(Objectives) Improvement of perioperative management for transurethral resection of the prostate (TURP) by revising the common clinical path was investigated in multiple hospitals.
(Methods) We discussed perioperative outcomes using the common path in 2002 and revised it for 2003. Changes in perioperative outcomes between 2002 and 2003 and differences among hospitals were compared.
(Results) There were no statistically significant differences in age, proportion of patients with mildly impaired activity of daily living and/or impaired cognition, general anesthesia, operating duration, resected weight, incidence of intraoperative complications and blood transfusion between 2002 and 2003. Although there were no differences in preoperative hospital stay, re-hospitalization rate and charges for surgery and anesthesia, Foley catheter was removed significantly earlier from postoperative day 2.9 to 2.3 and total medical charge significantly decreased from 43, 703 to 39, 661 units (1 unit=10 yen). The incidence of postoperative pyrexia increased from 2.4% to 11.2% in 2003, however, the incidences of epididymitis, postoperative bleeding and postoperative difficulty on micturition remained stable. The average and standard deviation of postoperative hospital stay and total medical charge at each hospital decreased, however, differences among hospitals found in 2002 remained in 2003.
(Conclusion) We found that standardization can be accomplished by discussing perioperative management using a common path in multiple hospitals and revising the path as needed. Common clinical path should be a valid method of advancing standardization in Japan.(Objectives) Improvement of perioperative management for transurethral resection of the prostate (TURP) by revising the common clinical path was investigated in multiple hospitals.
(Methods) We discussed perioperative outcomes using the common path in 2002 and revised it for 2003. Changes in perioperative outcomes between 2002 and 2003 and differences among hospitals were compared.
(Results) There were no statistically significant differences in age, proportion of patients with mildly impaired activity of daily living and/or impaired cognition, general anesthesia, operating duration, resected weight, incidence of intraoperative complications and blood transfusion between 2002 and 2003. Although there were no differences in preoperative hospital stay, re-hospitalization rate and charges for surgery and anesthesia, Foley catheter was removed significantly earlier from postoperative day 2.9 to 2.3 and total medical charge significantly decreased from 43, 703 to 39, 661 units (1 unit=10yen). The incidence of postoperative pyrexia increased from 2.4% to 11.2% in 2003, however, the incidences of epididymitis, postoperative bleeding and postoperative difficulty on micturition remained stable. The average and standard deviation of postoperative hospital stay and total medical charge at each hospital decreased, however, differences among hospitals found in 2002 remained in 2003.
(Conclusion) We found that standardization can be accomplished by discussing perioperative management using a common path in multiple hospitals and revising the path as needed. Common clinical path should be a valid method of advancing standardization in Japan.

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(Objective) Stone analysis is an important examination for treatment and prevention of recurrence in urolithiasis. A twenty-six years clinical study of patient with urinary stone formers performed stone analysis was conducted.
(Materials and methods) 1, 108 stone formers (male 726, female 382) who performed stone analysis from 1977 to 2002 was conducted. Location of the stone, sex, age, treatment and stone analysis was examined in this study. Phase 1 is from 1977 to 1983 mainly performed open surgery, phase 2 is from 1984 to 1992 mainly performed endoscopic surgery, and phase 3 is from 1993 to 2002 mainly performed extracorporeal shock wave lithotripsy (SWL).
(Results) Analytic numbers per year increased, especially phase 3. In the treatment of upper urinary tract (UUT) stone, open surgery, endoscopic surgery and SWL was carried out 78.4%, 72.8% and 71.4% of all cases in each phase. Many transurethral lithotripsy were performed for lower urinary tract (LUT) stone. The numbers of UUT and LUT stone were 1, 007 and 101 cases. The frequency of LUT stone was higher than that found in a nationwide urolithiasis survey carried out in Japan in 1995. The male-female ratio of UUT stone was 2.35:1, 1.74:1 in phase 2 and 3. The frequency of female increased in phase 2 more than that in phase 3. The incidence of calcium oxalate stone was increased, calcium phosphate stone and infectious stone was significantly decreased in UUT and calcium containing stone in LUT was decreased. The average age for incidence of UUT stone rose in man step by step. The frequency in male was significantly higher than that in female under 50's, not significantly higher over 50's in calcium oxalate with calcium phosphate stone former (p=0.009).
(Conclusion) In the present study, the clinical features were as follows: important urinary stone analysis, high frequency of LUT stone, high frequency in females, tendency to aging, high frequency of calcium containing stone in LUT, resolution of the difference in male and female over 50's in calcium oxalate with calcium phosphate stone former.

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(Purpose) We reviewed significance of multiple biopsies obtained from bladder mucosa in 59 patients of renal pelvic and ureteral carcinoma treated at Osaka Police Hospital between 1990 and 2003.
(Materials & Methods) The patients consisted of 41 males and 18 females. The median age was 68 years, ranging from 42 to 91 years. Multiple biopsies were carried out in principle to examine the following 5 cystoscopically normal-appearing bladder mucosal sites: (1) trigone, (2) posterior wall, (3) left lateral wall, (4) right lateral wall and (5) dome. Positive case of multiple biopsies was defined as patients having abnormalities in at least one biopsy specimen such as bladder tumor (BT) or dysplasia. Median follow-up period was 54 months.
(Results & conclusions) Of the 59 patients, 6 had positive multiple biopsies. Among them 3 had carcinoma n situ (CIS), and others had dysplasia. 4 patients with positive multiple biopsies had past or concurrent history of BT and received adjuvant intravesical instillation therapy. Positive rate of multiple biopsies significantly differed between patients with and without past and/or concurrent BT (4/15: 27% vs 2/44: 5% p=0.03), indicating that multiple biopsies were useful to detect abnormal lesion accompanied with past and/or concurrent BT. 3-year bladder recurrence free rate was 61%. Postoperative bladder recurrence rate did not significantly differ between positive (1/6: 17%) and negative (20/53: 38%) cases of multiple biopsies. Univariate analysis indicated stage (p=0.03) and venous involvement (p=0.02) to be significant prognostic factors for bladder recurrence free rate, but not multiple biopsies, although multivariate analysis with Cox's proportional hazard model revealed no independent prognosticators. Low recurrence rate of patients with positive multiple biopsies was possibly due to adjuvant intravesical instillation therapy to prevent bladder recurrence.

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(Purpose) There are three kind of assays related to human chorionic gonadotropin (hCG): free βhCG (fβhCG), which is the standard assay for the management of testicular cancer in Japan, intact hCG (ihCG), which detects hCG only, and total hCG (thCG), which detects hCG free-βhCG and possibly other degradation products. We examined the efficacy of thCG assay for the management of testicular cancer.
(Materials and Methods) The simultaneous determination of serum thCG (DPC IMMULYZE hCG), ihCG (hCG ⌈SRL⌋ or (ECLusys hCG STAT)) and fβhCG (BALL ELSA F-βhCG) was performed in 21 patients with germ-cell tumor (18 gonadal tumors and 3 extra-gonadal tumors; 8 seminomatous germ-cell tumors [SGCTs] and 13 non-seminomatous germ-cell tumors [NSGCTs]) during treatment. We examined the correlation, diagnostic sensitivity and efficacy of management with three assays.
(Results) There was no correlation between fβhCG and the other two assays in SGCTs, while there was good correlation among the three assays in NSGCTs. In SGCTs, diagnostic sensitivity was higher in thCG, whereas in NSGCTs diagnostic sensitivity was higher in thCG and ihCG. In 7 patients whose hCG assays were positive at diagnosis, serum fβhCG became negative first during treatment in all patients, but serum thCG and ihCG became negative after about 4 weeks.
(Conclusions) In this study, thCG assay was significant for the diagnosis and management of patients with testicular cancer especially NSGCTs compared with fβhCG assay. This study revealed that thCG assay is appropriate as the standard assay in NSGCTs.

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An infant was referred to our department with complaint of abnormality of the external genitalia. Hypospadias and right inguinal hernia were detected and left testis was palpable, but right testis was not palpable. Chromosomal examination revealed 45, X/46, X, idic (Y) (q 11.2). On ultrasonographic examination, uterus and ovary were not recognized. At one year of age, we performed operation of right inguinal hernia and right cryptorchism. During operation right spermatic cord and epididymis were detected, but right testis was not detected. At two years of age, urethroplasty was performed. After the operation closure of hypospadias fistulas was performed. Now the patient does not have fistulas and has good clinical progress.

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We report a 59-year old male patient who successfully underwent urinary reconstruction by ileal neobladder that was performed 16 years after total cystectomy and ureterocutaneostomy for bladder cancer. He had been suffering from refractory contact dermatitis around the ureterocutaneostomy stoma and was referred to our hospital. In 2003, bilateral percutaneous nephrostomy was performed together with ureteral ligation at the most distal part. However recurrent pyelonephritis developed afterward because of nephrostomy catheter troubles and the patient's quality of life was markedly impaired. Then urinary reconstruction was planned in 2005. Because the urethra had not been resected and remained intact, ileal neobladder (Hautmann's method) was successfully created and he was free from nephrostomy catheter. Postoperatively there has been no recurrence of pyelonephritis.
Long time insertion of nephrostomy catheter causes several complications, such as urinary tract infection and formation of urinary stones. To preserve renal function and improve quality of life, every chance for urinary reconstruction should be sought in those patients who suffer from upper urinary tract catheter troubles.

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A 70-year-old man consulted our hospital complaining of gross hematuria and bilateral hydronephrosis. Cystoscopic findings suggested non-papillary sessile tumor at the bladder neck. CT findings revealed bilateral hydronephrosis caused by the stricture of lower ureters. Tumorous structure existed between bladder and prostate. Abundant fatty tissue was observed around bladder and rectum, the shape of the bladder was distorted to inverted tear-drop and the bladder was transferred anteriorly, showing findings of pelvic lipomatosis. Urethrocystography revealed elongation of prostatic urethra and anterior displacement of the bladder. Transurethral tumor resection was performed under spinal anesthesia. Pathological diagnosis was proliferative cystitis and no malignant cells were observed. Transperineal tumor biopsy also revealed no malignant cells. The patient was followed under administration of “Saireitou” (chinese medicine) and cetirizine hydrochloride, followed by antibiotics and anti-inflammatory enzyme preparations.

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