S-1 as an alternative treatment after 5-fluorouracil-induced coronary vasospasm in a patient with small bowel adenocarcinoma: a case report

5-Fluorouracil (5-FU) is a chemotherapeutic agent used worldwide to treat various solid tumors. It may cause adverse cardiotoxic events, the most common of which is coronary vasospasm. Recently, the 2022 European Society for Medical Oncology guidelines for metastatic colorectal cancer recommended S-1 as an alternative therapy after 5-FU-induced cardiotoxicity; however, only limited data on Asian patients are available. Here, we report a case of safe administration of S-1 to a 72-year-old Japanese female patient with metastatic small bowel adenocarcinoma who developed 5-FU-induced coronary vasospasm. While receiving modified FOLFOX6 (5-FU plus leucovorin and oxaliplatin) as palliative chemotherapy, she experienced chest pain with electrocardiographic ST elevation. Chemotherapy was temporarily suspended, but treatment was resumed by switching from modified FOLFOX6 to SOX (S-1 plus oxaliplatin) as the tumor began to worsen. Owing to the adverse event of enteritis, the patient's treatment was switched to S-1 monotherapy after cycle 3, and S-1 monotherapy was continued without any cardiotoxicity. S-1 may be a promising alternative therapy after 5-FU-induced cardiotoxicity.

[Renal autotransplantation in a patient with acute renal infarction following surgery for a dissecting aneurysm]

A 58-year-old woman experienced a sudden onset of severe chest and back pain and thus visited our center in October 1999. Contrast-enhanced computed tomography (CT) revealed a Stanford type A acute aortic dissection. The CT also demonstrated a 50 mm ascending aorta and dissection from the ascending aorta via the abdominal aorta to the level of the left renal artery. The perioperative transesophageal echocardiogram showed an intimal tear in the ascending aorta without valvular abnormality. Therefore, we performed graft replacement of the ascending aorta. On the first postoperative day, she developed oliguria and showed a sudden rise in serum creatinine (Cr) and blood urea nitrogen (BUN) levels, necessitating hemodialysis. She required daily hemodialysis or hemofiltration for twenty days. Thereafter, renal function recovered and dialysis was no longer performed. However, on postoperative day 26, the patient complained of sudden lumber pain. Unheralded oliguria was associated with worsening renal function. A CT scan at this point revealed infarction of the left kidney. During surgery, the left kidney was excised for heterotopic autotransplantation. Extensive thrombosis within a true lumen of the left renal artery was revealed. Following removal of the thrombus and perfusion with heparinized cold saline, renal autotransplantation to a heterotopic site in the pelvis were performed. Although the patient required hemodialysis for five days, renal function recovered gradually. She was discharged five months later. In our experience, it appears that heterotopic renal autotransplantation by which normal arterial perfusion distal to the dissection is reestablished is a good therapeutic option for reperfusion of the ischemic kidney compromised by a progressive dissection of the thoracoabdominal aorta.

Determination of serum prostate-specific antigen-alpha1-antichymotrypsin complex for diagnosis of prostate cancer in Japanese cases

OBJECTIVE

The clinical utility of the determination of serum prostate-specific antigen-alpha1-antichymotrypsin complex (PSA-ACT) for the diagnosis of prostate cancer, especially in cases in the diagnostic gray zone, is still unclear.

MATERIAL AND METHODS

With the use of a newly approved enzyme immunoassay for the detection of PSA-ACT, 907 sera, including those from non-urological benign and malignant diseases, were analysed.

RESULTS

Serum values of PSA-ACT in non-prostate cancer males increased according to age from the 40s to 70s. The serum values were high only in the patients with prostatic diseases and, in prostate cancer patients, the values became high as the clinical stage progressed. By receiver-operating characteristic analysis significantly better results in PSA-ACT than total PSA were observed. In the group with a total PSA of 2-20 ng/ml, the detection of PSA-ACT showed better results, although not significantly so, than the free-to-total PSA ratio.

CONCLUSIONS

The detection of PSA-ACT showed a high clinical utility in the diagnosis of prostate cancer. Therefore, it may replace total PSA determination.

[A study on parameters to predict tumor volume for stage T1c prostate cancers of Gleason score 6 or less]

The number of cases of stage T1c prostate cancer has dramatically been increasing since the introduction of PSA as a screening test. The patients with T1c prostate cancer are usually treated by radical prostatectomy. In this group, however, some cancers are of small tumor volume and with a Gleason score of less than 7. These cancers are considered to be good candidates for watchful waiting management. We have investigated 40 patients with T1c prostate cancer treated by radical prostatectomy between 1996 and 1998. All 9 patients harboring tumors of Gleason score 7 or greater had tumors larger than 0.5 cm3. We have investigated PSA-related parameters including total PSA (PSA), PSA density (PSAD), free PSA, and % free PSA in 31 patients with T1c cancers of Gleason score 6 or less in order to clarify good preoperative predictors of tumor volume. We compared the distribution of PSA, PSAD, free PSA, and % PSA between the larger and smaller tumor groups. There was no significant difference in PSA, PSAD, or free PSA value. The small tumor group had a greater mean % free PSA than the larger tumor group (23.27 versus 11.88, p = 0.007). Areas under receiver operating characteristic curves were 0.715, 0.794, 0.636, and 0.842 for PSA, PSAD, free PSA and % free PSA. In stage T1c prostate cancer of Gleason score 6 or less, % free PSA may be the most useful preoperative predictor for tumor volume of 0.5 cm3 or greater.

[Epididymal sperm aspiration for obstructive azoospermia]

Epididymal sperm aspiration technique combined with assisted reproductive technology (ART) including intracytoplasmic sperm injection (ICSI) has provided new frontiers for the treatment of unreconstructable obstructive azoospermia, including congenital bilateral absence of the vas deferens and failed surgical intervention. Epididymal sperm is obtained by several procedures, including microsurgical epididymal sperm aspiration (MESA), mini-MESA (Modified MESA), macroscopic epididymal sperm aspiration (MaESA) and percutaneous epididymal sperm aspiration (PESA). Since 1991 in our department, epididymal sperm aspiration combined with ART was performed by MESA (26 cases, 41 times) and PESA (3 cases, 4 times). Motile sperm retrieval using MESA and PESA was obtained in 34 out of 36 times (94.4%) and 2 out of 4 times (50%), respectively. MESA-ICSI resulted in a 47.3% 2PN (metaphase II) fertilization rate per eggs and a 28.8% pregnancy rate per transfer. With advancement of ICSI technique in which frozen sperm can be used, elective sperm retrieval can be planned at our convenience. PESA is a convenient, inexpensive and effective outpatient clinic procedure for retrieving sperm assisted with ICSI. In summary, infertile couples need to be given realistic options regarding treatment outcome. The fertility potential and age of the female partner need to be considered when addressing male treatment options.

Urinary undiversion for pelvic actinomycosis: a long-term follow up

BACKGROUND

A 43-year-old woman who had been using intrauterine contraceptive devices for the past 10 years underwent an emergency operation for bowel and urinary obstruction.

METHODS/RESULTS

Frozen section analysis showed undifferentiated adenocarcinoma. Incomplete tumorectomy, ileal resection, partial cystectomy, colostomy and bilateral ureterocutaneostomy were palliatively performed. Postoperatively, periodic acid-Schiff and Grocott-Gomori methenamine tests revealed Actinomyces and the final diagnosis was pelvic actinomycosis. Treatment with penicillin G administered intravenously relieved her symptoms and the lesion was dramatically improved. The patient underwent colostomy closure and urinary undiversion.

CONCLUSIONS

Five years after urinary undiversion, the patient's renal function has been maintained and she can void without incontinence and dysuria.

Seminal tract obstruction caused by childhood inguinal herniorrhaphy: results of microsurgical reanastomosis

PURPOSE

Childhood inguinal herniorrhaphy is a frequent causes of seminal tract obstruction. We investigate the characteristics of this obstruction, surgical techniques for reanastomosis and outcomes in patients with bilateral or unilateral obstruction caused by inguinal herniorrhaphy in childhood.

MATERIALS AND METHODS

We treated 22 men an average of 30.5 years old in whom average duration of obstruction was 27.1 years. Obstruction was bilateral in 9 patients and unilateral in 13, and 14 had azoospermia preoperatively. Microsurgical 2 layer vasovasostomy and/or specific tubule epididymovasostomy was performed.

RESULTS

Inguinal and crossed vasovasostomy was done in 18 and 4 patients, respectively. The distal end of the vas was found at the internal inguinal ring or in the pelvic cavity in 57.1% of the vasa and more than 3 cm. of the vas had been resected in 37%. Sperm was noted in vasal fluid in 45.2% of the vasa during the operation and the patency rate of inguinal vasovasostomy was 88.9%. Ipsilateral epididymovasostomy performed after patent inguinal vasovasostomy in 5 patients with secondary epididymal obstruction resulted in normal sperm density and 3 pregnancies. In 7 men more than 2 procedures were done. There was sperm in the ejaculate in 12 of the 14 patients who had had azoospermia preoperatively and apparently increased sperm density postoperatively in 4 of the 8 who had not had azoospermia preoperatively. Pregnancy was achieved by 7 of the 21 married men (33.3%).

CONCLUSIONS

Microsurgical reanastomosis of the seminal tract resulted in high patency and pregnancy rates in cases of seminal tract obstruction caused by childhood inguinal herniorrhaphy. Patients should elect seminal tract reanastomosis or assisted reproductive technology using epididymal or testicular sperm after receiving sufficient information on each treatment modality.

Transperitoneal laparoscopic adrenalectomy: experience in 100 patients

Between July 1992 and October 1996, 100 transperitoneal laparoscopic adrenalectomies were performed on 99 patients at our hospital and affiliated hospitals. The clinical diagnoses were primary aldosteronism (41 patients), Cushing's syndrome (15), pre-Cushing's syndrome (6), pheochromocytoma (7; 8 adrenal glands), adrenal cancer (2), nonfunctioning adenoma (22), myelolipoma (3), and complicated adrenal cyst (3). Ninety-seven glands were removed laparoscopically. The mean operative time was 240 +/- 76 (SD) minutes and the mean blood loss 68 +/- 80 mL for the series. The mean blood was 77 +/- 113 mL when the three operations that were converted to open surgery are included. The mean times for the return to a normal diet and unassisted ambulation were 1.3 +/- 0.6 and 1.4 +/- 0.8 days, respectively. The mean duration of the use of analgesics was 1.5 +/- 1.3 days, including the day of surgery. In contrast, in the latest 10 open adrenalectomies done at Kyoto University Hospital, the mean operative time was 186 +/- 53 minutes and the mean blood loss 220 +/- 170 mL. The mean times for return to a normal diet and for unassisted ambulation and the mean duration of the use of analgesics were 1.9 +/- 0.3, 2.9 +/- 1.1, and 2.9 +/- 1.7 days, respectively. Thirty-six operations, excluding one converted to open surgery, performed at Kyoto University Hospital were selected to look at the learning curve for transperitoneal laparoscopic adrenalectomy and evaluated for operative time and blood loss. The mean operative time and mean blood loss in the first 10 procedures performed at Kyoto University Hospital were 256 +/- 63 minutes and 89 +/- 57 mL; however, these values were reduced to 177 +/- 39 minutes and 48 +/- 32 mL in the next 10 procedures at the same hospital. Laparoscopic adrenalectomy via the transperitoneal anterior approach can be equivalent to open adrenalectomy in efficiency with a shorter convalescence.

Quality of life survey of urinary diversion patients: comparison of continent urinary diversion versus ileal conduit

BACKGROUND

Continent urinary reservoirs (CUR) have become one of the major options for patients requiring urinary diversion to improve their quality of life (QOL). To assess whether CUR enhanced postoperative QOL, we surveyed patients with CUR and ileal conduit (IC) using a questionnaire sent by mail.

PATIENTS AND METHODS

The questionnaire consisted of 133 questions that covered physical and mental status, social life, sexual habits and symptoms related to urinary diversions. A total of 172 questionnaires were sent out, and 137 (80%) patients (74 CUR and 63 IC patients) responded.

RESULTS

Basic physical conditions were similar in the 2 groups, except for sleeping habits. Regarding social life, however, the CUR group showed better scores in bathing habits and frequency of overnight travel. Parastomal dermatitis was more frequent in the IC group and the patients were more hesitant to show their stoma to others. On the other hand, about half of the patients in the CUR group complained of troublesomeness in self-catheterization, especially at night. Overall, 74% and 41% of the patients in the CUR and IC group were satisfied with their urinary diversion. When the Kock pouch and Indiana pouch were compared, no statistically significant differences were found in average capacity, maximum capacity, or frequency of self-catheterization.

CONCLUSIONS

CUR recipients have enhanced QOL regarding the stoma, travel and sleeping habits as compared to ileal conduit. However, troublesomeness of night time self-catheterization was noted in the CUR group. Individualized selection of the type of urinary diversion with informed consent is essential.

Vitamin B12 deficiency in patients with urinary intestinal diversion

BACKGROUND

Because vitamin B12 is absorbed exclusively by the terminal ileum, we investigated vitamin B12 deficiency as a potential metabolic complication after urinary intestinal diversion.

METHODS

We measured serum levels in patients with Kock pouches (n = 35); Indiana pouches (n = 27); and ileal conduits (n = 25). Serial determinations of serum B12 levels were obtained in 19 patients with kock pouches and 14 patients with Indiana pouches. The dual-isotope Schilling test was performed in 9 patients with Kock pouches and 6 patients with Indiana pouches.

RESULTS

No patient had an abnormally low serum B12 level (< 200 pg/mL). Mean (+/-SD) serum B12 levels in patients with the Kock pouch (506 +/- 202 pg/mL) and the Indiana pouch (536 +/- 249 pg/mL) were lower than that in patients with the ileal conduit (727 +/- 391 pg/mL). The mean serum B12 level was not significantly different between patients with and without preoperative irradiation. Serial determinations showed that serum B12 levels in some patients with continent urinary reservoirs were persistently near the lower normal limit, or became progressively lower. Three of the 9 patients (33%) with Kock pouches and 4 of the 6 patients (67%) with Indiana pouches were B12 malabsorbers, although no patients had megaloblastic anemia or neurologic symptoms.

CONCLUSIONS

Some patients with continent urinary reservoirs are at risk for vitamin B12 deficiency due to malabsorption. Routine evaluation of serum B12 levels is recommended for all patients with continent urinary reservoirs, and a Schilling test for those with subnormal serum B12 levels.

Pros-Eight transurethral radiofrequency thermotherapy for benign prostatic hyperplasia: preliminary clinical results

BACKGROUND

We have developed a new transurethral thermotherapy device using 8MHz radiofrequency (RF) for the treatment of patients with symptomatic benign prostatic hyperplasia (BPH). We report the safety and effectiveness of the initial clinical experience with this device.

METHODS

Sixty patients with symptomatic BPH were subjected to a single 1-hour treatment under local anesthesia. The treatment device uses extracorporeal RF capacitive heating in combination with radiative heating and conductive cooling of the urethra.

RESULTS

In the 49 patients evaluable at 3 months, the mean International Prostate Symptom Score decreased from 17.8 to 13.1 (P < 0.0001) and the Quality of Life score decreased from 4.4 to 3.4 (P < 0.0005). Maximum flow rate increased from 8.1 to 9.7 mL/s (P < 0.05) at 3 months. Overall effectiveness by Homma's response criteria was as follows; excellent 4.1%, good 10.2%, fair 38.8% and poor 46.9%. Side effects were minimal. Gross hematuria was seen in 3 patients and erosion of the external urethral meatus was seen in 2 patients, but none had urinary retention.

CONCLUSIONS

In this initial clinical trial, transurethral RF thermotherapy was safe and resulted in modest symptomatic improvement. Further investigations for optimizing the treatment protocol seem warranted.

[Usefulness of ultrasound-guided prostate biopsy in the diagnosis and treatment of localized prostate cancer]

Recently the ultrasound-guided prostate biopsy, especially random systematic biopsy, is considered more sensitive than the usual site-directed biopsy for the detection of localized prostate cancers. To confirm the usefulness of the ultrasound-guided prostate biopsy in the diagnosis and treatment of prostate cancer, we analyzed 170 cases who underwent ultrasound-guided prostate biopsy due to the abnormal findings in digital rectal examination (DRE), transrectal ultrasonography (TRUS) or serum level of prostate specific antigen (PSA). Prostate cancer was detected in 53 patients including 25 patients with metastatic lesions. Excluding the advanced prostate cancers, the positive predictive value (PPV) of DRE, TRUS and serum PSA was 3.8, 8.1, and 20.8%, respectively, when only one category showed abnormal finding in spite of normal finding of the others. Although these values were very low, it seemed necessary to apply all three tests for the detection of localized prostate cancer because the prostate biopsy was indicated by the abnormal finding of a single category in 9 cases (32%; 6/28) with localized cancers. The PPV of hypoechonic region on ultrasonography was 36%, and no cancer was demonstrated in the hypoechoic region at the transition zone, suggesting a low specificity of the hypoechoic region. Although there was no statistical association between the clinical stage and the number of positive cores or the length of cancerous tissue in the sextant biopsies, 64% of coincidence was observed between Gleason's sum of biopsy cores and that of operative specimens.

Management of late complications of continent urinary diversion using the Kock pouch and the Indiana pouch procedures

BACKGROUND

Continent urinary diversion (CUD) is performed on patients after total cystourethrectomy due to invasive bladder cancer or other diseases requiring urinary diversion. Since 1984, we have performed CUD using either the Kock pouch procedure or a modified Indiana pouch method. During the long-term follow-up, increasing numbers of late complications occurred, especially after the Kock pouch procedure. We summarized the frequency of postoperative complications, their management, and outcome of CUD using these 2 methods.

METHODS

Between 1984 and 1995, CUD using the Kock pouch method was performed on 102 patients, and on 61 patients using the Indiana pouch method, with a mean follow-up period of 83 and 50 months, respectively. The patients were between 24 and 82 years old, with a mean age of 59 years. In most patients, the Kock pouch was constructed according to the original method, except for the use of a Dacron fabric collar, and the Indiana pouch was made using the ileal patch method.

RESULTS

Of 95 patients followed up for more than 3 months after CUD using the Kock pouch method, efferent and afferent nipple valve malfunction occurred in 21 (22%) and 26 (27%) patients, respectively. Efferent complications occurred during the first year after surgery, whereas afferent complications occurred several years after surgery. Open repair surgery (excluding ileus) was necessary for 36 (38%) patients. Of 59 patients followed for more than 3 months after CUD using the Indiana pouch method, 7 patients with stomal stenosis, 2 patients with stomal prolapse, and 1 patient with stricture at the ureterocolonic anastomosis were treated surgically. An hourglass-like deformity of the pouch was seen in 2 patients, on whom the original Indiana pouch method was performed. As a whole, 13 patients (22%) were retreated with open surgery. Urinary calculi occurred in 42 (44%) patients after CUD using the Kock pouch method and in 11 patients (19%) using the Indiana pouch method. The outcome was excellent, good, fair, and poor in 31, 37, 24, and 8% of the patients after CUD using the Kock pouch method, and in 36, 17, 42, and 5% of the patients after CUD using the Indiana pouch method.

CONCLUSIONS

We performed CUD using either the Kock pouch or the Indiana pouch method with a success rate of approximately 90%. The rates of revision, reoperation and stone formation were higher with the Kock pouch procedure than with the Indiana pouch procedure, while varying degrees of incomplete incontinence and difficulty in catheterization were seen more often in the latter.

[Prognostic factors of prostatic cancer]

In the past ten years, the treatment of prostate cancer has undergone remarkable changes. Furthermore, systematic prostate biopsy under transrectal ultrasonography or the measurement of prostate specific antigen has provided significant improvement in the detection of prostate cancer. Considering the increasing detection of prostate cancer, it is very important to clarify prognostic parameters in order to select the optimal treatment of given patients with localized or advanced prostate cancer. Recent statistical analyses showed that tumor volume, lymph node involvement and Gleason score would be significant prognostic indicators in localized prostate cancer. In advanced cancer, the response to the initial endocrine therapy might be a good prognostic parameter in addition to the histopathological features of primary tumors. In order to determine the factors which predict the prognosis of prostate cancer more accurately, the molecular biological approach is now ongoing, and may provide novel parameters for the decision making in the treatment of prostate cancer.

Increasing the thermal dose in transurethral microwave thermotherapy produces no improvement in therapeutic efficacy

BACKGROUND

Transurethral microwave thermotherapy (TUMT) is a minimally invasive treatment for benign prostatic hyperplasia (BPH). It has been reported that increased thermal dose and higher intraprostatic temperatures resulted in improved clinical response. Recently we treated BPH patients with the prostatron device using a new version of software (Prostasoft 2.5), which was intended to increase thermal delivery by allowing maximum power up to 70W. The safety and clinical results were compared between the patients treated with Prostasoft 2.5 and those treated with the currently available software (Prostasoft 2; maximum power up to 50W).

METHODS

A total of 105 patients were treated successively with two treatment protocols. Sixty-three patients were treated with Prostasoft 2 between September 1992 and July 1993, while 42 were treated with Prostasoft 2.5 between August 1993 and April 1994. Therefore, this investigation was a retrospective nonrandomized study. There was no significant difference in the baseline patient characteristics between the two groups.

RESULTS

Total thermal dose delivered to the prostate was significantly higher in the Prostasoft 2.5 group than that in the Prostasoft 2 group (137 kJ versus 116 kJ, P < 0.05). No serious complications were encountered in either group. Six months after TUMT, in both the Prostasoft 2.5 and Prostasoft 2 groups there was an improvement in patient condition as measured by the mean I-PSS, QOL, and peak flow rate values, as well as the overall therapeutic efficacy. The two groups differed in the amount of posttreatment improvement from between 8% and 22%, but this difference was not statistically significant.

CONCLUSIONS

Our study suggests that higher thermal dose attained by Prostasoft 2.5 does not necessarily result in more pronounced clinical improvement, although clinical response to TUMT has often been reported to be dependent upon thermal dose.

Mini-laparotomy staging pelvic lymph node dissection for localized prostate cancer

We report our early experience with mini-laparotomy staging pelvic lymph node dissection (PLND) for clinically localized prostate cancer. We have used virtually the same original technique described by Steiner and Marshall. A 5 cm lower midline abdominal incision provides excellent exposure, allowing complete PLND under direct visualization. If radical retropubic prostatectomy is indicated by the state of the pelvic lymph nodes, this can be performed only by extending the same incision. Nine patients with histologically proven prostate cancer underwent mini-laparotomy staging PLND. The average intraoperative time for mini-laparotomy PLND was 33 minutes (range, 25-50 minutes). The intraoperative blood loss was 44 ml (range, 20-90 ml). The mean number of pelvic lymph nodes removed was 6.9 (range, 5-10 nodes) on the right and 10.8 (range, 8-21 nodes) on the left. Eight patients underwent immediate radical retropubic prostatectomy and one had radiation therapy. There were no complications directly related to the mini-laparotomy staging PLND. Mini-laparotomy staging PLND is an attractive alternative to laparoscopic PLND, especially for patients at low risk of lymph node metastasis.

[Intravesical instillation of epirubicin hydrochloride in superficial bladder tumor--prophylactic and therapeutic instillation for carcinoma in situ]

Between May 1990 and May 1993 we performed intravesical instillation of epirubicin hydrochloride (EPI) to 52 patients with superficial bladder tumor after transurethral resection. Indications of these instillations were classified into 3 groups. Group 1 was for carcinoma in situ (CIS) or the CIS other than the original tumor, group 2 was for multiple tumors, and group 3 was for pT1G3 tumor. Intravesical instillations of the drug were given weekly for 10 weeks and close follow-up examinations were performed routinely. Group 1 was treated for CIS, whereas group 2 and group 3 were prophylactic instillations. The disease-free rate in group 1 was 67%, and that in group 2 and group 3 was 77% at 12 months, and 42% at 24 months according to the Kaplan-Meier method. The major side effects of the instillations were bladder irritation, hematuria and pyuria. However, we experienced 5 patients with severe side effects; 2 of atrophic bladder and 3 of hemorrhagic cystitis. Although this study was conducted retrospectively, these findings suggest that intravesical instillations of EPI can be as effective as other drugs, such as mitomycin C, and doxorubicin, by adding the maintenance instillation or by elevating the drug density and shortening the instillation time.

Interstitial laser coagulation for benign prostatic hyperplasia: preliminary clinical results

We report our early experience in the clinical application of interstitial laser coagulation of the prostate (ILCP) in the treatment of benign prostatic hyperplasia (BPH). Neodymium: YAG laser energy is transmitted via a specially designed interstitial thermotherapy light-guide. The light guides were inserted transurethrally into each lobe of the prostate by direct puncture, under direct visualization. The prostatic urethra is preserved during the procedure. From December 1993 to March 1994, 37 patients with symptomatic BPH were treated with ILCP. Treatment outcome was evaluated by the International Prostatic Symptom Score (I-PSS), flow rate, postvoided residual urine volume and quality of life score. Significant improvement in I-PSS and peak flow rate was observed at 3 months: I-PSS decreased from a mean of 19.3 to 10.4, and the peak flow rate increased from a mean of 7.2 to 9.4 ml/sec (p < 0.0001). The mean postvoided residual urine volume significantly decreased from 91 to 47 ml (p < 0.01). Two days after ILCP the serum prostate-specific antigen had increased by 860%, evidence of the significant tissue damage produced by laser irradiation. The quality of life score significantly decreased from a mean of 4.8 to 2.1 (p < 0.0001). No serious side-effects were observed. The early clinical results suggest that ILCP is safe and effective as a treatment of BPH and is less invasive than some other methods.

Intra-arterial infusion chemotherapy in combination with a biscoclaurine alkaloid, Cepharanthin, to treat bone metastasis arising from renal cell carcinoma

A 64-year-old man with iliac bone metastasis from left renal cell carcinoma was treated by intra-arterial infusion chemotherapy using vinblastine and epirubicine in combination with a biscoclaurine alkaloid, Cepharanthin. A good response was confirmed by computed tomography scan and the symptoms related to the metastatic lesion were much improved. Partial resection of the left iliac bone was performed when no viable cancer cells were found in the metastatic lesion.

[Intraarterial chemotherapy for metastatic renal cell carcinomas: combination with MDR-overcoming agents]

We analyzed the sensitizing activity of five agents, which have been assumed to be MDR-overcoming drugs, in two human renal cell carcinoma cell lines expressing the MDR1 gene at high levels. In addition, we studied the sensitizing activity of cepharanthin, an MDR-overcoming agents, to vinblastine, adriamycin, epirubicin, cisplatin, mitomycin C and etoposide. Based on the results, we treated 6 patients with metastatic renal cell carcinomas (4: bones, 2: contralateral kidneys) by intraarterial injection of vinblastine and adriamycin (or epirubicin) in combination with cepharanthin. Two of the 4 bone metastasis cases responded markedly to the treatment. Renal tubular impairment was observed in one patient who was treated for the contralateral kidney metastasis.

Evolving experience with continent urinary diversion using the Indiana pouch

The Indiana continent urinary reservoir procedure for urinary diversion was performed in 46 patients. After the first 8 cases several modifications were made to the Indiana pouch. These modifications include complete detubularization of the colonic segment, construction of the pouch augmented with a U-shaped patch of ileum and, more recently, the use of stapled plication. The mean postoperative follow-up period was 46 mo (range 4.5-74.1 mo). There was 1 perioperative death and this case was excluded from the follow-up study. Late complications related to the urinary reservoir occurred in 12 (26.7%) of the 45 patients. Stone formation was observed in 5 patients. Out of 45 patients, 42 achieved complete urinary continence while 2 suffered mild nocturnal incontinence and 1 had significant leakage. Three had unilateral hydronephrosis due to ureteroanastomotic stricture. Reservoirgraphy demonstrated no reflux into the upper urinary tract in all of the follow-up cases. Loopography of the efferent limb showed that a staple-plicated ileum functions better than a suture-plicated one in terms of reliability of the continence mechanism and ease of catheterization. The Indiana pouch should be considered for any patient requiring cutaneous urinary diversion because it is technically easy to perform and it has a low revision and high continence rate.

Laparoscopic ureterolysis for idiopathic retroperitoneal fibrosis

Ureterolysis and subsequent intraperitonealization were performed laparoscopically in 2 patients with unilateral idiopathic retroperitoneal fibrosis. The operative procedure was easily accomplished, and the outcome was excellent in the patient who had a ureteral stricture of 2 cm in length, whereas the operation was technically more complicated with a prolonged operation time in the other patient who had a stricture more than 5 cm in length. The convalescence period after the operation was short in both cases. Laparoscopic ureterolysis is a less invasive alternative to conventional open surgery, particularly in patients with involvement of a unilateral ureter of short length.

[A case of ileal leiomyosarcoma, difficult to differentiate from retrovesical tumor: report of a case]

A case of ileal leiomyosarcoma which was preoperatively diagnosed as a retrovesical tumor in a 41-year-old male patient was reported. He consulted our department with a complaint of tenesmus ani. CT, MRI and ultrasonography showed a mass in the retrovesical space which was palpable superior to the prostate in anal digital examination. Intraoperatively, the tumor was found to originate from the ileum, 250 cm from the ileocecal joint (Bauhin's valve). It is difficult to make diagnosis of leiomyosarcomas of small intestine preoperatively. Thirty-eight cases of leiomyosarcoma of small intestine reported in the recent 5 years in Japan are reviewed and discussed.

Eosinophilic sclerosing lipogranuloma of the male genitalia not caused by exogenous lipids

A type of sclerosing lipogranuloma of the male genitalia that is different from cases caused by injection or application of foreign bodies is reported in 4 patients. The characteristics of the disease are a symmetrical Y-shape of the granuloma, spontaneous regression, severe infiltration of eosinophils in the granuloma, eosinophilia of the peripheral blood and absence of any exogenous lipids by chemical analyses of the granuloma tissue. Ultrastructural study showed intracytoplasmic fat vacuoles of varied size in histiocytes and multinuclear giant cells. This is a new type of sclerosing lipogranuloma of the male genitalia and the pathogenesis of the disease is still unknown.

[Experience with combination chemotherapy consisting of methotrexate, vinblastine, adriamycin and cisplatin (M-VAC) in advanced urothelial cancer]

The M-VAC (methotrexate, vinblastine, adriamycin and cisplatin) regimen was used to treat 6 patients with metastatic transitional cell carcinoma of the urothelial tract. Three patients showed a partial response, all of them were made surgically disease free. Two of them are still alive 1 year and for 6 months after surgery with no evidence of disease and one other died of disease 11 months after surgery. The response in one case was no change and that in two others was a progressive disease. From our experience, we suggest that treatment with M-VAC is effective but that surgery after M-VAC appears essential for the successful management of the patients with metastatic transitional cell carcinoma of the urothelial tract.

Right iliac metastasis occurring eight years after resection of invasive bladder cancer: a case report

A case of transitional cell carcinoma of the bladder which metastasized to the right ilium eight years after resection of the original tumor without recurrence in the urinary tract is reported. Both the original and metastatic tumors were shown by immunoperoxidase technique to contain carcinoembryonic antigen (CEA). The patient received a combination of intra-arterial chemotherapy, irradiation and hyperthermia with partial response.

[Obstructive azoospermia treated by epididymovasostomy following vasovasostomy: a case report]

A case of secondary epididymal obstruction caused by vasal obstruction due to bilateral inguinal herniorrhaphy is reported. A 28-year-old patient, who had undergone right inguinal herniorrhaphy at the age of 3 and bilateral inguinal herniorrhaphy at the age of 25, was diagnosed as having obstructive azoospermia because testicular biopsy disclosed normal spermatogenesis. Vasography revealed bilateral vasal obstruction at the level of the inguinal canal. Bilateral microscopic vasovasostomy was performed but postoperative semen analysis showed azoospermia. At the operation only one sperm was found in the left vasal fluid while no sperm was found in the right. Postoperative vasography showed that the left vasovasostomy was accurate while the right vas was reobstructed. Microscopic epididymovasostomy using Silber's specific tubule technique was performed on the left side. The left epididymis was transected at its tail and numerous normal sperms were found in the epididymal fluid. Four months after the second operation, semen analysis showed normal sperm density of 34 x 10(6)/ml.

[Obturator foramen approach in vasovasostomy: studies on a cadaver]

We tested the obturator foramen approach first reported by Shafik in 1982, on an 84-year-old male cadaver. By this approach, the ductus deferens is by-passed through the obturator foramen for the reanastomosis in patients who require excision of a long segment of the ductus deferens. The length of the ductus deferens spared by this method was 10.5 cm. Preservation of the deferential artery and protection of the obturator nerve and vessels were considered to be essential in the operation. When the ductus deferens was cut more distal than the internal inguinal ring, this method was not feasible because the distal part of the vas was too short to come out to the upper scrotal region through the obturator foramen.