Extracorporeal shock wave lithotripsy became a main treatment method for the upper urinary tract calculi. About 500 ESWL machines of 28 types are currently used in Japan and ESWL therapy occupies more than 90% of the surgical intervention for upper tract stones. The doctors who are engaging in the ESWL therapy are strongly advised to know the features of their own ESWL machines, since the treatment strategy may differ considerably depending on the type of machines. The strategy has changed from the in-patient ESWL under anesthesia by oroginal Dornier HM-3 to out-patient anesthesia-free treatment by machines of second or third generations. At present, it is reasonable to treat the easy stones by initial out-patient ESWL without anesthesia. When the initial ESWL fails, the second ESWL may be performed under anesthesia with the help of various auxiliary procedures. If one use the machines requiring anesthesia, one should employ every possible ancillary procedures, e. g. ureteral catheterization, stenting, push-up etc. at the time of first session to achieve the highest pulverization rate and the highest stone free rate. The treatment strategy should be assesed individually in every case of problem stone. Simple repetition of ESWL at out-patient clinic should be avoided in these cases. In the case of staghorn calculi, especially of a large stone burden with calyceal dilatation, ESWL is not advised to be an initial treatment. In the review article, the author surveyed recent clinical reports on ESWL therapy and tried to convey their treatment strategies. The article may hopefully helps the readers to establish their own policy in the ESWL treatment for urolithiasis.
We analysed the clinical background of female who had no underlying disease but consulted out urology outpatient clinic with a chief complaint of symptoms of bladder irritation. Overally, 50.1% (102/200 cases) of the cases had urethral syndrome, without pyria or bacteriuria. Plotting of the age distribution of the urethral syndrome cases showed a bell-shaped curve, with the peak at the 40-49 year-old age bracket. The age distribution for the cystitis cases showed two peaks: at 20-29 years of age and 60-69 years of age. These results indicate that the cases of urethral syndrome involve multiple factors with increasing age. Examination of the external genitalia revealed the urethral smear specimens to be positive for leukocytes in 48.9% (88/180 cases) of the total urethral syndrome cases and in 72.7% (16/22 cases) of the urethral syndrome cases positive for urethral bacteria. Accordingly, it was surmised that there is considerd to be a precursor of cystitis-as a cuase of urethral syndrome cases. In addition, the rates of detection of chlamydia trachomatis from the vagina and urethra of the urethral syndrome cases in the reproductive age range of (2/34 cases) for the urethra. However, these rates were about the same as those determined for healthy volunteers. Nevertheless, it was surmised that urethritis or vaginitis caused by C. trachomatis was one of the causes of the symptoms of bladder irritation in some of the cases. Accordingly, it was concluded that infection due to C. trachomatis cannot be ignored as a possible cause of urethral syndrome.
In recent years the number of incidentally detected renal cell carcinoma (RCC) has increased. It is undoubtedly true that ultrasonography is the most useful tool to detect RCC in small size. However, the optimal interval of ultrasound examination is unknown. To elucidate this, we investigated the growht rate of RCC during the period of non-treatment in 6 patients. Their growth was slow and the tumor volume doubling time ranged 372 to 579 (468±84.6) days. Based on this growth rate, we conclude that we can detect the majority of RCC ranging from 1.5 to 3cm in diameter if ultrasonography is repeated every 3 years and that the age of subjects for screening is over 40 years.
The authors studied a 1-year effect of transurethral microwave thermotherapy (TUMT) using the PROSTCARE apparatus (Bruker Spectrospin Wissembourg, Frace) on 35 patients with symptomatic benign prostatic hyperplasia (BPH). The device is equipped with a unique noninvasive system “radiometry” for the measurement of the intraprostatic temperature to regulate the microwave emission power and to eliminate classic surface controls. All of the 35 patients received a single thermotherapy session (60 minutes), the average intraprostatic temperature was 43.6±1.2°C (mean±SD) and the average power output was 43.9±4.1 Watt. The clinical effects were evaluated at 2 months, 6 months and 1 year after TUMT by a specially designed score scale for subjective symptoms and objective findings as compared with the pretreatment score. Assuming that more than a 25% reduction of the total score indicates “effective”, 71.4%, 71.4, and 48.6% of the treatments remained effective at 2 months, 6 months, and 1 year after TUMT, respectively. The maximum prostatic urethral pressure profile decreased from 64.1±17.1 to 51.7±15.6cmH2O (p<0.05) at 2 months after TUMT. The thermotherapy by PROSTCARE is effetive in approximately 50% of patients at least 1 year and there were no major complications associated with TUMT during the follow up period.
We described the clinical results and efficacy of laparoscopic pelvic lymphadenectomy for localized prostate cancer. This procedure was followed by radical prostatectomy, if metastasis was not found in frozen section. In the presence of positive nodes, optional treatment, such as TUR or castration, other than radical prostatectomy was performed. We performed laparoscopic lymphadenectomy on twenty seven patients between April 1992 and September 1993. They range from 52 to 78 years in age and consist of 4 patients with stage A2, 17 with stage B, and 6 with stage C. We dissected the obturator lymph nodes on bilateral sides. The average operating time was 162 minutes (range 86 to 320 minutes). The average number of nodes removed from the right side was 7.1±5.9 and 6.1±4.5 from the left side, which was comparable to the number of lymph nodes obtained by open dissection. Colon injury occurred in one patient, which was managed by laparotomy procedure. Nodal metastases were found in 6 patients by frozen section, and in 10 patients by permanent section. This discrepancy suggested that two-staged operation might be preferable for the localized prostate cancer. Six patients were given suitable therapies besides radical prostatectomy. Laparoscopic pelvic lymphadenectomy is a safe and useful procedure for prostate cancer, especially for the patients who are likely to have nodal metastasis.
The incidence and mortality rate of urogenital cancers in Japan are both low compared to those in western countries. However, the incidence and mortality patterns of cancer in Japan are currently becoming closer to those of western countries, and the importance of urogenital cancers is increasing. We conducted an analysis of urogenital cancers in Gunma Prefecture. The subjects were newly detected urogenital cancer patietns living in Gunma Prefecture diagnosed between 1985 and 1992. Details were as follows: prostate cancer 1411, bladder cancer 1253 (male 937, female 316), renal cell carcinoma 411 (male 287, female 124), renal pelvic and ureter cancer 187 (male 127, female 60) and testicular cancer 162. Incidence rate was calculated by year, district and age, and was expressed per 100, 000/year and was adjusted to world population. Regarding the incidence rate per year for males, that of prostate cancer and renal cell carcinoma increased dramatically from 8.3 to 13.6 and from 1.1 to 3.2, respectively. Incidence rate of other cancers in males showed a slight increase or remained almost stable. Incidence rate by year for females showed a slight increase or remained almost stable as a whole. Gunma Prefecture was divided into 10 districts by the range of daily life of people and the incidence rates of prostate cancer, bladder cancer and renal cell carcinoma for each district were calculated. Incidence rate of prostate cancer tended to be higher in the northern parts of the prefecture, while that of bladder cancer showed no detectable trend. Incidence rate of renal cell carcinoma tended to be higher in the central parts of the prefecture and to be lower in eastern and western parts of the prefecture. Each cancer was categorized by the slope of the line when the age-specific incidence rate of each cancer was plotted on double logarithmic scales. The 3 categories were linear (prostate and bladder cancer), linear until a certain age and then leveled off or decreased thereafter (renal cell carcinoma and renal pelvic and ureter cancer) and irregular (testicular cancer). Age-specific incidence rates of prostate and bladder cancer increased in proportion to the 11th and 5th power of age, respectively.
We evaluated 59 patients with voiding dysfunction after abdominal radical hysterectomy for uterine cancer. Of 59 patients, 45 underwent the surgery alone, and the other 14 underwent surgery and postoperative radiotherapy. Irradiation (mean dose, 60Gy) was performed in bilateral commoni iliac regions excluding the bladder. In principle, the indwelling urethral catheter was removed 4 days after operation. All patients were followed up at the gynecological depatment until the onest of the voiding dysfunction. The mean interval between operation and the onset of voiding dysfunction was significantly longer (P<0.01) in the group treated by surgery alone (7.9 years) than in the group treated by surgery in combination with radiotherapy (3.8 years). Voiding dysfunction developed earlier as the age at the time of operation was higher. No differences were observed in the volume of residual urine, the detrusor function, or the incidence of urinary tract infection between the two groups. These results suggest that aged patients develop voiding dysfunction earlier after radical hysterectomy than young patients, and postoperative radiotherapy shortens the interval between operation and the onset of postoperative voiding dysfunction.
Roles of sacral spinal alpha-adrenoceptive mechanism in micturition reflex were examined in 19 decerebrate dogs. Alpha1- and alpha2-adrenergic agents were injected into the sacral subarachnoidal space. Micturition reflex was evoked by filling the bladder before and after the drug injection. The intravesical pressure (IVP), the intraurethral pressure (IUP) and the electromyogram (EMG) of the external urethral sphincter muscle (EUS) were recorded simultaneously. The bladder volume, the IVP at the threshold of micturition reflex, the minimum IUP, the maximum IUP and the mean IUP were measured during collecting phase. The maximum IVP and the minimum IUP were measured during contraction phase. The effects of adrenergic agents on these measured parameters were analyzed using Wilcoxon's test. The changes of the EUS-EMG were also studied. Intrathecal injection of phenylephrine, an alpha1-agonist, significantly increased the bladder volume and the mean IUP during the collecting phase, and tended to enhance the EUS-EMG during both phases. Intrathecal injection of prazosin, an alpha1-antagonist, tended to diminish the EUS-EMG during both phases. Intrathecal injection of clonidine, an alpha2-agoinst, significantly decreased the minimum IUP, the maximum IUP and the mean IUP during the collecting phase, and tended to diminish the EUS-EMG during both phases. Intrathecal injection of yohimbine, an alpha2-antagonist, decreased the maximum IVP during the collecting phase significantly. These results suggest that the sacral alpha-adrenoceptive mechanism mediates elevation of the threshold of micturition reflex and facilitation of the EUS activity via alpha1-receptor, while facilitation of the bladder contractility and inhibition of the EUS activity via alpha2-receptor.
In November 1991, a third generation extracorporeal shock wave lithotriptor (Piezolith 2500) was installed in our clinic. We examined the effective and safe aspect of this machine for urolithiasis. From Novemer 1991 to October 1993, we experienced 530 sessions of ESWL treatment on 235 patients (270 cases). All patients except two underwent ESWL treatment wihtout anesthesia, and in situ ESWL treatment was possible on 247 cases. The mean number of shock waves and sessions per patient of renal stone were 3369 and 2.1, respectively. Those of ureteral stone were 3970 and 1.9, respectively. The complete removal rate of renal and ureteral stone 3 months after the last session were 86% and 92%, respectively. This outcone was very satisfactory. On the other hand, endoscopic procedure was needed on 13 patients. In almost all cases hematuria was noted after ESWL, but major complications such as subcapsular hematoma or gastrointestinal hemorrhage were not experienced at all. It was concluded that Piezolith 2500 was very effective and safe in the treatment of urolithiasis.
Our recent studies demonstrated that experimental autoimmune orchitis (EAO) model was produced in C3H/He mice with high incidence by two subcutaneous injections of viable syngeneic testicular germ cells (TC) without the use of any adjuvants or immunopotentiators. In this study the developmental patterns of autoantigenicity of TC during postnatal period were investigated by examining the orchitogenic activity of TC, the lymphostimulatory activities of TC (including the TC-induced in vitro lymphocyte proliferative response and the cytokine release from sensitized spleen cells (SPC) in response to TC) and the immunohistochemical localization of target autoantigens in the testes of mice at various weeks of age. Delayed-type hypersensitivity-inducing capacity and anti-TC antibody-eliciting capacity were initially observed in mice that were immunized with TC of 4-week old (w. o.) mice. The TC from 6-w. o. mice had the capability of inducing EAO (orchitogenicity) for the first time. A significant stimulation of in vitro lymphocyte proliferative response, as well as of interleukin (IL) 5 and IL-6 production by sensitized SPC were detectable when TC of mice 3-w. o. or more than were employed as stimulant. IL-2 and interferon gamma production were detected with TC of 4-w. o. mice. Immunohistochemical staining reaction with anti-TC antisera was primarily localized at the acrosomal portion of spermatids and spermatozoa in the seminiferous tubules, being already detected in spermatids of as early as 3-w. o. mice. Thus, from these data it is suggested that the appearance of the lymphostimulatory activities of TC consistently precedes that of the orchitogenic activity and that relatively mature germ cells such as spermatids and spermatozoa developing in the testes during the postnatal weeks may be responsible for the induction of disease and relevant immune responses in our EAO system.
A case of multilocular cystic renal cell carcinoma was reported. The patient was 69-year-old male who had been examined for postoperative study of gastric cancer by abdominal CT. The abdominal CT incidentally revealed right adrenal tumor which was non-functional and multilocular cysts in the lower pole of the right kidney. Selective renal arteriography showed a hypovascular mass with fine neovascularity. These two findings of CT and arteriography were though to represent a probable malignant tumor but renal function of the patient decreased moderately. Surgical exploration was done and right renal masses were thought to be seen benign multilocular cysts without capsule. Simple excision of the wall of cysts and right adrenalectomy were performed. Pathological examinations showed multilocular cystic renal cell carcinoma and benign adrenal hyperplasia. Additionally partial nephrectomy was done. Surgical margin of the kidney was tumor free and postoperative course was uneventful. Prognosis of multiocular cystic renal cell carcinoma is good, therefore conservative surgery is recommended.
A 31-year-old man came to our hospital complaining of severe voiding pain. He had inserted a fishing line made of nylon into his urethra at the age of eighteen, which was unable to be taken out and had been left there for 13 years. Preoperative ultrasonogram showed severe bilateral hydronephrosis and the serum BUN and creatinine level were as high as 45.2mg/dl and 4.8mg/dl, respectively. A huge bladder stone was demonstrated in X-ray film, the patient was admitted and vesicolithotomy was performed. The size of the stone was 10.5×7.5×7.5cm and the weight was 360 grams. The fishing line was found inside the stone and the length was over 3 meters. The serum BUN and creatinine level after the operation were still high as 28.4mg/dl and 4.1mg/dl, respectively, and they did not improve even after six months following.
We observed a patient with 48 XXYY Klinefelter syndrome who visited our hospital because of a short penis as chief complaint. The patient was a 21-year-old, tall and obese man. He had gynecomastia. The penis was short and bilateral testes were underdeveloped. Endocrinologically the LH and FSH showed highe level and the testosterone was low. A diagnosis of very rare 48 XXYY Klinefelter was made based of the chromosomal analysis.