(Purpose) We performed intrarenal bacillus Calmette-Guerin (BCG) instillation for carcinoma in situ (CIS) of the upper urinary tract. Its efficacy and safety are evaluated. (Material and Methods) Eight patients (6 men and 2 women, median age of 63.7 years) diagnosed as upper urinary tract carcinoma in situ were studied. One had bilateral upper urinary tract CIS. Thus, 9 units of upper urinary tract were treated with BCG instillation. Diagnostic criteria of upper urinary tract CIS were: (1) positive voided urinary cytology, (2) negative multiple random biopsy of the bladder and the prostatic urethra, (3) negatie radiographic studies, (4) two serial positive cytologies in selective ipsilateral urine sampling. The BCG solution was administered weekly by retrograde ureteral catheterization under local anesthesia and instillation during one hour. Second course instillation was performed when 1st course was not effective. (Results) Of 9 renal units 7 (78%) had normalization of the urinary cytology at the end of the 1st course BCG therapy. One patient with CIS of the bilateral upper tract had negative cytology of the unilateral unit, and underwent the contralateral nephroureterectomy because of persistent positive urinary cytology and coincidental renal cell carcinoma. One patient did not have negative cytology even after three courses of BCG instillation and is now under observation. During the procedure, high fever and bladder irritative symptom were observed in 6 out of the 8 patients (75%) and 4 (50%), respectively. (Conclusions) Although longer followup and further experience with intrarenal BCG are required, this treatment is considered to be effective and safe for upper tract CIS.
(Purpose) A comparative study about the contractility of the external urethral sphincter in the pelvic floor muscle (PFM) and about that of the periurethral striated sphincter (PUS), which is independent of PFM, was made by employing adult male mongrels. (Methods) This study was done by using the compression-time curve. Moreover, the study about the formation of muscle fibers was carried out by the aid of ATPase staining. (Results) Stimulus to one side of pudendal nerve increased each sphincter M-wave amplitudes and its compressive differences in contraction. Easy repetitions of the experiment made it possible to use the compression-time curve. The compressive differences in the urethral contraction was significantly greater in the urethra of PUS than in that of PFM. Data obtained from the compressive-time curve showed PUS premotor time was significantly longer than PFM in electromyograms, PUS motor time and time to peak force was significantly shorter, and PUS rate of force development was significantly faster. The histochemical study showed that fast muscles account for 70% in PUS, while they account for approximate 50% in PFM, which supported the results of the compression-time curve. (Conclusion) The above sugested the contractility of PUS apparently differed from that of PFM; PUS contracts quickly, while PFM contracts slowly. Also, it seemed that forming conjectures with the compression-time curve on the formation of muscle fibers in the striated urethral sphincters were possible to some degree.
(Background) Mass screening program for prostatic cancer (PC) using prostate specific antigen (PSA) filter paper method was performed in an urban area of Kyoto in 1995. (Methods) In the primary study, males more than the age of 55 years were examined by PSA (Delfia PSA kit) with blood samples on a filter paper. The cut-off values were set at 4 and 10ng/ml. Subjects whose PSA level ranged from 4.1 to 10.0ng/ml (gray zone) were examined by digital rectal examination (DRE), transrectal sonography (TRS) and PSA density (PSAD; more than 0.15) in the secondary study, then the suspected subjects of PC underwent 6 sextant biopsies under interventional ultrasound. Subjects whose PSA level was more than 10.1ng/ml were biopsied directly. (Results) Of 3, 749 males who took the annual health checkup system organized by the goverment, 2, 387 males wished to submit this screening. Among them, 2, 217 (92.9%) showed a negative PSA, 107 belonged to the gray zone and 43 had a PSA more than 10.1ng/ml. Of these, 102 subjects underwent biopsy. PC was finally detected in 28 (1.2%). The positive predictive value for positive PSA and gray zone PSA was 46.3% and 8.4%, respectively. In the detected cancers, 17 cases (60.7%) belonged to Stage B, 5 (17.9%) to Stage C and 6 (21.4%) to Stage D. (Conclusion) The results suggested that this system of mass screening program for PC combined with the annual health checkup was suitable for the future “national-level” screening.
(Background) Although Carbohydrate antigen19-9 (CA19-9) is known to be high of its positive rate in blood in pancreatic cancer, etc., recently there have been scattered of cases of urothelial carcinoma in which elevated CA19-9 levels have been detected in both serum and urine. In this study we determined both urine and serum levels of CA19-9 in order to evaluate their diagnostic role of urinary CA19-9. (Materials) A total 82 patients, i. e., 32 with bladder cancer, 4 with renal pelvic/ureteral cancer, 5 with renal cancer, 13 with prostatic cancer, 5 with other malignancies, 10 with prostatic hyperplasia, 6 with urolithiasis, 7 with other benign diseases, served as the subjects of this study. (Methods) CA19-9 was determined by EIA method in first-morning urine and serum using a CA19-9 measurement kit (Centocor). Urinary values corrected for the creatinine level in the same sample have been used and are shown as U/mg creatinine (Cr). Urinary CA19-9 and urinary cytology were evaluated in some cases. An immunohistochemical study of CA19-9 for surgical specimens was conducted by the ABC method, using a Histo 19-9kit (COMPAGNIE ORIS INDUSTRIES S. A.). (Results) The cut-off value for serum levels was 37U/ml, and urine levels were determined in U/mg Cr with a cut-off value of 100U/mg Cr. The urinary CA19-9 level was significantly higher (390.9±934.1U/mg Cr) in urothelial cancer than in the control group (91.48±20.0U/mg Cr). In urothelial cancer, grade 1 and grade 2 cases were more sensitive than grade 3 cases and they also tended to be high level, although only 27.8% of urothelial cancer patients showed an elevation of sreum CA19-9. CA19-9 was detected in all urothelial cancers which could be studied immunohistochemically. In 8 out of 16 superficial cancers CA19-9 was detected in more than 90% of cancer cells, though there were few CA19-9 positive cells in infiltrating cancers. Urinary CA19-9 was more sensitive than urinary cytology, especially in low grade cancers. (Conclusion) The determination of urinary CA19-9 may be a useful tumor marker of urothelial cancer, and especially in low grade cancer it may be useful in diagnosing of them because its urinary level is high and it is more sensitive than urinary cytology.
(Background) An effective ureteroileal reimplantation without reflux and obstruction is indispensable for lower urinary reconstruction or diversion using an ileal segment. Based on our earlier experience of afferent nipple valve malfunction of the Kock pouch, we performed Le Duc-Camey antireflux ureteroileal implantation. In the present study, we evaluated the long-term outcome of the Le Duc-Camey technique on the upper urinary tract in patients with a postoperative observation period of 2 years or more. (Patients and Methods) From 1989 to 1994, 39 patients (73 ureters) underwent Le Duc-Camey technique for prevention of reflux of a Kock pouch. In 28 patients the ileal reservoir was connected to the skin for cutaneous urinary diversion, and in 11 it was connected to the urethra for lower urinary reconstruction. The ureters were implanted into the reservoir through the anterior wall window of the reservoir. In most patients, excretory urography (DIP) was performed once a year after the first year. Retrograde cystography or voiding cystourethrography was performed within 12 months postoperatively. After the first year, retrograde study was performed once during the follow-up period in the majority of the patients. The mean follow-up period was 44.8 months (range 24-71 months). (Results) There was no urinary tract dilatation in 68 renal units (93.1%), while slight dilatation was noted in 3 (4.1%), moderate dilatation in 1 (1.4%), and marked dilatation due to stenosis of ureteroileal anastomosis in 1 (1.4%). Retrograde studies revealed absence of reflux in all patients. Another complication that related to this procedure was not observed in any patients. (Conclusion) We conclude that Le Duc-Camey technique is effective in reflux prevention and protection of the upper urinary tract, and recommend it for use with detubularized ileal reservoir.
(Background) Most of patients with spinal cord injury (SCI) have fertility problems by anejaculation and a poor fertility of the ejaculate. The objective of this paper is to evaluate the clinical effectiveness of electroejaculation (EE) and combined use of EE and assissted reproductive techniques for the patients with SCI. (Patients and Methods) Using a Seager Model, EE was attempted on 69 patients with SCI. Of the 69 patients 14 (20%) had cervical, 49 (71%) thoracic and 6 (9%) lumbar paraplegia. Mean patient age was 30 years (range 19 to 47 years) and the mean interval from spinal injury to the first EE was 9 years (range 1 to 38 years). Artificial insemination of husband (AIH), in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) were used to achieve a pregnancy. (Results) Antegrade ejaculation was obtained in 60 patients (86.9%). Patients with under-active bladder showed low induction rate (58.3%). Volume of ejaculate was ranged from 0.05 to 5.2ml (average 1.0ml) and sperm concentration was ranged from 0 to 546×106/ml (average 40.3×106/ml), but sperm motility was poor (range 0 to 70%, average 9.4%). Assisted reproductive techniques was attempted on 87 occasions (AIH 80, IVF 2, ICSI 5) on 15 couples. To date, there have been 4 pregnancies (AIH 2, ICSI 2) resulting in 3 healthy live births. (Conclusion) Combined use of EE and assisted reproductive techniques is excellent management for the patients with SCI who wish to father children.
(Background) Our purpose was to clarify the effect of hormone replacement therapy (H. R. T.) for patients with stress incontinence. (Methods) We investigated 25 postmenopausal women, age 54-73 years, with a leakage volume is less than 15g/day. In this study 0.625mg of conjugated estrogen and 2.5mg of medroxyprogesterone acetate were administrated for a total of 4 months. A clinical evaluation, measurement of volume of leakage per day and urodynamic evaluation (urethral pressure profile) were performed three times at pre administration, and at 2 months and 4 months after administration. (Results) Five of the 24 patients (20.8%) were improved significantly both clinically and urodynamically. Six patients (25.0%) improved clinically, and two patients (8.3%) improved urodynamically, the remaining 11 patients (45.8%) showed no change. Side effects occurred in eight cases. In one patient, it was necessary to stop administration due to severe irregular genital bleeding and leukorrhea, and in one patient the dosage was reduced due to swelling of breasts. The side effects of swelling of breasts and genital bleeding were relatively mild in the remaining six patients and they could continue H. R. T. administration. (Conclusions) These results suggest that H. R. T. for patients with stress incontinence is not necessarily superior to the other non surgical methods. However, it may provide an alternative treatment method for incontinence.
(Back ground) The obejects of this study is to evaluate the ipsilateral stone recurrence who became stone free status after extracorporeal shock-wave lithotripsy (ESWL). (Methods) Three hundred ninety five patients who became stone free after ESWL with Lithostar and followed more than 6 months, were analyzed sotne recurrence. Stone recurrence were diagnosed by KUB and/or ultrasound. Actual recurrence free rate were calculated based on the period from the day of achieved stone free status to the day of estimated recurrence. Eight factors examined included sex, side, number, location, size, stone history, urological complication, hydronephrosis and also contralateral recurrence was analyzed. (Results) Over all ipsilateral recurrence free rate were 96.5%, 78.8%, 65.3% after 1, 3 and 5 years, respectively. Contralateral stone free rate were 98.1%, 92.5%, 87.2% after 1, 3 and 5 years. Five-year recurrence free rate according stone factors, there were significant difference in stone number (Single 71.1% and multiple 31.6%), in sotne history (with history 77.1% and without 35.7%), in urological complication (without complication 67.7% and with complication 35.7%). However, there were no significant difference in sex, side, stone location, stone size and hydronephrosis. (Conclusion) This results suggested that the stone number, stone history and urological complication were highly related to ipsilateral stone recurrence after stone free status by ESWL. Extracorporeal shock wave lithotripsy had probability of higher stone recurrence rate.
We experienced a case of adenocarcinoma occurring in the reconstructed bladder 38 years after ileocystoplasty. The patient was a 48-year-old woman, who had undergone ileocystoplasty and left nephrectomy at the age of 10 for the treatment of tuberculous contracted bladder and left renal tuberculosis. She had often suffered from right pyelonephritis following the operation. She visited our hospital for work-up of a high value of carcinoembryonic antigen (CEA). The findings of cystoscopy, cystogram and urine cytology showed a malignant tumor of the reconstructed bladder. Then, we performed total cystectomy and right ureterostomy. The histopathological examination showed that the tumor was an adenocarcinoma which developed mainly from the ileal segment of the reconstructed bladder.
A 70-year-old male was hospitalized for right scrotal mass without pain in October 1991. Right orchiectomy was performed under a diagnosis of right epididymal tumor. Histopathological diagnosis was testicular adenomatoid tumor. In June 1992, he was admitted with a mass in the right inguinal region and a tumor was resected. Histopathological diagnosis was malignant testicular mesothelioma. Therefore, retroperitoneal lymphadenectomy was performed as additional therapy. One year after surgery he showed signs of recurrence and was admitted for treatment and further examination. Computed tomography demonstrated right inguinal and femoral mass. Thus he underwent total penectomy and radical ilioinguinal lymphadenectomy under a diagnosis of metastatic and recurrent mesothelioma of the testis. Three months postoperatively he developed a recurrence in the skin and lung field. After combination chemotherapy, the metastatic skin lesion was in remission but the lung lesion did not respond. Metastatic lung tumor grew rapidly and the patient died. The incidence of malignant mesothelioma of the tunica vaginalis testis is rare and 48 cases have been reported in the literature.