The present status of urologic laparoscopic surgery in Japan is characterized by expanding indications to adrenalectomies, challenging nephrectomies including malignancies, and developing direct approach to the retro-peritoneal space for urologic disorders. Despite these trends in urologic laparoscopic surgery, few major complications have been reported but the real incidence is conceivable to be similar to the incidence reported from other countries.
The surgical risks including operating time and length of hospital stay are not diminished comparing with open surgeries. Particularly, length of hospital stay is not significantly shortened by laparoscopic surgery in Japan comparing to the reports from other countries. This might be mainly caused by the difference of medicare system and customs between Japan and the other countries.
In general, urologic laparoscopic surgery in Japan is aggressively extending its indications and technical modifications, and rapidly accumulating the cases; however, discussions on its true merits and basic research on surgical therapeutics seemed to be overlooked. Major tasks for the future are to improve the instruments and technology, and to improve learning curve by establishing efficient educational courses.

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We propose a new method of quantitative measurement of cell surface blood group antigen (BGA) in superificial transitional cell carcinoma (TCC) of the urinary tract by using flow cytometry. Flow cytometric analysis was performed on 22 cases of superficial urinary tract TCC registered at the department of Urology, Okayama University Hospital during April, 1992-Feb. 1993. Fresh samples were divided into two specimens. One specimen was fixed in 20% formalin and was subjected to immunohistochemical staining of BGA using avidine-biotine complex (ABC) method. The other specimen was dissociated into single cell with mincing. The single cell suspension was further divided into two specimens. One specimen was incubated on ice with anti-ABH mouse monoclonal antibody (DAKO) as a primary antibody. The other specimen was incubated on ice with mouse IgM as a negative control. These two specimens were reacted with FITC-conjugated rabbit anti-mouse IgM and propidium iodide (PI). Next, these cells were subjected to the flow cytometry using FACStar (Becton & Dickinson). By gating on the bivariate display of FSC vs. FL2 (PI), all nucleated cells were obtained separately and the positive rate was measured. The positive rate of FCM was successfully correlated with the degree of immunohistochemical stain. Compared with immunohistochemical staining thus far, this new technique provides a way to standerdize the quantitative measurement of BGA expressions.

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Since 1984, through 8 years, 29 cases of bladder tumor were treated with high dose rate intracavitary radiotherapy. All cases were transitional cell carcinoma in histology and consisted of 12 cases of CIS, 7 of Ta, 3 of T1, 1 of T2 and 6 of T3. At the intracavitary therapy, 3-way catheter made specially for high dose rate intracavitary radiotherapy was inserted into the bladder and the balloon of the catheter was inflated with air of 80 to 100ml. A radioactive source of ⁶⁰Co was remotely controlled and drove through the catheter into the bladder. The delivered dose was 5Gy per fraction and total dose was 40 to 50Gy in 8 to 10 fractions. Complete response (CR) rate was 7/12 (58.3%) in CIS, 4/6 in Ta, 1/3 in T1, 1/1 in T2 and 1/6 in T3. CR rate of CIS and superficial tumor (Ta, T1) was 57.1% (12/21), whereas that of invasive cancer was 2/7. Regarding complications, one case suffered severe cystitis as an acute reaction, however, the remaining cases only noted a mild or moderate acute reaction. It was concluded that high dose rate intracavitary radiotherapy was a useful treatment for CIS of the bladder and superficial bladder cancer.

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We report two cases of left nephrectomy and one case of left adrenalectomy which were managed with our new laparoscopic procedure. We treated the left renal vein first using trans-duodenal-recess approach. The left renal vein could be detected after an incision into the parietal peritoneum on the left side of the duodenojejunal flexure (duodenal-recess) was performed. When the nephrectomy was performed, the renal artery and vein were transected using endoGIA. When the left adrenalectomy was performed, the adrenal vein was clipped and divide after lysis of the left renal vein. Our new method allowed the renal vein to be treated first, so the remainder of the operation could be performed without the risk of bleeding.

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MBT-2 in C3H/HeN mice was used as a model to examine cytotoxic activity. The cytotoxic activities examined were those of natural killer cells (NK), lymphokine activated killer cells (LAK), and tumorcidal macrophage (Mφ). NK activity increased in early tumor bearers, but LAK and Mφ activities increased in middle tumor bearers. NK activity was inhibited in late tumor bearers, but LAK and Mφ activities were not inhibited. Cell surface markers and production of various cytokines were examined in order to analyze the changes in each activity.

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The urethral pressure profiles (UPP) at rest and under stress, using double lumens microtip transducer catheter, in 17 females without urinary incontinence (normal group) were compared with those in 39 females with stress urinary incontinence (SUI group). And UPP were compared pre- and postoperatively in 21 females of SUI group who had surgical cure of SUI by bladder neck suspension (operative group). Pressure transmission ratios (PTR) were calculated in each quartile dividing functional urethral length (FUL) into four equal lengths.
Maximum urethral closure pressure (MUCP) and Functional urethral length (FUL) in normal group were significantly higher than those in SUI group. In normal group, although bladder neck opening under stress (bladder neck incompetence) existed in 41% of them, the PTR in the distal three-quarters of the FUL were significantly larger than those in SUI group and urinary continence was remained in all of them. On the contrary, in SUI group, there was an almost linear decrease in the value of the PTR along the FUL. Therefore, it was suggested that SUI patients might lose distal urethral compensatory mechanisms.
The results, obtained from the resting UPP, show that there is no significant change in MUCP or FUL following bladder neck suspension. In contrast, the stress UPP shows that successful operation generated a magnification of the PTR in the proximal three-quarters of the FUL. Only 1 case of post operative group showed bladder neck incompetence. Therefore suspending the bladder neck in a high position might produce the ability to occlude proximal three-quarters of the FUL.

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Between 1985 and 1992, 9 patients (6 men and 3 women), 50-76 years old (mean age 63.6), underwent radical nephrectomy and removal of the tumor thrombus for the treatment of renal cell carcinoma extending into the vena cava at the Department of Urology, Hiroshima University Hospital. Seven tumors were located in the right kidney and two in the left kidney. Three tumor thrombi extended into the vena cava within 2cm (level 1 according to the Novick's classification), 2 extended into the infrahepatic vena cava (level 2), 2 extended into the suprahepatic vena cava (level 3), and other 2 extended into the right atrium (level 4). Two patients had distant metastases preoperatively.
The tumor thrombi at the level 1 were removed by venacavotomy with a short duration of surgery and a small amount of blood loss, while in those at the level 2 or 3, both the duration of surgery and the amount of blood loss increased because the mobilization of the liver needed to remove the thrombi. For removing tumor thrombi at the level 4, cardiopulmonary bypass and deep hypothermic circulatory arrest were applied, resulting in longer duration of surgery but less amounts of blood loss than those at the level 2 or 3. Postoperatively, 2 patients had a renal insufficiency and another 2 had a liver dysfunction. One operative death occurred in this series because of pulmonary embolism.
Five of 8 patients (62.5%) are alive for a mean duration of 34 months (8-95 months), while one patient with preoperative metastases died with cancer 4 months after surgery and 2 patients with level 2 thrombus died after 23 and 24 months. The 1-year survival rate was 88% and the 3-year survival rate was 44%.
Although the application of modern cardiac surgical techniques leads to safely performing the extensive surgery for the patients with renal cell carcinoma extending into the vena cava, a careful selection of patients is mandatory.

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During the nine years period from April 1984 through March 1993, we performed conservative surgery on 26 kidneys in 25 patients with renal cell carcinoma. Of these 25 patients the indication was imperative in 8 patients (the imperative group) and elective in 17 patients (the elective group). Eight patients of imperative group consisted of 5 patients with bilateral renal cell carcinoma (3 synchronous and 2 asynchronous), 1 patient who had renal cell carcinoma on one side and renal pelvic carcinoma on the other side, and 2 patients with renal cell carcinoma in a solitary kidney. In these 8 patients of the imperative group, conservative surgery was performed on 9 kidneys since 1 of 3 patients with synchronous bilateral renal cell carcinoma underwent the conservative surgery for both kidneys. In the elective group, all 17 patients had a small renal cell carcinoma, with the contralateral kidney normal in all. Enucleation was conducted on 4 kidneys out of 9 kidneys in 8 patients of the imperative group. On a total of 22 kidneys consistidng of the remaining 5 kidneys and 17 kidneys of the elective group partial nephrectomy was done. The tumor size ranged from 0.9 to 7.0cm (mean: 3.5cm) for the imperative group and from 0.8 to 3.0cm (mean: 2.3cm) for the elective group. Thus, the tumor size was less than 3.0cm in all of these 17 cases. As to the histologic atypia, 12 patients were classified as grade 1 and 14 patients as grade 2. None of the patients were classified as grade 3. In 2 patients with asynchronous bilareral renal cell carcinoma, distant metastasis was found at the time of operation, with the tumor diagnosis as pT1N0M1 and pT3aN0M1, respectively. For all of the remaining 24 patients the diagnosis was pT1-2N0M0. One patient in the imperative group died of cancer 11 months after the operation. However, all of the remaining 7 patients are alive without recurrence, the 3-year survival being 87%. The 3-year survival for 17 patients of the elective group was 100% when assessed from deaths from tumor. Conservative surgery provides effective therapy for patients with bilateral renal cell carcinoma or carcinoma in a solitary kidney. We considered that conservative surgery can be done to the selected patients even if the contralateral kidney is normal.

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During 7 years and 3 months from October 1983 to December 1990, 68 patients underwent radical cystectomy for primary bladder cancer at Yamanashi Medical College. Of these 68 bladder cancers, 16 were superficial and 52 were invasive. Among the 52 patients with invasive cancer, a conbination chemotherapy of methotrexate and cisplatin and/or radiotherapy were given in 18 as an adjuvant therapy. All the adjuvant therapies were performed after the operation except for 2 patients with T4 bladder cancer who received chemotherapy before the operation. There were 23 recurrences and 25 deaths, 20 from bladder cancer and 5 from other causes. Of 20 bladder cancer deaths, 17 deaths (85%) were observed within 2 years after the operation. The 5-year survival rates were 92% for stage pTa-pT1, 83% for stage pT2, 80% for stage pT3a, 24% for stage pT3b and 43% for stage pT4-T4, respectively. A significant difference (p<0.05) in survival curve was observed between pT3a and pT3b. The 5-year survival rate for pT2-pT3a without nodal metastases was as high as 89% (95% confidence limits 75 to 100%) although 18 out of 19 patients received no adjuvant therapy. On the other hand, the 5-year survival rate for pT3b-pT4 without nodal metastases (25%) was as low as that of patients for any T category with nodal metastases (35%). Most patients with tumor confined within bladder wall seemed to be cured by surgery only. Therefore, any adjuvant chemotherapy with severe side effects seemed not to be justified for these patients. However, an effective adjuvant treatment seemed to be required for patients with tumor penetrating bladder wall and/or with nodal involvement.

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The significance of six sextant ultrasound guided biopsies of the prostate (SS-biopsy) was evaluated in a total of 114 patients. The presence of prostate cancer was suspected (Pca) in 59 subjects through mass screening (MS) for Pca and in 47 patients in out-patient clinics (OPC). The reccurrence (REC) was suspected in 3 patients diagnosed previously as Pca. All of them had elevated PSA, abnormal digital rectal examination (DRE) and/or abnormal transrectal ultrasonography (TRUS). All of these tests in 5 patients with benign prostate hypertrophy (BPH) were normal. Moreover, in 34 patients among them, oriented biopsies were performed to the area where Pca was suspected by DRE and or TRUS.
Twelve Pca patients were detected in MS group (20.3%), 17 Pcas in OPC group (36.2%) and 3 Pcas in REC group (100%). No Pca patients were detected in BPH group. In 12 Pca patients with T1 or T2, only one Pca patient (8.3%) had over 3 Pca samples among the samples obtained by SS-biopsy. In 20 patients with T3 or T4, 13 patients (65%) had over 3 Pca samples. There was significant relationship between T category and Pca sample numbers among 6 samples obtained by SS-biopsy (p<0.01). Ten of 12 Pca patients in MS group (83.3%) and 8 of 17 patients in OPC group (47.1%) had less 3 Pca samples. Pca was detected in 9 of 34 patients examined by the oriented biopsy. However al of these Pca were detected by SS-biopsy. It may be not necessary to examine Pca suspected patients by the oriented biopsy if they were examined by this SS-biopsy.
SS-biopsy is simple and easily learned. Especially it will provide the significance to patients with early stage Pca.

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To study the mechanism of action of BCG against transitional cell carcinoma of the bladder from the immunological standpoint, we observed time-course changes in the serum and urine levels of tumor necrosis factor (TNF-α) and interleukin-2 (IL-2) before and after an intravesical BCG instillation in 16 patients with superficialis transitional cell carcinoma. Serum TNF-α concentrations were roughly constant and lower than normal though there was a slight difference between the values before and after BCG instillation or between the test and control values. TNF-α secretion in urine was increased irrespectine of the time for sampling specimens as compared with the control values sampling, remained unaffected by BCG installations and was increased in many patients even before BCG instillation, probably due to presence of vesical inflammation. No significant changes were detected regarding serum or urine IL-2 before and after BCG instillation and between the test and control values. Thus, the present study failed to demonstrate the involvement of a direct action of TNF-α, activation of immunological cells by IL-2 or its direct action as an anti-tumor effect of intravesical instillation of BCG.

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DNA ploidy of 49 renal cell carcinomas of 46 patients were examined with static cytofluorometry (SCM) and flow cytometry (FCM). We used several paraffin blocks for each tumor (mean, 2.4), separated each block into several samples based on histological findings, and measured the DNA content of each sample. More samples could be analyzed with SCM than with FCM. With FCM, it was sometimes difficult to detect polyploid cells, or to determine whether diploid cells were tumor cells or stromal cells. DNA heterogeneity might thus be more accurately detected with SCM than with FCM. DNA aneuploidy was demonstrated for 59% of the tumors, and was significantly less common in grade 1 tumors than in higher-grade tumors. The incidence of polyploid cells in diploid tumors tended to increase with grade of tumor. Fifty-five percent of the tumors displayed DNA heterogeneity, the incidence of which tended to increase with grade of tumor. Ninety-four percent of the tumors were found to yield a diploid cell line.
The findings of this study indicate that DNA content is associated with the histological grading. Diploid tumors with polyploid cells should be dealt with clinically in a separate fashion from diploid tumors without them. These findings suggest that diploid renal cell carcinomas with polyploid cells may be an intermediate stage between diploidy and aneuploidy.

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Fourty-eight patients with stage D₂ prostate cancer, initially treated with endocrine therapy at the University of Tokyo between 1981 and 1990, were followed up and analysed. For the assessment of a subjective response, pain score, narcotic score, and performance stages (PS) were used.
Of the fourty-eight patients, twenty-one suffered from cancer pain due to bone metastases. These patients showed significantly (p<0.01) more lesions of bone metastases and higher PS, compared with patients without cancer pain. The progression free servival of these patients was significantly (p<0.01) lower than that of patients without cancer pain, although the actuarial survival was not significant.
In twenty-one patients with cancer pain, the objective and subjective response rates to endocrine therapy were 75% and 86%, respectively. The duration of pain relief was 1.25-54 (median 19) months. Those rates to anti-cancer chemotherapy in refractory patients (8 patients) previously treated with endocrine therapy were both 25%, and those to additional administration of flutamide (FUL) or diethylstilbestrol (DES) in refractory patients (6 patients) were 33% and 100%, respectively. Although the duration of pain relief was 0.78-8 (median 2) months, the additional administration of DES or FLU led to pain relief and improved quality of life (QOL) in all 6 patients.
Endocrine therapy such as LH-RH agonist and non-steroidal pure anti-androgen, which has no severe side effects, would be of great usefulness in stage D₂ prostatic cancer patients with pain on the basis of efficacy and safety. An additional administration of DES or FLU in hormone-refractory patients might be effective for the relief of cancer pain and improvement of QOL, although the duration of pain relief was not so long.

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Forty patients who had transitional cell carcinoma of the bladder with positive pelvic lymph node metastasis, treated at Chiba University Hospital between April 1975 and March 1991 were investigated to evaluate the significance of pelvic lymph node dissection.
The frequency of the patients with positive lymph node was 9.1% in all patients with transitional cell carcinoma of the urinary bladder, 4.0% in the clinical T1, 3.4% in T2, 35.7% in T3a, 32.1% in T3b, 46.2% in T4, and none in Tis and Ta. Of the 40 patients, 16 underwent cystectomy with pelvic lymph node dissection, 19 had biopsy of suspitious lymph nodes which turned out to be positive for metastasis, and 5 were defined by computed tomography. Pelvic lymph node dissection was performed at the common iliac, presacral, external iliac, internal iliac, and obturator nodes.
In the 16 patients who underwent cystectomy with pelvic lymph node dissection, the frequency of metastasis in each nodal group was 38% in common iliac, 31% in external iliac and obturator, and 25% in presacral and internal iliac. Out of the 16 patients, eight had regional lymphatic metastasis, three had only extra regional lymph node metastasis, and five had both regional and extra regional metastasis. Three of nine patients who had single positive node had common iliac or presacral positive node without regional lymph node metastasis.

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The distribution of S-100 protein positive dendritic cells (S100-DCs) inside the cancer nest and the expression of HLA-DRα antigen (HLA-DR) and blood group antigen (BGA) on cancer cells in 90 cases of transitional cell carcinoma (TCC) of the urinary bladder were immunohistochemically investigated in relation to the degree of malignancy and its prognosis.
A dense infiltration of S100-DCs inside the cancer nest (“many”, i. e. more than 10DCs/HPF) was detected in 47 (52%) out of 90 cases. The HLA-DR positive cancer cells (DR-CCs) were detected in 24 cases (27%), including in the 16 most dense cases (“many”, i. e. more than 100DR-CCs/HPF). BGA positive cancer cells (BGA-CCs) were detected in 49 cases (54%) (“positive”, i. e. more than 100BGA-CCs/HPF).
In connection with the degree of malignancy and with the number of cases affected by S100-DCs infiltration. HLA-DR expression and BGA expression. A statistical analysis showed significant correlation between the number of cases affected by S100-DC and each clinicopathological factor including G, pT, ly, v, and showed also between that affected by BGA expression and each clinicopathological factor including G, pT, INF, but showed no significant correlation between that affected by HLA-DR and each clinicopathological factor.
As regards the prognosis, the 10-year survival rates for all 90 cases were 60.4%. In the 10-year survival rate, S100-DCs “many” (77.7%) and “few” (39.0%), DR-CCs “many” (85.7%) and “no” (56.9%), DR-CCs “many” and “few” (43.8%), BGA-CCs “positive” (74.3%) and BGA-CCs “negative” (46.5%) were statistically significant.
A multivariate analysis using Cox's proportional hazards model demonstrated that the most important factor affecting survival was the distance to the organ and lymph node metastasis (m+n), the number of cases affected by S100-DCs, BGA-CCs and DR-CCs in this order and these were statistically significant.
These results suggest that S100-DCs, DR-CCs and BGA-CCs may play a role independently as a prognostic factor which is to prevent tumor growth.

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The initial symptom of a testicular tumor is painless enlargement of the testis in most cases, but in some cases can manifest itself with metastatic lesions associated with a small focus. On the other hand, a occult testicular tumor accompanied by a minimal lesion in the testis may be included in the category of extra gonadal germ-cell tumors.
We have seen a 41-year-old male with a chief complaint of swelling of a cervical lymph node, who was found to have a tumor in the testis of normal size. A CT scan revealed a tumor in the retroperitoneal space. The serum levels of HCG and AFP were markedly elevated. Biopsy of the cervical lymph node established a diagnosis of embryonal cell carcinoma. The left testis, free from a palpable mass but tender, was excised. A gonadal cell tumor approximately 7mm in size was just below the epididymis. A stage III-a testicular tumor was diagnosed in the patient. Three courses of VAB-6 yielded parcial relief in the patient.
We concluded that the testis should be carefully examined with echogram whenever a extra gonadal germ-cell tumor is suspected, since a tiny lesion can exist in the testis concomitantly in some cases.

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A 41-year-old man incidentally found to have a right renal and left large lung tumor in the course of screening for liver dysfunction was admitted to our hospital. Needle biopsy of each tumors revealed histologically renal cell carcinoma and pulmonary blastoma. The renal tumor grew rapidly and soon he died of DIC. Autopsy was performed and the final diagnosis was adult Wilms' tumor and its metastasis to the lung.
Histological findings of each large tumors showed different histologic pattern. The renal tumor revealed diffuse nephroblastic subtype and the lung tumor showed epitherial type. This is a rare case of Wilms' tumor in terms of its adult onset and different histologic pattern between the primary tumor and its metastatic lesion.

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Autourethrography (A-UG), a new method of retrograde urethrography was developed, in which the patient injects the contrast medium by himself under fluoroscopical observation by urologists out side of the room. For clinical study of A-UG, comparative study between A-UG and the conventional retrograde urethrography (C-UG) was performed on 20 patients with benign prostatic hypertrophy. The mean age was 68.8 years (range 49-85 years) in A-UG and 69.4 years (range 61-86 years) in C-UG. We evaluated complications of A-UG, compared with these of C-UG.
Opacification of the posterior urethra was achieved in all but one in A-UG. None of these patients in A-UG experienced pain during the examination of A-UG. On the other hand, all patient experienced pain in C-UG. Urethral bleeding occurred in only one of 19 patients in A-UG, compared with eighteen of 20 patients in C-UG. Extravasation occurred in one of 19 patients in A-UG, compared with three patients of 20 patients in C-UG. A-UG leaved the urologists free from the radiological exposure. It is concluded that A-UG is highly usefull examination for patients and urologists.

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