(Background) To select suitable treatment for stress urinary incontinence (SUI), both urethral function and urethral mobility must be assessed. Abdominal leak point pressure (ALPP) is considered to be useful to evaluate urethral function, and radiographic findings are effective to evaluate urethral mobility. However no adequate methods to measure urethral mobility with videourodynamics study (VUDS) exist. We measured the downward movement of the membranous urethra at the same time as ALPP was measured on VUDS, and examined whether or not the urethral descent on VUDS is useful to evaluate urethral mobility. (Methods) The subjects were 28 women with over grade II SUI (according to McGuire's grading) who underwent bead chain cystography and VUDS. As a classical index of urethral mobility, we measured the change of posterior urethrovesical angle (PUVA) and vesical neck descent duringValsalva maneuver on bead chain cystography. The videourodynamic urethral catheter had a radiographic marker that permitted the identification of the location of the urethral pressure sensing aperture. The catheter was fixed at the position where the urethral pressure aperture reached the point of highest pressure. The urethral descent was defined as the downward movement of the urethral marker during Valsalva maneuver while measuring ALPP. According to the urethral descent the patients were classified as follows: 1) hyper-mobile group; urethral descent was over 5mm. 2) non-mobile group: urethral descent was under 5mm. The severity of SUI was evaluated with 1hr. pad weighting test, ALPP and maximum urethral pressure. (Results) The urethral descent was significantly related to vesical neck descent and PUVA change. In the non-mobile group (11 cases), ALPP was significantly lower, and urine loss on the pad weighting test was significantly greater than that in the hyper-mobile group (17 cases). The non-mobile group exhibited more severe incontinence than the hyper-mobile group. When the patients were classified according to Blaivas's classification, all patients in type III and 2 in type I were in the non-mobile group. These 2 type I patients had low ALPP (40cm. water and 70cm. water) and a history of radical hysterectomy. Therefore these patients were diagnosed with ISD due to the fixed urethra. (Conclusions) Urethral descent is an useful index of urethral mobility. In the non-mobile group, the pathophysiological cause of SUI was not urethral hypermobility but ISD, and it was diagnosed as type III SUI without urethral mobility. We consider that urethral descent assesses urethral mobility more accurately than vesical neck descent, and that urethral descent is a valuable parameter on VUDS.
Thirty-eight patients with genuine stress incontinence underwent the Gittes procedures of the bladder neck suspension under ultrasonical monitoring. We performed the following two procedures. Original Gittes procedure: the puncture of the needle made twice through the different holes of the rectus fascia for each side and the bilateral helical suture was tied down separately above the rectus fascia. Modified Gittes procedure: the needle was passed through the rectus fascia once for each side and the both end of the helical suture was drawn up to suprapubic area, then the bilateral threads were tied over the rectus fascia. Original Gittes procedure was performed for twenty-nine patients and modified Gittes procedure for nine patients. Tightness of the suspension was decided by monitoring the posterior urethrovesical angle with use of the transrectal ultrasonography during the operation. A long term follow up survey was made up by means of a questionnaire by the phone or the mail. A total of thirty-six patients responded the questionnaire for a 94.7% respose rate. The mean follow up was 33.1 months. 83.3% of the patients were cured and 5.6% were significantly improved. None of the patients claimed dysuria. There was no difference between the continent rates of the two procedures. We conclude that the Gittes bladder neck suspension with use of ultrasonography is effective for correction of female stress urinary incontinence.
(Purpose) In the newborn female with congenital adrenal hyperplasia (CAH), there are variable degres of clitoral enlargement and virilization of the urethra. In order to investigate the factors that cause these variations, the degree of musculinization of the external genitalia in 44 patients with CAH was studied retrospectively. (Patients and Methods) This study includes a total of 44 patients with CAH aged 2 months to 12 years and 11 months old who had consulted Nagoya City University Hospital from 1977 to 1994. The length of clitoris on the first consultation was compared with the age and its change was followed. Also, the relationship among the length of clitoris on the first consulation, the degree of urethral virilization, the clinical forms i. e. salt-losing or simple-virilization. and the glucocorticoid hormonal condition were investigated with each other. In 5 pairs of sisters, the length of clitoris on the first consultation was compared within each pairs, and also the degree of urethral virilization was compared. (Results) The clitoral length on the first consultation was significantly correlated with the age (y=1.8x+1.8, r=0.7, p<0.0001). The mean clitoral length at birth calculated from these data was 18mm, which is as large as that of adult female one, and the clitoral enlargement rate was 1.8mm/yr. The correlation was not clear between the clitoral length and the degree of urethral virilization, the clinical forms, and the glucocorticoid hormonal condition, either. On the other hand, the degree of urethral virilization was comparable withinclitoral length was not comparable within them. (Conclusions) The urethral virilization was suggented to be determined by the internal hormonal environment during embryonal stage which was shared by the each pair of sisters. On the Other hand, the clitoral length was depend on the patient's age though the factor which determined the length was not apparent. These facts indictated that, not only the severely musculinizing cases, but also the new born female with mildly virilizing urethra should be followed strictly not to undergo the clitoral enalargement.
(Purpose) We invastigated the prevalence of lower urinary tract symptoms and the effect of subjective urinary symptoms on quality of life (QOL) in elderly males examined prostate cancer screening in total health check from April 1996 to March 1997. (Patients and methods) A total of 922 eligible examineers 50 to 70 years old completed a questionaire with questions worded similarly to those of the international prostate symptom score (I-PSS) and AUA Impact index score and so on. (Results) The prevalence of moderate to severe symptoms was 19.6%, which increased with age. I-PSS was well correlated aging but not prostate size. The most prevalent symptoms were nocturia (61.1%), frequency (50.0%) and weak stream (47.7%). There was good correlation between symptom severity and QOL and AUA Impact index scores. While QOL was correlated with obstructive and irritative symptom scores, wish for treatment was associated mainly with irritative symptoms by multiple regrresion analyses. However, some examineers (15.5%, 28/181), who had moderate to severe symptoms, did not feel a decrease of QOL in daily life. (Conclusions) A large percentage of elderly men 50 years old or older experienced symptoms. However, subjective urinary symptoms did not always correlate with QOL in some individuals. We should independently consider not only symptom severity but also QOL and AUA Impact index score in clinical dicision making.
(Background) Many men with clinically suspicious findings would not be diagnosed to have prostate cancer. Establishing criteria for indicating repeat biopsy is imperative for early detection of prostate cancer. (Methods) Eighty-one patients underwent repeat prostatic biopsies under sonographic guidance at Kitasato University Hospital between March 1992 and October 1996. Clinicopathological parameters such as age, prostate specific antigen (PSA), PSA adjusted for transition zone volume (PSAT), PSA density (PSAD), PSA velocity, transition zone volume, prostatic volume, rectal findings, ultrasound findings and initial biopsy histology were compared with the results of repeat biopsy for searching for possible predictors of positive biopsy. (Results) Cancer was confirmed in 14 patients (17.3%), 10 patients by the second biopsy (15.4%, 10/65) and 4 patients by the third biopsy (28.6%, 4/14). No cancer was found at the 4th or more biopsies. Twelve (85.7%) of these patients had prostatic volume less than 40cm3.Univariate analysis indicated PSAT, PSAD, transition zone volume and prostatic volume to be more frequent in men with positive biopsies (p<0.05). But multivariate logistic regression analysis failed to identify any significant predictors of positive results in repeat biopsies. (Conclusions) No clinicopathological parameters could reliably predict repeat biopsy findings. One or 2 additional sets of biopsies is recommended based on clinical judgement (symptoms, life expectancy, small glands≤40cm3etc.) for the purpose of early detection of prostate cancer in patients with previously negative biopsy but still with suspicious findings in consideration of approximately 20% false negative rates by the initial biopsy.
A 60-year-old man was admitted to our hospital because of a right renal mass incidentally detected by ultrasonography during a general health check. Computerized tomography (CT) and magnetic resonance imaging (MRI) revealed a solid mass measuring 6cm diameter containing a cystic portion in the right kidney. Cystic renal cell carcinoma was suspected, and right nephrectomy was performed. The gross appearance showed a well circumscribed mahogany brown tumor in the lower portion. On cross section of the tumor, a solid mass was seen in the cystic portion. Microscopically, oncocytic cells with eosinophilic granular cytoplasm were scattered on the cystic wall, and tumor cells formed microcystic structures in the solid part. Therefore, the tumor was diagnosed as renal oncocytoma with cystic formation. Only twelve cases have previously been reported in the literature.
Cyclophosphamide (CPM) has been considered to be a factor of bladder carcinogen. A 60-years old woman had been received a total dose of 370g of CPM for the treatment of Wegener's granulomatosis since August, 1977. She was consulted to our department with chief complaint of macrohematuria in August, 1986. Hemorrhage cystitis was diagnosed and cystoscopy and urine cytology were performed as follow-up schedule in every year. In 1996, urine cytology showed class IV and cystoscopy revealed multiple nonpapillary tumors. Abdominal computerized tomography demonstrated a low density mass on the posterior wall of the bladder. A transurethral cold cup biopsy showed G3 transitional cell carcinoma (TCC). Radical cystectomy and tubeless cutaneous ureterostomy was performed on December 6, 1996 and histopathological diagnosis was TCC, G3, pT3 bNXM0. She died of liver failure due to metastatic bladder cancer after seven months postoperatively.
At the time of donor nephrectomy, congenital abnormalities of the inferior vena cava was discovered. A 56-year-old woman was worked up preoperatively and no abnormalities were found. Abdominal aortography was normal. At the time of operation, the inferior vena cava was located to the left and anterior to the abdominal aorta. In the renal hilus, the location of the renal artery and vein was reversal. We thought the ideas of operation and could successfully performed renal transplantation using donor kidney with congenital abnormalities of the inferior vena cava.