Eight urinary stone formers with primary hyperparathyroidism (PHPT), as evidenced by surgical removal of parathyroid adenoma in every case, and 5 control subjects underwent intravenous CaC1₂ infusion (calcium 12mg/kg/4 hr added to 500ml of 0.9% NaCl)⁸ in order to determine changes in serum magnesium level and urinary excretion of magnesium during calcium infusion.
The infusion was begun at 2 P.M, with sufficient hydration and was continued for 4 hours. Urine samples were collected hourly and blood samples were drawn in the midpoint of each urine collection. Basal values were obtained similarly from 1 P.M, to 2 P.M, prior to the infusion.
The results obtained were as follows: In the normal controls, serum calcium level and urinary excretion of calcium increased continuously to elevated levels, whereas serum magnesium levels remained virtually unchanged. Urinary magnesium excretion increased similarly to the urinary calcium excretion (Table 1, Fig. 1). The patients showed nearly identical changes to the controls with virtually no change in serum magnesium (Table 2, Fig. 2).
In conclusion, we demonstrated a continuous increase of urinary magnesium excretion along with a continuous increase of urinary calcium excretion during calcium infusion in patients with PHPT. It is assumed that renal tubular reabsorption of calcium and magnesium functions normally in patients with PHPT. It is also probable that calcium and magnesium are reabsorbed competitively in the renal tubules although there is an exceptional instance in which dissociation of urinary calcium and magnesium excretion (calcium ↑, magnesium ↓) was demonstrated by administration of acetazolamide⁴.

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Functional enuretics were studied by voiding cystourethrography (VCUG) and cystometry. VCUG was done on 106 cases, and cystometry on 48 cases. Both were performed on 35 cases.
1) All cases had smooth vesical outline at rest. Abnormal base plate at rest was recognized in 14 of 26 cases (53.8%). This finding was often appeared in older children and the prognosis of enuresis was poor.
2) On voiding, the form of the bladder was various. Mural irregularity was recognized in 42 of 106 cases (40.6%), and it was more often in younger children.
3) The constricted bladder neck was recognized in 58 of 106 cases (54.7%). This finding was more often recognized in boys (67.1%) than in girls (23.3%). The diameter of the bladder neck in mid voiding varies from 5mm to 20mm. Girls usually had a wider diameter.
4) The diameter of the prostatic urethra in mid voiding was under 13mm except one case. The diameter of the mid urethra was relatively large, and the functional distal urethral stenosis was considered. The ring-like filling defect was observed in five cases.
5) The author classified voiding cystourethrogram from type I to type IV. Type I had smooth bladder neck. Type II had anterior defect of the bladder neck. Type III had posterior defect of the bladder neck. Type IV had anterior and posterior defects of the bladder neck. In boys type III and type IV were often seen, and in girls type I was usually seen.
6) On cystometry uninhibited contraction was observed in 45.8% of 48 cases, and more in boys. It was considered that girls with uninhibited contraction had high possibility of urinary tract infection.
7) Mural irregularity and constricted bladder neck on VCUG were correlated with abnormal cystometric findings.

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Double inferior vena cava is a relatively rare variation. As we have experienced two such cases recently, we report in this paper our observations obtained chiefly by computed tomography (CT).
Case 1, a forty-nine-year-old man, was admitted complaining of anorexia, general malaise and weight loss. Excretory urogram showed a mass laterally in the left kidney. CT scans difined a mass arising from anterolateral aspect which was considered to be consistent with a renal carcinoma. In addition, two round structures were found on both sides of the aorta of prevertebral space. Subsequent contrast-enhanced scans showed that the round left prevertebral structure was contrast density and received the left renal vein. Inferior vena cavogram demonstrated double inferior vena cava, and the right inferior vena cava joined with the left inferior vena cava at the level of the twelve thoratic vertebra.
Case 2, a thirty-six-year old woman, was admitted for investigation of left renal bleeding. Excretory urogram was normal; however, inferior vena cavogram demonstrated double inferior vena cava joined by interiliac vein. On CT scans, three round prevertebral structures which represent the right inferior vena cava, aorta, the left inferior vena cava were found, and the left inferior vena cava joined with the right inferior vena cava at the level of the upper pole of the kidney.
When two round structures were found on both sides of the aorta by CT scans, it is required to differentiate double inferior vena cava from enlarged para-aortic lymph nodes. In our cases differentiation could be made based on the fact that the right and left renal veins flowed into the right and left vena cava separately and that the density was increased on CT after contrast enhancement. In addition, the findings of confluence of the left inferior vena cava with the right inferior vena cava at the level of the upper pole provide some information.
It is recommended that urologists should evaluate the retroperitoneal venous anatomy by means of CT and vena cavography before operations are made to the inferior vena cava or its surrounding area in such a case as radical nephrectomy, taking into consideration the possibility of the variation of double inferior vena cava.

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Urinary excretion of sodium, potassium, chloride, urea nitrogen and creatinine was measured in the development of the post-DCA hypertension in rats. After discontinuing the treatment of DCA plus 1% saline, polydipsia and polyuria were ameriolated in four weeks.
However, one month after the treatment, post-DCA hypertensive rats excreted a larger amount of electrolytes, urea nitrogen and creatinine than the control. Seven months after the treatment, urinary excretion of electrolytes, urea nitrogen and creatinine reached the control level. Elevated serum urea nitrogen (BUN) and serum potassium were recognized in post-DCA hypertensive rats whose kidneys had arteriolar sclerosis.
On the contrary, BUN and serum potassium were within normal ranges in post-DCA normotensive rats who had histologically normal kidneys.
When the post-DCA hypertensive kidneys were transplanted into normal rats, the blood pressure rose and the high blood pressure persisted for four weeks. After transplanting normal kidneys into the post-DCA hypertensive rats, the blood pressure was normalized and stayed at the normal level for four weeks. In the experiment in which the normal kidneys were transplanted into the post-DCA hypertensive rats, without removing the recipients' right kidneys, the blood pressure change was divided into two groups. In the one group, the blood pressure was normalized. In another group, the blood pressure stayed at a high level.
As a result of the renal transplantation, BUN and serum potassium in the high blood pressure group were higher than the normalized blood pressure group after the transplantation. Moreover, nephrosclerotic changes in the high blood pressure group appeared severer than the normalized blood pressure group.
These results suggest that the excretory dysfunction of the post-DCA hypertensive kidneys which showed the arteriolosclerotic changes may be the cause of this hypertension.

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Experimental studies simulating ambithermic condition during renal ex vivo surgery were performed by means of histopathology, electron microscopy, microangiography, tissue culture, LDH in perfusate and renal autotransplantation in dogs.
As for perfusates at the time of initial flushing, lactate Ringer solution, hyperosmolar intracellular electrolyte solution (Sacks solution) and mannitol added hyperosmolar (430 mOsm) lactate Ringer solution were selected.
These experiments demonstrated relative superiority of Sacks solution over the other solution in preventing renal deterioration during renal ambithermia.
Although renal ischemic damage during ambithermic condition was prevented by flushing ice-cold Sacks solution after nephrectomy, renal protective effect of Sacks solution was not complete if ischemic time exceeds 6 hours and suggested the necessity of cumbersome surface cooling during surgery in such cases.

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Various operative methods have been proposed to treat benign prostatic hypertrophy, but the results of these procedures have several problems to be discussed clinically because they remove adenoma only. Some of them are prolonged postoperative hematuria, secondary hemorrhage, postoperative long term existence of urinary tract infection, interference with normal micturition, especially nocturnal frequency and occult carcinoma.
To resolve these problems, I have carried out a new surgical method “Retropubic Prostato-Vesiculectomy” to remove adenoma as a mass involving a part of the posterior capsule and seminal vesicle in 205 consecutive cases of prostatic hypertrophy.
The therapeutic results were as follows:
1. Patients age ranged from 49 to 88 years with an average of 70.8±6.0 years.
2. One hundred and five patients (51.4 per cent) had associated disease or a significant medical history.
3. The operating time ranged from 56 to 140 minutes with an average of 92.7±17.5 minutes.
4. The average operative blood loss was 916±609ml.
5. Postoperative macroscopic hematuria continued for 1.9±4.2 days on the average, and none of the patients had secondary hemorrhage.
6. The urethral catheter was removed 10.59±6.03 days postoperatively on the average.
7. Postoperative pyuria continued for 5.83±3.10 weeks on the average.
8. Postoperative stay in hospital ranged from 11 to 130 days with an average of 27.5±14.6 days.
9. After two months postoperatively, nocturnal frequency was reduced to be almost normal.
10. Postoperative complication rate was 30.7 per cent in this series.
11. Mortality rate was 0.98 per cent in this series (2 deaths resulted from brain hemorrhage).
12. Ten patients (4.9 per cent) had carcinoma of the prostate on pathological examination of the tissue. None of them represented recurrence except one who was revealed to be stage C histologically.

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Six cases of extensive ureteral disorders were corrected by the renal autotransplantation technique. They were ureteral obstructions caused by retroperitoneal fibrosis (2 cases), localized amyloidosis (1 case) and postoperative stricures (3 cases). After surgery, hydronephrosis disappeared or improved and urinary tract infection disappeared in all six cases.
Renal autotransplantation is an excellent procedure to correct ureteral disorders and to preserve renal function. Advantages of using renal autotransplantation technique are (1) direct restoration of pelvo-uretero-vesical continuity by pelvoureterostomy, by uretero-ureterostomy or by ureterneocystostomy is possible. (2) these procedures can be performed in fresh operative fields. (3) any lesion of any length and/or location can be corrected.
Indication of renal autotransplantation as a reconstructive operation of upper urinary dranage system and its operative details is also discussed.

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Although vertical interrupted parenchymal suture for nephrotomy is thought to be a well defined technical procedure, damage to the postoperative function of the kidney can not be disregarded. Experimentally I have studied the effect of nephrolithotomy on renal function with special reference to microcirculation using microangiography.
Fourteen kidneys in 14 dogs were subjected to renal bivalve incisions made from the upper to the lower pole and deepened sufficiently to allow access to the pelvis. This incision was made in the convex border of the kidney. The kidney was reconstituted using a continuous pelvic suture and also vertical interrupted parenchymal sutures. The contralateral kidney was not treated. All operated kidneys had 30min of ischemia. The results were summarized as follows:
1) The influences of the nephrotomy on the vascular system were slight.
2) In the group 2 weeks after operation, a large wedge avascular area near the incision could be seen. In this area, histopathologically, necrotic tissue was recognized. AV-fistula were seen in some cases.
3) In the group 2 months after operation, the large wedge avascular area disappeared. But the renal cortex became thinner.
4) From the point of view of the contact microangiogram, in the 2 weeks group, the minor vasculature was dilatated, tortuous and deviated in the area of parenchymal sutures. And in the 2 months group, the number of glomeruli decreased in the same area.
5) In the 500μ section of the contact microangiographic specimens, the individual glomerular area (gA), the number of glomeruli (No. Gl.) and total vascular area (TVA) which is the sum of the glomerular area (GA) and the vascular area (VA) were measured with a πMC Particle Measurement Computer System. GA (No. Gl×average individual glomerular area) and VA (TVA-GA) were calculated. In the area of parenchymal sutures, there was a decrease of TVA, especially GA in the 2 weeks group, and in the 2 months group, there was a marked decrease of GA compared with the control group. The latter was due to a marked decrease of the number of glomeruli.
Thus, vertical interrupted parenchymal sutures decreased the number of functional glomeruli and I concluded that this was not the ideal operative procedure following nephrotomy.

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In the former report, I concluded that the vertical interrupted parenchymal sutures were not the ideal operative procedure following nephrotomy.
Therefore, in this experimental study, I established the new operative procedure following nephrotomy.
Fifteen kidneys in 15 dogs were operated on. Nephrotomy was performed similarly to the former procedure and the collecting system was closed with a continuous suture. Vascular sections were ligated with transfixion sutures and paired on the cut surface. Several pairs of ligatures were not cut off, and after hemostasis was obtained, they were tied up together in pairs, and the capsule was closed over the incision by a continuous suture. Bleeding from the section was uncommon. The average ischemic time was about 50 minutes and the contralateral kidney was not treated. The results were summarized as follows:
In the immediately sacrificed roup, the contrast medium slightly leaked out to the operated section, but the vascular tree could be followed to the minor arteries. In the group 2 weeks after operation, leakage of the contrast medium disappeared, the avascular area seen in the former procedure was not observed and vascular structures of the operated kidney resembled those of the control group. Histologically the tissue damage was seen only in the narrow area. In the 2 months after operation, the operated kidney was almostly similar to the group 2 weeks after operation and the size and weight at the operated kidney were almost identical to the contralateral kidney.
In the same manner as the former report, the individual glomerular area, the number of glomeruli and total vascular area were measured in the area of nephrotomy. There was a slight decrease of total vascular area and the number of glomeruli, but the degree of decrease in the new procedure was smaller than that in the vertical interruped parenchymal suture. The average individual glomerular area had no change compared with the control group.
In the clinical study, ten kidneys were operated on using a new operative procedure. The kidneys were compared between preoperative and postoperative status using a CT scanning.
As a result, the same results were obtained in the experimental study using a microangiography.
Therefore, I believe that the new operative procedure for nephrolithotomy is better than the vertical interrupted parenchymal suture.

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ABH isoantigens are widely distributed in various normal tissues including urothelium. These isoantigens have served as natural labels for the study of antigenic alterations associated with malignant transformation. We examined 79 bladder tumors of various grades and stages for the presence or loss of ABH isoantigens, to investigate the effect of malignant transformation on the distribution of these surface antigens in transitional cells of the bladder. For detection of the antigens specific red cell adherence test with slight modifications and immunofluorescence technique were used successfully. There was a high degree correlation between the histological grade and the retention of the antigens, although 17 of 47 grade I tumors lost the antigens completely. In a follow up study of 25 cases of grade I, stage O-A, initial transitional cell carcinoma, the presence of the antigens correlated with a lower recurrence rate, while the loss of the antigens correlated with a higher recurrence rate and subsequent invasion. Therefore, the analysis of the isoantigens in bladder tumors may be valuable for prediction of malignant potential, especially in the low grade and low stage tumors.

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Recent advances in tumor biology of renal cancer, obtained in estrogen dependent tumor of hamster, leads to a clinical utilization of progesterone and testosterone as adjunct therapy for human renal cancer, and now it is generally recognized that some patients respond to endocrine therapy to a certain degree objectively or subjectively.
At present, however, there is no knowledge about what kind of patient should be selected for this therapy or which of the steroids is indicated. To answer these questions, direct measurement of progesterone receptor (PR) and androgen receptor (AR) was carried out in the cytosol of 8 normal renal tissues and 25 renal cell carcinoma tissues.
PR and AR were detected mainly by dextran coated charcoal (DCC) method, utilizing synthetic progesterone and androgen, R5020 and R 1881 respectively.
Specific binding molecules to R5020 detected by DCC assay were determined 7-8s sedimentation constants with sucrose density gradient centrifugation. And the ability to this binding was not inhibited by cortisol competitively. For these reasons, it was confirmed that the specific binding protein was not a corticosteroid binding globulin (CBG) but PR itself.
Specific binding protein to R 1881 detected by DCC was 8-9s molecules with sucrose density gradient. This binding was not inhibited by estradiol, therefore, the contamination of serum sex hormone binding globulin (SHBG) was avoided. But it was slightly inhibited by progesterone and R5020 competitively. Therefore, it was thought that AR was detected with non-negligible contamination of PR.
The results obtained were as follows:
1) PR was detected in all 8 normal kidneys. PR contents were lower in those below 50 years of age than in those over 50.
Out of 25 renal cell carcinoma tissues, PR was detected in 7 cases (28.0%). There was no correlation between the presence of PR and age, sex, cell type or malignancy.
2) AR was detected in 5 out of 8 normal kidneys. Since AR-negative 3 kidneys were normal portion obtained by nephrectomy due to renal cancer, it was speculated that some unknown endocrinological change had already processed in normal portion of tumor bearing kidneys.
Out of 25 renal cell carcinomas, AR was detected in 11 cases (44.0%), and no obvious correlation was found between the level of AR and the histological character of the tumor.
3) In 6 cases, comparative study of concentration of these receptors in cancerous tissue against their normal counterpart was performed and it was revealed that in 4 cases, AR concentration was higher than that in normal controls, but lower or almost equal in other 2 cases. On the other hand, PR was surely detected in all 6 normal tissues but not detected or lower in malignant part of these specimens. This finding might show the disappearance of the differentiated biochemical function accompanied by malignant transformation.

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Two cases of pheochromocytoma, one in a 7 year-old child and the other in a 70 year-old woman were reported. The former was the youngest and the latter the oldest surgical case in Japan.
Case 1: A 7 year-old boy was admitted to our hospital due to easy fatigability, hypertension and excessive sweating lasting for one year. Physical examination revealed a clever well-nourished boy with normal body developments. He showed proteinuria and elevated basal metabolic rate. The urinary excretions of catecholamines were elevated and phentolamine test was positive. Tomograms after pneumoretroperitoneum revealed a mass in the upper abdomen. With the suspicion of an ectopic pheochromocytoma exploratory laparotomy was performed. Surgery revealed a fist-sized tumor located behind the vena cava and bilateral renal vein, lateral to the aorta and anterior to the vertebral column. The tumor was removed completely. Both adrenals were normal and were not resected. Pathological diagnosis was a pheochromocytoma arising from the organ of Zuckerkandl. Convalescence from the surgery was uneventful and all the symptoms disappeared. The postoperative level of urinary noradrenalin was still high, although less in amount. The excretions of catecholamines returned normal 2 years after surgery. He was well without any signs of recurrence for 5 years.
Case 2: A 70 year-old woman with a history of hypertension for 2 years was referred to our hospital because her hypertension was difficult to control. Physical examination disclosed an elevated blood pressure of 2 76/140, pulse deficits and sclerotic arterial walls. Routine laboratory studies revealed a high fasting blood glucose level, proteinuria and glucosuria. Glucose tolerance test showed a diabetic pattern. The urinary excretions of catecholamines were elevated. Phentolamine and abdominal massage tests were positive. Abdominal aortography revealed a mass measuring 5×4cm in the right adrenal region. Surgery was performed under the diagnosis of right adrenal pheochromocytoma. An adrenal tumor, weighing 35gm and 4.2×4.0×2.8cm in size was removed. Histology was a typical pheochromocytoma of the right adrenal gland. She recovered from the surgery without anycomplications. Although all the laboratory data returned normal, mild hypertension lasted after surgery. Hypertension, however, was easily controlled by anti-hypertensive agents.
In the Japanese literature, we have found 31 children and 34 elderly people suffering from the pheochromocytoma. The analysis of these cases showed that pheochromocytomas were more frequent in the males than in the females in the children and the reverse was true in the elderly people.
Malignant pheochromocytoma occurred in 14 (40%) of the 35 elderly cases and only in 2 (6.3%) of the 32 children. Signs and symptoms were more manifest in the children than in the aged. The clinical signs were scanty in the aged and it was not unusual that the hypertension was the sole symptom. Results of surgery were satisfactory in children (28 of 30, 93.3%) compared with those of the aged (11 of 15, 73.3%), The infrequent signs and symptoms in the elderly cases may cause the delay of diagnosis which, in turn, may explain the lower rate of surgical cure. The early diagnosis and prompt treatment is desirable for the elderly people with this disease.

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