ヒト肛門管の括約筋間隙における神経 : 腸神経叢へのつながり

内容の要旨 , 審査の要旨広島大学(Hiroshima University)博士(医学)Doctor of Philosophy in Medical Sciencedoctora

Longitudinal analysis of laparoendoscopic single-site adrenalectomy and conventional laparoscopic adrenalectomy regarding patient-reported satisfaction and cosmesis outcomes

Summary: Background/Objective: To compare longitudinal patient-reported cosmesis of laparoendoscopic single-site adrenalectomy (LESS-A) to that of conventional laparoscopic adrenalectomy (CLA). Methods: A total of 23, 15, and 9 patients underwent transumbilical LESS-A (TU-LESS), subcostal LESS-A (SC-LESS), and CLA, respectively. A questionnaire was administered asking the patient to assess wound pain (0: not painful to 10: very painful), satisfaction (0: not satisfied to 10: very satisfied), and cosmesis (0: very ugly to 10: very beautiful) on the basis of a visual analogue scale. We mailed questionnaires to all patients who received LESS-A and CLA at postoperative 1, 3, 6, 9, and 12 months. Results: No significant differences were observed in the pain scores between TU-LESS, SC-LESS, and CLA at every time point. In the CLA group, the cosmesis and satisfaction scores were significantly lower at postoperative 3 months (p = 0.0033, 0.0130). There were no significant inter-group differences in the cosmesis score between the three groups after postoperative 6 months. However, the satisfaction score of SC-LESS decreased after postoperative 3 months and was significantly lower at postoperative 9 and 12 months (p = 0.0333, 0.0160). The difference between the satisfaction scores of each procedure gradually increased after postoperative 6 months. Conclusion: This study is the first comprehensive longitudinal analysis of patient-reported satisfaction and cosmesis outcomes between LESS-A and CLA. The resulting data provide important insights into the improvement in satisfaction in patients who underwent TU-LESS. These findings can facilitate the treatment decision-making process for patients who are considering laparoscopic adrenalectomy. Keywords: Cosmesis, Laparoendoscopic single-site surgery, Adrenalectomy, Longitudinal stud

Site-dependent differences in the composite fibers of male pelvic plexus branches: an immunohistochemical analysis of donated elderly cadavers

Abstract Background Although the pelvic autonomic plexus branches are considered to be a mixture of sympathetic and parasympathetic nerves, little is known regarding the composite fibers of the pelvic plexus branches. This study aimed to investigate the immunohistochemical features of sympathetic and parasympathetic nerves in the pelvic autonomic plexus branches. Methods Using 10 donated elderly male cadavers, the detailed topohistology of nerve fibers at and around the bladder, seminal vesicle, prostate, and rectum was examined. Neuronal nitric oxide synthase (nNOS) and vasoactive intestinal polypeptide (VIP) were used as parasympathetic nerve markers; tyrosine hydroxylase (TH) was used as a sympathetic nerve marker. The myenteric plexus of the colon was utilized as a positive control. Results Most nerve fibers in the bladder, seminal vesicle, prostate, and rectum were both nNOS- and TH-positive. Thus, pelvic plexus branches were classified into two types: 1) triple-positive mixed nerves (nNOS+, VIP+, TH+, thick myelinated fibers + or -) and 2) double-positive mixed nerves (nNOS+, VIP-, TH+, thick myelinated fibers + or -). Notably, triple-positive nerves were localized within the posterosuperior part of the plexus (near the rectum) and travelled anteroinferiorly toward the posterolateral corner of the prostate. The posteriorly and inferiorly located nerves were predominantly composed of parasympathetic, rather than sympathetic, fibers. In contrast, nerve fibers within and along the bladder and seminal vesicle contained either no or few VIP-positive nerves. These superiorly located nerves were characterized by clear sympathetic nerve dominance. Conclusions The nerves of the pelvic plexus branches were clearly classified into nerves around the bladder and seminal vesicle (VIP-negative) and nerves around the prostate (VIP-positive). Although nNOS- and VIP-positive nerve fibers are candidate cavernous nerves, cavernous nerve identity cannot be definitively concluded for these nerves in the periprostatic region

Centrality angle is a novel nephrometry score to predict tumor complexity and perioperative outcomes for partial nephrectomy

Abstract To propose the centrality angle (C-angle) as a novel simple nephrometry score for the evaluation of tumor complexity and prediction of perioperative outcomes in nephron-sparing surgery (NSS) for renal tumors. The analysis was based on 174 patients who underwent robot-assisted partial nephrectomy retrospectively. C-angle was defined as the angle occupied by the tumor from the center of the kidney in the coronal CT images. Other nephrometry scores were calculated and compared with C-angle. Associations between C-angle and perioperative outcomes were examined. Significant differences were found in C-angle between tumors greater and less than 4 cm, exophytic and endophytic tumors, and hilar and non-hilar tumors. C-angle was correlated with other nephrometry scores, including RENAL, PADUA, and C-index. Significant positive correlations with WIT, operation time, and EBL, and significant negative correlations with preserved eGFR. C-angle could predict perioperative complications. Patients with a C-angle > 45° had worse perioperative outcomes, including longer operative time, longer WIT, lower rate of preserved eGFR, and complications. C-angle can be used to evaluate the complexity of renal tumors and predict perioperative outcomes. C-angle can potentially be used for decision-making in the treatment of patients and to guide surgical planning of NSS

A case of bloodstream infection caused by Ruminococcus gnavus without gastrointestinal involvement

We report a case of bloodstream infection due to Ruminococcus gnavus (R. gnavus) associated with pelvic abscess in a 74-year-old female patient undergoing radiotherapy for cervical cancer. Gram staining of positive anaerobic blood cultures revealed short chains of gram-positive cocci. Matrix-assisted laser desorption ionization time-of-flight mass spectrometry was performed directly on the blood culture bottle, and 16S rRNA sequencing identified the bacterium as R. gnavus. There was no leakage from the sigmoid colon to rectum on enterography, and R. gnavus was not found in the culture of her pelvic abscess. After the administration of piperacillin/tazobactam, her condition markedly improved. This patient with R. gnavus infection demonstrated no gastrointestinal involvement, whereas past published cases reported diverticulitis or intestinal damage. It is possible that bacterial translocation of R. gnavus occurred from the gut microbiota, due to damage to the intestinal tract caused by radiation

First reported human case of isolation of Vagococcus fluvialis from the urine of a former zoo clerk in Japan: a case report

Abstract Background Vagococcal infections are extremely rare in humans. There are limited studies on the optimal methods for identification, antimicrobial susceptibility testing, and clinical manifestations of vagococcal infections. Herein, we report a patient with a urinary tract infection who had Vagococcus fluvialis in the urine. Case presentation An 84-year-old man presented to our urology department with a fever that had persisted for several days. He previously worked as a zoo clerk. The patient underwent a left nephroureterectomy for ureteral cancer 5 years ago, and total cystectomy and right cutaneous ureterostomy for muscle-invasive bladder cancer 1 year prior. He was empirically treated with 500 mg of levofloxacin intravenously every 24 h for the urinary tract infection. V. fluvialis was detected in his urine samples and Pseudomonas aeruginosa was detected in his urine and blood samples. Two bacterial species were identified using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. He was administered intravenous levofloxacin for approximately 1 week, followed by oral levofloxacin for another week, after which the infections were eradicated. Conclusions To the best of our knowledge, this is the first report of V. fluvialis detected in human urine in Japan. Vagococcus spp. is commonly isolated from fish or animals, and based on the patient’s work history, it is possible that the patient was a carrier because of transmission from animals

Table_1_Complexity in radiological morphology predicts worse prognosis and is associated with an increase in proteasome component levels in clear cell renal cell carcinoma.docx

BackgroundWe previously reported preoperative radiological morphology (RM) as an independent predictor for pathological upstaging after partial nephrectomy in patients with T1 renal cell carcinoma (RCC).PurposeTo investigate the prognostic importance of RM in all stages and the molecular characteristics underlying the differences between each type of RM in patients with clear cell RCC (ccRCC).Design, setting, and participantsThe Cancer Imaging Archive datasets (TCIA), comprising CT images and RNA-sequencing data, were used (n = 163). Specimens from 63 patients with ccRCC at our institution and their CT images were used. All images were divided into three types according to RM classification.Outcome measurements and statistical analysisRelationships with outcome were analyzed using Cox regression analysis and log-rank test.Results and limitationsThe irregular type was a significant independent predictor of worse disease-free survival (odds ratio: 2.22, p = 0.037) compared to round and lobular types in TCIA datasets. The irregular type showed a significant increase in both mRNA and protein expression of proteasome components, PSMB1 and PSMB3. Moreover, high expression of their coding genes shortened the progression-free survival of the patients with ccRCC who received sunitinib or avelumab plus axitinib therapy. The study limitations include the qualitative classification of RM and the need for novel radiomics and texture analysis techniques.ConclusionsInvestigating RM on pre-treatment CT scans can effectively predict worse prognosis. Increased RM complexity may indirectly predict drug sensitivity via increased expression of PSMB1 and PSMB3 in patients with ccRCC. Specific targeting of the ubiquitin-proteasome system might be a novel treatment strategy for ccRCC with increased RM complexity.Patient summaryThe clinical and morphological characteristics of patients with ccRCC vary greatly according to cancer staging. In this study, we built upon our prior findings of the prognostic importance of RM in T1 RCC and expanded it to encompass all stages of RCC, using a series of patients from a Japanese hospital.</p

Image_1_Complexity in radiological morphology predicts worse prognosis and is associated with an increase in proteasome component levels in clear cell renal cell carcinoma.tif

BackgroundWe previously reported preoperative radiological morphology (RM) as an independent predictor for pathological upstaging after partial nephrectomy in patients with T1 renal cell carcinoma (RCC).PurposeTo investigate the prognostic importance of RM in all stages and the molecular characteristics underlying the differences between each type of RM in patients with clear cell RCC (ccRCC).Design, setting, and participantsThe Cancer Imaging Archive datasets (TCIA), comprising CT images and RNA-sequencing data, were used (n = 163). Specimens from 63 patients with ccRCC at our institution and their CT images were used. All images were divided into three types according to RM classification.Outcome measurements and statistical analysisRelationships with outcome were analyzed using Cox regression analysis and log-rank test.Results and limitationsThe irregular type was a significant independent predictor of worse disease-free survival (odds ratio: 2.22, p = 0.037) compared to round and lobular types in TCIA datasets. The irregular type showed a significant increase in both mRNA and protein expression of proteasome components, PSMB1 and PSMB3. Moreover, high expression of their coding genes shortened the progression-free survival of the patients with ccRCC who received sunitinib or avelumab plus axitinib therapy. The study limitations include the qualitative classification of RM and the need for novel radiomics and texture analysis techniques.ConclusionsInvestigating RM on pre-treatment CT scans can effectively predict worse prognosis. Increased RM complexity may indirectly predict drug sensitivity via increased expression of PSMB1 and PSMB3 in patients with ccRCC. Specific targeting of the ubiquitin-proteasome system might be a novel treatment strategy for ccRCC with increased RM complexity.Patient summaryThe clinical and morphological characteristics of patients with ccRCC vary greatly according to cancer staging. In this study, we built upon our prior findings of the prognostic importance of RM in T1 RCC and expanded it to encompass all stages of RCC, using a series of patients from a Japanese hospital.</p