[Comparison of ventral and dorsal lymph node metastases of obturator nerve in radical prostatectomy].

OBJECTIVE: In this study, we assessed the significance of complete dissection of the dorsal lymph node of the obturator nerve during radical prostatectomy. PATIENTS AND METHODS: Fifty-six patients undergoing open radical prostatectomy and pelvic lymph node dissection for treatment of prostate cancer were included in this study. Neoadjuvant hormonal therapy and radiation therapy were not performed in any of the patients. First, pelvic lymph node dissection was performed between the external iliac vein and obturator nerve and classified as "ventral lymph node of the obturator nerve". Then, the tissue located in the area between the obturator nerve and the surface of the obturator internus muscle was removed and classified as "dorsal lymph node of the obturator nerve". Both lymph nodes were meticulously examined by identical pathologist. Lymph node yields, lymph node positive rate, and the factors associated with lymph node metastasis were studied. RESULTS: Eight of the 56 patients had pelvic lymph node metastases (6 were high risk and 2 were intermediate risk according to the D'Amico's criteria). In the 8 node-positive patients, only 1 patient had positive lymph node in "ventral lymph node of the obturator nerve" exclusively. Four patients had positive lymph node exclusively in "dorsal lymph node of the obturator nerve" and 3 patients had in both "ventral and dorsal lymph nodes of the obturator nerve". The total lymph node yields from "ventral lymph node of the obturator nerve" and "dorsal lymph node of the obturator nerve" were 459 (8.2 per patient) and 117 (2.1 per patient), respectively. The total numbers of positive lymph nodes from "ventral lymph node of the obturator nerve" and "dorsal lymph node of the obturator nerve" were 6 and 12, respectively. Lymph node positive rate was significantly higher in "dorsal lymph node of the obturator nerve" (10%) than "ventral lymph node of the obturator nerve" (1.3%) (P < 0.0001). The level of prostate-specific antigen (> or = 20 ng ml), Gleason score sum at prostate biopsy (> or = 9), and lymph node yield (> or = 16) were associated with lymph node status on univariate analysis. In multivariate analysis, only lymph node yield was associated with lymph node status. CONCLUSIONS: Dorsal lymph nodes of the obturator nerve should be dissected completely during radical prostatectomy.

[A case of hand-assisted laparoscopic radical nephrectomy in a severely obese patient (body mass index : 62.6)].

A 41-year-old Japanese man (177 cm, 196 kg, body mass index 62.6) was referred for treatment of a right renal mass 7 cm in diameter. Preoperative examination showed slight liver dysfunction and elevated hemoglobin A1c level (7. 2%). Cardiac and respiratory functions were within normal limits. Hand assisted laparoscopic radical nephrectomy with a transperitoneal approach was performed. The patient was laid on two parallel-shifted beds and intubation was performed in the lateral position. Insufflation time was 6.5 h, and estimated blood loss was 550 ml. Although the amount of bleeding was greater than usual, surgery was uneventful and no blood transfusion was required. On postoperative day 1, the patient resumed oral fluid intake and ambulation. An antithrombotic drug was administered subcutaneously as prophylaxis for deep vein thrombosis. The patient was discharged 9 days after surgery without any complications. Pathological diagnosis was renal cell carcinoma (clear cell carcinoma, pT3a). The surgical margin was negative. Despite the increasing prevalence of obesity, laparoscopic surgery in severely obese patients is uncommon in Japan and standard procedures have not been established. The transperitoneal approach is appropriate for such patients because it provides good orientation and surgical space. Hand-assisted laparoscopic surgery in obese patient has the advantage that the first incision for the hand port is long enough for safe laparotomy. Moreover, counter-traction by the hand is useful and the pulse of the renal artery can be perceived. However, extraction of the specimen from the hand port was more difficult than expected and an extra incision was required in this case.

Relationship between Toe Temperature and Lower Urinary Tract Symptoms.

OBJECTIVE: Cold stress can elicit increases in urinary urgency and frequency. We determined if there was a relationship between finger and toe temperatures and lower urinary tract symptoms (LUTS). METHODS: We studied 50 people who visited a public health management seminar. The participants were divided into two groups according to self-described sensitivity to cold stress. The cold non-sensitive (CNS) group consisted of 3 males and 20 females (66.9 ± 10.8 years old), and the cold sensitive (CS) group consisted of 4 males and 23 females (65.8 ± 8.01 years old). Each participant was assessed to determine international prostate symptom score (IPSS), overactive bladder symptom score (OABSS), and quality of life (QOL) score. They were then instructed on lifestyle changes and exercises that could improve peripheral blood flow and provide relief for their LUTS. Next, the temperatures of their middle fingers and toes were measured before and after 5-10 min of the exercises. Two weeks later, the IPSS, OABSS, and QOL scores were reassessed. RESULTS: Before exercise, the middle fingers were significantly warmer than the middle toes. Exercise had no significant effect on the middle finger temperature of either group; however, it did increase the middle toe temperature for both groups. The increase was greatest for the CS group. The CS group had higher LUTS storage symptoms than the CNS group, and these improved after 2 weeks of lifestyle changes and exercise. CONCLUSION: Improvements in lifestyle and daily exercise may be effective for LUTS in CS people.

[Two cases of urethrovaginal fistula repaired by Martius labial-rotation flap].

Urethrovaginal fistulas are rare. In case 1, a 48-year-old woman had undergone transvaginal drainage for an paraurethral abscess. In case 2, a 33-year-old woman had undergone resection of vaginal varicocele with massive bleeding during pregnancy. Postoperatively both patients complained of total incontinence. Urethroscopy and urethrography revealed an urethrovaginal fistula in each case. Repair ofurethrovaginal fistula using Martius labial-rotation flap was performed and the fistula was closed in both cases. We concluded that repair of urethrovaginal fistula using Martius labial-rotation flap may be useful for patients with urethrovaginal fistula.

Reconstruction of posterior urethral disruption: tips for success from our experience and from a literature review.

Repair of a posterior urethral disruption associated with a pelvic fracture is a challenge for urologic surgeons. Here, we provide surgical and strategic tips to facilitate the delayed surgical repair of urethral distraction defects. Nine patients each with a traumatic posterior urethral distraction defect underwent delayed transperineal or transperineoabdominal bulboprostatic anastomosis. Four patients had previously undergone multiple procedures. Seven patients regained satisfactory urination without incontinence, although one other patient is suffering from incontinence. In one patient, urethral disruption occurred again after removal of the urethral catheter, and he is being managed by suprapubic catheter. In our experience, the key to success is to perform a true bulboprostatic mucosa-to-mucosa anastomosis without tension. For this purpose, a transperineoabdominal approach is of particular importance when the healthy mucosa of the prostatic apex cannot be revealed through a perineal approach due to dense fibrous scar or fractured bone. A partial pubectomy may be necessary according to the situation. By the transperineoabdominal approach, the scar tissue can be bypassed through a broad sub-pubic-arch tunnel, and a reliable anastomosis achieved.

Rupture of urachal diverticulum in radiation cystitis and neurogenic bladder dysfunction after radical hysterectomy.

We experienced a rare case of the rupture of the urachal diverticulum in radiation cystitis and neurogenic bladder after radical hysterectomy. A 61-year-old woman presented with severe lower abdominal pain and urinary retention. Abdominal computed tomography revealed that the urachal remnant contained a large volume of urine that leaked to subcutaneous tissue. We excised the urachal diverticulum and bladder together and created a continent urinary diversion using transverse colon. Nine months after the operation, the patient could manage clean intermittent self-catheterization 6 times a day through her umbilical stoma without any urinary complications.

Anatomical reconsideration to renal area: lessons learned from radical nephrectomy or adrenalectomy through a minimal incision over the 12th rib.

BACKGROUND: To perform radical nephrectomy or adrenalectomy through a minimal incision over the 12th rib and to compare this with the traditional supracostal or transcostal approach. We review and clarify the related surgical anatomy through close observation. METHODS: We performed radical nephrectomy in six patients with upper urinary tract carcinoma through a minimal incision over the 12th rib and in five patients with renal cell carcinoma through a medium-sized incision, and adrenalectomy in five patients (bilaterally in one) again through a minimal incision over the 12th rib. During surgery, special points were noted to find out the differences between the new minimal-incision approach and the conventional approach. RESULTS: The procedures were accomplished smoothly with no complications through either a minimal or medium-sized incision. From our observation, it is clear that most of the procedures involved in the minimal-incision approach were and should be carried out within the space created in the retroperitoneum beneath the lateroconal fascia. CONCLUSION: Entering the correct anatomical planes posteriorly and anteriorly in the renal fasciae is a prerequisite for full mobilization of the kidney, together with the perinephric fat. To perform this, recognition of the lateroconal fascia and incising it along the correct lines are of the utmost importance for minimal-incision radical nephrectomy and adrenalectomy. Furthermore, this anatomical approach is also important for the conventional open approach and laparoscopic approach.

Successful treatment of arterial priapism with radiologic selective transcatheter embolization of the internal pudendal artery.

We report our successful treatment of arterial priapism by means of radiologic selective transcatheter embolization of the internal pudendal artery using an absorbable gelatin sponge (Spongel).

Synthesis and Reactivity of New 1,4-Bis(alkylthio)-3,6-diarylthieno[3,4-c]thiophene Derivatives.

1,4-Bis(tert-butylthio)-3,6-diphenyl- and 3,6-di(2-thienyl)thieno[3,4-c]thiophenes (2a,b)were synthesized from 2-(tert-butylthio)-3-phenyl- and 3-(2-thienyl)cyclopropenethiones (1a,b) and triphenylphosphine in dry benzene at 50 degrees C, although similar treatment of 2,4,6-triisopropylphenyl, N,N-diethylamino, pyrrolidino, and diphenyl-substituted cyclopropenethiones (1c-h) did not result in the production of the corresponding thieno[3,4-c]thiophene derivatives. The possible reaction pathway for the formation of 2a,b is described. The protonation of 2a with trifluoroacetic acid (TFA) gave 4-(tert-butylthio)-3,6-diphenylthieno[3,4-c]thiophene-1(3H)-thione (13a), the treatment of which with sodium hydride and then isopropyl iodide led to 4-(tert-butylthio)-3,6-diphenyl-1-(isopropylthio)thieno[3,4-c]thiophene (16) by the regeneration of the thieno[3,4-c]thiophene ring system, this making possible the synthesis of other alkylthio-substituted thieno[3,4-c]thiophene derivatives. The reactions of 2a,b with N-phenylmaleimide (NPM) gave predominantly the endo-cycloadducts (17a,b) at the 1- and 3-positions, and that of 2a with dimethyl acetylenedicarboxylate (DMAD) led to the benzo[c]thiophene derivative (19) by desulfurization.