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Approximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.

Background This article is a duplicated publication from the Japanese version of “2019 JSDT Guidelines for Peritoneal Dialysis” with permission from the Japanese Society for Dialysis Therapy (JSDT). This clinical practice guideline (CPG) was developed primarily by the Working Group on Revision of Peritoneal Dialysis (PD) Guidelines of the Japanese Society for Dialysis Therapy. Recently, the definition and creation process for CPGs have become far more rigorous; traditional methods and formats no longer adhere to current standards. To improve the reliability of international transmission of our findings, CPGs are created in compliance with the methodologies developed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group. Part 2 of this PD guideline is the first CPG developed by our society that conforms to the GRADE approach. Methods Detailed processes were created in accordance with the Cochrane handbook and the GRADE approach developed by the GRADE working group. Results Clinical question (CQ)1: Is the use of renin-angiotensin system inhibitors (RAS inhibitors), such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), effective in PD patients? Recommendation: We suggest the usage of RAS inhibitors (ACEI and ARB) in PD patients (GRADE 2C). CQ2: Icodextrin or glucose solution: which is more useful as a dialysate among patients with PD? Recommendation: We suggest using icodextrin when managing body fluids in PD patients (GRADE 2C). CQ3: Is it better to apply or not apply mupirocin/gentamicin ointment to the exit site? Recommendation: We suggest not applying mupirocin/gentamicin ointment to the exit sites of PD patients (GRADE 2C). CQ4: Which surgical approach is more desirable when a PD catheter is placed, open surgery or laparoscopic surgery? No recommendation. CQ5: Which administration route of antibiotics is better in PD patients with peritonitis, intravenous or intraperitoneal? Recommendation: We suggest intraperitoneal administration of antibiotics in PD patients with peritonitis (GRADE 2C). Note: The National Insurance does not currently cover intraperitoneal administration. CQ6: Is peritoneal dialysis or hemodialysis better as the first renal replacement therapy in diabetic patients? No recommendation. Conclusions In the future, we suggest that society members construct their own evidence to answer CQs not brought up in this guideline, and thereby show the achievements of Japan worldwide.

Introduction: New treatments to inhibit neointimal formation after percutaneous transluminal angioplasty (PTA) are needed for patients undergoing chronic hemodialysis (HD). We compared the efficacy and safety of AMG0102, a balloon catheter containing nuclear factor κB (NF-κB) decoy oligodeoxynucleotide (ODN) with the PTA balloon catheter (control group) for arteriovenous fistula (AVF) stenosis. Methods: In total, 175 patients (age ≥20 years, undergoing HD, with venous stenosis at the anastomotic region) were registered in this prospective open-label, randomized study. Patients were followed postoperatively for 36 weeks. The duration of primary patency on the targeted venous stenosis site (primary endpoint) was estimated by the Kaplan–Meier method. Results: A lower restenosis risk was observed for the AMG0102 group, but it was not statistically significant (stratified log-rank test P = 0.250, hazard ratio [HR] 0.774; 95% confidence interval [CI]: 0.500–1.198). The median duration of primary patency was 245 days and 172 days in the AMG0102 and control groups, respectively. After stratification based on the status of diabetes complications, the HR was 0.666 (95% CI: 0.366–1.212; P = 0.183) and the median duration of primary patency was prolonged by 108 days in the AMG0102 group with diabetes complications (245 days) compared with the control group (137 days). Adverse event (AE) incidence up to 36 postoperative weeks did not differ between groups. Four device failures occurred in 3 patients (AMG0102 group), but none resulted in AEs. Conclusion: Further modifications to enhance NF-κB decoy ODN uptake and efficacy are necessary to show its clinical utility for AVF stenosis in chronic HD. Keywords: arteriovenous fistula stenosis, balloon catheter, diabetes, hemodialysis, nuclear factor κB, percutaneous transluminal angioplasty

Rationale & Objective: Individuals faced with decisions regarding kidney replacement therapy options need information on how dialysis treatments might affect daily activities and quality of life, and what factors might influence the evolution over time of the impact of dialysis on daily activities and quality of life. Study Design: Observational cohort study. Setting & Participants 7,771 hemodialysis (HD) and peritoneal dialysis (PD) participants from 6 countries participating in the Peritoneal and Dialysis Outcomes and Practice Patterns Studies (PDOPPS/DOPPS). Predictors: Patient-reported functional status (based on daily living activities), country, demographic and clinical characteristics, and comorbidities. Outcome: Employment status and patient-reported outcomes (PROs) including Kidney Disease Quality of Life (KDQOL) instrument physical and mental component summary scores (PCS, MCS), kidney disease burden score, and depression symptoms (Center for Epidemiologic Studies Depression Scale [CES-D] score > 10). Analytical Approach: Linear regression (PCS, MCS, kidney disease burden score), logistic regression (depression symptoms), adjusted for predictors plus 12 additional comorbidities. Results: In both dialysis modalities, patients in Japan had the highest PCS and employment (55% for HD and 68% for PD), whereas those in the United States had the highest MCS score, lowest kidney disease burden, and lowest employment (20% in HD and 42% in PD). After covariate adjustment, the association of age, sex, dialysis vintage, diabetes, and functional status with PROs was similar in both modalities, with women having lower PCS and kidney disease burden scores. Lower functional status (score 10). The median change in KDQOL-based PROs was negligible over 1 year in participants who completed at least 2 annual questionnaires. Limitations: Selection bias due to incomplete survey responses. Generalizability was limited to the dialysis populations of the included countries. Conclusions: Variation exists in quality of life, burden of kidney disease, and depression across countries but did not appreciably change over time. Functional status remained one of the strongest predictors of all PROs. Routine assessment of functional status may provide valuable insights for patients and providers in anticipating outcomes and support needs for patients receiving either PD or HD.

Auscultation by a medical doctor means the diagnosis is made in a short time. Therefore, the unrecorded data and skill-dependent approach, changing an assessment over time through long-term diagnosis, is rather difficult. Thus, development of health monitoring equipment with long-term recording is desired. Previously, such a system was based on a self-organizing map (SOM) and a maximum entropy method (MEM) for data analysis, as suggested by the authors. SOM is an artificial neural network, which is trained using unsupervised learning in order to produce a feature map useful for visualizing the analogous relationships between input data. The authors recorded body sounds in order to produce a SOM. In this paper, we attempted the recording of body sounds over a long term period and assessed the changes over time. The result is that a SOM output is almost near areas (nodes)

Introduction To promote the increase in patients undergoing peritoneal dialysis (PD) in Japan, the Japanese Society for Dialysis Access started offering workshops on peritoneal access (PA) preparation procedures for doctors with less experience. Since the transfer of technology used in surgical procedures is difficult in small communities such as individual hospitals, a specialist group such as a society should take the initiative and fulfill this responsibility. Methods Here we used a hybrid simulator developed by Terumo Medical Pranex that uses the abdominal wall of an edible pig (a lump from the peritoneum to skin) and a mannequin. Since the structure of the porcine abdominal wall is similar to that of humans, the PA procedure can be simulated in this actual procedure. With three-dimensional reproduction of the Douglas pouch and other features of the pelvis using human computed tomography images, we created a system in which even drainage is possible if the catheter is well placed. Results Using this simulator, students were able to experience the PA access preparation procedure 2-4 times and easily observed the catheter position after insertion by peeling the abdominal wall from the mannequin. Conclusions In the future, by leveraging the advantages of the hybrid simulator, we aim to promote the training of medical staff interested in PD health care and increase the number of patients able to benefit from the many advantages of PD.

Background: Cannabinoid receptor subtype 1 (CB1) has a relationship to the proliferation of various cells including malignant tumoral cells. We investigated and compared the expression of CB1 in benign and malignant human prostate tissues and in benign and malignant human prostate cell lines, as well as its function for the proliferation of human prostate cancer cells. Methods: Real-time quantitative PCR was performed to compare its expressions in human prostate tissues (normal, benign hyperplasia, and cancer) and prostate cell lines (3 normal and 3 malignant). For localization of CB1, immunofluorescent staining with rabbit anti-CB1 polyclonal antibodies and tetramethyl isothiocyanate (TRITC)-labeled swine anti-rabbit immunoglobulin (DAKO) were used under fluorescence microscope. To further analyze whether cell death was induced by anandamide (non-selective agonist for CB1/CB2) via a receptor dependent mechanism, the viability of DU145 cells, which is known as androgen-insensitive prostate cancer cell, was measured using MTT assay. Results: CB1mRNA was found to be expressed in the all 3 human prostate tissues, however, CB1 protein was expressed in BPH and low grade malignant PC tissues, but not in high grade malignant PC tissues. CB1 as for cell lines, the expression of CB1 was low in malignant cell lines except for DU145. Anandamide elicited cell death, which was significantly inhibited by AM251 (selective antagonist for CB1), indicating that cell death induced by anandamide in DU145 cells was mediated by CB1. Anandamide time-dependently elicits up-regulation of CB1 in DU145 cells. Conclusions: CB1 may be an inhibitory regulator of androgen-insensitive human prostate cancer epithelial cell growth.

It is desired to detect stenosis at an early stage to use hemodailysis shunt for longer time. Stethoscope auscultation of vascular murmurs is useful noninvasive diagnostic approach, but an experienced expert operator is necessary. Some experts often say that the high-pitch murmurs exist if the shunt becomes stenosed, and some studies report that there are some features detected at high frequency by time-frequency analysis. However, some of the murmurs are difficult to detect, and the final judgment is difficult. This study proposes a new diagnosis support system to screen stenosis by using vascular murmurs. The system is performed using artificial neural networks (ANN) with the analyzed frequency data by maximum entropy method (MEM). The author recorded vascular murmurs both before percutaneous transluminal angioplasty (PTA) and after. Examining the MEM spectral characteristics of the high-pitch stenosis murmurs, three features could be classified, which covered 85 percent of stenosis vascular murmurs. The features were learnt by the ANN, and judged. As a result, a percentage of judging the classified stenosis murmurs was 100%, and that of normal was 86%.

Introduction: We investigated how generic and disease-specific measures differ in estimating the quality of life (QoL) impact of lower urinary tract symptoms (LUTS). Materials and Methods: A total of 172 men and 67 women ≧40 years old who attended the public lectures completed the questionnaire comprising the International Prostate Symptom Score, benign prostatic hyperplasia impact index and SF-36 Health Survey. The multiple regression analysis was performed to evaluate the QoL impact of LUTS. Results: Both storage and voiding symptoms showed significant correlations with disease-specific QoL. Among men, voiding symptom correlated more closely with disease-specific QoL than storage symptom did, and this finding was reversed among women. Storage but not voiding symptoms showed a significant correlation with generic QoL. Among men, storage symptom correlated more closely with mental health than physical health, and the reversed finding was obtained among women. Generic QoL, especially physical health, was significantly influenced by some comorbid diseases, but disease-specific QoL was not. Conclusions: The QoL impact of LUTS was differentially estimated by disease-specific and generic measures with sex differences.

Aim: The expression of the telomerase subunits such as human telomerase reverse transcriptase (hTERT) and human telomerase RNA component (hTR) may be associated with tumor development and progression. We evaluated the relationship between mRNA quantification of both hTERT and hTR and clinicopathologic parameters in bladder cancer. Methods: We examined the mRNA expression of hTERT and hTR in 29 specimens with bladder cancer (Grade: Grade I, 9 cases; Grade II, 13 cases and Grade III, 7 cases. Stage: pTa-pT1, 18 cases; pT2-T4, 11 cases). We immediately froze all of specimens obtained during TUR-Bt and isolated the total RNA from each specimen. We measured the quantity of hTERT, hTR and GAPDH mRNA by a real-time reverse transcription–polymerase chain reaction method based on TaqMan technology. Results: The hTERT/GAPDH mRNA ratio and hTERT mRNA/total RNA in superficial bladder tumor was significantly lower than in invasive bladder tumor. The hTR/GAPDH mRNA ratio and hTR mRNA/total RNA in superficial tumor were significantly lower than in invasive bladder tumor. The hTERT mRNA expression significantly correlated with tumor grade, but the hTR mRNA expression did not correlate with tumor grade. There was no significant difference in the hTERT/GAPDH mRNA ratio and hTR mRNA/total RNA according to multiplicity of bladder tumor. Conclusions: Our results demonstrated that the expression of hTERT mRNA correlated with the progression of stage and grade in bladder cancer. The quantitative analysis of hTERT and hTR mRNA might be a marker for clinicopathologic parameters in bladder cancer.

腹膜透析カテーテルの位置異常は時に注排液困難を呈し, 臨床上対応に苦慮することを経験する. このようなカテーテル位置異常に対して, われわれは腹腔鏡下に留置針を穿刺しナイロン糸を挿入してカテーテルを腹壁に固定する簡易な方法 (Peritoneal Wall Anchor Technique: PWAT) の有用性に関して以前本誌において報告した. しかし, 操作にあたっては腹腔鏡システムを用いなければならない煩雑さや, カテーテル位置異常がおきてから半緊急処置として施行しなければならないといった問題があった.そこでわれわれは, 腹壁固定術は実際にカテーテル位置異常が生じてから施行するのではなく予防こそが重要であると考え, カテーテル挿入時に併施する方法を考案したので報告する. この方法は今までの体表面からの穿刺ではなく腹腔内から体表への穿刺になるため, 元法による腸管穿孔などの合併症も解決できたと考える.この方法で今までに計21症例に行い, 全例施行時に合併症なく施行することができた.本法は簡便かつ安全にPWATが施行できる有用な方法であろうと考えられた.

Objectives To examine the prevalence of urinary incontinence (UI) and the relationship between UI and generic quality of life (QOL) in working women. Methods Of 7229 female hospital nurses in Japan, 3734 (51.7%) responded to a self-administered postal questionnaire that included the Rand Medical Outcomes Study 36-item Health Survey (SF-36) and the International Consultation on Incontinence questionnaire (ICIQ) for evaluating symptoms and health-related QOL. Results The overall prevalence of UI in Japanese working women aged 20 to 64 years (mean 35.2) was 16.7%. The main type of incontinence was stress UI (73%). Its prevalence increased with age and reached a plateau at age 45 to 49 years (34.7%). The ICIQ score also correlated significantly with age. Generic QOL, especially physical functioning, role-physical, social functioning, and role-emotional, was significantly impaired by UI. A comparison of subjects with and without UI revealed that the differences in the physical and mental component summary scores of the SF-36 were largest in the age groups of 25 to 29 and 55 to 59 years, respectively. The correlations of the ICIQ score with the physical and mental component scores were most significant in the age groups of 25 to 29 and 45 to 49 years, respectively. The impact of mixed UI on QOL showed a greater tendency than that of stress or urge UI. Conclusions The prevalence of UI showed an age-related increase, with a peak at 45 to 49 years old. The impact of UI on physical health was great in individuals in their 20s, but its impact on mental health increased in the older age groups.

近年, 内シャント血管狭窄や閉塞症例に対する血管内治療の有用性が報告されその治療の主流になりつつある. 一般的にはその際の画像検査および治療には非イオン系ヨード造影剤を用いた血管造影検査が施行されている. しかし, ヨード造影剤はイオン性非イオン性に限らず, ヨードアレルギー患者に対して使用すると重篤な合併症を引き起こすことになる. このような症例に対しては, 体表あるいは血管内の超音波検査や, 陰影造影剤である炭酸ガスを用いたDigital Subtraction Angiography (DSA), またはMagnetic Resonance Imaging (MRI) を代用するしかなかった. しかしヨード造影剤を使用したDSA検査で得られる良好な空間分解能と同様の画像を, 安全にかつ手軽に得ることは難しかった.そこでわれわれはヨード禁忌の3症例, 計7回のblood access intervention therapy (BAIVT) に際し, MRI造影検査で用いられるガドリニウム造影剤 (Gd剤) を用いてDSAを施行した. 既報告の基礎検討ではヨード造影剤の5倍希釈溶液と, Gd剤の原液がほぼ同等のコントラストが得られると報告されており, 本施行にあたってはGd剤原液を用いて行い, 全例に特に副作用なく良好な画像を得た. Gd剤の総使用量はMR使用時より多い傾向にあった.このようにGd剤の造影効果はヨード剤に比し明らかに劣るため, 使用にあたってはDSA装置の使用が原則であるが, ヨードアレルギーがあるために内シャント血管内治療が躊躇されている症例には有効な手段と考えられた.

Many reports indicate that a high homocysteine (Hcy) level is a potential risk factor for such thrombotic diseases as arteriosclerosis, myocardial infarction, and cerebral infarction in healthy individuals or hemodialysis (HD) patients. The methylentetrahydrofolate reductase (MTHFR) C677T polymorphism has been reported to be closely related to plasma Hcy level.Using a cross-sectional design in this study, the relationship between arteriovenous fistula (AVF) obstruction and the MTHFR C677T point mutation was examined in 337 HD patients.Results of multivariate analysis showed no significant influence of age, HD therapy duration, sex, or the presence of diabetes mellitus, cerebral infarction, or myocardial infarction. Only the presence of the MTHFR C677T polymorphism yielded a significant difference. Percentages of patients who experienced AVF obstruction were as follows: CC (12.6%), CT (20.3%), and TT (31.8%). The number of those who experienced obstruction was significantly larger with the TT than CC (P0.01). Moreover, total obstruction episode ratios were as follows: CC, 1 in 107.21 episodes/patient-month; CT, 1 in 74.08 episodes/patient-month; and TT, 1 in 50.33 episodes/patient-month. Episode percentages tended to be greater when the degree of mutation was greater, and a significant difference was observed between the CC and TT alleles (P0.01).Although AVF obstruction is affected by numerous factors, there was a strong relationship between MTHFR C677T mutation and AVF obstruction. These findings suggest that the MTHFR C677T point mutation could serve as an important indicator in identifying susceptibility to AVF obstruction.

慢性腎不全, 内シャント血流不全の治療としてのblood access intervention therapy (BAIVT) の有用性が数多く報告されている. 近年その手技の高度化や複雑化に伴い長時間に及ぶ治療が行われるようになっている. ごく少数の例外を除きX線を用いた透視下に治療が行われているため, 術者と患者の放射線被曝線量の把握が重要となる. このたびわれわれはBAIVT手技中の線量をthermoluminescence dosimeter (TLD) にて測定した. 当院での施行60症例の測定結果において, 術者の1症例あたりの皮膚の等価線量 (H 70μm) の平均値は左手指1.04mSv, 右手指1.41mSv, 左手0.50mSv, 右手0.43mSv, 左肩0.10mSv, 右肩0.10mSv, 頸部0.13mSvとなり, 平均値の最大部位は右手指であった. 患者皮膚入射線量は1症例あたりの平均値が58mGyと頭部・心臓・腹部領域IVRに比較し大幅に少ない線量であった. 従って, BAIVT時の放射線被曝においては, 術者の利き腕の手指線量を最も注意しなければならないと考えられる. 本研究より, 術者手指の皮膚等価線量は透視時間と強い相関が認められた. このため実際に測定が困難な場合には透視時間より線量推定が可能である.

Between 1996 and 2003, ten patients with small renal tumors underwent retroperitoneoscopic partial nephrectomy without renal ischemia, nine patients with small renal tumors underwent open partial nephrectomy via a retroperitoneal approach. Both groups were operated on using a microwave tissue coagulator. We compared the results of retroperitoneoscopic group with those of a retroperitoneal open surgery group. Retroperitoneoscopic partial nephrectomy without renal ischemia was performed without any major or minor complications in any patient. The mean operation time for retroperitoneoscopic surgery significantly longer than that for open partial nephrectomy. However, the mean estimated blood loss for retroperitoneoscopic surgery was less than that for open partial nephrectomy. In addition, the retroperitoneoscopic group seemed to recover more rapidly than the open surgery group. This endoscopic surgery is feasible as minimally invasive procedure. It results in saving renal function, minimal blood loss and rapid recovery.

血液透析において安定した維持透析療法を施行するためには, 内シャントをいかに維持していくかが大きな鍵になる. しかし手術時の血管剥離に伴う外膜損傷や非生理的な血流負荷, 穿刺による機械的な損傷などにより, いくら注意深く管理しても狭窄や閉塞などは起きうる. これに対してblood access intervention therapy (BAIVT) が, 各種デバイスの進歩に伴い近年普及してきている. しかし高耐圧のバルーンカテーテルを使用しても “くびれ (balloon indentation)” が残存し不十分な拡張になってしまうことも時に経験する. 我々はこのような高度狭窄症例に対して, 冠動脈形成術の技術として考案されたparallel wire technique (PWT) に若干の改良を加えて施行している.通常のPWTではカテーテルのガイドに用いたワイヤー以外にさらに1本必要であるが, 変法である自己反転式PWT (self reversed PWT: SRPWT) は1本のみで可能な方法である. この方法によりシースはバルーンの適応シースで十分となり, 元法で問題となる施行中の血液ロスもなく施行可能となった. またさらに簡便にSRPWTを施行するため, 先端柔軟長3cmの通常ガイドワイヤーを改良し, 柔軟長5cmを作成し現在施行している. これによって反転させたワイヤーのループ部分がバルーンの拡張長より十分長く得られるようになり, 容易に施行可能となった. PWTは高耐圧バルーン拡張に抵抗するような強固な狭窄に対しても拡張可能であり, さらに簡便に行えるSRPWT本方法は, 手技を断念する前に試行してみる有用な手段であるものと思われた.

A case of ectopic prostatic tissue in urinary bladder and uretero-seminal vesicle fistula with ipsilateral aplastic kidney is reported. A 29-year-old man was admitted to our hospital for residual sensation and perineal pain. Ultrasound examination revealed a cystic change in the right side of urinary bladder. C.T. and M.R.I. revealed a defect of a right kidney and ipsilateral ureteral dilation and seminal vesicle swelling. A cystscopy under lumbar anesthesia revealed a edematous cystic change of the right side of trigone and defect of the right ureteral orifice. Trans urethral resection of the wall of urinary bladder was simultaneously performed. And the contents of the cyst were sperum and old red blood cells. A retrograde ureterograph showed blind-ending ureter at L5 level and seminal vesicle swelling. A resected bladder tissue contained prostatic tissue. After operation he was free from complaints. Uretero-seminal vesicle fistula with ipsilater aplastic kidney is rare disease. In addition a case complicated ectopic prostatic tissue in urinary bladder was not reported in Japanese medical literature.

Editor: For patients undergoing hemodialysis treatment who have a rigid stricture of an arteriovenous fistula, it is extremely difficult to achieve sufficient dilation even if a highpressure resistant balloon catheter is used. In such cases, the parallel wire technique (1,2) has been a better alternative to achieve arteriovenous fistula dilation. The effectiveness of the parallel wire technique has been explained as being a result of the guide wire indwelling between the balloon and the stricture causing a cracked or cut intima, by which the vessel is extended. In other words, the cutting balloon’s blade is replaced with the guide wire. Eventually, the intimal injury is limited to the cracked area. It is speculated that the recurrence of strictures at these points will be less frequent. In the parallel wire technique, there are three alternative ways to indwell the guide wire, as shown in Figure 1: the conventional method passes another wire through the sheath of larger size (Fig 1a); the wire can also be passed through another puncture (Fig 1b); and finally, the selfreversed parallel wire technique, described herein, can be used (Fig 1c). Disadvantages of the conventional technique are that the sheath is required to be thicker than the optimum size and that blood is lost from the point at which the sheath is applied (2). It was reported that 200 mL of blood is generally lost with this method, and use of a Y-shaped connector was recommended (2). The disadvantage of the second method is that a new vein puncture is required and another guide wire is needed. To improve upon these techniques, we chose the method illustrated in Figure 1c: the self-reversed parallel wire technique. In this method, only one guide wire is passed through the sheath, so a sheath of appropriate size is sufficient and a connector preventing blood loss will not be needed. In our hospital, initial implementation of this method used two wires for conventional parallel wire technique (1,2), but this method presented problems such as blood loss from the sheath and required the use of an oversized sheath. Self-reversed parallel wire technique is a simple modification of the conventional one. Details of its implementation and effectiveness are reported herein. Between January 1999 and September 2001, blood access intervention therapy was carried out in 163 patients undergoing hemodialysis treatment. All these patients also had native arteriovenous fistulae. For these cases, we usually used noncompliant balloon catheters (balloon diameter: 4–6 mm) with a rated burst pressure of 15 atm and inflation times of 2 minutes for each dilation. Ultra-short braidedtype sheaths were used (5 F, 3 cm long; Medikit, Tokyo, Japan). In our experience, insufficient dilation was achieved in 22 cases (13%) in which only the high-pressure resistant balloon was used. The self-reversed parallel wire technique was applied in these cases. Figure 2 shows the self-reversed parallel wire technique procedure. A sheath of the required size (5 F) was inserted, through which a flexible-tipped guide-wire with an angleshaped tip (Radifocus; Terumo, Tokyo, Japan) was passed. The tip was then turned in a 180° curve by pushing the tip Figure 1. There are three alternative parallel wire techniques. (a) The conventional method requires an oversized sheath; (b) another puncture can be made to insert the guide wire; or (c) the self-reversed parallel wire technique can be employed.

The number of examinations using interventional radiology (IVR) has increased recently. Because of the more advanced and more complex procedures for IVR, longer treatment time is required. Therefore, it is important to determine exposure doses. We measured operator exposure dose during IVR using a thermoluminescence dosimeter. The results revealed the dose equivalent to the operator’s hands and fingers to be higher than that of other parts, although the effective dose for the operator was low. Moreover, we looked into the factors that affected exposure dose to the operator’s fingers, and examined ways to reduce the dose. In regard to the exposed dose to the operator’s fingers, dose reduction was possible as a result of a geometric arrangement of the fluoroscopic unit, the radiation field size, using a radiation protective device and deliberation to exposure dose reduction of the operator. It is possible to carry out IVR more safely using the method of exposure dose reduction to the operator’s fingers.

The expression of the telomerase subunits such as human telomerase reverse transcriptase (hTERT) and human telomerase RNA component (hTR) may be associated with tumor development and progression. We evaluated the relationship between mRNA quantification of both hTERT and hTR and clinicopathologic parameters in bladder cancer.We examined the mRNA expression of hTERT and hTR in 29 specimens with bladder cancer (Grade: Grade I, 9 cases; Grade II, 13 cases and Grade III, 7 cases. Stage: pTa-pT1, 18 cases; pT2-T4, 11 cases). We immediately froze all of specimens obtained during TUR-Bt and isolated the total RNA from each specimen. We measured the quantity of hTERT, hTR and GAPDH mRNA by a real-time reverse transcription-polymerase chain reaction method based on TaqMan technology.The hTERT/GAPDH mRNA ratio and hTERT mRNA/total RNA in superficial bladder tumor was significantly lower than in invasive bladder tumor. The hTR/GAPDH mRNA ratio and hTR mRNA/total RNA in superficial tumor were significantly lower than in invasive bladder tumor. The hTERT mRNA expression significantly correlated with tumor grade, but the hTR mRNA expression did not correlate with tumor grade. There was no significant difference in the hTERT/GAPDH mRNA ratio and hTR mRNA/total RNA according to multiplicity of bladder tumor.Our results demonstrated that the expression of hTERT mRNA correlated with the progression of stage and grade in bladder cancer. The quantitative analysis of hTERT and hTR mRNA might be a marker for clinicopathologic parameters in bladder cancer.

A 59-year-old man presented with a 2-month history of left flank pain and a possibility of gross hematuria. Left renal cell carcinoma stage II was diagnosed and radical left nephrectomy was performed. Twenty-two months postoperatively, lung metastases were demonstrated and 6 x 10(6) units of alpha-interferon (IFN-alpha) were administered for 9 months, only to keep the sizes of the metastases unchanged. Thirty-four months after the operation, liver metastases and bone metastasis in the left sacroiliac joint were revealed. The combination cytokine therapy was performed with 1.4 x 10(6) U of interleukin-2 (IL-2) and 3 x 10(6) U of IFN-alpha for 16 weeks, and the left sacroiliac joint metastasis was treated with radiation therapy of 4 Gy per day for 7 days. Six months after the 16 weeks of immunotherapy, computed tomography and bone scintigraphy revealed that the metastases of the lung, liver and bone substantially disappeared and this complete response is still kept after 16 months.

We examined the influence of aging on bladder function in men and women.Using the International Prostate Symptom Score questionnaire with an additional question on urinary incontinence lower urinary tract symptoms were evaluated in all outpatients who first visited our urological department from June 2001 to December 2002. In 550 of the 1,201 patients who completed the questionnaire any pathological conditions that might cause micturition disorder could not be detected with urological examinations. Symptom scores of these patients without underlying disease causing micturition disorder were the basis of this study.In men and women total and storage symptom scores but not the voiding symptom score increased significantly with age. In each age group total, storage and voiding symp-tom scores were not significantly different between men and women. Women 50 to 69 years old had significant higher incontinence scores than men of the same age, whereas a significant increase in the incontinence score with age was found only in men. The quality of life score increased with age in men but not in women. However, the 2 sexes did not significantly differ in quality of life score.Lower urinary tract symptoms, especially storage symptoms, showed age related alterations in the 2 sexes without any underlying disease causing micturition disorder. The prevalence of urinary symptoms was not different between men and women. Therefore, bladder function in each sex might be subject to a gender independent aging process.

Intraperitoneal rupture of hydronephrosis is rare. We report a case of hydronephrosis caused by ureteral cancer accompanied by ipsilateral renal cell carcinoma. CASE REPORT A 72-year-old man complaining of general weakness and a tumor in the left upper abdomen without tenderness presented at our hospital. Abdominal ultrasonography and computerized tomography (CT) revealed a giant renal cystic mass and a solid mass at the lower end of the ureter (fig. 1, a to d). Diagnosis was tumor of the left ureteral stump, and a series of operations was scheduled. However, the patient complained of sudden reduction of the mass and resolution of the sensation of abdominal fullness. CT revealed a marked decrease in hydronephrosis and a large amount of ascites in the peritoneal cavity (fig. 1, e and f). Intraperitoneal rupture of left hydronephrosis was diagnosed, and an emergency procedure was performed. When the intraperitoneal cavity was entered through a midline incision there was approximately 1,000 ml. of dark brown ascites and an approximately 5 mm. foramen, from which bloody liquid was excreted into the descending colonic mesentery. Total nephroureterectomy was performed. Extirpated weight was 2,900 g. (including 1,900 ml. of dark fluid). There was a large amount of clotted blood within the renal pelvis, which revealed marked wall thickening. Papillary tumors were noted along the entire ureter. Cytological evaluation of the ascites and renal pelvic urine revealed class IV. Pathological diagnosis regarding the ureter was transitional cell carcinoma, grade 2 greater than 1, pT1, interferon-, pR0, pN0. An induration 3.5 cm. in diameter (fig. 2, a) was noted in the totally destroyed renal tissue (fig. 2, b). Pathological diagnosis was renal cell carcinoma, clear cell subtype, grade 2, interferon- ,V (), pT1a, pN0. Also, the ruptured portion of the kidney comprised necrotic

A 64-year-old woman was admitted to our hospital on August 19, 1996 with the chief complaint of microscopichematuria. A solid mass was found in her lower abdomen. An abdominal CT scan suggested a large intrapelvic cystic mass and the existence of a fistulous connection between the mass and the small intestine. The existence of a fistula was confirmed by a preoperative barium enema and a cystscopic study. On September 25, 1996, a suprapubic partial cystectomy and total hysterectomy were performed since an intrapelvic abscess was suspected. The cystic mass was observed to adhere to the hollow viscus (uterus, rectum, appendix, ileum and bladder). As a result a part of the ileum and bladder were also removed with the mass. The contents of the cyst included a foul smelling gas and white-green pus. Using a probe, we found two fistulous openings to the ileum and bladder. The histopathological findings indicated a dermoid cyst of the left ovary with thyroid follicles, which are known as "Struma ovarii".