Sexual dysfunction is a well-decumented complication among male hemodialysis patients. To evaluate it in detail, we conducted a sexual function survey using the Sapporo Medical University Sexual Function Questionnaire. Two hundred five male patients receiving outpatient hemodialysis were entered into this study. Patients with diabetes mellitus and severe anemia (Hb value<8.0g/dl) were excluded. The control group consisted of 3, 462 healthy male subjects.
Of male hemodialysis patients, 33.7% showed deterioration of libido, while 44.4% showed deterioration of potency, both of them decreased greatly with age. Ejaculatory ability correlated with potency.
We compared the frequency of sexual intercourse in male hemodialysis patients with that in normal males. Twelve point nine percent of hemodialysis patients (HP) ranging from 30 to 39 in age versus 3.5% of age-matched normal males had no sexual intercourse and 22.4 %of HPs from 40 to 49 versus 3.0% of age-matched normal males, 52.2% of HPs from 50 to 59 versus 7.5% of age-matched normal males, and 89.3% of HPs from 60 to 69 versus 18.0% of age-matched normal males had no sexual intercourse. These results revealed that the sexual frequency in hemodialysis patients decreased more than that in normal males in all age groups and with age.

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Erectile dysfunction is a well documented complication among male hemodialysis patients. The cause has been reported to be related to multiple factors, including neurological, endocrinological and vasculogenic elements. The purpose of this study was to identify the factors which most greatly determine erectile dysfunction in hemodialysis patients.
Male hemodialysis patients without diabetes mellitus and severe anemia (Hb value<8.0g/dl) were entered into the study.
We measured nocturnal penile tumescence (NPT) values in these patients and carried out neurological studies (measurement of the penile dorsal nerve conduction velocity and the bulbocavernosus reflex (BCR) latency). a vasculogenic study (measurement of the penile blood pressure index (PBPI)) and endocrinological studies (measurement of serum free testosterone levels and serum prolactin levels before hemodialysis).
NPT values (maximum penile circumference changes) in hemodialysis patients decreased compared with those in healthy males. In both hemodialysis patients and healthy males, NPT values decreased with age. NPT values in hemodialysis patients were significantly lower than those in healthy males inthe fifties and sixties.
32.2% of hemodialysis patients had severe penile neurological disorder. 55.6% of them showed abnormal NPT.
PBPI was low in only 10.0% of hemodialysis patients. However, there was a significant correlation between PBPI and the NPT value (r=0.387).
Serum free testosterone levels in hemodialysis patients were significantly lower than those in healthy males. There was a significant correlation between the serum free testosterone level and the NPT value (r=0.328). However, there was no correlation between the serum prolactin level and the NPT value.
To identify the factors which most greatly determine erectile dysfunction in hemodialysis patients, we carried out multivariate analysis. The criterion variables in this analysis were NPT values. The coefficient of determination was highest for a neurological disorder (30.7%), followed by an endocrinological disorder (a reduction in the serum free testosterone level) (11.6%) and a vasculogenic disorder (a reduction in PBPI) (4.2%).

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Clinical and pathologic characteristics of stage T1c disease (nonpalpable and nonvisible cancer) was studied retrospectively in men who underwent radical prostatectomy in order to better understand this disease entity. Findings in stage T1c disease (16 patients) were directly compared with those in stage T2b disease (11 patients). No significant difference was observed between these groups with regard to age, preoperative serum prostatic acid phosphatase level, prostatic weight, numbers of tumor foci, total tumor volume, volume of index cancer and tumor grade (p>0.05). Preoperative prostate specific antigen concentration was significantly lower in stage T1c group (p<0.05). Substantially larger number of patients with stage T1c disease had pathologically organ confined disease when compared with T2b group (86.7% versus 45.5%, p<0.05). Seventy-five percent (12/16) of stage T1c and 90.9% (10/11) of stage T2b disease were considered clinically significant.
Most of stage T1c disease is organ confined and clinically significant. Clinical and pathologic features of these tumors are similar to those in T2b disease. Twenty-five percent of stage T1c disease, however, are small and thus may potentially be overtreated. Enhanced detection of prostate cancer achieved with modern technology can lead to undesirable treatment of clinically insignificant tumors. Preoperative diagnostic modalities which can reliably distinguish groups of tumor with different biological potential are needed to overcome this contradiction.

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A questionnaire was used to assess the quality of life (QOL) of forty-two outpatients with prostate cancer. Most of the patients were old, so reduced physical comfort was correlated with bodily factors other than those caused by prostate cancer. Many patients with progressive disease reported disease —and treatment— related physical problems that tended to be correlated to the extent of the disease. Many patients treated with female hormones complained of breast induration or discomfort. Patient's sexual life was impaired remarkably. Our treatment for cancer pain would be especially inadequate to cancer pain relif. We must give positive aid to cancer pain relief from now on. Most patients lost sexual interest after developing prostate cancer. Only three of the patients were able to have sexual intercourse. Some of the patients who underwent radical prostatectomy suffered from urinary incontinence after the operation. Thus, the patients' social life was remarkably affected for relative good performance status. Many patients lived only with other elderly individuals. Therefore, it is also important to manage patients in the light of their living environment.

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We investigated the spermatogenic function of patients with testicular cancer, and the influences of anti-cancer chemotherapy on testicular function in these patients. Fifty-one patients with testicular cancer were selected for evaluation of their testicular function, including spermatogenesis and endocrinological function, before and after chemotherapy with anti-cancer agents.
Before chemotherapy with anti-cancer agents, 22 of 49 patients (44.8%) had a sperm concentration of less than 20×10⁶/ml, and 8 patients (16.3%) showed azoospermia. The mean sperm concentration of the patients with testicular cancer was 29.0×10⁶/ml before therapeutic chemotherapy with anti-cancer agents, but within 3 months after chemotherapy, it decreased to 3.86×10⁶/ml (p<0.01). Fifteen of 19 patients (73.7%) were revealed to have azoospermia.
Damage to spermatogenesis became more severe with the number of chemotherapy treatment. No patients had a detectable sperm count at the completion of 3 or more courses of chemotherapy. But some patients who received 3 courses or more of chemotherapy showed recovered sperm counts after 2 or more years. Thus, a lack of sperm after chemotherapy for cancer did not necessarily indicate inability to recover spermatogenesis over 2 years after chemotherapy.
Serum FSH levels of the patients were 5.62±3.43mIU/ml before chemotherapy, and 19.70±17.06mIU/ml (p<0.05) at the time of its completion. Serum FSH levels could reflect damage to spermatogenesis in these cases. Cases in which spermatogenesis did not recover may have higher serum FSH levels than those with recovery of spermatogenesis.

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We performed primary immature Sertoli cell culture to investigate whether or not anticancer agents would have a direct effect on rat Sertoli cells. Sertoli cells, isolated from testes of 18-day-old rats, were cultured in pellets with medium for 5 days. The concentration of transferrin in cultured medium were measured as the function of Sertoli cells.
The anti-cancer agents cis-diamminedichloroplatinum (CDDP), adriamycin and vinblastin were selected for this study, and added to the culture medium. CDDP decreased the level of transferrin concentration in cultured medium, namely 0.5μg/ml of CDDP resulted in 54.9% of the transferrin concentration in the medium compared with that without any anti-cancer agents (p<0.05), and 1.0μg/ml of CDDP produced transferrin concentrations of 57.5% and 46.2% (p<0.05), respectively. Adriamycin (0.4μg/ml) and vinblastin (0.5μg/ml) produced transferrin concentrations of 35.2% and 31.3% in cultured medium (p<0.05), respectively.
These findings revealed that anti-cancer agents have direct damaging effects on rat Sertoli cells.

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From 1991 to 1994, we experienced 5 patients with Fournier's gangrene. Their age, associated diseases, etiology, area of the disease, microbiologic findings, treatment and prognosis were reviewed.
Patient age ranged from 25 to 72 years, with a mean age of 47 years. An associated disease process could be identified in all patients. Two patients had diabetes mellitus, 1 systemic lupus erythematosus, 1 chronic alcoholism and 1 multiple myeloma. The etiology of the infectious process was presumed to be wound infection in 2 patients and indwelling urethral catheter in 2 patients. All patients were treated with broad-spectrum antibiotics. Extensive débridment with later skin graft was done in 2 patients. Multiple Penrose-drains were placed subcutaneously after limited removal of necrotic tissue in 3 patients. In these 3 patients, redness and swelling reduced quickly, the wound was curred without defects of skin except 1 patient who had multiple myeloma and was in a very serious condition. Although inflammation reduced after the placement of drains, the patient with multiple myeloma died of sepsis and DIC.
The majority of patients with Fournier's gangrene are immunocompromised. Although extensive débridment is commonly performed as the surgical treatment, defects of the skin seem to have some disadvantages, such as the need for the skin graft and the chance of secondary wound infection. In the narrow excision of necrotic tissue and drainage of involved areas by multiple Penrose-drains, skin defects are minimum, and the effectiveness of the surgical management seems to be competitive with the wide debridment. Therefore, the use of broad-spectrum antibiotics, small excision of necrotic areas and drainaae are likely to be the treatment of choice in Fournier's gangrene.

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Penile Doppler ultrasonography is widely accepted as an essential examination in the diagnosis of impotence. However, measurement blood flow velocity using Doppler ultrasonography may be subject to some errors.
We performed color Doppler ultrasonography in 63 patients with normal penile vascular function as diagnosed using positive responses to intracavernous pharmacological stimulation. We compared the Doppler measurement results of the 126 cavernous arteries and the ultrasonic beam angles. We used a Hitachi EUB 515, a sonographic probe of 7.5MHz, a sampling width of 0.8mm, a sampling depth of 1mm, and a wall motion filter was not used. Ultrasonic beam angles were 5 to 77 degrees. The mean peak systolic velocity and end diastolic velocity values were 40.0cm/s and 3.9cm/sec, respectively. The peak systolic velocity and end diastolic velocity values remained stable regardless of the ultrasonic beam angles (Kruskal-Wallis test, p=0.56, p=0.70). However, the variance of values became greater when the ultrasonic beam angles was larger than 55 degrees in the case of peak systolic velocity (F test, p<0.05) and 50 degrees in the case of end diastolic velocity (F test, p<0.05), indicating a reduction in reliability. Resistance index variance was significantly higher when ultrasonic beam angle exeeds 50 degrees (F test, p<0.05).
We believe that we should accept only those cavernous artery peak systolic velocity measurements as reliable when the ultrasound beam angle is less than 55 degrees. For end diastolic velocity values or resistance index, the Doppler examination should be carried out with the ultrasonic beam at an angle smaller than 50 degrees to the cavernous artery.

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To observe the upper urinary tract more clearly with a thin flexible endoscope, we developed a novel real-time processing system. This system enhances the parts of the dark cladding around the core by individual strong brightness of each image fiber. The upper urinary tract in eight patients was examined using a thin flexible endoscope with this system at retrograde pyelography or at urological operation. Six patients had hydronephrosis and 2 had filling defects in the renal pelvis or calyx. The endoscope was 0.75mm in diameter and had 3000 pixels of image fiber. The objective portion could be assessed successfully in seven of eight. Significantly finer and colorful image could be obtained with this system compared with the conventional method and the epithelium could be clearly observed. We conclude that this real-time processing system remarkably improves the quality of image obtained with the thin flexible ureteroscope and makes it a more promising modality in the diagnosis and treatment of the upper urinary tract.

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The goal of any treatment strategy for cancer is to improve not only patient survival but also quality of that survival. Between March 1990 and February 1993, we treated 10 patients with advanced RCC (9 men and 1 women) by combined immunotherapy using natural interferon-α (IFN-α), recombinant interleukin-2 (rIL-2) and lymphokine-activated killer (LAK) cells, and resulting the quality of life (QOL) issues examined. The ages of the patients ranged from 36 to 78 years (mean: 60.2) and the performance status (PS) ranged from 30 to 100% (mean: 77%). There were 8 lung, 3 bone, 2 brain and 1 neck and para-aortic lymph node metastases. We could evaluate 8 patients, 2 patients dropped out because of bone fracture and acute pneumonia. The protocol was as follows; 1×10⁶IU of rIL-2 as an intravenous infusion and 6×10⁶IU of IFN-α intramuscularly on days 1-7 and 15-21. In additions LAK cells obtained from the patients were given on days 14, 21, 28, and 35 intravenously. This protocol was repeated for more than three cycles (mean: 4.13 cycles) in each patient. The maintenance therapy on outpatient basis were performed in 4 patients after confirmation of the safety of the combined immunotherapy. This outpatient regimen was composed of 1×10⁶IU of rIL-2 intravenously, 6×10⁶IU of IFN-α intramuscularly on days, 1, 8, 15, 22, and 29, plus LAK cells on days 15 and 29. We repeated this protocol for 3-5 cycles (mean: 4.25 cycles). PS were 78.8±8.61% (mean±S. E.) when the patients entered into this study. After one month, PS increased to 92.5±4.12% (p=0.054) and after three months, to 90.0±4.23% (p=0.122). The mean survivsal period was 18 months. PS were improved remarkably from 30% to 80% in the patient who had cervival vertebrae metastasis. PS was maintained in 3 patients of 4, over 3 months by the maintenance therapy. The side effects were fever (75%), anemia (50%), granulocytopenia (25%), and gastrointestinal toxicity (12.5%), but no toxicities were more than grade II according to WHO classification. No toxicity worse than WHO gradel I was observed in the maintenance therapy, therefore this outpatient regimen was completed safely in all four patients. The response rate was 25% (2 PR, 1 NC and 5 PD) by this combined immunotherapy. These findings suggested that this combined immunotherapy regimen was the alternative strategy in order to improve QOL in the patients with advanced RCC.

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We have developed a new combination intravenous chemotherapy regimen called COMPA (IV-COMPA). The clinical value of IV-COMPA chemotherapy was evaluated based on the results of 24 patients with urothelial cancers.
From October 1989 through October 1993, a total of 24 patients (20 males and 4 females) received IV-COMPA chemotherapy at Tokyo Medical College Hospital and Tokyo Medical College Hachioji Medical Center. All patients had advanced transitional cell carcinoma or adenocarcinoma of the urothelial tract (renal pelvis, ureter or bladder). One course of IV-COMPA was delivered at 2-week intervals and consisted of 30mg/m² CDDP on day 4 and 5, 0.6mg/m² VCR (Oncovin^®) on day 1 and 2, 5mg/m² MTX on day 2 and 3, 5mg/m² PEP on day 1, 2 and 3, 20mg/m² ADM on day 4. A few patients received the same regimen without peplomycin called IV-COMA to avoid pulmonary fibrosis.
Fifteen patients with surgically confirmed invasive carcinoma were defined by at least 1 of the following criteria: multiple tumors or size greater than 5cm, grade 3, stage P3 or P4, pN+, pR1, pL1, pV1, or secondary carcinoma in situ. These patients were treated with 2 or 3 courses of postoperative IV-COMPA chemotherapy to improve proqnosis. In this group, 14 of 15 (93%) are alive at a median follow-up of 22 months (range, 8-57 months) and actuarial survival rates of 1 and 3 years were 100%, 90.9%, respectively. The other nine patients with locally or distant metastatic disease, or with recurrent disease following initial therapy were treated with 3 to 7 courses (median, 5 courses) of IV-COMPA chemotherapy. One patient achieved complete resonse (CR), 5 patients partial response (PR), 1 patient no change (NC) at a median follow-up of 15 months (range, 8-34 months). The effective rate of response (CR+PR/total) was 66.7%. IV-COMPA chemotherapy was associated with mild and acceptable toxicity. General fatigue (100%), nausea and/or vomiting (87.5%), leukopenia less than 2000per mm³ (83.3%), hair loss (79.2%) were common. No patient had severe gastrointestinal toxicity, myelosuppression or neurotoxicity. Six patients (25%) had 1-week delay in treatment because of leukopenia, liver dysfunction or numbness of fingers and toes. However, no dose reduction was necessary. No nephrotoxicity or pulmonary fibrosis were seen. There were no treatment-related deaths in this series.
IV-COMPA chemotherapy was safely performed and showed relatively high effective rate of response in patients with advanced urothelial cancers. This chemotherapy may prolong the survival in the patients with surgically confirmed invasive carcinoma.

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We clinically evaluated the efficacy of neoadjuvant M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) therapy followed by radical cystectomy. A total of 21 patients with locally invasive bladder cancer received neoadjuvant M-VAC therapy with an average of 2.4 courses (range 2-4). Of the 21 patients, 4 had stage T2N0M0, 11 had stage T3aN0M0, 5 had stage T3bN0M0 and 1 had stage T4N0M0 at diagnosis. Of the 21 patients, 3 had clinically complete responses (cCR) and 12 had partial responses (cPR), for an overall response rate of 71.4%. The patients who responded to the chemotherapy (cCR+cPR) had a 2-year disease free rate of 80.0% in contrast to 50.0% for the remaining patients who did not respond. A pathological response (pT0, pT1) was achieved in 6 (28.6%) of the 21 patients. The 5 patients in this group remain free of disease for 15 to 79 months (mean 58.8 months). These preliminary results suggest that the patients who achieve either a complete or partial response, in particular those had pathological stage of pT0 or pT1, may have a favorable clinical course.

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The patient was a 68-year-old woman, who had underwent radical hysterectomy and postoperative radiation therapy thirteen years ago, and suffered from typical symptoms of panperitonitis in 1992 and 1993. Based upon laboratory findings of ascites, intraperitoneal urinary extravasation was suspected as the cause of panperitonitis. However, IVP, cystography, cystoscopy could not show the direct evidence of extravasation. On urodynamic study, poor flow rate, large postvoided residual urine, disturbance of the bladder sensation, and low compliance were present. We considered the neurogenic bladder dysfunction and detrusor weakness due to the previous radical hysterectomy and radiation therapy as the possible causal factors of spontaneous bladder rupture causing urinary extravasation from the bladder in this case.

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A 60-year-old man who had renal cell carcinoma with renal hypofunction underwent partial nephrectomy followed by alpha-interferon therapy (LHBI 3×10⁶IU/day intramusclar injection for 4 weeks, then twice a week for 6 months). Glomerulusfiltration rate slightly decreased to 28.5 from 32.6ml/m after partial nephrectomy. On single injection of IFN, its serum level reached the maximum of 20.3IU/ml, at 12 hours of injection, and 10.4IU/ml at 24 house. After 4 weeks, that was 50.6IU/ml. NK activity and ADCC which were 32, and 68%, respectively before treatment, reduced to 6, and 28%, respectively after 4 weeks. After maintenance therapy they were shown to rise up to 26, and respectively 73%, and increased immunoactivity was confirmed.

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Between 1984 and 1991, six of 105 renal transplant recipients at our institution formed urinary tract calculi after transplantation (5.7%). In these 6 patients, one case of nephrolithiasis in a transplanted kidney was treated with extracorporeal shock wave lithotripsy (ESWL). A 37-year-old woman underwent cadaveric renal transplantation twenty months before, and her renal function remained stable. However calculi in the transplanted kidney and bladder were formed and ESWL was used for the treatment of the renal calculus in the transplanted kidney. She was discharged from the hospital two weeks postoperatively while passing small gravel in the urine after successful fragmentation of the calculus without any major complications. As follow-up KUB film two weeks later demonstrated that all stone fragments had been passed, but she was treated again by ESWL four months later because IVP films four weeks later revealed recurrent calculi in the transplanted kidney. The stones were fragmented successfully and spontaneously passed with voiding. Moreover we performed total parathyroidectomy with autotransplantation for persistent hyperparathyroidism, with subsequent good clinical results.

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