A number of new treatment modalities for benign prostatic hyperplasia (BPH) have been introduced in these days: for example, laser ablation, α-adrenergic blocker, antiandrogens, hyperthermia, stanting and balloon dilation. The author basically mentioned the personal experiences in some of these modalities, and gave a general review on their effectiveness and safety. Also pointed out were a variety of problems, important but sometimes ignored, in the evaluation of treatments for BPH, including severity grading of BPH, response criteria of effectiveness, method for proper selection of treatment.

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Motor unit action potentials (MUPs) of the external urethral sphincter muscle during cystometry were analysed on six normal males. Electrodes were of consentric needle type having the exposed tip surface of 0.07mm², and the potential changes were analysed by automatic decomposition electromyography (ADEMG), for isolation and characterization of unit discharges. Number of analysed units was as follows: Two at rest, 4 at first desire to void, and 6 at maximum desire to void. Number of the recorded units and the firing rate were increased along with the degree of bladder filling. Average MUP figures as follows: Amplitude of 206μV, 8.3msec. duration, and 5.4Hz firing rate at rest; 246μV, 9.7msec and 7.3Hz at first desire to void; 277μV. 9.7msec and 7.2Hz at maximum desire to void, respectively. It is concluded that external urethral sphincter maintains its urinary continence by excitation of the neuromuscular units, and by the increase in the firing rate of individual MUP during bladder filling.

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External urethral sphincter electromyography (EMG) during bladder filling was quantitatively analysed using automatic decomposition electromyography (ADEMG). These include 7 normal volunteers, 7 patients with outlet obstruction, 9 with sphincter dyssynergia, and 7 with pelvic nerve injury (PNI). Recruited number of participated motor unit action potentials (MUPs) at maximum bladder filling was significantly larger than that at rest in the normal volunteers, patients with outlet obstruction, and sphincter dyssynergia. In patients with PNI, MUPs were not increased. The MUP amplitude did not differ significantly among groups during bladder filling. In PNI group, MUP duration at rest tended to be larger than those in other groups. Firing rates at first desire to void and at maximum desire to void were significantly increased than that at rest in every groups except the PNI group.
Effect of alpha-1 adernergic blocking agent, phentolamine (5mg intravenously), was examined on 3 patients with benign prostatic hypertrophy (BPH), and in 4 patients with sphincter dyssynertia. Effect of an alpha-1 adrenergic stimulating agent, norepinephrine (5μg/min intravenously), was also evaluated on 5 patients with PNI during bladder filling. Immediately after administration of phentolamine, number of MUPs was decreased in BPH and sphincter dyssynertia groups. But in 2 paraplegic patients having reflex bladder with sphincter dyssynergia, number of MUPs did not decrease. Even with the continuous intravenous administration of norepinephrine for the elevation of the blood pressure, number of MUPs did not increase in any PNI patients. Effect of intravenous administration of phentolamine to induce urethral pressure elevation and the recording of the evoked EMG from external urethral sphincter by electrical stimulation of the penile dorsal nerve was tested on 4 patients without PNI before and after the administration. Phentolamine lowered urethral pressure at membranous urethra, but no significant change of evoked urethral pressure response and EMG activities was observed. It is concluded that the decrease of MUP after phentolamine administration is due to the relaxation of periurethral part of external urethral sphincter, and clinical denervation supersensitivity of the external urethral sphincter after norepinephrine administration was not demonstrated in the PNI groups.

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In order to minimize the late complications of transurethral ureterolithotripsy with a rigid ureteroscope such as distal ureteral stricture or vesicoureteral reflux, we have performed a balloon dilation of the ureteral orifice and the intramural ureter prior to insertion of a rigid ureteroscope in 62 cases with ureteral calculi between October 1986 and December 1991. A 7F balloon dilator (Bard Co. USA) was cystoscopically inserted into the ureter over a 0.038 inches Radifocus gide wire (Terumo Co., Japan) and then, a balloon was inflated to 15F size with saline using a 10ml disposal syringe. Thereafter, an 11.5F rigid ureteroscope (Wolf Co., Cermany) was inserted instead of a balloon dilator. The stone was disintegrated and removed by ultrasonic lithotripter, electrohydraulic lithotripter and/or basket forceps. The stone was removed completely in 45 cases (72.6%) and incompletely in 10 (16.1%). In 7 cases (11.3%), the stone removal was failed. Long-term follow up with an excretory urography obtained at 6 months or later in 31 cases showed no distal ureteral stricture. Voiding cystography was performed in 33 cases at a mean 2.8 months postoperatively and no vesicoureteral reflux was observed.
In control group, 309 cases were treated with trausurethral ureterolithotripsy without dilation of the ureteral orifice and the intramural ureter between the same period. A complete removal was achieved in 262 cases (84.8%) and an incomplete removal in 16 (5.2%). 31 (10%) was failed. Distal ureteral stricture due to this procedure was found in 3 cases (2.1%) in 141 long term followed up cases. Vesicoureteral reflux was observed in 17 of 184 cases (9.2%) who were examined at a mean 5.4 months postoperatively.
These results indicated that balloon dilation of the ureteral orifice and the intramural ureter prior to insertion of a rigid ureteroscope had efficacy to minimize the late complications of transurethral ureterolithotripsy.

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Intraurethral catheters (IUC) were used for elderly male patients with prostatic urethral obstruction (PUO) due to maliugnancy (MA) and benign prostatic hypertrophy (BPH). Thirty-three men complaining of urinary retention in spite of medical therapy at the risk for prostatic surgery underwent insertion of IUC (16Fr Puroflex, Angiomed Co., Ltd., Germany). Six of 33 were patients with PUO due to MA (5 prostatic cancer, and 1 urethral invasion of rectal cancer, mean 82.7 years old), and the other 27 were patients with BPH (average 80.1 years old). Follow-up period of the former ranged from 2 to 9 (mean 6.5) months, and that of the latter ranged from 6 to 23 months. Water filling cystometry (CMG) before the insertion of IUC and fluoroscopic voiding cystourethrography (VCU) just after insertion of IUC were performed. We defined normal CMG and normal VCU as normal bladder, overactive CMG and normal VCU as overactive bladder, and normal or poor sensitive CMG and underactive VCU as underactive bladder. Five of 27 BPH patients had previous prostatic operations (TUR-P, and/or balloon dilation), but 6 MA did not. All of MA (3 normal bladder, 2 overactive bladder, and 1 underactive bladder) voided satisfactorily, and average duration of IUC in place was 6.5 months without exchange of IUC. Although sixteen of 27 (59.3%) BPH patients voided satisfactorily, and average duration of IUC in place was 12.1 months without exchange of IUC, in the other 11 of these 27 BPH patients were removed IUC, and average duration of IUC in place was 4.7 weeks. Five of above failed 11 patients had underactive bladder, and 3 of these 11 patients had previous operation. There was no difference in the success rate of IUC between the two groups. In conclusion, IUC indwelling can be successful for the patients with PUO due to MA as well as BPH. However, the patients with malignancy should be followed up carefully.

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Eight strains of Staphylococcus epidermidis were isolated from clinical specimens and were subjected to the tests for encapsulation, slime-production, mouse-virulence, capsular-typing and adherence to the plastic surface, the renal cells and the bladder epithelial cells.
With the intraperitoneal injection of these strains into mice, three encapsulated strains were observed in mouse-virulent, while two slime-producing and three unencapsulated strains were mouse-avirulent. In ultra-thin sections of mouse-virulent strains, capsules were demonstrated by electron microscopy, however no capsule was seen around the walls of mouse-avirulent strains. On the other hand, slime-producing strains were shown to have higher adherence rate to plastic surface, compared to encapsulated strains. The direct adherence rate to the bladder epithelial cells was greater in the encapsulated strains than the slime-producing strains, although there was no difference to the renal cells. Also, cell suspension containg 10⁷ colony forming units of these strains were injected intravenously or intravesically into mice. Of these encapsulated strains showed kidney and bladder lodgements with in 28 and 21 days after intravesical injection, respectively, although slime-producing and unencapsulated strains could only be obtained for 7 days in the kidney and 3 days in the bladder. However, there was no difference in the internal organs lodgements of the strains after intravenous injection into mice.
These experimental results suggested that the encapsulation of the strains would be an important factor for bladder lodgement, however, significant effects were not observed with the slime-producing and unencapsulated strains.

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Assessing the QOL in cancer clinical trials is becoming increasingly important. However, a suitable device of assessment of QOL has not been developed yet for prostate cancer patients in Japan. We tried to assess the QOL of prostate cancer patients using the EORTC questionnair translated in Japanese, and examined its validity and reliability. Thirty-six patients filled in a questionair. The reliability of this device was confirmed by the results of test-retest reproducibility. Good correlation was shown between the results and patients performance status, and between the results and clinical stages, which support the validity of the device. As for the results of assessment of QOL, these patients were severly damaged in sexuality. Those factors of functional status, physical symptoms and fatigue/malaise were closely related to disease activity and clinical stage.

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Since July 1991, we have performed laparoscopic nephrectomy for removal of damaged kidneys in thirteen patients. In addition, we recently developed a new procedure of laparoscopic nephrectomy for renal cell carcinoma and successfully removed the kidney with renal cell carcinoma.
Patients' age ranged from 18 to 80 years with the average being 50 years. There were 8 male and 6 female patients. Original disease was calculous disease in 5 patients, vesicoureteral reflux in 4, renovascular disease in 2, ureteropelvic junction obstruction in 1, ectopic ureter in 1 and renal cell carcinoma in 1. The mean size of the diseased kidney was 9×5×4cm in the initial 13 cases and 13×7×6cm in the case with renal cell carcinoma. The size of the tumor was 2.5×2×2cm. In the first 13 patients, nephrectomy was performed as diescribed previously. In the patient with renal cell carcinoma, a new procedure was applied. In the new procedure, five trocars were introduced into the abdominal cavity through the lateral abdominal wall. The kidney was removed en bloc together with the adrenal gland, perirenal fat and Gerota's fascia in the same fashion as traditional radical nephrectomy. Thirteen kidneys were successfully removed, but one failed because of dense adhesion to the surrounding tissue. Three of the 13 patients required additional laparotomies to control bleeding or to remove missed stone. There were no other severe complications in this series. The mean operative time was 308min and the mean volume of estimated blood loss was 635ml. The average hospital stay was 11 days after surgery.
These results indicate that (1) this procedure as currently carried out was not minimally invasive, however, does have the potential to become minimally invasive surgery and (2) a new procedure of laparoscopic nephrectomy for renal cell carcinoma might be applied for the patients with small volume renal cell carcinoma.

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The relationship between the urokinase-type plasminogen activator (u-PA) content in extracts of cancer tissues and the histological grade or the extent of the primary tumor as prognostic factors in bladder cancer were examined in 55 cases of bladder cancer. The patients were divided into 2 groups, high u-PA (8ng/ml of protein and more) and low u-PA (less than 8ng/mg of protein) groups. The incidence of vascular invasion was 37% in the high u-PA group, and 7.1% in the low u-PA group (p<0.05). The incidence of high u-PA group increased with the grade of cancer and the extent of the primary tumor. The 3-year survival rates were 87.3% in low u-PA group and 42.6% in high group (p<0.005). The survival rates of the patients in the high u-PA group were lower than in the low group, by grade or stage. In a multivariate analysis, the prognostic value of u-PA antigen content was the same as that of tumor grade and stage. Therefore, the content of u-PA may be a useful prognostic marker for bladder cancer in addition to tumor grade and stage although the prognosis of the patients with bladder cancer is considered to be determined by many factors.

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Two α₁-adrenoceptor subtypes (α_1A and aα_1B) have been distinguished by competitive antagonists and alkylating agent chloroethylclonidine (CEC). The CEC-insensitive subtype (α_1A) had been suggested to selectively activate Ca²⁺ influx through Ca-channels in smooth muscle cell membrane. We examined the effects of WBC4101, CEC and verapamil on contractile responses to phenylephrine in rabbit aorta, urinary bladder and urethral smooth muscle and in human prostatic adenoma to examine the α₁-adrenoceptor subtypes in these tissue. Pretreatment with WB4101 caused a large shift to the right for phenylephrine-induced dose response curves and verapamil decreased the phenylephrine-induced contractions of rabbit aorta, urinary bladder and urethral smooth muscles and human prostatic adenomas. CEC inhibited only phenylephrine induced contractions of human prostatic adenomas. The pA₂ value for WB4101 was significantly lower in human prostate than in rabbit aorta, urinary bladder and urethra. These results suggest that functional α₁-adrenoceptor subtypes involve α_1A and α_1B in human prostatic adenoma, while only α_1A in rabbit aorta, urinary bladder and urethral smooth muscles.

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Magnetic resonance imaging (MRI) was performed on 13 testes of 12 patients with testicular abnormalities. In all cases, scrotal palpation and initial clinical course had suggested malignant testicular tumors.
The normal testes showed homogeneous intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images such as the appearance of the corpus cavernosum penis.
Ten patients proved to have testicular tumors. In eight of them, the tumors showed homogeneous intermediate signal intensity on T1-weighted images, while in the other two, these images showed heterogeneous signal intensity. In four patients, tumors were of homogeneous low signal intensity on T2-weighted images, while in the other six, these images showed heterogeneous signal intensity.
The rate of correspondence about local staging of testicular tumor between MRI and pathological diagnosis was 70 percent.
In three patients whose testes were undoubtedly malignant according to clinical findings and examination data, MRI enabled us to diagnose one case of testicular atrophy. However, MRI suggested benign disease in the other two patients; nevertheless, surgery was performed as indicated by the other findings.

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Proliferating cell nuclear antigen (PCNA) of formalin-fixed, paraffin-embedded bladder cancer section was identified by immunohistochemistry in 42 bladder cancer patients. In 29 (69%) patients, the cancer cells showed a strong immunoreactivity for PCNA. An increase in the labeling index for PCNA (PCNA-LI) was significantly correlated with a higher clinical stage (p<0.05) and pathological grade (p<0.05). However, there was no significant correlation between PCNA-LI and the recurrence rate of superficial bladder cancer. The relationship between changes of PCNA-LI after neoadjuvant chemoradiotherapy and prognosis was investigated in 20 patients with invasive bladder cancer. Patients with a decreased PCNA-LI after chemoradiotherapy had a better prognosis than those with a stable or increased PCNA-LL. The 5-year cause-specific survival rate of the patients with a decreased PCNA-LI after treatment was 86%, while that with a stable or increased PCNA-LI was 30% (p<0.01). This finding suggests that changes of PCNA-LI could be a new parameter for the histological evaluation of chemoradiotherapy.

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Effects of endothelin-1 (ET-1) on the smooth muscle contractility of human detrusor, spermatic cord and hypertrophied prostatic adenoma were examined in muscle bath studies. ET-1 increased the contractile forces of all above smooth muscle strips in concentration dependent manner. The contractile force induced by 10^-6M ET-1 was approximately 30% of that induced by 3×10^-5M carbachol in detrusor muscle strips, approximately 40% of that induced by 10^-4M norepinephrine in spermatic cord muscle strips and almost equal to that induced by 10^-5M phenylephrine in prostatic adenoma muscle strips. The contractions induced by ET-1 in those muscle strips were not inhibited by any of tetrodoxine, atropine, phentolamine, propranolol and indomethacine. These results suggest that ET-1 may act as a constrictor on lower urinary tract and genital smooth muscles and especially on prostatic adenoma and that ET-1 may affect those smooth muscles directly not through autonomic receptors or prostaglandins.

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It is well known that there are various differences in the biological characteristics and clinical behavior between prepubertal testicular germ cell tumors and adult ones. We analyzed the nuclear DNA ploidy of testicular tumors in childhood using DNA flow cytometry for clarifying those biological features and shedding some insights in the pathogenesis of testicular germ cell tumors.
Formalin-fixed, paraffin-embedded specimens of primary tumors taken from 9 boys with histological evidence of yolk sac tumors and 8 with prepubertal teratoms treated in our clinic were used for flow cytometry analysis with some modification of the Hedley's technique. The results were compared with those of adult testicular tumors which we previously reported.
All specimens in children showed “DNA euploid”; DNA diploid in all teratomas and 6 yolk sac tumors, DNA tetraploid in other 3 yolk sac tumors. Neither distinct DNA aneuploidy nor DNA heterogeneity were detected in children. Our previous study proved that the vast majority of adult testicular tumors contain DNA aneuploid stemlines. Although prepubertal yolk sac tumor and teratoma are histologically identical with those in adults, this study apparently reveal the different DNA stemline ploidy in prepubertal testicular tumors compared with that in adult ones.
It has been known that carcinoma in situ (CIS) of the testis is a precursor of adult testicular germ cell tumors and the CIS cells in precancerous state already shows aneuploid DNA histogram patterns. Moreover, CIS has never been observed in children. The current results are in agreement with the hypothesis that the pathogenesis of prepubertal testicular tumor is different from that of adult ones. That is, the evolution of adult testicular germ cell tumor start from DNA aneuploid CIS cells, while prepubertal yolk sac tumor and teratoma might be derived from premordial germ cells in early mitotic stage.

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Non-adrenergic non-cholinergic nerves (NANC) are thought to be important in the relaxation of corpus cavernosum for erectile function. On the other hand, it has been shown that nitric oxide (NO) is synthesized from L-arginine and released by the endothelium of blood vessels and accounts for the activity of endothelium-derived relaxing factor (EDRF). We studied whether electrical field stimulation (EFS) of isolated strips of human corpus cavernosum released NO and whether it could act as a NANC neurotransmitter.
Human penile tissue specimens were mounted in an organ bath and the isometric tension recorded. EFS was applied to precontracted strips between two parallel platinum electrodes. Relaxation induced by EFS was not influenced by guanethidine or atropine, but was markedly inhibited by N^G-nitro-L-arginine which is an analog of L-arginine that inhibits the conversion of L-arginine to NO, and hemoglobin which is an agent that inhibits the biological actions of NO. Methylene blue which is an inhibitor of cytosolic guanylate cyclase also reduced the relaxation of EFS, but not completely. The inhibitory effect of N^G-nitro-L-arginine was reversed by addition of excess L-arginine. Exogenous NO relaxed human corpus cavernosum. The relaxation was only a transient response and concentration-dependent. The profile of responses is similar to that evoked by EFS.
Our data clearly demonstrate the release of NO during EFS and the function of NO as a NANC neurotransmitter. Human penile erection may be mediated by NO generated in response to NANC neurotransmission.

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The surgical outcome in 42 patients with seminal tract obstruction who underwent microsurgical vasovasostomy or epididymovasostomy and were followed up for more than 3 months postoperatively is reported. Causes of the obstruction were vasectomy in 7 patients, childhood inguinal herniorrhaphy in 15, epididymitis in 5, Young's syndrome in 3 and others in 12. Twenty-eight patients had bilateral obstruction while 14 had unilateral obstruction. After 51 operations, including 11 reoperation in 9 patients, the anastomosis was patent in 83.3%, semen quality normalized in 21.4% and pregnancy was achieved in 31.0% of the 42 patients. Success rate of vasovasostomy and epididymovasostomy was 57.7% and 78.3%, respectively. Factors detrimentally affecting the operative outcome were obstruction due to Young's syndrome, obstruction for more than 10 years, absence of sperm in vasal fluid during the operation, elevated serum FSH levels and presence of seminal tract anomaly. Presence of serum antisperm antibodies had no effect on pregnancy rate.
Microsurgical reanastomosis of the seminal tract resulted in restoration of fertility in many patients with seminal tract obstruction who had normal testicular spermatogenesis.

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Since January, 1992, 8 patients with adrenal disease have been treated by laparoscopic surgery. There were 4 males and 4 females (35-65 years old), seven patients had primary aldosteronism and one non-functioning adrenal tumor. Six trocar-sheath units were placed in the upper abdomen. In case of the lesion being on the right side, the posterior layer of the peritoneum was incised at the point of the hepatic flexure of the colon and on the left side, the dissection was begun by dividing the peritoneal reflection over the lateral aspect of the descending colon, adrenal tumors were removed with normal adrenal gland.
In all cases adrenal tumors were removed successfully. The operative time was from 165 to 572 (293min., average) minutes and there was no major complication.

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From 1970 to 1992, 10 patients with hormone refractory stage D2 adenocarcinoma of the prostate presenting themselves with urinary retention and/or gross hematuria were treated by palliative irradiation for local progression at Cancer Institute Hospital. External beam irradiation was delivered to the primary lesion at dose of 38Gy to one patient and 30-27Gy to seven patients. Five of these patients in whom an urethral catheter had been indwelt were able to void without difficulty following the treatment. Of four patients with severe hematuria resulting vesical tamponade, none had hematuria after the treatment. These effect lasted until patients' death or more than 11 months follow-up. In other 2 patients, irradiation had to be discontinued at dose less than 20Gy because of deteriorated general conditions and no significant effect. Complications of the treatment were miminal.
These results indicate that the optimal dose of local palliative irradiation is around 30Gy. Irradiation is a good choice for palliation of locally progressive hormone refractory prostate cancer in view of its certain and long-lasting effect, low invasiveness and minimal complications. When to institute palliative irradiation is one of the most important question in order to secure a good quality of life for patients. From our experiences, it is our belief that if local progression is symptomatic, palliative irradiation should be initiated as soon as possible.

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We treated fifty cases of prostatic cancer that had no distant metastase and no other primary cancers between October 1983 and September 1990. Our initial treatment for clinical stages A2, B1, B2 included radical prostatectomy, pelvic lymphadenectomy, and bilateral orchiectomy. Staging lymphadenectomy with bilateral orchiectomy was applied to patients with clinical stage C tumor, and if there was no lymph node metastasis, external beam radiation therapy for the prostate was performed. Patients who did not consent to major surgeries or had poor general status or had clinical stage D1 tumor underwent bilateral orchiectomy. Mean observation period was forty-one months. Eleven cases relapsed. Of the eleven cases, ten had local relapse at the diagnosis of relapse (two of them had distant metastasis simultaneously, six of them had distant metastasis later, and two of them had no distant metastasis in the observation period). All these ten cases had no underwent the initial local treatment. The remainder who had underwent radical prostatectomy relapsed with distant metastasis alone. This study suggests that the local relapse tends to precede distant metastasis as the mate of relapse of prostatic cancer excluding stage D2. There is a possibility that initial local treatment is useful improving the prognosis of the patients for clinical stage A2-D1 prostatic cancer.

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In a 35 year old arteriogenic impotent patient without a history of hypertension, arteriosclerotic disease, or diabetes mellitus, the corpus cavernosum of the penis was revascularized using Hauri's method. Before surgery, erection after the intra-cavernous injection of 20 micrograms of prostaglandin E1 was very weak. In a color ultrasonography the peak systolic velocity of the cavernous arteries was recorded as being only 18cm/sec. Furthermore, no artery except the right dorsal artery was evident even with a digital subtraction angiography. Accordingly he was diagnosed as having arteriogenic impotence, and we carried out the corpus cavernosum revasularization using Hauri's method under microscopic magnification. The dorsal artery and the deep dorsal vein were anastomosed side-to-side, and the hypogastric artery and dorsal artery were anastomosed end-to-side.
After the revascularization surgery, the peak systolic velocity of cavernous arteries returned to normal (53cm/sec), and the penis showed complete erection after an intracavernous injection of 20 micrograms of prostaglandin E1. Before surgery this patient had not experienced sexual intercourse, but he could achieve full sexual intercourse 2 weeks after the surgery. His erectile ability has been maintained for 4 months since the surgery. This is the 1st case of arteriogenic impotence treated using Hauri's method in Japan

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Renal metastases of ostcogenic sarcoma are unusual clinical occurrence and cases of osteogenic sarcoma treated by nephrectomy for renal metastases have been rarely reported.
We report a 19-year-old male who was successfully treated by left nephrectomy for a metastatic tumor of osteogenic sarcoma from the right femur. In 1989 above-knee amputation was performed and the initial relapse with right pulmonary metastasis was treated by right upper lobectomy in 1991. In February 1992 he developed left renal and left pulmonary metastasis, hense left nephrectomy and left upper lobectomy were performed.
Metastases of osteogenic sarcoma to the organs other than the lung and bone will increase because of the improvement of diagnostic modalities. Our study suggests that a bone scan is useful for routine follow-up of patients with osteogenic sarcoma and that resection of the metastatic lesion can improve these patients' quarity of life.

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