良平 服部’s scientific contributions

右精巣腫瘍ステージI nonseminomatous germ cell tumor(NSGCT)3例,化学療法後の右精巣腫瘍ステージIII NSGCT 2例,左精巣腫瘍ステージIII seminoma1例に対する腹腔鏡下後腹膜リンパ節郭清術の成績を報告した.手術時間は3.0～5.3時間(平均3.9時間),出血量は50～247ml(平均114ml)であった.1例では腰静脈を下大静脈流入部で損傷したが,損傷部にクリップをかけることによりコントロールできた.6例とも術後1日目より経口摂取と歩行を開始し,勃起障害,射精障害はなく,術後3～27ヵ月の現在,再発は認めていない Three patients with stage I disease and 3 patients with stage III disease were treated with laparoscopic retroperitoneal lymphnode dissection. The patient was placed in a semilateral position and 5 trocars were introduced through the lateral abdominal wall. After incising the peritoneum along the Toldt line, the colon was reflected medially and the retroperitoneal structures such as the ureter, aorta, inferior vena cava and both renal arteries and veins were exposed. For right-side disease the paracaval and interaortocaval lymphnodes were dissected, and for left-side disease, the interaortocaval and paraaortic lymphnodes were dissected. The procedure was completed successfully on all 6 patients. The average operative time was 3.4 hours for 3 patients with stage I disease and 4.4 hours for 3 patients with stage III disease treated with prior chemotherapy. All patients started to walk and resumed oral intake from the first post-operative day and the average duration to full convalescence was 21 days. Anteriograde ejaculation and erection were preserved in all six patients. Laparoscopic retroperitoneal lymphnode dissection will be a useful technique for management of testicular cancer.

献腎移植340例(男230例,女110例,平均38.8歳;A群),生体腎移植163例(男93例,女70例,平均25.2歳;B群).慢性拒絶反応が移植腎喪失に関与したのはA群81.6%,B群72.7%であった.腎移植後3ヵ月以内に臨床的に急性拒絶反応を発症した例と拒絶反応のなかった例に分けて比較したところ,両群とも急性拒絶反応は長期予後に有意に影響していたが,慢性拒絶反応による移植腎喪失に与える影響は有意ではなかった.初回急性拒絶反応の発症時期でみると,半減期はA群で拒絶反応なしが14.5年,1ヵ月以内発生が7.3年,2～3ヵ月発生が6.7年,4～6ヵ月発生が4.0年,7～12ヵ月発生が4.9年,1年以降5年以内が2.3年,B群は各々38年,10.1年,15.8年,4.7年(4～12ヵ月発生),3.5年で,移植後4ヵ月以降の発症が特に影響大であった.又,拒絶反応中の最高血清クレアチニン値が2mg/dl以上の群では,3ヵ月未満の発生でも非廃絶率は低下した Chronic rejection is the most prevalent cause of renal transplant failure in the late post-transplant period. The clinical significance of acute rejection episodes on occurrence of chronic rejection is controversial. We analyzed 503 cases of the first renal transplantation maintained by calcinurine inhibitor for the correlation of acute rejection and clinical chronic rejection. The later the first episode of acute rejection occurred, the shorter was the half-life of graft. The acute rejection occurring within 3 post-transplant months worsens long-term graft survival if the peak creatinine level exceeds 2 mg/dl. Multivariate analysis by the Cox proportional hazard model for factors affecting cadaver graft loss by chronic rejection, revealed that the risk factor of acute early rejection was lower than those of donor age and post-transplant hypertension.

腹腔鏡下根治的前立腺摘除術を行った80例を対象に, 術前後の尿流動態検査より排尿筋低活動の発生について検討した。その結果, 1)術後に排尿筋低活動は6例(7.5%)で認められた。この6例全例とも術前排尿筋収縮は良好で, 術中操作により排尿筋低活動が発生したと考えられたが, 発生原因は特定できなかった。2)全例, 排尿は腹圧により代償され, 残尿は認めなかった。初発尿意容量, 最大尿意容量, 最大尿道閉鎖圧は術前後で変化はみられず, また蓄尿機能も変化はなく, 1例で軽度尿失禁を認めたものの, 他の5例は尿失禁を認めなかった。 Strain voiding has been reported to be a frequent symptom following radical prostatectomy. However, pathophysiology of vesicourethral function underlying voiding difficulty has not been well studied. In the present study, we investigated detrusor underactivity following radical prostatectomy. The records on urodynamic study (pressure-flow study, urethral pressure profile) were retrospectively investigated in 80 patients undergoing laparoscopic radical prostatectomy and all urodynamic studies pre- and post-operatively. We extracted the cases with detrusor underactivity according to the criteria of overt strain voiding pattern on post-operative pressure flow study; detrusor pressure at the maximum flow rate (Pdet Q(max)) of less than 10 cmH2O in conjunction with an increase of abdominal pressure. Of the 80 patients, 6 (7.5%) were found to have detrusor underactivity. In all patients, good detrusor contraction was confirmed on the pre-operative urodynamic study performed before surgery. On the voiding phase of pressure-flow study in these patients, mean Pdet Q(max) showed a significant decrease postoperatively from 58.5 cmH2O to 3.0 cmH2O (p < 0.01), although mean abdominal pressure at Q(max) significantly increased from 24.2 cmH2O to 105.8 cmH2O (p < 0.05). Mean Q(max) on free uroflowmetry showed a significant increase from 12.8 ml/sec to 22.1 ml/sec (p < 0.05). No patient had significant post-void residual urine. On the storage phase of the study, however, maximum cystometric capacity, maximum urethral closing pressure showed no significant change between pre- and post-operative studies. Five patients acquired continence and one had mild urinary incontinence using one pad a day. The present study showed that detrusor contaractility could be impaired during radical prostatectomy, but, no apparent operative procedure related to detrusor dysfunction could be identified in the present patients.

1996～1999年1に治療した胚細胞腫瘍15例を対象に検討した.施行した化学療法は22回で,骨髄回復期に43回の末梢血幹細胞採取を施行した.2回の大量療法に必要なCD34陽性細胞数を4×1000000/kgとするとBEP療法4回で必要量の幹細胞を採取できなかった.しかし,nadirにおける末梢白血球数が2000/ml以上であっても必要量の採取は可能であった.BEP療法時にはday 14,15から5μg/kgのG-CSFを採取日まで投与し,day 19～21にアフェレーシスを行うのが良いと考えられた.VIP療法では1回のアフェレーシスあたり1.7×1000000/kgのCD34陽性細胞しか採取できなかった.大量エトポシド療法は骨髄回復期のばらつきが少なく,1回のアフェレーシスあたり7.9×1000000/kgのCD34陽性細胞を採取できた.大量エトポシド療法はBEP,VIP中に必要量が採取できない場合には,極めて有用な幹細胞動員方法であると考えられた From January 1996 to December 1999, fifteen patients with germ cell tumors underwent peripheral blood stem cell harvest during 15 courses of bleomycin, etoposide, cisplatin (BEP), 4 courses of etoposide, ifosfamide, cisplatin (VIP) and 3 courses of high-dose etoposide mobilization at Nagoya University Hospital. We performed 29 aphereses during BEP, eight during VIP, and six during high-dose etoposide. Although we were able to harvest 4.4 x 10(6)/kg of median CD34 positive cells per apheresis during BEP, the number of stem cells (more than 4 x 10(6)/kg of CD34 positive cells), which are needed for tandem high-dose chemotherapy, could not be obtained during four courses of BEP. For three patients in whom white blood cell counts at nadir were 2,000/microL or more, however, the required number of CD34 positive cells were harvested. VIP provided only 1.7 x 10(6)/kg of median CD34 positive cells per apheresis, while, 7.3 x 10(6)/kg of CD34 positive cells were harvested during high-dose etoposide mobilization. The dose of G-CSF was a significant factor for the number of CD34 positive cells harvested during BEP (p = 0.02); however, there might be some relationship between the harvest and the number of the peripheral white blood cells on the day of apheresis (p = 0.08), the day to start G-CSF (p = 0.13), or the day to initiate apheresis (p = 0.27). Based on our experience, it is recommended that 5 micrograms/kg of G-CSF should be started from the 14th or 15th day of BEP until the last apheresis and that aphereses should be performed between the 19th and 21st day, especially at the days when the peripheral white blood cell count increases beyond 10,000/microL.

Stage B, Cの限局性前立腺癌50例に対し,腹腔鏡下骨盤内リンパ節郭清を施行した. 1)後腹膜的到達法は経腹的操作に比較して合併症は少なく,出血量の有意な減少,手術時間の短縮がみられ,minimally invasive surgeryとして優れた術式といえる. 2)両側の骨盤内リンパ節郭清を行えた48例のうちリンパ節転移は19例に認められたが,術中凍結切片による迅速病理検査では7例がfalse negativeであった. 3)Stage C,低分化癌以外にstage B,高分化,中分化癌のうちPSADが0.5ng/ml/ml以上の症例ではリンパ節転移の可能性が高いと考えられた We report the clinical results and efficacy of laparoscopic pelvic lymphadenectomy for localized prostate cancer. This procedure was followed by radical prostatectomy, when metastasis was not found in the frozen section, and by optional treatment, such as transurethral resection (TUR) or castration, other than radical prostatectomy when metastasized nodes were found. We performed transperitoneal laparoscopic lymphadenectomy on 30 patients and extraperitoneal approach on 20 between April, 1992 and September, 1995. The patients were between 52 and 78 years old. Nineteen, patients had stage B1, 17 stage B2 and 14 stage C cancer. Bilateral obturator nodes were dissected. We could not perform laparoscopic lymphadenectomy on two patients because of adhesion. The average operation time and blood loss were 166 minutes and 151 ml, respectively, in the transperitoneal group, while 142 minutes and 126 ml in the extraperitoneal group. The average number of removed nodes was 12 in the transperitoneal group and 10 in the extraperitoneal group. The extraperitoneal approach is a safer and useful procedure. Nodal metastasis were found in 12 patients by frozen section. Additional positive nodes were found in 7 patients by a further study. Two were not harvested laparoscopically and 5 were ascertained only by permanent section. Therefore, the two-staged operation might be preferable. Nodal metastasis was likely to be found in localized prostate cancer patients with clinical stage C, poorly differentiated cancer, or prostatic specific antigen density (PSAD) over 0.5 ng/ml/ml. Laparoscopic pelvic lymphadenectomy might be indicated for these cases.

A randomized clinical trial was conducted to determine the optimum does of iohexol (iodine concentration 300 mgI/ml) as a contrast agent for excretory urography in screening outpatients. Cases were divided into two groups, 30 cases in Group A receiving 0.4 ml/kg of iohexol and 29 cases in group B receiving 0.8 ml/kg. Urography was performed at intervals of 5 minutes and 10 minutes following the injection. The diagnostic effectiveness of various X-ray images including nephrograms, the pyelocaliceal system, ureter and bladder were assessed. There was a significant disparity between the two groups during pyelocaliceal urography after 5 minutes, with a fair diagnosis attainable for 73.3% of group A versus 89.6% for group B (P less than 0.05), but after 10 minutes the rates for the two groups had evened out to 93.4% for group A and 96.6% for group B. During urography of the ureter after 5 minutes, only 16.6% of the cases in group A could be easily diagnosed against 51.7% of the cases in group B (P less than 0.05). However, after 10 minutes the rate for group A was up to 56.7% while the rate for group B was 82.8% (P less than 0.1). In the ureter after 5 minutes, non-diagnosable images constituted 26.7% of group A and 10.4% of group B, while after 10 minutes this had dropped to 16.6% for group A and 0% for group B. A comprehensive study of these results suggests that for diagnostic screenings which use iohexol as a contrast agent in excretory urography, optimal results may be obtained using iohexol in amounts of between 0.4 ml/kg and 0.8 ml/kg.

58例(平均68歳)の患者を対象として塩酸プロピベリン経口投与による治療を行い, 治療前, 治療4週後および8週後において, 国際尿失禁会議質問票(ICIQ-SF)・キング健康調査票(KHQ)・排尿日誌および尿意切迫感に関する問診票により症状・QOLスコア, 自覚症状の改善を評価した。1日の平均排尿回数, 平均失禁回数, 平均尿意切迫感回数および尿意切迫感程度はいずれも治療前と比較して治療4週後に有意に減少し8週後も効果は持続した。また, ICIQ-SF総スコアおよびKHQスコアも治療後有意な改善を認めた。安全性評価症例42例中10例(23.8%)に有害事象を認めたが, いずれも重篤ではなく投与中止あるいは減量した例はなかった。 The present study was prospectively conducted for female patients with wet overactive bladder to assess the efficacy of propiverine hydrochloride in improving their symptoms and quality of life (QOL). Propiverine hydrochloride was administered orally to 58 patients for 8 weeks. Prior to administration and at 4 and 8 weeks after administration, symptoms and QOL were assessed by the micturition diary, the International Consultation on Incontinence-Short Form (ICIQ-SF), and the King's Health Questionnaire (KHQ). After administration, numbers of daily micturitions, incontinence episodes, urgency episodes and severity of urgency which were assessed based on the micturition diary and urgency scale questionnaire showed significant improvement when compared to baseline values. Furthermore, both ICIQ-SF and KHQ scores improved significantly after administration. The incidence of adverse events was 23.8% and none were serious. Propiverine hydrochloride was shown to contribute not only to the improvement of symptoms in female patients with wet overactive bladder but also to their QOL.

αインターフェロンを用いて尖圭コンジローム18例の治療を試みた.1)局所投与を行った17例中完全消失は,6例に認めた.2)総投与量が12×106単位を越えた,11例での完全消失は5例であった.3)完全消失例の6ヵ月以内の再発は認められなかった Eighteen cases of condyloma acuminata were treated by human lymphoblastoid interferon (HLBI). Seventeen were male and one was female. Five cases were recurrent cases. Except one patient, all the patients were administered HLBI by intralesional injection. Five patients were treated by single injection. Others were given 2 to 8 injections during one to 5 weeks. Total dose varied from 3 x 10(6) to 24 x 10(6) U. Of the eighteen patients, 6 showed a complete response and 3 a partial response (greater than 50% reduction in size of the lesion). In 5 of the 11 patients (45%) who were treated with a total dosage of more than 12 x 10(6) U, the lesion was completely cleared. Six patients who showed a complete response did not experience recurrent disease during the 6-month follow-up period. In conclusion, intralesional administration of HLBI for condyloma acuminata proved to be effective.

1歳8ヵ月女児,結石の嵌頓により腎後性腎不全となったシスチン尿症に対し,経皮的腎瘻造設後,溶解療法とPNLの併用により結石の完全除去を行い得た A 20-month-old child was admitted to our hospital due to obstructive renal failure caused by cystine calculi. After recovering from the renal failure by bilateral percutaneous nephrostomy, pelvic irrigation with N-acetylcysteine was performed using a 12Fr. flexible double lumen catheter. In 2 weeks the calculus was reduced by 39% in size, then residual calculi were successfully removed by percutaneous nephrolithotripsy using 11.5Fr. rigid ureteroscope and postoperative irrigation with N-acetylcysteine.

高位精巣摘除術2年後に後腹膜に再発した3歳男児の精巣卵黄嚢腫例に対し化学療法およびリンパ節廓清術を施行し,完全寛解をえた。VAC療法により顆粒球減少症・脱毛・口内炎等の合併症を認めたが,顆粒球減少症に対してはG-CSFの投与により予定した治療を完遂しえた。小児精巣腫瘍に対するVAC療法は有効で安全な治療法と考えられた A case of recurrent yolk sac tumor in a three-year-and five-month old child is reported. Left high orchiectomy was performed two years earlier at which time no evidence of metastatic disease was demonstrated. Twenty-four months postoperatively, serum alpha-fetoprotein (alpha-FP) was elevated and recurrent mass appeared in the left para aortic region. Treatment by VAC regimen consisting of vincristine, actinomycin D and cyclophosphamide was performed. Complete response was obtained after two courses of this therapy, which was confirmed by retroperitoneal lymphadenectomy. We believe that this chemotherapy is effective and safe for the treatment of yolk sac tumor of infantile testis.