The collaborate studies of clinical application of Extracorporeal Shock Wave Lithotripsy (ESWL) using Sonolith 2000, performed at Departments of Urology of Nara Medical University, the University of Tokai School of Medicine and Wakayama Medical College between March and August 1987, were reported. In total 155 ESWL sessions were carried out on 111 patients suffering from in total 119 upper urinary tract stones. The localization system using ultrasound imaging with a computer assissted multiarticulated arm were evaluated as excellent or effective in 117 cases (98.3%). The stone fragmentations were evaluated as excellent (≤3mm) or effective (≤5mm) in 101 cases (84.9%). On the X-ray film obtained six weeks after the final ESWL treatments, 61 cases (51.3%) were free from stone fragments, 20 cases (16.8%) had sand-like fragments and 18 cases (15.1%) had stone fragments less than 5mm. 99 cases (83.2%) without stone or with stone fragments less than 5mm were considered to be with satisfactory results. No serious adverse effect was observed, but petchia on the flanks where shock wave penetrated and mild hematuria were observed in all cases. It is concluded that ESWL treatment using Sonolith 2000 is applicable in the managements of patients with the upper urinary tract stones without serious adverse effects.
Nephrotoxic effects of cis-Diammine-1, 1-cyclobutane dicarboxylate platinum II (CBDCA) were investigated in male 6 weeks old Wistar rats. The animals were divided into 4 groups: Group I (each received a single intraperitoneal injection of CBDCA 80, 120mg/kg); Group II (a single intraperitoneal injection of CBDCA 80, 120mg/kg after withdrawal of food and water for 2 days); Group III (intravenous administration of CBDCA 15, 30mg/kg for 7 consecutive days after withdrawal of food and water for 2 days); Group IV (controls). Rats from each group were sacrificed at 3, 7, 10 and 14 days following the start of the experiment. Serum levels of BUN and creatinine were then measured and renal histopathological examination was conducted by light and electron microscopy. In addition, the total platinum concentration in the serum was measured in Group I, and X-ray microanalysis was performed after intraperitoneal administration of CBDCA (100mg/kg) and cis-Diamminedichloroplatinum (II) (CDDP) (6mg/kg) for 2 consecutive days (Group V). The results showed increased levels of BUN in each group due to catabolism. No significant increase in serum creatinine was observed and there appeared to be no evidence of renal dysfunction. For all groups, localized vacuolar degeneration in the epithelial cells of the tubules was predominantly apparent. Electron microscopy revealed only degeneration of the epithelium mainly in the proximal tubules and also showed reabsorption of platinum from the lumen of the tubules. X-ray microanalysis on the rat kidney receiving CDDP revealed the presence of platinum ions in the epithelial cells of the tubules, but it was not detected after higher doses of CBDCA. The difference in the affinity for serum proteins between the two platinum compounds suggests that CBDCA is excreted into the urine by glomerular filtration and CDDP mainly by secretion into the tubules. Therefore, the difference of urine excretory mechanisms between the two platinum compounds seems to be most related with nephrotoxicity.
The inhibitory effects of sodium pentosan polysulfate (SPP)on the formation, growth and aggregation of calcium oxalate (CaOx)crystals were estimated by means of a Coulter counter TA II by the seed crystal method, whole urine method and infrared spectroscopic method. In the seeded crystal system, the inhibitory activities on aggregation (Ia), growth (Ig) and size (Is) were calculated from the change of the number, volume and diameter of crystals. At above 0. 5μg/ml, SPP inhibited the aggregation and growth of added CaOx monohydrate (COM) and dihydrate (COD) crystals. In the whole urine system, after determining the metastable limit, the formation and growth of CaOx crystals precipitated in response to a load of sodium oxalate was measured. SPP had a strong inhibitory effect on the formation and growth in the concentration of over 5μg/ml. In infrared spectroscopic study, the ratio of COD/COM formed in whole urine increased with the concentration of SPP. SPP therefore might have prevented the recurrence of stone formation.
Twenty-nine kidneys of seventeen patients (nine boys and eight girls) with vesicoureteral reflux and repeated urinary tract infection were studied by magnetic resonance imaging for diagnosis of renal scarring and correlation between clinical data and the degree renal scarring. Renal scarring is classified into three types according to findings in magnetic resonance imaging. The degree of renal scarring are classified into five grades according to traditional grading of intravenous pyelogram. If a fine deformity of calyx is shown on intravenous pyelogram, magnetic resonance imaging demonstrates renal scarring. Magnetic resonance imaging without irradiation is exceedingly valuable for the diagnosis of renal scarring. The appearances of magnetic resonance imaging were supported by X-ray computed tomography. There is a substantial correlation between serum creatinine and the grades of renal scarring by magnetic resonance imaging. There is a substantial correlation between fever attacks and the grade of renal scarring, and there is a significant reverse correlation between the age of the onset of upper urinary tract infection and the grade of renal scarring. It is suggested that upper urinary tract infection is the most significant factor in scar formation.
Multiple biopsy specimens obtained from nontumorous bladder mucosa were investigated histologically. An average of 3.6 specimens was taken in 142 transurethral resection operations for 112 patients with bladder cancer. The histological categories used were normal epithelium, metaplasia, hyperplasia and G1-G3 dysplasia. Thirty-seven patients (27.7%) had G2<dysplasia within normal looking bladder mucosa. In patients with high grade bladder cancer, the incidence of the association with dysplasia was 51.7%, which was significantly higher than the rates in patients with low or moderate grade bladder cancer (p<0.05). The tumor recurrence was observed in 45 patients of 102 patients who were followed with bladder preservation. The recurrence was seen in 13 of 19 patients (68.4%) with mucosal dysplasia in the previous operation. The rate was significantly higher than 38.6% in patients without dysplasia (p<0.05). Thus, the epithelial dysplasia seen in nontumorous bladder mucosa were associated with higher grade bladder tumors more often, and the histology of multiple biopsy specimens might be one of predictors for tumor recurrence in near future.
Giant sections were prepared from 31 totally removed bladders because of transitional cell carcinoma and examined for accompanied urothelial dysplasia. Preoperatory urinary cytology related to dysplasia was also investigated. Dysplasia of the urinary bladder was morphologically defined as the urothelium with intermediate atypism between normal transitional epithelium and carcinoma in situ (CIS) of grade 3 anaplasia. Dysplasia was divided into four groups from two points of view: slight and severe dysplasia on the basis of cellular anaplasia, epithelial stratification and cellular polarity, and clear cell and compact cell dysplasia on the basis of features of dysplastic cell cytoplasm. Compact cell slight dysplasia was recognized in all specimens examined. Compact cell severe dysplasia as well as CIS was frequently accompanied with high grade papillary and non-papillary cancers, but not with low grade papillary cancer. Both slight and severe clear cell dysplasia tended to be frequently associated with high grade cancer. Because of no distinctiveness in nuclear atypia from CIS, severe dysplasia could be regarded as so called CIS of grade 2 anaplasia. From the current results, it appears likely that severe dysplasia is related to the occurrence of high grade bladder cancer. In addition, dysplastic cells exfoliated in to urine retained features of each type of original dysplasia, which were identified with a more than 70% accuracy. The result indicates that urinary cytology offers histologic aspects of coexisting dysplasia as well as bladder cancer.
We have used the continent ileal bladder as a bladder replacement after radical cystectomy. The ileal bladder is an ileal pouch which is anastomosed to the urethral stumpf. The ureters are implanted by a free end ureteroileostomy. The long term results with 26 patients who underwent this procedure are reported. In the early postoperative period, urodynamic and radiographic studies revealed small capacity and high intravesical pressure of the ileal bladder. However, it became a low pressure reservoir with increased capacity gradually. The average bladder capacity was about 250ml and average residual urine was 30ml. Most of the patients were continent in the daytime if the voiding intervals were less than 3 hours at night, some patients were incontinent. Urinary leakage was the most frequent complication. VUR and hydronephrosis were still the problems to be solved. The ileal pouch bladder is a valuable peocedure in properly selected cases.
Using a new acrosome stain named “Spermac stain”, the relationship between the staining rate of sperm acrosome and conventional semen parameters, i. e., sp. density and sp. motility efficiency index (SMEI) was studied. The mean positive staining rate of sp. acrosome in ten fertile men was 81.5%. In 72 infertile men, a significantly higher (p<0.001) correlation was noted between the positive staining rate and sp. density and SMEI. 5 out of 8 male partners of unexplained infertility couples showed low staining rates (40-60%), in spite of normal sp. density and SMEI. Ejaculates from two infertile men with “round-headed” spermatozoa were examined by Spermac stain and electron microscopy. The staining rates of sp. acrosome in these two case were 4.5% and 16.5%. The fine structures of the sperm and the spermatid were presented. Because Spermac stain is quick, reliable and easy to use, this staining method is recommended for evaluating sp. acrosomal morphology in practical use.
On 6 female mongrel dogs (denervated group), bilateral hypogastric nerves were cut distally to the inferior mesenteric ganglion. Five dogs were kept intact as a control group. After 2-5 months, urethal pressure response to continuous noradrenalin infusion (0.1μg/kg/min) was monitored. The urethral pressure rose significantly after noradrenalin loading in each group. however there was no significant difference in the degree of the response between the denervated group and control group. Subsequently, the bladder and the urethra were extirpated to determine the intrinsic noradrenalin content. The tissue noradrenalin concentration was highest in the posterior urethra, intermediate in the bladder base and lowest in the bladder dome. Although these values tended to be lower in the denervated group than in the control group, no significant difference was obtained between the groups in each portion. These results suggest that the majority of sympathetic components which consists in the hypogastric nerve may involve short adrenergic neurons. Thus, chronic hypogastric denervation alone does not induce sympathetic denervation supersensitivity. Simultaneous decentrarization of the pelvic nerve may be nessesory for inducing sympathetic denervation supersensititivy.
Three children at the ages of 4, 10 and 12 years, with external genital malformation, were diagnosed to be with the Klinefelter syndrome by chromosome analysis. To clarify the pubertal changes in this syndrome, all of them were studied for physical and endcrinological examinations and two underwent testicular biopsy. Before puberty any remarkable abnormality were not observed in the hypothalamus-pituitarygonadal axis and in the physcial status. After the onset of puberty they started showing increases of the basal levels of plasma FSH and LH with over-response to LH-RH stimulation test. During the period of this study the levels of plasma testosterone were in the normal range and increased gradually with age. One boy showed a transient high level of plasma testosterone at early puberty. The reactions of plasma testosterone to HCG stimulation of all cases showed the normal pattern. The histological examination of the testis revealed that the number of spermatogonia was reduced in both cases compared with that of normal boys reported by Mancini et al. These findings indicate that most endocrinological and histological abnormalities in adult Klinefelter syndrome occur after the onset of puberty. These changes may be induced at puberty by hypergonadotrophic condition which result from slightly impaired testicular function which is present before puberty.
The results of clinical trial using the second generation extracorporeal shock wave lithotripter (Piezolith 2200, Wolf, West Germany) were presented. The treatments were performed between December 1987 and March 1988 at the University of Tokyo. In total 59 ESWL sessions were carried out on 32 patients with 48 upper urinary tract stones. The treatment could be performed without anesthesia or analgegic agent in every case. A double-J ureteral stent was indwelled in 6 patients with ureteral stones or large stones before ESWL treatment, and transurethral lithotripsy (TUL) was performed in two patients after the treatment. On the X-ray film obtained three weeks after the final ESWL treatment, 13 cases (40.6%) were completely free from stone fragments, while g cases (28.2%) had stone fragments less than or equal to 5mm. Others had fragments greater than 5mm. ESWL using this device was clinically useful in 71.9% in the three weeks follow-up period. No serious complication was observed after treatment except macroscopic hematuria for a few days in all cases, pyrexia in 4 cases (12.5%) and flank pain in 7 cases (21.9%). There were slight and transient changes in the laboratory data after the treatment, but these changes were milder than those with sparkgap lithotripters. It is concluded that Piezolith 2200 is useful in the management of patients with upper urinary tract stones, and it is applicable more safely than the first generation lithotripters.
Urological assessments were done on 132 patients with cerebral palsy, ranging from 5 to 59 years in age (mean 23.2). Concerning urological symptoms, urinary incontinence, decreased urinary stream and urinary tract infection were at 31.8, 14.4 and 16.7%, respectively. Patients with functionally impaired ambulation had a high incidence of urinary incontinence and decreased urinary stream. Decreased urinary stream was more prominent in an elderly patient group, and urinary incontinence was observed almost at the same rate in all age-classified groups. Urodynamic studies were performed in 30 patients with cerebral palsy who were referred to with uroloigcal symptoms. The patients were classified into two groups according to the presence or absence of spinal cord lesions. In a group of 15 patients with spinal cord lesions, electromyography of the external sphincter demonstrated detrusor-sphincter dyssynergia (DSD) in 9, of whom 6 complained of decreased urinary stream; while in the group without spinal cord lesions there was no DSD. These findings suggest that the cause of decreased urinary stream in cerebral palsied patients could be explained by DSD secondary to spinal cord lesions.
The case is a 55-year old woman whose mother died of gastric cancer. In 1984 she underwent radiotherapy for cervical squamous cell carcinoma stage IIIb and had since been under the periodical observations. In 1987 she happened to undergo abdominal X-ray CT scans, and with an image of tumor mass revealed in the right kidney, she was admitted to our hospital. A clinical diagnosis of the rigtht renal cancer was made, and radical nephrectomy was performed. Histological diagnosis was renal cell cancer pT2N0M0. This is the 7th reported case among the cases of double cancer of the cervix and the kidney in Japan. Multiple primary malignancies consist of these two cancers, and the renal carcinoma as an incidental finding with image prosedure were discussed.
A case of carcinoma in situ (CIS) in the right renal pelvis in a 71-year-old women is reported. The patient was admitted because of macroscopic hematuria. Drip infusion pyelography showed a filling defect (coagulum) in the right renal pelvis. Other abnormal findings were not made. Malignacy was suspected by cytology examinaiton in both voiding urine and that obtained by catheter from the right pelvis. A right total nephrouretercetomy was performed. Macroscpic abnormal findings were only of the coagulum in the renal pelvis. Pathologic examination showed CIS in the renal pelvis. We studied the features, pattern of recurrence, and prognosis of 19 cases of primary CIS in the upper urinary tract in the Japanese literature. A slight higher frequency was reported for women than for men. When the CIS was in the ureter, abnormal roentgenological findings, such as stenosis, filling defects, or a dilated ureter, were common (77%), contrary to expectation. But when the CIS was in the pelvis, such findings were rare. Urine cytology examination was positive in 95% of the patients. In four of the 19 patients, a recurrence was found. In all four patients, the first recurrence was in the bladder within 2 years of surgery. The kind of recurrent bladder tumors varied with the patients. The prognosis with recurrence was poor. If signs of recurrence were not recognized within 2 years of surgery, the prognosis was good.
Percutaneous nephrolithotripsy was performed successfully to the stones in the left kidney, in which pyelolithotomy had been done three years earlier. They were foreign body stones with silk sutures used in the previous surgery as the nuclei. All the stones were removed, and a stricture in the renal pelvis was liberated endoscopically. No reports of endoscopic management to foreign body stones in a kidney are found in the Japanese literature. A few ways of the treatment are discussed.