(Purpose) In the 1997 the TNM staging system for prostate cancer was changed, reclassifying, T2 cancers from 3 groups (T2a, less than one half of one lobe; T2b, one lobe; and T2c, both lobes) to 2 groups (T2a, one lobe; and T2b, both lobes), combining the 1992 T2a and T2b into the 1997 T2a subclassification. We investigated the pathological stage and prognosis of cancers in the 1992 and 1997 subclassification to determine whether this change was warranted.
(Material and Methods) We studied a consecutive series of 555 patients with clinical stage T2 prostate cancer treated with radical prostatectomy (RP) between 1983 and 1998. We analyzed the clinical, pathological features and PSA non-progression rate after prostatectomy for patients classified according to the 1992 and the 1997 TNM system. Median follow-up was 51.3 months.
(Results) In the 1992 TNM system T2a tumors were more likely to have a low PSA (5.8 versus 7.2 and 8.1ng/ml, p=0.034, p=0.012), be confined to the prostate (67% versus 45% and 40%, p<0.001 for both), be poorly differentiated (48% versus 63% and 66%, p=0.002 for both) and have a low cancer volume (1.22 versus 2.27 and 2.63cm³, p=0.005 for both) than T2b and T2c tumors. But there were no significant differences between T2b and T2c. Reflecting these results, the patients with T2a cancer had a significantly better prognosis with 82±4% PSA non-progression rate at 5 years compared to 68±4% of patients with T2b and 73±4% of patients with T2c (p=0.007, p=0.048, respectively).
In the 1997 TNM system T2a tumors were also different from T2b tumors in terms with the frequency of confined cancer (54% versus 40%, p=0.006) and cancer volume (1.78 versus 2.63cm³, p=0.013). However, the those differences were smaller than those in 1992 system. There were no significant differences between 1997 T2a and T2b cancers in the serum PSA level and the frequency of a poorly differentiated cancer. In fact, the 5-years recurrence-free survival rate for patients with T2a (73±3%) was identical to that for T2b cancer.
In a Cox proportional hazard regression analysis, however, neither the 1992 nor the 1997 TNM staging subclassifications of T2 cancers were independent predictor of PSA non-progression when the age of patient, serum PSA level and biopsy Gleason grade were included in the analysis.
(Conclusion) Since a palpable tumor less than half of one lobe (1992 T2a) has a distinctly different pathological and prognostic significance compared to T2b and T2c cancers, the T2a subclassification should be retained in future revisions of TNM staging system. However, because the digital rectal examination provides limited information, both PSA results and histological grade in a biopsy specimen should be incorporated into future revision of the TNM staging system.

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(Purpose) Prostate-specific antigen (PSA) is an important tool in the diagnosis of prostatic cancer and also is an essential marker for observing the therapeutic effect and clinical course. Though the conventional limit of PSA measurement was 0.1ng/ml it recently became possible to determine PSA by means of a 3rd generation high sensitive PSA assay with the detectable sensitivity as highly as 0.003ng/ml. The clinical utilities of this highly sensitive PSA was examined in this study.
(Methods and Subject) In 51 patients with fresh untreated prostatic cancer diagnosed during the period from November 1996 to March 2001 and for whom endocrine therapy was selected, PSA (Tandem-R) and highly sensitive PSA (DPC Imrise 3rd generation kit) were determined at regular intervals.
(Results) According to the nadir for highly sensitive PSA, the subjects were divided into 3 groups, Group, the nadir below 0.01ng/ml, Group II, the nadir between 0.01 and 0.1ng/ml and Group III, the nadir of 0.1ng/ml or more. PSA failure was observed in none of Group I (0/10), 3 out of 19 cases in Group II and 10 out of 21 cases in Group III. Highly sensitive PSA failure was observed 3 out of 11 cases in Group I and 5 out of 19 cases in Group II. Furthermore highly sensitive PSA failure subsequently progressed to PSA failure in 3 cases.
(Conclusion) As for the clinical usefulness of highly sensitive PSA in patients with prostatic cancer during endocrine therapy, We propose that; (1) Nadir of highly sensitive PSA might be useful as an index for predicting the prognosis of prostatic cancer and (2) highly sensitive PSA failure could predict a possible recurrence of cancer relatively earlier than PSA failure.

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(Background) In patients with prostate cance, radical prostatectomy specimen frequently exhibits non-organ confined disease. We should detect clinically significant small cancer to cure the patients, because tumor volume is one of factors with respect to progression of prostate cancer. The distribution of clinically significant small cancer foci of the prostate was studied to determine an adequate sampling portion in needle biopsy using the maps of radical prostatectomy specimens.
(Materials and Methods) Thirty seven cases with less than 1.5cc tumor volume in the main cancer focus who underwent radical prostatectomy were pathologically evaluated using step-sectioned specimens.
(Results) Seventy three clinically significant cancer foci with less than 1.5cc tumor volume were recognized. Fourty six of 73 foci (63.0%) exsisted only in the lateral aspect of the prostate compared to 14 foci (19.2%) only in the mid-lobe aspect. The remaining 13 foci (17.8%) exsisted in both aspects. Moreover, 53 of 73 foci (72.6%) were detected in lateral aspect of the middle and apex of the prostate.
(Conclusion) Systematic biopsy including sampling of lateral aspect in the apex and middle portion of the prostate may improve the detection of clinically significant cancer with small tumor volume.

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(Objectives) Renal arteriovenous (AV) fistula is uncommon, but sometimes causes severe hematuria. To assess the value of color Doppler ultrasound (CD-US) for the detection of renal AV fistula, we retrospectively reviewed our experience with this disease.
(Materials and Methods) Between 1994 and 2001, five patients with renal AV fistula were diagnosed in our institution. Postbiopsy AV fistula of the transplanted kidney was found in 1 patient. Renal AV fistula was detected in 2 patients who presented with gross hematuria. In the remaining 2 patients, renal AV fistula was discovered incidentally during abdominal ultrasonography. We evaluated gray-scale and CD-US imaging in those five patients.
(Results) In all 5 patients, CD-US showed a whirling flow pattern within an echo-free structure suggesting AV fistula. However, it was difficult to distinguish AV fistula from aneurysm using only CD-US. While pulsed spectral Doppler evaluation of the lesion might be helpful, prompt venous filling on dynamic CT scan and/or renal arteriography was the most definitive sign for diagnosing the renal AV fistula.
(Conclusions) CD-US is excellent for demonstrating turbulent blood flow signals within the kidney. However, another radiographic study is required to give a definite diagnosis of renal AV fistula. Due to its low cost, low risk and wide availability, we recommend that CD-US be the first-line imaging procedure for the evaluation of hematuria and renal cystic lesion as well as for followup for renal AV fistula.

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(Purpose) The present two-tiered study demonstrates first, the value of upper urinary tract sampling in cytological diagnoses, and multiple cold punch biopsies of bladder, in the cases of carcinoma in situ (CIS) of the urinary tract. The second segment assesses the value of Double-J catheter-based BCG treatment, in the case of positive upper urinary-tract sampling.
(Materials and Methods) We tested a total thirty three patients (26man, 7 woman, median age: 67.8 years) who demonstrated two serial positive voiding cytologies. Cystoscopic investigations of bladder tumors, as well as radiologic studies of the upper urinary tract both yielded negative findings. Cytological samples obtained from upper urinary tract of all 33 individuals were next to subjected to multiple cold punch biopsies of bladder.
(Results) Among the seven patients whose bladders displayed no abnormalities, cytological tests of the upper urinary tract samples determined that 2 of subjects fell into class III, while the other five were diagnosed class V. In 7 other cases diagnosed as suffering from dysplasia of bladder, cytological findings for two upper urinary tract were class I and II, while one case was class III, and 4 others fell within class V. Of the 19 patients suffering from bladder CIS, eight were diagnosed class I or II, three cases as class III and eight other cases, class V, in upper urinary tract cytologies. At the original site of the urinary CIS, the bladder was affected in 11 cases, the upper urinary tract in 9 patients, and a combined attack on the bladder and upper urinary tract, in 8 others.
Of seventeen patients whose upper urinary tract samples produced positive reading, thirteen had had double-J catheter run from bladders to renal pelves as well as treatment consisting of the intravesical instillation of BCG. From thorough cytological evaluations, we learned that the urine of eleven of these 13 individuals, which initially tested positive, had turned negative following intravesical instillation of BCG. Although bladder vesicles proved susceptible to certain minor irritations and slight fevers were not uncommon on treatment-days, such side effects disappeared, once BCG treatment ended.
(Conclusions) From painstaking observations, it was concluded that cytological investigations of the upper urinary tract were indispensable to the proper diagnosis of urinary tract CIS, and that intravesical BCG treatment with Double-J catheter is both safe and effective when treating the patients suffering from upper urinary tract CIS.

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(Purpose) We evaluated both efficacy and feasibility of laparoscopy-assisted live donor nephrectomy.
(Materials and Methods) Since September 2000, 11 living kidney donors (2 males and 9 females) underwent laparoscopy-assisted live donor nephrectomy. All of sides were left. Gasless surgery was performed with a 7cm pararectal upper abdominal incision and three trocars via a retroperitoneal approach, After creating the working space using balloon dissection technique, the abdominal wall was lifted using a metal retractor attached to the margin of the abdominal incision. Additionally, a metal plate, which was attached to the abdominal wall inside, was raised. The surgeon dissected left kidney from the skin incision under both direct vision and magnificated view on the monitor.
(Results) The operating time, estimated blood loss and warm ischemic time were a mean of 209 minutes, 219g, and 4.2 minutes, respectively. The mean times for the return to a normal diet and unassisted ambulation were 1.3 and 1.8 days, respectively. One case required blood transfusion due to subcutaneous hematoma at trocar entry site on the second day after surgery, in the remaining 10 cases there were no complications. All of donated kidneys achieved immediate function after engraftment.
(Conclusions) Gasless laparoscopy-assisted donor nephrectomy is recommended and advantageous for healthy kidney donors as a minimally invasive method.

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As a result of the Westernization of life style in Japan, the incidence of pulmonary embolism (PE) has been increasing, mainly after surgery and vessel catheterization. We encountered 4 cases of PE associated with urological surgery and angiography during the 3 and half years since 1995; one occurred after nephrouretectomy, one after TUR-P, and two after abdominal angiography. Three patients recovered from PE, but the other is still on a respirator. As risk factors of PE, 3 patients were over 60 years old, one was obese, two had hypertension, and one had atrial fibrillation (Af). Three patients were given tranexamic acid (AMCA). Prophylactic procedures against PE, such as intermittent compression devices for the lower extremities and low-molecule heparinization, are recommended for high-risk patients. AMCA should be used with care in patients who undergo surgery and angiography.

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Percutaneous nephropyelostomy is commonly performed prior to endoscopic procedures, such as percutaneous nephrolithotomy or endopyelotomy. We report a case of colonic perforation, complicating percutaneous nephrostomy, which was managed conservatively.
A 10-year-old girl was admitted to our hospital for the diagnosis of ureteropelvic junction obstruction. The first percutaneous nephrostomy with sonographic guidance was performed for evaluating renal function. About three weeks later, the second percutaneous nephrostomy with fluoroscopic guidance was performed for endopyelotomy. The tract was dilated to 26F incision was made at the ureteropelvic junction without any problems. A nephrostogram, taken 53 days later, revealed a large amount of contrast material in the colon. Abdominal CT scan showed that the nephrostomy tube had passed through the most posterior aspect of the ascending colon. A double-J ureteral stent was placed and the nephrostomy tube tip was withdrawn to lie in the colon. A retrograde pyelography, taken next day, showed no communication between the colon and the right kidney. After 2 days, the tube was removed and no further complications occurred.
Reports of percutaneous iatrogenic colonic perforation are rare. The etiology and treatment of this complication are discussed.

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A 65-year-old housewife presented with a diagnosis of malignant spindle cell tumor of the bladder which had been diagnosed by work up for chance hematuria. Urine cytology revealed a small number of squamous epithelial cells showing dyskeratosis but no spindle cells. Computed tomography and magnetic resonance images showed a markedly enhanced mass, 4cm in diameter, on the anterior wall of the urinary bladder, which appeared to be adhesive to the pubic bone. However, no metastasis was found. Under the suspicion of sarcoma of the urinary bladder, we performed anterior pelvic exenteration with construction of an ileal conduit. Although the anterior wall of the urinary bladder was mildly adhesive to the pubic bone, the surgical margin was negative for malignant cells. The tumor corresponded to a fibrosarcoma that infiltrated the adipose tissue surrounding the urinary bladder. The entire mucosa of the bladder showed diffuse squamous metaplasia, and well differentiated squamous cell carcinoma with pearl formation was found in part. These two malignant tumors were clearly apart from each other, resulting in the histologic diagnosis of synchronous multiple malignant tumors of the bladder. The patient developed a local relapse and pulmonary metastasis of fibrosarcoma one month postoperatively and died two month later without any response to chemotherapy (CYVADIC) and radiotherapy. The current case seems to be the first one in Japan (third in the world) of a patient with multiple synchronous primary malignant tumors, carcinoma and sarcoma, arsing in the urinary bladder.

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A 70-year-old man with poorly controlled diabetes mellitus, and an elevated serum prostatic specific antigen, underwent transrectal prostate biopsy. He received one dose of cefotium before, and three doses of cefotium (1.0 gram every 12 hours intravenously) after prostatic biopsy. He was doing well until postbiopsy day 1, when he developed high fever, dysuria and lower abdominal pain. His perineal area exhibited black-purpish discoloration. On postbiopsy day 3, laboratory data showed leukopenia and DIC. Operative findings during laparotomy on the same day, included malodorous cloudy fluid and tissue edema involving the perivesical space. Intraoperative tissue cultures as well as postoperative cultures of blood and drainage revealed Escherichia coli. serotype O-6. Despite maximal supportive therapy, the patient developed multiorgan failure and died on the tenth postbiopsy day. This patient's history and hospitalization course suggests that transrectal prostatic biopsy induced Fournier's gangrene.

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A 13-year-old boy with ulcerative colitis was admitted to our hospital for the purpose of controlling diarrhea. He had received total colectomy and had been managed by intravenous hyper alimentation because of severe diarrhea (10 times/day). Oral intake had been prohibited except for fluid. Abdominal CT scan incidentally revealed two small calculi in the left kidney, which were left untreated. Two months later, one of them descended and was impacted into the urethra. Transurethral cystolitholapaxy showed the stone composition to be pure ammonium acid urate. Although ammonium acid urate lithiasis is rare in Japan, it should be reminded as a complication of chronic diarrhea secondary to inflammatory bowel disease in children.

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