We evaluated vesico-urethral function after radical retropubic prostatectomy in 18 male patients by consecutive urodynamic studies. At the time of the operation average age was 68 years with a range between 56 to 78 years old. The follow-up period after the operation was over 12 months in all patients. Pathological stage was T1 in 2, T2 in 6, T3 in 8 and T4 in 2 patients. Urodynamic evaluation including uroflowmetry, cystometry, urethral pressure profilometry (UPP) and external anal or urethral sphincter electromyography was performed before and 1, 3, 6 and 12 months after the operation. The status of postoperative urinary incontinence was reported by the patients. Sixty-five per cent of the patients revealed the low compliance bladder less than 10ml/cm water at one month after the operation, however, most patients had normal vesical compliance and normal cystometrogram at 12 months. Both functional profile length (FPL) and maximum urethral closure pressure (UCPmax) in UPP were markedly lowered immediately after the operation and both indexes were significantly lower even at one year after the operation than preoperative ones. Both the incidence and the degree of incontinence improved during postoperative 12 months; complete urinary control was achieved in 11 patients (61%), stress urinary incontinence was present in 6 patients (33%) and one patient (6%) was still totally incontinent. Shortening FPL was considered to be the risk factor on postoperative urinary incontinence. Resection of bilateral neurovascular bundles and lower UCPmax seemed to have the possibility of the influence on it. Low compliance bladder is also likely to be one of the factors to cause early postoperative incontinence.
We treated 42 females (26 with genuine stress urinary incontinence, 13 with incontinence and cystocele, and 3 with cystocele) with bladder neck suspension using transrectal ultrasonography during operation. The optimum tightness of suspension was decided by adjusting the posterior urethrovesical angle to about 90 degrees in 26 patients with genuine stress urinary incontinence accompanied with flattened posterior urethrovesical angles and by adjusting the angle of inclination of the upper urethra to about 10 degrees in 16 patients with cystocele accompanied with rotationally descended urethra. Urinary continence was achieved in 35 of 39 patients presenting with urinary incontinence. Three patients with cystocele without urinary incontinence remained dry after the operation. The average of maximum urinary flow rate significantly increased after operation. The angles of inclination of the upper urethra measured on the ultrasonogram during operation corresponded well with those measured on the post-operative lateral urethrocystogram. In 26 patients without cystocele, the angles of inclination of the upper urethra and the posterior urethrovesical angles were correlated significantly on the pre-operative urethrocystograms. Roentgenographic changes in pre- and post-operative urethrocystograms showed concomitant restoration in the angles of inclination of the upper urethra and in the posterior urethrovesical angles as well as significant elevation of the bladder neck. Present results indicate that the angles of inclination of the upper urethra measured by transrectal ultrasonography during operation as well as the posterior urethrovesical angles are useful and reliable to decide the optimum tightness of bladder neck suspension for the patients with stress urinary incontinence accompanied with rotationally descended urethra. Especially in the patients with cystocele accompanied with rotationally descended urethra and normal posterior urethrovesical angle, the angle of inclination of the upper urethra is an irreplaceable index.
Clinical and pathological factors that affect short-term responses and long-term prognosis of muscle-invasive bladder cancer were studied in 73 patients who underwent a combination of intra-arterial chemotherapy and low-dose radiotherapy. Complete Response (CR) was observed in 41 (56%) of the 73 patients. The frequency of CR was significantly different according to the sex (males 64%, females 29%; p=0.0239), clinical stage (T2 74%, T3 64%, T4 20%; p=0.0005), tumor size (<3cm 81%. ≥3cm 31%; p<0.0001), and tumor grade (G3 72%, G2 41%, p=0.0127). By multivariate analysis, a significant difference was observed only in the tumor grade. The 5-year survival rate after bladder-preserving operations (median duration of follow-up 69 months) was significantly different according to the sex (males 75.2%, females 57.1%; p=0.0427), clinical stage (T2 86.3%, T3 82.3%, T4 33.8%; T2 vs T4, p=0.0005; T3 vs T4, p=0.0107), tumor size (<3cm 89.6%, ≥3cm 47.2%; p=0.0012), and tumor response (CR 95.0%, non-CR 38.6%; p<0.0001). By multivariate analysis, a significant difference was observed only in the tumor response. The combination therapy of intra-arterial infusion and irradiation produced excellent short-term effects and prolonged the survival of the patients. Preservation of the bladder is considered to be possible in patients who obtained CR.
It has been shown that molecular cytogenetics in interphase nuclei is applicable to human sperm nuclei from formarin-fixed clot sections utilizing in situ hybridization (ISH). Ejaculates from a normal volunteer were studied utilizing biotinylated DNA probes specific for the alpha satellite region for numerical aberrations of chromosome 17 and Y. With respect to the appearence of the ISH signal, optical concentration and time for the digestion enzyme has to be established essentially. This allows precise identification of numerical abnormalities of chromosome in sperm nuclei without disruption of the morphology. This technique can now be applied to the detection of chromosomal aneuploidy in human sperm from patients with male inferitility.
Fourteen hundred seventeen patients with a single stone under either general or epidural anesthesia were treated by one session of ESWL using the Dornier HM3 while 255 cases by one session of ESWL using the Dornier MPL9000 under no anesthesia but only with some analgesics, with 3 months' follow up available in all patients. The ratio of stone location in the kidney vs ureter was 7 to 3 in the Dornier HM3 and 5 vs 6 in the Dornier MPL9000. The overall success rate (stone free and residual stone fragments of less than 4mm, 3 months after ESWL) was 58% (591 cases/1016 cases) for kidney stones with the Dornier HM3 and 35% (41/117) with the Dornier MPL9000. On the other hand, the overall success rate for ureter stones was 61% (245/401) with the Dornier HM3 and 70% (96/138) with the Dornier MPL9000. The overall success rate for stones of more than 10mm, was poor when treated by the Dornier MPL9000 compared with the Dornier HM3.
From August, 1989 to December, 1992, 11, 386 indivisuals consisting of 6, 981 males and 4, 405 females were examined in the general health check at Mito Saiseikai general hospital. Occult blood in dipstick urinalysis was detected in 190 of 6, 981 males (2.7%) and 503 of 4, 405 females (11.4%). Two renal cell carcinomas and ten bladder carcinomas were found out, but prostatic carcinoma could not be found out. None of these tumors were symptomatic. Two renal cell carcinomas, of which all patients had negative occult blood, were confirmed by computed tomography and angiography. Revealing the locally-confined tumor (Stage I) in the radiologic study, both tumors were resected with radical nephrectomy, and the pathological specimens showed pT2pNOpVO in both tumors. Of 10 bladder carcinomas seven transitional cell carcinomas, of which 6 patients had negative occult blood and one had positive occult blood, were confirmed by cystoscopy and TUR-BT. All of them were low-grade and low-stage tumors. Other three bladder carcinomas were detected by ultrasonography and cystoscopy, but these patient rejected TUR-BT. All of them had negative occult blood. We consider that the transabdominal ultrasonography is a very useful test for detecting the early stage of renal cancer and superificial bladder cancer. We recommend that transabdominal ultrasonography involving the kidney and the lower urinary tract should be performed in the general health check.
Radical nephrectomy was performed in 30 cases of renal cell carcinoma in which CT scan and angiography findings had indicated the possible suitability of enucleation. The lesions were then enucleated from the operative specimens and assessed histologically to find the feasibility of tumor enucleation and to determine its indications. Histological investigation demonstrated that the tumor was completely surrounded by the pseudocapsule in only 17 cases, and even in such tumors the thickness of the pseudocapsule was not always regular and sometimes tumor invasion was seen in the pseudocapsule. It is therefore advisable to resect the tumor with no less than several mm of surrounding renal tissue when the pseudocapsule can not be clearly distinguished. Success of the enucleation was confirmed histologically in 22 out of 30 cases (73.3%). The factors related to failure of the enucleation were invasion throughout the renal capsule in 2, tumor exposure on the resected surface in 5, residual tumor in the tumor bed in 2 and venous invasion in 6 cases. Satellite tumors were not detected in any case. Favorable results were obtained in low grade, low stage tumors less than 6cm in diameter and clearly distinct from normal renal tissue, therefore such cases were thought to be appropriate indications for enucleation. Although we selected the cases thought to be appropriate for enucleation by imaging techniques preoperatively, success was not obtained in all cases. Enucleation is a useful and recommendable operative technique for bilateral renal cell carcinoma or renal cell carcinoma in a solitory kidney. However, surgical enucleation does not always result in curative resection and therefore it should not be selected when the contralateral kidney is normal.
Fifty cases of untreated human T-cell lymphotropic virus type I (HTLV-I) associated myelopathy (HAM) were evaluated by urodynamic studies to clarify the nature of urinary disturbance and to find out suitable urological treatment. Both irritative and obstructive symptoms coexisted in the HAM patients. 38% of the patients experienced only urinary symptoms throughout the affected period. A main cause of frequency was detrusor hyperreflexia at filling phase, which was found in 58% of the patients. However, decreased effective bladder capacity due to large amount of residual urine was possibly an another cause of frequency. Detrusor sphincter dyssynergia was the main cause of difficulty of urination, but in some cases underactive detrusor at voiding phase was also the cause of difficulty of urination. Hydronephrosis was observed in only 5 kidneys, although as many as 30 out of 46 cases (65.2%) showed bladder deformity. 17 cases (34%) had urinary tract infection at first visit. As the activity of daily living was deteriorated, the mean volume of residual urine, incidence of detrusor hyperreflexia and detrusor sphincter dyssynergia were all increased. Medical treatment was effective to relieve subjective symptoms, but urodynamic examination did not necessarily review improvement. Intermittent catheterization was needed and successful in 64% of all cases. Patients with HAM must be carefully followed up by urologists.
The patients having bone metastases from prostatic and renal cancer, of whom 4 were resistant to prior radiotherapy, hormone therapy and/or chemotherapy, were subjected to arterial chemoembolization with mitomycin C microcapsules. In these patients, 12 metastatic lesions in the pelvic bone (5), lumbar spine (3), scapula (1) and rib (1) were treated. The mean size of the target lesions was 41.5cm2 (range, 6-143). The mean number of microcapsule infusion into the tumor supplying arteries was 2.6 (1 to 10) and the mean interval of repeat infusion in 6 patients was 6.4 months (0.5 to 28). A complete remission of pain was obtained in 9 (75%) of the 12 evaluable lesions and a partial remission in 3 (25%). Motor disturbances were remarkably improved in all of the evaluable 6 lesions. Objective tumor respose such as recalcification and reduction of size or vascularity was found in 9 (75%) of the evaluable 12 lesions. These effects were maintained for the mean follow-up period of 17.1 months (3 to 48). The results will indicate that this therapy can be used as an effective measure in the treatment of metastatic bone tumors.
Effects of L-arginine and the inhibitors of nitric oxide/cyclic GMP pathway on the internal urethral relaxation were examined in anesthetized rats. The bladder pressure and internal urethral pressure were continuously recorded during the rhythmic bladder contractions before and after intraarterial administration of the following drugs. Used drugs were L-arginine from which nitric oxide is synthesized, NG-monomethyl-L-arginine (L-NMMA), NG-nitro-L-arginine methyl ester (L-NAME) which inhibit the synthesis of nitric oxide from L-arginine, and methylene blue which inhibitis the activation of soluble guanylyl cyclase. In anesthetized rats, rhythmic bladder contractions with concomitant urethral relaxations were occurred. Administration of L-arginine (30mg/kg, i. a.) produced a decrease in the internal urethal pressure. Administration of L-NMMA (3-30mg/kg, i. a.), L-NAME (3-10mg/kg, i. a.), and methylene blue (3-30mg/kg, i. a.) produced an inhibition of the relaxations of the internal urethral sphincter during rhythmic bladder contractions. Present study suggests that nitric oxide/cyclic GMP pathway takes an important role for the relaxation of the internal urethral sphincter during rhythmic bladder contractions.
A 22-year-old woman had a well differentiated nephroblastic tumor. The tumor was composed of mesenchymal elements with mature tubules and occasionally smooth muscle elements. None of the cellular elements showed any feature indicative of malignancy. Histologically this was similar to congenital mesoblastic nephroma, but the tumor showed an evidence of a uniform expansile growth. It was considered to be a form of mature nephroblastoma.
A 69-year-old woman was admitted to the hospital complaining of general fatigue and lower abdominal pain. She had undergone total cystectomy because of invasive recurrent bladder carcinoma three months ago. Histopathological diagnosis was transitional cell carcinoma (TCC) grade 3 and squamous cell carcinoma (SCC), pT3a. A goose egg-sized painful mass was noticed at the lower abdominal region. A CT scan revealed an intrapelvic fist-sized mass and suggested tumor recurrence with ileus caused by intestinal invasion. The laboratory examination showed remarkable leukocytosis of 79, 700/mm3 in the peripheral blood and serum analysis revealed high value of granulocyte colony stimulating factor (G-CSF), 240pg/ml (normal: less than 30pg/ml). In spite of active treatment, the patient died of cachexia about a month after detection of the leukocytosis. The autopsy showed that the recurrent tumor had positive immunohistochemical staining for G-CSF, and the bone marrow had reactive proliferation mainly by granulocytes. From these findings, this case was diagnosed as bladder carcinoma producting G-CSF. G-CSF producting tumor of the bladder is very rare. This was the 8th case in Japanese literatures. The previous reports were reviewed and discussed.
A case of normotensive primary aldosteronism in association with non-functioning adenoma and aldosterone producing adenoma in ipsilateral adrenal gland is reported. Fourteen cases of normotensive primary aldosteronism were previously reported and our case was considered as the fifteenth case. Furthermore, its association with non-functioning adenoma and aldosterone producing adenoma is very rare. Only four cases of such association were reported, and in these four cases non-functioning adenoma existed in contralateral side of aldosterone producing adenoma. In our case, its association with non-functioning adenoma and aldosterone producing adenoma was seen in the ipsilateral adrenal gland. The report of this kind of association has not been seen in the literature so far.