(Purpose) To determine the efficacy of extraperitoneal laparoscopic adrenalectomy for patients with adrenal tumor, the clinical results of 9 patients treated with this procedure were analysed.
(Patient and Method) Between July 1994 and March 1995, we have performed extraperitoneal laparoscopic adrenalectomy using the modified Gaur technique of balloon dilatation of the retroperitoneum in 4 men and 5 women with unilaterla small adrenal tumor who were 30 to 79 years old (mean age 56 years). Preoperative diagnosis was primary aldosteronism in 2, 18-hydroxycorticosterone producing adnoma in 1, pre-Cushing syndrome in 5, and nonfunctioning adrenal tumor in 1 patient. The operations were performed with the patients on lateral position and 4 torocars were positioned. The retroperitoneal space was first dissected bluntly by the index finger and a balloon dissector through a small skin incision, and the retroperitoneal space was insufflated with carbon dioxide at the pressure of 10 to 12mmHg. After the dissection of the adrenal gland, adrenal vein was clipped and transected. The completely freed adrenal gland was enclosed in an entrapment sack and removed en bloc through the open laparoscopy wound.
(Results) All 9 procedures were successfully performed. The mean estimated blood loss and the mean operating time were 53ml and 168min respectively. There was no intraoperative complication. A postoperative retroperitoneal hematoma was observed in one patient, however it spontaneously resolved without surgical management.
(conclusion) In open adrenalectomy, the benefit of the extraperitoneal approach (excluding patients with pheochromocytoma or bilateral lesions) have already been established elsewhere. Although the working space is smaller than that of peritoneal approach, and the surgical techniques are slightly more difficult, extraperitoneal laparoscopic adrenalectomy promises to be safe and a minimally invasive treatment for patients with unilateral small adrenal tumors except for pheochromocytoma.

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(Background) To evaluate urinary symptoms, the International Prostate Symptom Score (I-PSS), which queries about frequency of symptoms, has been recently used in a clinical setting. However, there are men who are not satisfied with their voiding conditions in spite of a low symptom score. In such cases, their dissatisfaction may not be appropriately expressed by querying about frequency of the symptoms alone. We investigated whether the degree or the frequency of the obstructive symptoms correlated with the symptom-related problems.
(Methods) We analyzed obstructive symptoms in 739 males 40 years old and older who participated in a field survey for prostatic diseases.
(Results) Although not only frequency but degree of “hesitancy”, “intermittency during urination”, “strain or pushing” or “weak stream” correlated with the trobule, the correlations were higher in frequency than in degree. However, since some participants felt bothered when they expressed some degree of the symptoms alone but not frequency of the symptoms, evaluation of symptom degree may be helpful to identify such participants. Of the participants who answered “none” for frequency of the symptoms, some reported “having a mild symptom” in degree. This indicated that in recognition of symptoms degree may precede frequency. If the obstructive symptoms are very mild, men may express the symptoms as changes in degree, but not as changes in frequency.
(Conclusions) These results suggested that evaluation of symptom degree is necessary for some participants.

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(Purpose) Recently, several reports showed that immunohistochemistry using MIB-1 antibody, which recognizes Ki-67 antigen, is one of the usefull methods to determine the proliferative activity in various cancer. To evaluate the prognostic usefulness of the MIB-1, antibody we assessed the cell proliferation immunohistochemically in urothelial cancer.
(Methods) The proliferative activity of thirty cases of renal pelvic and ureteral cancer has been investigated immunohistochemically using MIB-1 antibody, which recognizes Ki-67 antigen, a human nuclear antigen expressed in proliferating cells.
(Results) The Ki-67 index correlated with prognostic factors such as pathological stage and histological grade. The patients with early stage or low grade tumors had lower Ki-67 indices. And the Ki-67 index significantly correlated with recurrence and prognosis. The tumors of patients with recurrence or cancer death had higher Ki-67 indices. When the patients were subgrouped according to Ki-67 indices (more than 22%) had significantly worse prognosis even in the same grade. Especially in the grade 2 group, all the four patients in the higher Ki-67 index subgroup had recurred and died of cancer, whereas, in the subgrouped patients with tumors of lower Ki-67 indices, only three patients had bladder cancer recurrence, and no patients had died of cancer, except one case with advanced tumor (T4, N3, M0) resected incompletely.
(Conclusions) These results indicate that the Ki-67 index is a useful prognostic factor and may enhance the prognostic accuracy determined by conventional morphological grading systems.

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(Background) E-selectin is an adhesion molecule expressed on IL-1 activated endothelial cells and it binds to carbohydrate ligands such as Bialy Lewis A antigen (SLeA) or Lewis X antigen (SLeX) on cancer cells. This mechanism is supposed to play an important role during hematogenous metastasis. Some of renal cell carcinomas (RCC) are known to produce inflammatory cytokines such as IL-1β and IL-6 and clinical evidence shows that the prognosis of this type of tumor is generally poor. We investigated whether this adhesion molecule was involved in hematogenous metastasis.
(Method) In the present study, soluble E-selectin level was measured in the sera of 89 patients with RCC prior to nephrectomy or IFN treatment using sandwich ELISA method.
(Results) The results indicated that high E-selectin concentration in the patients' sera was correlated with low incidence of metastasis and consequently correlated with good prognosis of RCC patients. Inflammatory serum parameters, such as serum C reactive protein (CRP), immunosuppressive acid protein (TAP) and erythrocyte sediment rate (ESR) were also assessed and these parameters were revealed to be negatively correlated with the serum level of E-selectin.
In order to investigate this mechanism, we performed in vitro study on RCC cell/endothelial cell adhesion. IL-1β enhanced adhesion of 2 RCC cell lines and this adhesion was partially inhibited by adding exogenous E-selectin into the culture medium. Expression of SLeA and SLeX were demonstrated on the cell surface of 2 RCC cell lines by flowcytometric analysis.
(Conclusion) The results suggested that E-selectin and SLeX/SLeA interaction was involved in the adhesion between RCC and endothelial cells and also inflammatory cytokine production by RCC cells was a risk factor for metastasis through E-selectin induction. Although expression of E-selectin on endothelial cells facilitates metastasis, excessive production of E-selectin into the serum was suggested to have inhibitory effect against metastasis.

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(Background) The clinical outcome of laparoscopic surgery performed in 143 patients, including laparoscopic adrenalecotmy, nephrectomy, pelvic lymph node dissection (PLND) and varicocele ligation is reported.
(Methods) In patients who underwent laparoscopic adrenalectomy (32 cases), laparoscopic nephrectomy (7) or PLND (44), the following parameters were evaluated and compared to those obtained in patients undergoing the same surgeries but by conventional open procedure; operation time, hospital stay, pain killer doses and the time necessitated for ambulation.
(Results) The operation was successful in 95.8% (137/143). Open laparotomy was necessitated in 4 patients to control bleeding (two in adrenalectomy and two for PLND) and in one nephrectomy case due to massive adhesion with the descending colon. The major complication occurred in 4.2% of the cases, but without mortality. The laparoscopic adrenalectomy, nephrectomy and PLND had an average operating time of 260, 304 and 139 minutes, respectively, while the open surgery for each procedure required 251, 212 and 128 minutes, respectively (p=0.24-0.82). Likewise, the total dose of pain killer was 0.8, 1.8 and 0.9 for the former, whereas it was 3.2, 6.0 and 3.9 for the latter, respectively (p<0.01). The average hospital stay for laparoscopic surgery was 4.9, 6.4 and 4.7 days in the same order, whereas open adrenalectomy or nephrectomy required about 14 days (p<0.001). Convalescence was completed within significantly shorter term in patients with laparoscopic surgery.
Potential complications of laparoscopic surgery included not only those unique to pneumoperitoneum (8.1%), but also those which may be encountered during any endoscopic operation such as compartment syndrome in the lower extremities. The physiologic changes accompanying increased intra-abdominal pressure affected renal function, characterized by a significant decrease in urinary output (p<0.02), which, however, resumed to normal range within several hours after the operation without causing permanent renal dysfunction.
(Conclusion) These results suggest that the laparoscopic surgery in certain area in urology has less morbidity and equal accuracy compared with conventional open surgery.

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(Background) We studied the dynamic estimation of biological activity to evaluate stage progression using clinical findings of the superficial bladder cancer.
(Methods) From 1983 to 1993, 111 patients who underwent transurethral resection initially. 54 (48.6%) cases showed tumor recurrences at least once were estimated the tumor growth speed, dividing the total amount of tumor volume of summing all tumors at a certain recurrence with the duration between recurrences, and which was compared with various prognotic factors of the superficial bladder cancer. The Prognotic factors included age, sex, frequency of recurrences, tumor's number, tumor's size, stage, histological grade, shape, intravesical treatment and duration to recurrence from the last transurethral resection.
(Results) Seven (13%) cases showed disease progression in the sense of tumor stage (T2<) out of 54 recurrent patients. The tumor growth speed during one episode of recurrence was not statistical different between any factors. However, the average of tumor growth speed, which was calculated based on all episodes of recurrences, was statistically different (the cases with stage progression versus without: P<0.05) between the cases with and without stage progrssion.
(Conclusion) The results suggested that the dynamic estimation of biological activity of the superficial bladder cancer has a potencial to be an important prognostic factor to determine the stage progression of the disease.

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(Background) The object of this study is to evaluate the efficacy of preoperative chemotherapy combined with radiation therapy for bladder cancer.
(Method) A total of 44 patients with bladder cancer were treated by preoperative chemotherapy combined with radiation therapy between October, 1981 and December, 1986. Of the 44 patients, ranging in age from 40 to 82, with an average age of 65.8, 34 were male and 10 were female. Clinical stages included 4 patients in Ta, 25 in T1, 11 in T2, and 4 in T3. Each patient was treated twice with 15 gray of radiation to the small plevic cavity and a chemotherapy combination of adriamycin, cis-platinum, tegaful, and peplomycin. The average observation time after the therapy was 83 month, with the maximum being 146 months.
(Results) Complete remission was included in 5 patients, partial remission in 27, and no change in 12. Thus, the overall effective rate was 72.8%. Operations, selected by the results of the preoperative therapy, included transurethral resection on 28 patients, transurethral fulguration on 2, partial cystectomy on 4, resection of tumor on 4, and total cystectomy on 3. Operations were not performed on 2 patients and not allowed on 1 patient.
The outcome during the long-term follow-up included cancer related deaths in 4 patients, and death resulting from other disorders in 9. The 5-year survival rates for superficial and invasive bladder cancer were 92.4%, and 83.9%, respectively. The 10-year survival rates for superficial and invasive bladder cancer were also 92.4% and 83.9%, respectively. The 3-year and 5-year non-recurrence rates for superficial bladder cancer were 75.8%, and 66.9% respectively, according to the Kaplan-Meier method. On the other hand, the 3-year and 5-year non-recurrence rates for invasive bladder cancer were both 73.8%. During the follow-up between 9 and 11 years, 3 upper tract tumor were diagnosed (2 ureteral cancer, and 1 renal pelvic cancer).
(Conclusion) We concluded that preoperative chemotherapy combined with radiation therapy may be effective for the treatment of bladder cancer.

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(Background) Urinary calculus consists of inorganic substances as a major component and organic substances as a minor component. In this study, the organic substances playing an important role in the formation of calculus, such as osteopontin, calprotectin, macrophage and cytokines, are investigated for their significance in the calculus formation mechanism.
(Methods) Using renal tissues of rats having intraperitoneal glyoxylic acid-induced calculus, mode of the expression of osteopontin was examined by in situ hybridization method, immunohistological staining and northern blot method. Then human renal tissues obtained from the nephrectomy specimen conducted for a renal calculus were subjected to immunohistological staining by an enzyme antibody method using antibodies against osteopontin, calprotectin, macrophage and cytokines.
(Results) In rats, while the expression of osteopontin mRNA was observed in renal distal tubular cells, no expression was observed in glomerulus or renal interstitial tissues. The level of osteopontin mRNA expression in calculus forming rats was higher than in control rats by northern blot method. In human tissues, all of osteopontin, calprotectin, macrophage exhibited positive results in the renal distal tubular cells and in the calculus nucleus in the renal distal tubular cavity. Calprotectin and macrophage exhibited positive result also in the renal interstitial tissues. Cytokines exhibited positive results for interleukin-1, 6, tumor necrosis factor α and transforming growth factor β. Cytokines exhibited positive results in the distal tubular cells. Negative results were observed for interleukin-2, 4 and 5.
(Conclusion) Based on the findings described above, it is concluded that accumulation of macrophage in the renal interstitial tissues takes place and then one type of cytokines sensitive to macrophage is secreted. Subsequently, in the renal distal tubular cells stimulated with macrophage and cytokines, the expression of osteopontin and calprotectin takes place, and these organic substances bind to calcium, whereby forming the calculus nucleus.

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A 46-year-old man had received a long-term induction plus salvage chemotherapy for anaplastic seminoma with stage IV disease. Chemotherapy regimens and cycles included the following; four cycles of bleomycin plus vinblastine plus cisplatin (BVP); eight cycles of cyclophosphamide, vincristine, and cisplatin (COP); three cycles of etoposide plus cisplatin (EP); thirteen cycles of etoposide with ifosfamide and cisplatin (VIP). The total cumulative dose of etoposide was 4250mg/m². Severe and persistent pancytopenia developed 32 months after starting etoposide-based salvage chemotherapy. Bone marrow examination showed hypercellular marrow containing 68% myeloblasts but peroxidase reaction was negative. CD-13 was 30.1% which meant that leukemia was myelogenous. Therefore, he was diagnosed as acute myelogenous leukemia. French-American-British classification was MO. Chromosome analysis revealed at (8; 21) (q22; q22) cytogenetic abnormality. This case may be compatible with the clinical and cytogenetic characters of epipodophyllotoxin-related leukemia. We conclude that high doses of etoposide seem to be leukemogenic. To our knowledge, this is the first reported case in the literature relevant to epipodophyllotoxin-related secondary leukemia in testicular tomor in Japan.

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