Changes in axial alignment of the ipsilateral hip and knee after total hip arthroplasty.

AIMS: We investigated changes in the axial alignment of the ipsilateral hip and knee after total hip arthroplasty (THA). PATIENTS AND METHODS: We reviewed 152 patients undergoing primary THA (163 hips; 22 hips in men, 141 hips in women) without a pre-operative flexion contracture. The mean age was 64 years (30 to 88). The diagnosis was osteoarthritis (OA) in 151 hips (primary in 18 hips, and secondary to dysplasia in 133) and non-OA in 12 hips. A posterolateral approach with repair of the external rotators was used in 134 hips and an anterior approach in 29 hips. We measured changes in leg length and offset on radiographs, and femoral anteversion, internal rotation of the hip and lateral patellar tilt on CT scans, pre- and post-operatively. RESULTS: The mean internal rotation increased by 11° (-15° to 46°) and was associated with underlying disease (OA), pre-operative range of internal rotation, gender, surgical approach, leg lengthening, and change of femoral anteversion (adjusted R(2) : 0.253, p < 0.001). The mean lateral patellar tilt increased by 4° (-5° to 14°) and was associated with age, leg lengthening, and increment of hip internal rotation (adjusted R(2): 0.193, p < 0.001). CONCLUSION: Both internal rotation of the hip at rest and lateral patellar tilt are increased after THA. Changes in rotation after THA may affect gait, daily activities, the rate of dislocation of the hip, and ipsilateral knee pain. TAKE HOME MESSAGE: Internal rotation of the hip at rest and lateral patellar tilt increase after THA.

Testicular sperm extraction and ICSI in patients with post-chemotherapy non-obstructive azoospermia.

146 MD-TESE procedures were performed in 74 patients presenting with non-obstructive azoospermia (NOA). Five of the 74 patients displayed a history of chemotherapy. Etiology of chemotherapies included testicular cancer, osteosarcoma, Ewing sarcoma, and malignant lymphoma of the stomach. Post-chemotherapy duration was 2.5-18 years. All patients underwent MD-TESE using local anesthesia with spermatic block and sedation. Extracted sperm was cryopreserved for ICSI. Histopathologic examination revealed Sertoli cell-only syndrome in all five patients; however, sperm were retrieved in 3 subjects. Post-chemotherapy MD-TESE and ICSI can be applied successfully in some patients with NOA. However, freezing semen prior to chemotherapy is recommended.

Probability of sperm recovery in non-obstructive azoospermic patients presenting with testes volume less than 10 ml/FSH level exceeding 20 mIU/ml.

We evaluated the sperm recovery rate in non-obstructive azoospermia (NOA) patients presenting with bilateral testicular atrophy characterized by testes volume of less than 10ml and FSH levels exceeding 20 mIU/ml (group NOA-1), and compared the results to those NOA cases displaying unilateral testis volume exceeding 10 ml or FSH levels less than 20 mIU/ml (group NOA-2). Sperm retrieval was conducted in 261 azoospermic patients from April 1995 to December 2002. Forty-six NOA-1 and 37 NOA-2 individuals underwent microdissection TESE or 3-4 standard biopsies. Sperm recovery was achieved in 11 (24%) and 12 (32%) cases in NOA-1 and NOA-2, respectively. All couples received ICSI. Four clinical pregnancies (36.3%) in NOA-1 and two (17%) in NOA-2 resulted. Five subsequent healthy deliveries were obtained. NOA patients presenting with bilateral severe atrophic testes volume and obviously elevated FSH levels exhibited approximately 24% probability of sperm recovery. On the other hand, NOA characterized by testicular atrophy or elevated FSH levels displayed probability of approximately 32%. Differences in sperm recovery were not evident between NOA-1 and NOA-2. No successful pre-operative predictors of sperm recovery were identified.

[A case of transitional cell carcinoma of the bladder in a juvenile patient].

A 15-year-old male was referred to our hospital with the chief complaint of gross hematuria. Cystoscopic examination revealed a papillary tumor on the posterior wall. Transurethral resection of the bladder tumor was performed. Histological examination of the excised tumor showed transitional cell carcinoma, grade 1, pTa. Recurrence has not been observed for about 2 years after the operation. We investigated 54 previously reported Japanese cases of bladder cancer before age twenty including the present case.

Sialyl-Tn antigen as a useful predictor of poor prognosis in patients with advanced stomach cancer.

Sialyl-Tn antigen (STn) expression was studied immunohistochemically in 211 primary advanced gastric carcinomas. The overall rate of positive STn staining was 17% (35/211), and positive STn staining was found not to be correlated with tumor size, depth of invasion, lymph node metastasis, liver metastasis, or peritoneal metastasis. However, patients with tumors that were immunoreactive for STn demonstrated significantly lower survival (P < 0.05). Multivariate analysis revealed that STn staining was an independent prognostic factor. From these findings we conclude that careful followup and intense postoperative therapy are required for patients with advanced gastric cancer who have positive immunoreactivity for STn.

Soybean agglutinin binding as a useful prognostic indicator in stomach cancer.

Soybean agglutinin (SBA)-binding carbohydrate expression was studied immunohistochemically in 353 primary gastric carcinomas. The overall rate of positive SBA staining was 23% (81/353), and positive SBA staining was significantly correlated with tumor size, macroscopic tumor type, depth of invasion, lymph node metastasis, and venous invasion (P < 0.05). Moreover, patients with tumors that were immunoreactive for SBA demonstrated significantly higher survival (P < 0.01). From these findings we conclude that careful follow-up and intense postoperative therapy are required for patients with gastric cancers that lack immunoreactivity for SBA.

An improved technique for low anterior resection using a PDS endoloop.

We describe herein the results of performing a new technique of low anterior resection of the rectum using a PDS endoloop, on ten patients with rectal cancer. This technique involves first preparing the rectosigmoid colon with an anvil as in the conventional low anterior resection; then, after the stapler is inserted transanally, two endoloops are solid over the colon and rectum. The rectum is ligated by pushing the knot of the endoloop and a second knot is applied 2 cm proximal to the first. Finally, the rectum is cut and the stapler is closed and fired to make a circular end-to-end anastomosis. The level of the anastomosis ranged from 2.5 to 6 cm with a mean of 4.7 cm in the ten patients, only one of whom developed a minor anastomotic leakage postoperatively. Moreover, no patient has developed local recurrence or distant metastasis to date. In summary, this technique offers certain advantages that allow the operation to be done with more skill and safety in a narrow pelvis.

Somatosensory evoked blink response: findings in patients with Miller Fisher syndrome and in normal subjects.

Reflex blinking was elicited by the electrical stimulation of peripheral nerves and various parts of the body of seven of 11 patients with Miller Fisher syndrome. This reflex blinking disappeared during recovery. Reflex blinking was elicited in normal subjects only with specific stimulation of the peripheral nerves of their upper extremities. This response may be due to a release phenomenon transmitted via the brainstem reticular formation and may be useful in detecting latent CNS involvement in patients with Miller Fisher syndrome.

[A case of scrotal bladder hernia containing bladder cancer].

A 70-year-old man had a history of total laryngectomy for laryngeal cancer and bilateral inguinal hernia repair 5 years previously. The patient had suffered from difficulty with urination since then and had been treated for prostatic hypertrophy at our department. He developed microscopic hematuria from June 1991, and was admitted because a bladder tumor was detected by cystoscopy. Cystography showed a scrotal bladder hernia with filling defects in the bladder per se and the bladder hernia as well. Cystoscopy revealed tumors in the hernia and in the vicinity of the ureteral orifice. Biopsy indicated transitional cell carcinoma. Voiding cystourethrography showed normal urination and no residual urine. Excision of the tumor-containing hernia, partial cystectomy with right ureteral orifice, and reconstruction of the right inguinal canal were performed on October 25, 1991. The postoperative course was favorable and he was discharged on the 40th postoperative day. The tumors were respectively stage as TCC, G1, and pT1a, and TCC, G1 greater than G2, and pT1b. Thirty five cases of bladder hernia that have been reported in Japan. Eight cases of accompanied by cancer have been reported in Japanese (3 cases) and foreign (5 cases) literatures. These are reviewed and discussed.

[A study of 114 cases of urinary tract injury].

In 11 years between January, 1974 and December, 1984 114 patients (92 males and 22 females) were admitted to our departments for urologic injuries. As there were four patients with multiple injuries (both kidneys 1, kidney and ureter 1, kidney and urethra 1, and bladder and urethra 1), the number of cases with kidney, ureter, bladder and urethral injuries were 76 (64%), 33 (28%), 6 (5%) and 3 (3%), respectively. The most frequent incidence was in the second decade. Out of the 75 cases of renal injuries there were 42 cases (56%) of contusions, 21 (28%) of lacerations, 7 (9.3%) of ruptures and 5 (6.7%) of pedicle injuries. Only 14 cases (18.7%) were treated surgically, namely six by nephrectomy and eight by a conservative approach (suture 1, drainage 3, partial nephrectomy 3 and pyeloplasty 1). Of the 3 cases of ureteral injuries all cases were treated surgically. Of the 6 cases of bladder injuries four cases were treated surgically. Of the 33 cases of urethral injuries 10 cases were complicated by fractures of the pelvis. Twenty three cases (74%) were treated surgically.

[A case of primary ureteral carcinoma in the duplicated renal pelvis and ureter diagnosed by transurethral uretero-renoscopy].

We present a case of primary ureteral carcinoma in the duplicated renal pelvis and ureter diagnosed by transurethral uretero-renoscopy. The case was of a 78-year-old man with the complaint of sudden asymptomatic macrohematuria. An excretory urogram strongly suggested the presence of duplication of the right collecting system, and cystoscopy revealed a gross hematuria from the right ureteral orifice. A retrograde ureteropyelogram revealed incomplete duplication of the right renal pelvis and ureter fused at about the ureter crossing over the iliac vessels, and a polyp-like filling defect in the lower segment of duplicated ureter at about 4 cm from the fusion of the ureters. Transurethral uretero-renoscopy was employed to investigate the filling defect, and a papillary tumor extended into the lower segment of duplicated ureter was revealed. Tumor was resected by a rigid operating instrument under transurethral uretero-renoscopy. The pathological diagnosis was grade I-transitional cell carcinoma of the ureter, so that right total nephroureterectomy with partial cystectomy was carried out subsequently. Surgical specimen after right total nephroureterectomy with partial cystectomy showed no other tumor in the pelvis or ureter macroscopically, and histopathological studies of surgical specimens were no evidence of malignancy. We believe that transurethral uretero-renoscopy significantly increases the diagnostic accuracy in determining the nature of upper urinary tract lesions, and this procedure is indispensable in the diagnosis of ureteral tumors. The present case was the 7th case of primary ureteral carcinoma in the duplicated renal pelvis and ureter in the Japanese literature.

[Clinical experience of norfloxacin in urinary tract infection].

Norfloxacin (NFLX) was administered to outpatients and inpatients with urinary tract infections at our department. Clinical efficacy and safety were evaluated in 50 patients by the criteria for evaluation of clinical efficacy of antimicrobial agents on urinary tract infection. Overall clinical efficacy for 17 cases with acute simple cystitis was excellent in 13 cases, moderate in 4 cases with an effectiveness rate of 100%. The overall clinical efficacy for 33 cases with chronic complicated UTI was excellent in 18 cases, moderate in 6 cases and poor in 9 cases with an effectiveness rate of 73%. The eradication rate of 21 strains from acute simple cystitis patients was 100%. Forty four out of 60 strains from chronic complicated UTI patients were eradicated and the eradication rate was 73%. Neither subjective nor objective adverse reactions were observed in 50 patients. Abnormal changes in laboratory tests were found in 8 patients, but were probably not related to NFLX administration. Judging from these results, NFLX is considered to be an effective and safe antibacterial for the treatment of UTI.

[Experience in using a ureterorenoscope in 14 cases].

We carried out studies using an ureterorenoscope in 14 cases, including 13 patients suffering from an ureteral stone. The stone was smaller than 1 cm and existed in lower and middle portion. The other patient had a foreign substance, which was a double J-stent catheter that had been passed into the middle portion of the ureter accidentally. Initially, the size and course of ureter, the position of stone and foreign substance were ascertained using a retrograde pyelogram. The patients were placed in a lithotomy position under spinal anesthesia or epidural anesthesia. The ureterorenoscope was inserted into the bladder through urethra and the instrument was further extended through ureteral orifice and ureteral lumen to the position of the calculus or foreign substance while observing the procedure. Once the calculus or foreign substance was observed, a 4F Pfister-Schwartz stone retriever or forceps was inserted through working channel. After coming in contact with the stone or foreign substance, the matter was removed while observing it with the scope. The foreign substance and 77% of the stones observed were removed by this procedure and the usefulness of the ureterorenoscope was successfully demonstrated in the cases. However, on the other hand, of these 14 cases, 2 (14%) experienced ureteral injury. In one case, the ureter was penetrated by the scope; and in another, injury occurred during the biopsy of the ureteral wall. Therefore, it is our opinion that more careful use of the ureterorenoscope is necessary to prevent these types of injuries.

[Evaluation of neurogenic bladder in patients with spinal cord injury using a CMG.EMG study and CMG.UFM.EMG study].

Simultaneous recording of intravesical pressure, sphincter electromyography and uroflowmetry (CMG.UFM.EMG study) was performed following cystometry simultaneously with electromyography (CMG.EMG study) on 20 patients with spinal cord injuries. Differences in the influence to micturition between the CMG.EMG study and CMG.UFM.EMG study is thought to be due to whether the catheter is indwelling in the urethra or not. We examined those differences and patient's rehabilitation maneuver (Cred'e maneuver). Micturition pressure and opening pressure measured by the CMG.EMG study were larger than that measured by the CMG.UFM.EMG study (P less than 0.05, P less than 0.01 respectively). Incidence of detrusor-sphincter dyssynergia measured by the CMG.EMG study was greater than that measured by the CMG.UFM.EMG study in the detrusor hyperreflexic cases. The Cred'e maneuver caused increase in opening pressure, micturition pressure and peak flow rate, but the voiding volume and voiding time did not increase to any effective extent. The Cred'e maneuver exaggerated the detrusor sphincter dyssynergia.

[Therapeutic effect of Robaveron tablet (KN-7) on urinary disturbance by benign prostatic hypertrophy].

Therapeutic effect of Robaveron tablet (KN-7) was studied on 101 patients with urinary disturbance accompanied by benign prostatic hypertrophy. Robaveron tablet, which contains 20 mg of a swine prostatic extract per tablet, was administered 6 tablets daily for 3 weeks in principle. Evaluation of drug efficacy was based on residual urine, cystometric findings, urethral pressure profile, uroflowmetry and subjective symptoms. Remarkable decrease of residual urine was observed at all stages of Guyon classification, in parallel with increases of cystometric pressure amplitude and average flow rate. Rate of residual urine reduction rose in proportion to the higher stage or bulkier volume of residual urine. Improvements of subjective symptoms were also obtained. The overall effectiveness, rated slightly improved or better was 76.8%. Side effects were seen at a low rate of 3.9%, and there were no abnormal changes directly due to the drug in clinical laboratory tests. These results indicate that Robaveron tablets act on the detrusor muscle and contribute to improve the depressed voiding efficiency and incidental symptoms of the subjects.

[Comparative double-blind trial of KN-7 tablet and Robaveron injection in the treatment of neurogenic bladder].

The clinical effectiveness, safety and usefulness of KN-7 tablet as a new oral application of the prostatic extract, on urinary dysfunction of neurogenic bladder were compared with those of Robaveron injection by the double-blind test method. In the study, 2 tablets t.i.d. and a shot of intramuscular injection 1 ml a day were given successively for 3 weeks. A total of 233 cases were reported from 37 facilities belonging to the KN-7 Clinical Research Group. Some of them were excluded or dropped out. The number of cases used for analysing the effectiveness, safety and usefulness were 214, 232 and 215, respectively. There was no bias between the two groups with a significant homogeneity in the background. In the overall clinical effectiveness, the effective rate including excellent, moderate and slightly effective was 76.9% with KN-7 and 77.4% with Robaveron. In the clinical usefulness, the rate of usefulness of slightly useful or above was 75.0% with KN-7 and 75.7% with Robaveron. There was no significant difference between the two groups in the clinical effective and useful rates at a significant level of 5%. Side effects were observed in 1 of the 114 (0.9%) patients given KN-7 and 8 of the 118 (6.8%) patients given Robaveron. The incidence of adverse reactions with KN-7 was significantly lower than that with Robaveron. Based on the results, it was concluded that KN-7 tablets, 2 tablets t.i.d., would be as effective and useful as a Robaveron injection 1 ml daily and safer than the latter in the treatment of neurogenic bladder.

Nephrogenic adenoma of the ureter.

We report a case of nephrogenic adenoma in the left ureter. The patient presented with lumbago on the left side. A small calculus was incarcerated in the left ureter 4 cm. from the ureteropelvic junction and an adenoma, which resembled histologically the renal tubules, was observed in the ureter. A search of the world medical literature revealed 58 cases of nephrogenic adenoma, although only 1 case in the ureter has been reported previously.