伸一郎 山田’s scientific contributions

A 42-year-old man with testicular tumor arising in the left undescended testis is reported. The patient had bilateral cryptorchidism and was admitted to our clinic on March 20, 1989, complaining of a mass in the lower abdomen. Colography indicated complete obstruction at the sigmoid colon, and computed tomography showed a larger mass in the lower abdomen and paraaortic lymph node swelling, as well as left hydronephrosis. We suspected that a testicular tumor had arisen in the undescended testis, and ileus was caused by the tumor mass. Since the patient was in a poor condition from preexisting ileus, chemotherapy consisting of cisplatin, bleomycin and vinblastine (PVB regimen) was immediately started without confirming the histology. After two courses of PVB regimen, bilateral orchiectomy, retroperitoneal lymphadenectomy, and left nephrectomy were performed. Pathological examination of the testis and resected lymph nodes revealed no residual tumor cells, and we could not identify the original histology. Additionally, two courses of chemotherapy were performed after surgery. The patient is well without evidence of disease one year and ten months after surgery.

1)1990年7月より1993年10月迄に膀胱腫瘍に対する膀胱全摘後のKock式自排尿型代用膀胱症例37例で,その長期成績を検討した. 2)術後3ヵ月の時点で,35例中32例が,術後4年以上経過した患者では22例中19例が自排尿のみで管理が可能.自排尿可能な患者のうち殆ど失禁のない例は術後3ヵ月では25/35,術後4年以上では15/21. 3)術後のパウチに起因した合併症として,輸入脚滑脱3例・パウチ尿道吻合部狭窄5例及びパウチ内結石2例の10例に計14回の再手術を要した. 4)現在生存中の患者にアンケートを施行したところ,19例中8例(42%)は排尿状態に不満があるか,QOLが制限されていると答えた. 5)本法は煩雑な術式のため合併症はやや多いが,排尿状態に関しては長期的に安定している術式と考えられた We analyzed the long-term results and the quality of life in patients who received orthotopic lower urinary tract reconstruction using the Kock ileal neobladder. Between July 1990 and October 1993, 37 consecutive patients including 2 females received orthotopic hemi-Kock neobladder after radical cystectomy. In these patients, we analyzed the urinary continence, complications and urethral recurrence, and performed a questionnaire survey by mail. Good continence all day had been achieved in 71% of the patients 4 years after surgery. The rate of the pouch-related complications requiring reoperation was 27%. There was no urethral recurrence. Compared with preoperative conditions, 42% were not satisfied with urination. In these dissatisfied patients, the need to use pads in the daytime, sensation of residual urine and weak urine stream were significantly more frequent than in satisfied patients. In summary, the rate of complications was higher than that of other methods. However, the Kock orthotopic ileal neobladder is a stable procedure providing good function over the long-term.

難治性排尿困難患者に対しCICを指導した120例について臨床的検討を行った。1)CIC経過中,尿路感染を認めなかったのは早期治療例は65%,陳旧例は20%であった。無症状の尿路感染症に対しては,特に抗菌剤の投与は不要と考えられた。2)CIC前に水腎症を認めた20例うち,CICにより18例が改善し,悪化した症例は認めなかった。3)骨盤内臓器摘出術後の神経因性膀胱のCICの離脱時期は,早期治療例は3ヵ月以内が45%,時期の差はあれ84%が離脱できた。陳旧例は,ほとんどの症例で継続中である。残尿が100ml以下であれば,定期的観察を行うことによりCICは不要と考えられた We evaluated 120 patients with neurogenic bladder treated by clean intermittent self catheterization (CIC) in our department. These cases were divided into 2 groups: early treatment cases in which CIC started within 1 year after onset of dysuria, and late treatment cases in which CIC started after more than 1 year. Urinary tract infections (UTI) were recognized in 35% of the early treatment cases and 80% of the late treatment cases in the subsequent period. Pyelonephritis was experienced in 4% of the early treatment cases and 12% of the late treatment cases. Antibiotics therapy was considered unnecessary for asymptomatic UTIs. After CIC treatment, hydronephrosis detected by intravenous pyelography (IVP) and ultrasonography was improved in 18 of the 20 cases, and no cases showed deteriorated renal function. In the cases with neurogenic bladder after radical operations of the uterus or rectum, 45% of the early treatment cases have become free from CIC within 3 months postoperatively, and 84% eventually became free. Most of the late treatment cases have been continuing CIC. We considered that CIC was unnecessary when the residual urine was less than 100ml based on the periodical urinalysis and observation of renal function.

A case of blind-ending bifid ureter is presented. A 65-year-old man was admitted with the complaint of dysuria. He had no past episode of left flank pain or pyelonephritis. Digital examination and urethrography suggested benign prostatic hypertrophy. Drip infusion pyelography showed an abnormal cavity at the lower portion of the left ureter. He was diagnosed as benign prostate hypertrophy and left blind-ending bifid ureter. During suprapubic prostatectomy, the bifid ureter was resectd. The related reports are reviewed in the Japanese literature.

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.

前立腺癌臨床病期stage A2, B, Cの症例44例について検討した. 1)術後の5年生存率は,リンパ節転移陽性例で77%,陰性例で90%であり,5年の術後無病率は,リンパ節転移陽性例で54%,陰性例88%であった.根治的前立腺全摘除術及び骨盤内リンパ節郭清術は,臨床病期stage C以下の前立腺癌症例に対して有用な方法と考えた. 2)臨床病期stage D1症例に対する根治的前立腺全摘除術の是非については,QOL等を含めたrandomized studyによる確認が必要と考えた. 3)リンパ節転移陽性の14例32%の転移部位は,閉鎖節8例57%,内腸骨節6例43%,外腸骨節6例43%,総腸骨節4例29%,正中仙骨節2例4%であった Between September, 1987 and September, 1993, a total of 44 consecutive patients had undergone radical retropubic prostatectomy and pelvic lymphadenectomy for the treatment of prostate cancer. The patients were between 56 and 77 years (mean, 68 years). Eleven patients had clinical state A2 disease, 21 had stage B disease, and 12 had stage C disease. Fourteen of the 44 patients (32%) had positive lymph node metastases. The 5-year survival rate for patients with pT1, pT2 and pT3 was 100%, 71% and 87%, respectively. It was 77% in patients with positive node disease and 90% in patients with negative node disease. The 5-year disease-free survival rate for patients with pT1, pT2 and pT3 was 82%, and 78%, respectively. It was 54% in patients with positive node disease and 88% in patients with negative node disease. In 14 positive node patients, metastases were located in obturater nodes in 8 patients (57%), hypogastric nodes, in 6 patients (43%), external iliac nodes in 6 patients (43%), common iliac nodes in 4 patients (29%) and presacral nodes in 2 patients (14%). We confirmed that radical retropubic prostatectomy is effective treatment for locally confined prostate cancer and removal of obturater, hypogastric lymph nodes and the internal chain of external iliac lymph nodes is important in detecting metastases.

A 17-year-old woman consulted our clinic with the complaint of gross hematuria and lower abdominal pain. Blood examination showed severe anemia and renal failure. Emergent hemodialysis and blood transfusion were performed. CT scanning revealed left retroperitoneal hematoma, right severe hydronephrosis and loss of uterus shadow. Under diagnosis of left renal rupture, left nephrectomy and removal of retroperitoneal hematoma were performed. The area of rupture in the left renal pelvis was identified on its posterior wall. Postoperatively renal function did not improve and periodic hemodialysis has been done.

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)膀胱癌において抗癌剤が投与された治療群は未治療群に比べ,有意に高いmultidrug resistant 1(MDR1)mRNA発現レベルを示した. 2)膀胱癌14例におけるneoajuvant動注化学療法前後の比較でも,投与後に有意に高いMDR1mRNA発現レベルを認めた. 3)抗癌剤投与により膀胱癌のMDR1遺伝子発現が誘導されることが示唆された Using a reverse transcriptase-polymerase chain reaction (RT-PCR)-based quantitative analysis method, we investigated MDR1 mRNA expression levels in 58 bladder cancer specimens to determine whether MDR1 gene expression was induced or enhanced in bladder cancers during chemotherapy. In bladder cancer specimens which were obtained from patients treated with anticancer drugs, significantly higher expression levels of MDR1 mRNA were observed than in those from patients not treated with any anticancer drugs (p = 0.0134, Mann-Whitney U test). From 14 patients who had bladder cancer, clinical specimens were obtained before and after neoadjuvant intra-arterial chemotherapy. The expression levels of MDR1 mRNA were significantly higher in the post-treatment specimens than in the pre-treatment specimens (p = 0.0298, Wilcoxon signed-rank test). Of these 14 patients, 7 patients exhibited increased levels of MDR1 mRNA expression after chemotherapy. In 6 patients, there were no changes in the MDR1 mRNA expression levels before and after chemotherapy. Only one patient exhibited decreased levels of MDR1 mRNA expression after chemotherapy. No significant correlations were observed, between MDR1 mRNA expression levels and effect of the chemotherapy determined microscopically, dosage of anticancer drugs, or patient outcome. In conclusion, this study indicates that MDR1 gene expression in bladder cancers is induced and enhanced during chemotherapy. This overexpression of the MDR1 gene may contribute to resistance to anticancer drugs after repeated chemotherapy.