(Purpose) We report our early experience of laparoscopic radical prostatectomy for clinically localized prostatic cancer.
(Material and Method) Between April and December 2000, 17 patients with clinical stage T1c to T2b prostatic cancer underwent laparoscopic radical prostatectomy. The median age was 70.9 year old, the median preoperative PSA and the median Gleason score of biopsy specimens was 7.1ng/ml, 6, respectively. We followed the operation technique from the “Montsouris technique”. Briefly, we used five trocars (two 10-mm and three 5-mm trocars) and the operation was performed transperitoneally. Pelvic lymph node dissection was performed in only one patient (case 3). Urethrovesical anastomosis was performed with 6 to 9 interrupted 3-0 absorbable sutures.
(Results) No conversion to open surgery or reoperation was required in all cases. Median operation time was 450 minutes (range 290 to 750) and median intraoperative bleeding (including urine) was 600ml (range 100 to 3, 135). Only one case (case 3) needed homologous blood transfusion. Median postoperative Foley catheterization period was 9 days (range 5 to 19). Intraoperative complications related to operation procedure were one rectal injury and three vesical injuries, which were treated by absorbable suturing laparoscopically. Major complication was one complete A-V block (case 3) who was required a transient discontinuance of the procedure. Surgical margins were negative in 13 cases. Postoperative pathological evaluation was one pT0, five pT2a, seven pT2b and four pT3a. PSA value decreased less than 0.2ng/ml after surgery in all patients. Although six months have passed after the surgery in only 4 patients, all of them were fully continent.
(Conclusion) Although the operation time is still longer than that of conventional open procedures, intraoperative magnified vision allows a more precise and safer dissection, especially for apical dissection. We believe that operative time will decrease with more experience. These results show that laparoscopic radical prostatectomy can be an acceptable treatment option for localized prostatic cancer.

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(Purpose) The major drawback of the current treatment for superficial bladder tumor is the high rate of recurrence. Especially, the tumor with grade 3 component has a tendency to recur and progress in stage. However, we have difficulty in predicting tumor recurrence and stage progression accurately by conventional clinicopathological factors. We evaluated the efficacy of p53 and Ki-67 overexpression as a predictor of recurrence or prognosis in patients with superficial bladder tumor of grade 3.
(Materials and methods) Samples were obtained from 41 patients with superficial transitional cell carcinoma of the bladder of grade 3 who were treated by transurethral resection (TUR). The immunohistochemical study was performed using the antibodies against the p53 protein and Ki-67 antigen on formalin-fixed, paraffinembedded tissue specimens from initial tumors. We evaluated the correlation between these results and several clinicopathological factors.
(Results) The p53 index and the Ki-67 index in pTa, pT1a and pT1b tumors were 26.4±30.1%, 28.6±30.0%, and 34.6±32.6% (p53) and 20.5±22.5%, 20.0±29.3%, and 29.2±28.4% (Ki-67). There was no significant difference between the each index and tumor stage.
Eighteen cases (43.9%) had intravesical recurrence. The p53 index of the initial tumor from the tumor free cases (n=23), recurrent cases without stage progression (n=12), and stage progression cases (n=6) were 19.7±28.2%, 42.0±28.7%, and 42.5±32.0%. Between the recurrence-free cases and the recurrent cases without progression, the p53 index of the initial tumor had statistical significance (p<0.05). The Ki-67 index was shown to be the same pattern as the p53 index, but there was not statistical significance.
Four of patients with stage progression had tumor progression within six months. Three of the patients with tumors with stage progression died of the cancer.
In multivariate analysis, tumor multiplicity (p=0.01), BCG intravesical instillation (p=0.04), p53 index (p=0.01), and Ki-67 index (p=0.02) were the positive risk factors for tumor recurrence, but only the p53 index was the positive risk factor for prognosis fo the patients (p=0.03).
(Conclusion) These results suggest that the immunohistochemical study of p53 overexpression is a useful predictor for tumor recurrence and prognosis in patients with superficial bladder tumor with grade 3.

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(Objectives) This study investigates the influence of erectile dysfunction (ED) on daily life and the attitude of citizens toward ED treatments. (Materials and Methods) A mail survey targeting married males and females, aged 30-79, was conducted throughout the nation. The effective responses were 2, 034 males and 1, 820 females.
(Results) The ED prevalence rate of male respondents was 29.9% and that of females (indicating the recognition of husband's ED) was 30.1%. For both males and females, the frequency of sexual intercourse and satisfaction about their sexual lives were significantly lower in respondents with ED. 23.6% of males with ED and 16.0% of females whose husbands have ED experienced a negative influence of their married lives.
Among male ED sufferers, however, only 4.8% of them had consulted a physician. The reasons cited most often for not consulting a physician were: “no influence on daily life”, “not annoyed by ED”, and “no interest in sex”, Moreover, the barriers to visiting physicians were frequently cited, such as “shyness”, “don't know which hospital to go to”, and “expensive”.
With regard to insurance coverage of ED treatment, 80% or more of both men and women say that “it should be reimbursed for all ED patients” or “it should be conditionally reimbursed”.
(Conclusions) It becomes clear that ED is found at considerable frequency. However, only 4.8% of ED patients had received appropriate treatment at medical facilities. With regard to insurance coverage for ED treatment, it turned out that 80% or more of both men and women supported reimbursement for ED treatment.

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(Background) CT angiography reconstructed by a multidetector-row helical CT scanner is a newly developed form of imaging. We compared CT angiography and ultrasonic Doppler examination with digital subtraction angiography (DSA) in the diagnosis of arterial lesion.
(Method) Eighteen patients with arteriogenic erectile dysfunction (ED) underwent color Doppler study, DSA, and CT angiography after providing informed consent. The CT angiography images were obtained by a multidetector- row helical CT scanner, Asteion^TR TSX021A (TOSHIBA). We injected prostaglandin E₁ into the penile cavernous body, and then rapidly infused nonionic contrast medium into the antecubital vein. DSA and CT angiography images of the bilateral internal pudendal arteries and cavernous arteries were examined for stenotic lesions or occlusion. We also compared the peak systolic blood flow velocity in the cavernous artery measured by color Doppler ultrasound with CT angiography and DSA.
(Results) The CT angiography and color Doppler studies were performed on an outpatient basis, but DSA required hospitalization. In the 36 internal pudendal arteries, DSA represented 22 normal arteries and 14 stenosis or occlusions. CT angiography showed 15 normal arteries and 21 occlusions. For the diagnosis of stenosis or occlusion in the internal pudendal artery, the CT angiography image had a good agreement, with a sensitivity of 1.00, specificity of 0.68, and accuracy of 0.81. For diagnosis in the cavernous artery, CT angiography image also showed a good agreement with DSA; however, the quality of the images of fine arteries was better in the DSA images. The inferior view and internal view of the pelvis in CT angiography were helpful for visualizing the internal pudendal artery, especially at the pubic bone. There was insufficient correlation between peak systolic blood flow velocity and DSA findings. There were no serious complications involved in either examination.
(Conclusions) CT angiography has not yet reached the same level as DSA in the evaluation of fine arteries. However, CT angiography can produced images sufficient for the diagnosis of arteriogenic ED with some advantages. We believe that with improvement, CT angiography will become an adequate replacement for DSA in the diagnosis of penile arterisl lision.

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(Background, Purpose) Twenty-two institutes have organized Keio University Prostate Cancer Study Group to study clinical efficacy and safety of Leuprolide acetate (Leuplin) for the treatment of advanced prostate cancer (clinical stage D₁ and D₂). Cotreatment of Leuplin and Estramustine phosphate disodium (Estracyt) has been performed to investigate its clinical efficacy.
(Materials and Methods) One hundred and two cases of advanced prostate cancer were treated either with Leuplin alone (group I), Leuplin and Estracyt (group II) or Estracyt alone (group III). After 12 weeks tretment, clinical effects against subjective symptoms (pain, voiding difficulty, performance status and body weight), serum testosterone level, tumor size and serum PSA level were examined to investigate short-term effect of each treatment. The treatment had been continued for 24 months and the treatment effects including progression free survival and overall survival were analzed.
(Results) Clinical efficacy after 12 weeks treatment were examined among 97 cases (group I; 35 cases, group II; 36 cases, gorup III; 26 cases). The background of those patients in each group was statistically equal. Treatment effects against subjective symptoms and serum testosterone level statistically revealed no significant difference among 3 groups. Treatment effects against primary tumor, bone metastatic lesion, lymphnode metastatic lesion and serum PSA level were investigated and anti-tumor effect was characterized by total efficacy rate (complete remission rate plus partial remission rate) of each treatment group. Treatment efficacy rates for each lesion and PSA demonstrated no statistical difference among 3 treatment groups. Total efficacy rate of group I, II and III were 88.2%, 84.0% and 78.3%, respectively, which statistically revealed no significant difference.
Total efficacy rate of each group after completing 24 months treatment was; group I 80.0%, group II 55.6% and group III 83.3%, which statistically showed no significant difference among 3 treatment groups. The median day for progression free furvival of group I, II and III were 661, 731 and 517, respectively. The overall survival rate of group I, II and III after completing 24 months treatment were 77.5%, 83.0% and 72.4%, respectively. Both progression free survival rates and overall survival rates revealed no significant difference among 3 groups.
Side effects during 24 months treatment were seen in 8.6% of group I, 47.2% of group II and 26.9% of group III, and these occurrence rates were significantly different among the groups (p=0.0013).
(Conclusion) Although number of the cases had not been able to contine the treatment for their side effects, the statistical characterization demonstrated that cotreatment of Leuplin and Estracyt had no greater treatment effect than monotreatment of each drug.

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A 47-year-old woman underwent left radical nephrectomy in 1995, and pathological diagnosis showed a primary renal cell carcinoma with clear cell subtype. Four years later on her routine checkup, abdominal computerized tomography revealed a 9-cm of predominantly solid and partially cystic tumor in the pelvic cavity. The patient was referred to Gynecologic Department and a total hysterectomy with bilateral salpingo-oophorectomy was subsequently performed under the diagnosis of a left ovarian tumor. A cut surface of the solid component of the tumor was macroscopically yellowish. Pathological examination revealed alveolar growth of tumor cells with abundant clear cytoplasm including fat components. In some areas of the tumor, there were patterns of tubular structures which were cystically dilated. The typical findings usually found in the primary ovarian clear cell adenocarcinoma were absent in the tumor, and the final pathological diagnosis was left ovarian metastasis of renal cell carcinoma. The ovarian metastasis of renal cell carcinoma is quite rare and to our knowledge only eleven cases were reported in the past 20 years. We report on a case and review the literature.

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An 82-year old man received total androgen blockade therapy (bilateral orchiectomy and 375mg/day flutamide) for the treatment of stage C prostate cancer. Serum PSA levels were undetectable for 13months and thereafter increased gradually. We administered estramustine phosphate sodium (EPS) instead of flutamide under the diagnosis of hormone refractory prostate cancer. EPS therepy was discontinued after 9months because serum PSA levels increased again. Then, the patient complained of bilateral breast nodules and pain. Bilateral mammectomies were performed due to bilateral breast cancers which had been diagnosed by aspiration biopsies and radiographic examinations, but he died four months after the operations. Final pathological diagnosis was ductal adenocarcinoma of the breasts. Immunohistochemical study revealed expressions of PSA in the breast cancers. We diagnosed double cancers of the prostate and the breast because of the different expression patterns of progesterone receptor between them. We review the literatures and discuss the diferential diagnosis of prostate cancer and PSA-producing breast cancer.

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A 66-year-old man had been receiving anticoagulant therapy for myocardial infarction with warfarmn potassium (abbreviated as warfarin) 2mg/day. Though he had been treated with tamsulosin hydrochloride 0.2mg/day as diagnosis of benign prostatic hyperplasia, he experienced severe dysuria and wanted to undergo transurethral resection of the prostate. We decided to continue antico-agulant therapy because cardiologist judged that intermission of anticoagulant therapy could cause myocardial infarction. Warfarin 2mg/day P. O. was replaced with heparin sodium (abbreviated as heparin) 5000u×2/day S. C. 6 days prior to surgery, and anticoagulant therapy was stopped on the day of surgery, but resumed on the following day. Purpura appeared around the extremities 18 days after the surgery. Although coagulation testing was normal, platelet counts had markedly been reduced (2, 000/mm³). Platelet counts recovered to a level of 228, 000/mm³ 13 days after cessation of heparin. No other adverse effects were observed. Heparin-induced thrombocytopenia (abbreviated as HIT) was diagnosed clinically.
We consider monitoring of platelets to be necessary because an increasing number of patients are on anticoagulant therapy in Japan, and accordingly, the use of heparin is likely to be increased.

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A 60-year-old man underwent transrectal six sextant ultrasound-guided prostatic biopsy because of gradual elevation of PSA. Despite postoperative use of amikacin, spiking fever developed the next day and after emergency admission (39 hours after the biopsy), his blood pressure decreased to 56/40mmHg with WBC 800/mm³, platelets 6.9×10⁴/mm³ (decreased further to 0.4×10⁴/mm³ on the following day) and FDP 51μg/dl. Intensive care including chemotherapy with broad-spectrum antibiotics and endotoxin removal therapy using a polymyxin B immobilized fiber column (PMX), was useful to recover the patient from septic shock and disseminated intravascular coagulation. As the number of systematic prostatic biopsy is increasing rapidly in Japan, more attention must be paid to potential hazards of this procedure.

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We have reported the favorable therapeutic results of non-ischemic complete enucleation using a microwave tissue coagulator as a method of nephron-sparing surgery for small renal cell carcinoma (RCC). We experienced two elective cases that underwent translumbar nephrectomy subsequent to the tumor enucleation. The first case showed another RCC in a cyst, concomitant with the enucleated RCC. The second case was a pT3a spindle cell carcinoma with high-grade malignancy. We decided to nephrectomize these enucleated kidney after obtainig well-informed consent. Here we report these controversial cases and discuss about the indication and outcomes of complete tumor enucleation for small RCC.

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