysis revealed a body mass index of less than 23 kg/m2 and a history of previous inguinal hernia repair were significant risk factors for postoperative inguinal hernia.

CONCLUSIONS

We found that retraction of the vasa deferentia with a retractor did not affect the high incidence of postoperative inguinal hernia after RRP.

Clinical outcome of tubeless cutaneous ureterostomy by the Toyoda method

AIM

Cutaneous ureterostomy is the least invasive method of urinary diversion, but it carries a risk of stomal stenosis. We retrospectively examined the long-term outcome of tubeless cutaneous ureterostomy by the Toyoda method.

METHODS

Since 1983, the Toyoda cutaneous ureterostomy has been performed in 97 patients (169 renal units) with a minimum follow up of 3 months. The ureteral patency rate was reviewed according to whether the stomal type was single (one ureter, one stoma) or double-barrel (two ureters, one stoma).

RESULTS

After a median follow up of 23 months (range 3 to 169), a tubeless condition was achieved in 102 (82%) of 124 renal units associated with double-barrel stoma and in 35 (78%) of 45 renal units associated with single stoma. Although mild to moderate hydronephrosis was observed in 19% of patients, serum creatinine levels did not change after a minimum of 12 months after surgery (median 35).

CONCLUSIONS

A high ureteral patency rate was achieved with cutaneous ureterostomy using the Toyoda method. This procedure, especially double-barrel stomal creation, is a reasonable alternative to other forms of urinary diversion in patients at high risk.

Antibiotic prophylaxis in radical prostatectomy: 1-day versus 4-day treatments

OBJECTIVE

The standard protocol of antibiotic prophylaxis in radical prostatectomy remains to be established. We retrospectively compared the occurrence of perioperative infections following radical prostatectomy between two different protocols of antibiotic prophylaxis.

METHODS

This study included 106 cases of radical retropubic prostatectomy managed on the clinical pathways. Two different protocols of antibiotic prophylaxis were used in otherwise identical pathways. Between January and December 2004, 50 patients received a second generation cephem, cefotiam, for 4 days, beginning 30 min before surgery (4-day group), whilst between December 2004 and July 2005, only two doses of cefotiam were given on the day of operation in 56 patients (1-day group). The incidence of surgical site infection (SSI) and remote infection (RI) was retrospectively investigated.

RESULTS

Superficial incisional SSI occurred in one (1.8%) patient in the 1-day group, whereas no patient in the 4-day group developed SSI. No RI was observed in either the 1-day or 4-day group. Intravenous antibiotics were administered besides the pathway in a patient in the 1-day group because unexplained fever more than 38 degrees C continued postoperative day (POD) 2 through POD 4 without signs of SSI or RI. Excluding this case, postoperative more than 38 degrees C was rare and transient after POD 2.

CONCLUSION

The incidence of SSI and RI was low and not significantly different between the 1-day and 4-day groups. Therefore, the 1-day protocol of prophylactic antibiotic treatment seems adequate for preventing perioperative infections in radical prostatectomy.

Obstructive azoospermia associated with chronic sinopulmonary infection and situs inversus totalis

We describe 2 cases of obstructive azoospermia associated with situs inversus and sinopulmonary infection due to ciliary defects. Electron microscopy of testicular sperm flagella demonstrated normal morphology with nine peripheral doublets surrounding a central pair and complete sets of inner and outer dynein arms. Electron microscopy of the nasal mucosa revealed partial defects of the dynein arms of cilia, although the "9+2" morphology was preserved. Our cases were considered unique variants of Young's syndrome but also had characteristic features of Kartagener syndrome, and thus support the hypothesis that Young's syndrome has a genetic etiology similar to that of Kartagener syndrome.

Automatic switching and guidance system to facilitate unassisted uroflowmetry using commercial electronic devices

To enable male patients to undergo uroflowmetry in a private condition without medical supervision, we devised an automatic switching and patient guidance system for the spinning disk uroflowmeter Urodyn 1000, using two commercial electronic devices (an infrared motion sensor tap and a memorizable vacuum fluorescent display). Instead of running the uroflowmeter continuously, which shortens the life of the spinning disk due to mechanical wear, an infrared motion sensor turns on the devices each time a patient enters the room. The patient urinates according to the timely instructions on the visible display and voided urine directly flows into a urinal. The devices are automatically turned off 5 min after the patient leaves the room. With the use of our system, men already acquainted with uroflowmetry could perform self-administered uroflowmetry any time in private. The system was considered useful for improving the quality of patient service.

Application of siphon principle to fluid drainage in transurethral surgery

Transurethral resection is usually performed using an all-in-one drape with a fluid collection pouch, drainage port and hose. Gravity drainage of irrigation fluid through the hose is often hampered, resulting in fluid retention in the pouch. We applied a siphon principle to facilitate fluid drainage by making a U-shaped bend near the distal end of the hose, using an adhesive tape, and hooking the distal end of inverted U shape on the edge of bucket placed on the floor. When the hose is filled with irrigation fluid up to the crest of the siphon, fluid flow driven by atmospheric pressure continues until the pouch is evacuated. Repriming and restarting occur automatically throughout the operation. This simple device has virtually eliminated fluid retention in the pouch and proved to be especially useful in transurethral prostatectomy, which requires a large amount of irrigation fluid.

Dynamic contrast-enhanced subtraction magnetic resonance imaging in diagnostics of testicular torsion

OBJECTIVES

To retrospectively correlate the magnetic resonance imaging (MRI) diagnosis with the surgical findings and/or clinical outcomes in patients presenting with an acute scrotum.

METHODS

From January 1997 to June 2004, 39 selected patients presenting with an acute scrotum underwent dynamic contrast-enhanced subtraction MRI as a 24-hour stand-by examination. The MRI diagnosis was based solely on the presence or absence of testicular contrast enhancement, without respect to the clinical history or physical examination findings.

RESULTS

Contrast enhancement of the affected and normal testes could be accurately compared in all cases. The MRI diagnosis was testicular torsion (no testicular contrast enhancement, n = 13), nonspecific (reduced to normal enhancement, n = 10), appendiceal torsion (n = 3), and epididymitis (n = 13). The surgical findings and/or subsequent clinical outcomes showed that MRI diagnosis of testicular torsion was accurate in all 13 cases. Furthermore, exploration revealed testicular torsion in 1 case with very little enhancement. The sensitivity and specificity of MRI in the diagnosis of testicular torsion was 93% (13 of 14) and 100% (25 of 25), respectively. Although MRI detected testicular perfusion, 5 of the 6 patients with clinical suspicion of intermittent torsion underwent surgical exploration.

CONCLUSIONS

MRI is a highly accurate imaging modality for the diagnosis of testicular torsion. However, it could not be used to rule out intermittent torsion and the clinical use of negative findings for an MRI torsion test was less than 100% specificity. Because this was a preliminary retrospective study, the true clinical value of MRI should be evaluated by prospective studies.

Adult onset of declining spermatogenesis in a man with nonmosaic Klinefelter’s syndrome

OBJECTIVE

To examine an unusual case of Klinefelter's syndrome.

DESIGN

Case report.

SETTING

An infertility clinic at a private hospital.

PATIENT(S)

A patient with nonmosaic Klinefelter's syndrome who had had a child with his ex-wife without artificial reproductive technologies.

INTERVENTION(S)

Karyotyping with peripheral blood lymphocytes, microdissection testicular sperm extraction, and intracytoplasmic sperm injection (ICSI).

MAIN OUTCOME MEASURE(S)

Sperm count and testicular histopathology.

RESULT(S)

Semen analysis revealed severe oligoasthenozoospermia. Intracytoplasmic sperm injection using ejaculated spermatozoa was performed, and successful pregnancy and delivery were achieved. Two years later, multiple semen analyses revealed azoospermia. Microdissection testicular sperm extraction was performed, and motile sperm were successfully retrieved. Unfortunately, the first cycle of ICSI using testicular sperm failed. Testicular histopathology was compatible with decreased spermatogenesis.

CONCLUSION(S)

This is a case of a man with nonmosaic Klinefelter's syndrome who exhibited progressive decline of spermatogenesis. This case suggests the merit of early sperm retrieval and cryopreservation for future management of infertility in Klinefelter's syndrome.

Testosterone-induced priapism in Klinefelter syndrome

We present the case of a patient with Klinefelter syndrome and priapism after testosterone administration. The patient underwent testicular sperm extraction for interventional fertilization, but no sperm were found. Because he had given up trying to father a child and his testosterone level had been low, testosterone replacement therapy was started with testosterone enanthate. After the third injection, he presented with low-flow priapism. Conservative management was successful, and no recurrence developed during the next 15 months. Testosterone replacement therapy carries some risk of priapism even for patients with Klinefelter syndrome.

Use of acute normovolemic hemodilution in patients undergoing radical prostatectomy

OBJECTIVES

To evaluate the efficacy and safety of acute normovolemic hemodilution (ANH) in patients undergoing radical prostatectomy. Preoperative autologous blood donation (PAD) is widely accepted as a means of reducing the need for allogeneic blood transfusion in radical prostatectomy. ANH is an alternative method for obtaining autologous blood.

METHODS

On the basis of our previous report that showed the equivalence of PAD and ANH, we prospectively replaced PAD with ANH as a standard practice for radical prostatectomy after September 1999. Of 174 radical prostatectomy patients between September 1999 and June 2004, 153 underwent ANH alone, 15 chose to receive both PAD and ANH, and ANH was contraindicated in 15 because of comorbidities.

RESULTS

For the 153 patients undergoing ANH alone, 1032 +/- 201 mL of autologous blood was collected. With an intraoperative blood loss of 1602 +/- 926 mL, 14 patients (9.2%) received allogeneic blood transfusion. The preoperative, intraoperative nadir, and postoperative hematocrit value was 43.6% +/- 3.4%, 25.8% +/- 3.8%, and 31.9% +/- 4.3%, respectively. No patient experienced a perioperative adverse event related to hemodilution or blood transfusion.

CONCLUSIONS

Our continued experience has shown that ANH is a safe and effective means of autologous blood procurement. Given its advantages, including lower cost, lower risk, and simplicity, we conclude that ANH can replace conventional PAD for use in radical prostatectomy, although the true value of ANH should be determined by future randomized studies including a no-treatment control group.

[Superselective endovascular treatment of renal artery aneurysms with detachable microcoils]

Selective transcatheter embolization using an interlocking detachable coil was performed in two cases with renal artery aneurysms. Case 1, a 73-year-old male, was referred to our department complaining of macrohematuria persisting for three days. Case 2, a 52-year-old female, visited our department because calcifications in both renal pedicle areas were found in a health check up. Drip infusion pyelography (DIP) and computerized tomography (CT) revealed in case 1 an aneurysm which was 11 x 10 cm in diameter with nearly circumferential calcification in the right renal pedicle area and in case 2 two aneurysms, one 12 x 10 cm in the right and one 22 x 20 cm in the left with imperfect calcification. Enhanced CT confirmed blood flow in the aneurysms. Because abdominal surgery, was considered to be a highrisks in both cases 1 and 2 the coil embolization was performed. The patients have been followed up after the embolization without any particular complications or changes in the coil location.