Preoperative determination of the staging of renal cell carcinoma is extremely important for decision of treating methods including operative techniques. In the present study we classified the stages of renal cell carcinoma by means of computed tomography (CT), which proved to be of great value as diagnostic aid. The results obtained are described below.
The subjects of the present study consisted of 20 patients with renal cell carcinoma who were seen at the Jikei University Hospital during the 15 months period from January 1979 to March 1980. Their age ranged from 44 to 76 years. There were 13 men and 7 women. The affected side was left in 14 cases and right in 6 cases. CT was carried out using Somatom, with scanning time 4.5sec and section thickness 0.7 or 0.8cm. In each of the 20 cases the stage was classified according to the system of Robson. Five cases were rated as stage 1, 4 cases as stage 2, 3 cases as stage 3A, 2 cases as stage 3B, one case as stage 3C, 2 cases as stage 4A, and 4 cases as stage 4B. In 18 of these cases, thus diagnosed stage was compared with the findings obtained at the time of operation, while in one case it was compared with autopsy findings.
In 5 cases the tumor was found to be confined to the renal capsule by CT, which revealed no prominence of renal contour or, if it was present at all, it had a smooth outer surface. In 4 of these 5 cases, the diagnosis as determined by CT could be confirmed by operation, while in the remaining one case the pathological findings revealed infiltration of tumor extending into the perinephric fat.
In 4 cases infiltration of tumor was shown to be extending to the perinephric fat, which was corresponding to the pathological findings in all of the 4 cases. The findings obtained in these cases included remarkably irregular contour of the tumor, blurring of perinephric fat, and thickening of Gerota's fascia.
CT showed an invasion into the renal vein or the inferior vena cava by tumor in 5 cases. These were detected by dilatation of veins and filling defects after contrast enhancement. In 4 of these 5 cases, the diagnosis as determined by CT could be confirmed by operation, while in the remaining one case the operative findings revealed no venous tumor thrombus. In addition, in other one case, in which invasion of the right vein by tumor was noted at autopsy, diagnosis could not be established by CT. Enlarged regional lymph nodes were detected by CT in 5 cases, where metastasis of tumor was confirmed pathologically also.
In 2 cases it was shown by CT that the tumor extended over Gerota's fascia to infiltrate adjacent organs, which could be confirmed by operation. CT revealed hepatic and vertebral metastasis in each one case.
A comparison of the findings obtained at operation and those at autopsy demonstrated that the stage diagnosed by CT was correct in 16 of 19 cases (84%). Therefore, it can be said that CT enables one to diagnose the staging of renal cell carcinoma easily and accurately and provide informations useful for deciding the treating method.

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The clinical, pathologic and survival data were analyzed for 104 patients with renal cell carcinoma treated by nephrectomy with or without adjuvant therapy. Factors influencing prognosis were evaluated.
The patients could be regarded as “fully cured” after 5 years of follow-up, at which time the survival was the same as the survival for a normal population. The prognostic values of individual parameters were evaluated in comparing the “fully cured” patients with the others.
The staging was a most important factor which influenced prognosis. The invasion of the renal vein, hematuria alone, weight of the renal tumor mass, and invasion of the renal pelvis, were also correlated well with prognosis but were of lesser importance than the staging.

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The relationship between calyces and pelvis was studied in vitro throughout the simultaneous recording of electromyograms and pressure changes at the upper and lower major calyx and the renal pelvis.
Low voltage potentials with a constant frequency were recorded at the upper calyx. Pressure changes in the upper calyx were correlated in a one to one manner with the electrical discharge recorded at the upper calyx. On the lower calyx, low voltage action potentials with a constant frequency that differed from the upper calyceal rhythm were recorded at the same time. Pressure changes in the lower calyx were in a one to one fashion with the electrical activity at the lower calyx. These pressure changes of the two major calyces were independent and did not conflict with each other.
The pelvic pressure changes correspond in one to one fashion with the action potentials on the same region and its rhythm differ from those at the both two calyces. Pelvic pressure did not reflect the calyceal contraction. Furthermore, calyceal pressures did not reflect the pelvic peristalsis.
We conclude from those data that there is a sphincter action at the pelvi-calyceal border and it protects the calyx, i. e. pacemaker region, from the renal pelvic back pressure.

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To investigate the action of the autonomic nerves on the proximal urethra, isovolumetric pressure response to electrical hypogastric and pelvic nerve stimulations in the proximal urethra of the female dog was examined in control conditions and after administration of several autonomic blocking agents. The hypogastric nerve was transected just distal to the inferior mesenteric ganglia and the pelvic nerve was transected just proximal to the pelvic plexus. Both nerves were stimulated with bipolar stimulating electrodes (MT. Technical Research Co.) placed at the distal end of the transected nerves.
Hypogastric and pelvic nerve stimulations produced contraction of the proximal urethra. Proximal urethral contraction responses to hypogastric nerve stimulation were blocked by administration of phentolamine and guanethidine, and not influenced by administration of propranolol and hexamethonium. These contraction responses seem to be mediated through the long postganglionic adrenergic fibers which arise from the inferior mesenteric ganglia. Proximal urethral contraction responses to pelvic nerve stimulation were blocked by administration of phentolamine, guanethidine and hexamethonium, and not influenced by administration of propranolol. These contraction responses seem to be mediated through the short postganglionic adrenergic fibers which arise from the intramural ganglia.
These experimental results suggest that adrenergic fibers play an important roll in the resting wall tension of the proximal urethra.

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The author studied the clinical peripheral blood test findings and fibrinolytic enzyme activity in blood and urine of normal persons, used as controls, and patients with macroscopic renal hematuria. The patients were classified into three groups, those with renal hematuria in whom the bleeding side had or had not been confirmed and those with various abnormalities of the perirenal venous system. The activity of fibrinolytic enzyme in blood and urine was determined respectively by the affinity chromatography with lysine sepharose and celite.
The results are as follows:
1) Bleeding tendency and disorder of the coagulation system were not recognized in the three groups with renal hematuria.
2) The levels of activity of antiplasmin, plasminogen activator, plasminogen and FDP in peripheral venous blood of these groups were almost equal to those of the controls. There was no significant difference in activity of the same fibrinolytic enzyme among blood samples taken from various sites such as both renal veins, aorta and antebrachial vein.
3) In the three groups, the 24-hour urokinase (UK) activity was significantly higher than that of the controls. On the other hand, the activity of urinary trypsin inhibitor (UTI) was significantly lower than the controls. UK levels of the affected side were higher than the opposite side, but with respect to UTI there was no difference between the sides for split renal urine.
4) There was no significant difference in fibrinolytic enzyme activity in blood and urine among the three groups.
From these results, it is assumed that renal venous congestion which was found in the group with various venous abnormalities, was also present to some degree in the other two groups with unexplained renal hematuria. It is also considered that renal venous congestion resulting from various mechanisms was the cause of renal hematuria and also had effects on the urinary fibrinolytic enzyme.

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The author performed experimental studies on mongrel dogs to elucidate the mechanism of abnormalities in the urinary fibrinolytic enzyme systems of patients with renal hematuria. Renal venous congestion and ischemia which are considered to be the cause of renal hematuria were induced in dogs by constriction of the renal vein and occlusion of the renal artery. Changes of fibrinolytic enzyme activity in blood and urine by these manipulations were measured. Furthermore, the secretion site of urokinase (UK) and urinary trypsin inhibitor (UTI) were studied by the stop-flow technique.
The results are as follows:
1) Microscopic hematuria was noted in the urine from the treated side during and/or after constriction of the vein and occlusion of the artery, the degree of hematuria being more marked in the former.
2) Significant increases in the UK and UTI levels on the treated side were recognized, whereas significant changes of the fibrinolytic activity were not observed in the blood of treated renal vein and femoral artery. A difference in the secretion modes of both urinary enzymes was noted.
3) UK activity was observed only in fractions with the highest PAH concentration, which was considered to be at the level of the proximal tubule as determined by the stop flow technique. UTI activity was recognized in all fractions and presented a pattern similar to that of urinary protein concentration, and its highest activity was noted in the site which was considered to be the proximal tubule.
On the basis of these results, it is considered that renal venous congestion and ischemia are the causes of renal hematuria. It is also assumed that these abnormalities of renal hemodynamics give rise to UK secretion, and that the site of such secretion is the proximal tubule of the nephron.

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An attempt was made to clarify the regional difference of the morbidity of bladder tumor in Nagano Prefecture.
Clinical records of all patients with primary bladder tumor first diagnosed during the 5 year's period from 1974 to 1978 were obtained from 12 big hospitals located in Nagano Prefecture. Excluding bladder tumor associated with renal pelvic or ureteral tumor and that of non-urothelial origin, 432 cases (330 males and 102 females) were ascertaind.
On the assumption that nearly all patients with bladder tumor in Nagano Prefecture are seen or referred to one of the 12 hospitals, because other medical facilities have few urologists and because geographical circumstance prevents the patients from visiting hospitals outside the Prefecture, approximate morbidity rates related to the age, sex and place of residence were calculated using the results of the census in 1975.
The average annual morbidity of bladder tumor was 6.8 per 100, 000 in male and 2.0 in female (male-female ratio 3.5:1). Limited to the age over 30, it was 12.3 in male and 3.4 in female.
The age related morbidity increased with age in an exponential fashion.
As for regional difference of morbidity, a comparison was made between the urban and rural areas, and among the 10 districts of Nagano Prefecture, each of which has a different climatic and socioeconomic background. There was no significant difference in the morbidity between the urban and rural areas in either sex. In male, a morbidity significantly higher than the average was found in Taihoku district (10.5) and a significantly lower one in Hokushin district (3.8). On the other hand, the morbidity in female showed no significant difference among the 10 districts.

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E. coli: 07 was inoculated into the vesical cavity or submucosal layer of the rat bladder. After several periods of free voiding, the bladder was observed with electron and light microscope.
From the present study, we conclude several roles of polymorphonuclear leukocytes (PMN) participating in the anti-bacterial defense mechanism of the bladder. At the time when bacteria were found in the epithelial cells, PMN began to infiltrate into the epithelial layer. PMN in the epithelial layer were present only in the intercellular space and we could not find phagocytosis of bacteria by them. PMN gathered around the infected cells and isolate them from the normal epithelial cells. In this way, PMN might not only phagocytize the E. coli which could empty to the intercellular space, but also accelerate desquamation of infected cells by means of destroying the junction of epithelial cells.
In the submucosal layer, inoculated bacteria were all phagocytized by the PMN. Though we have not found out infiltration of bacteria inoculated into the bladder cavity beyond the basement membrane of the epithelial layer, if such a condition might occur, we conclude, bacteria would be phagocytized soon by PMN concentrated there.
Some bacteria released from the desquamated epithelial cells and some free bacteria in the bladder cavity may be phagocytized by the PMN released from epithelial layer. Then, free bacteria, bacteria within epithelial cells and bacteria phagocytized by the PMN will be washed out by urination.

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To clarify the possible regional immunity which might represent well the interrelation between tumor and patient with the tumor, the markers and functions of lymphocytes infiltrating in urologic tumors were studied.
For bladder cancer and testicular seminoma, the distributions of B and T-lymphocytes and its subsets, T_M and T_G cells, were examined. In the former case, it was found that all of the patients who were proved to have lung metastasis during 3-18 months' follow up period had significantly reduced T cell proportion among lymphocytes obtained from their tumors compared with that of peripheral blood from the same patients, whereas both in patients who had demonstrated neither distant metastasis nor intravesical reccurrence and those who had intravesical reccurrence, the proportions of T and B lymphocytes did not change significantly between tumor tissue and peripheral blood. The proportion of T_G cells among T cells infiltrating in the bladder tumor was significantly increased when compared with that of peripheral blood from the same patients. In the latter case, the proportions of T lymphocytes and T_G cells were increased compared with those of peripheral blood from the same patients, whereas the proportions of B lymphocytes and T_M cells did not change. As for renal cell carcinoma, T_G cells increased significantly in tumorous venous blood compared with arterial blood. Antibody-dependent cellular cytotoxicity (ADCC) was increased in the lymphocytes from the tumorous venous blood than that of arterial blood, whereas spontaneous lymphocyte-mediated cytotoxicity (SLMC) did not change significantly.
These results might indicate that significantly reduced proportion of T lymphocytes infiltrating in tumor tissues compared with that in peripheral blood was correlated with reduced regional cell mediated immunity of cancer patients and their poor prognosis. However, increased number of T_G cells infiltrating tumors might be contributory to the favorable prognosis of patients in view of ADCC activity attributable to T_G subset. Thus, these parameters might become valuable monitors of the newly available immunological markers reflecting the regional immunity in addition to the general immune status.

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Between May 1976 and July 1980, in 12 patients who had had refractory renal osteodystrophy, subtotal parathyroidectomy was attempted at Social Insurance Chukyo Hospital. The results obtained were
1) Subtotal parathyroidectomy was successfully done in 9 cases but all of the four parathyroid glands were not found in the other 3 cases. The average weight of parathyroid glands of the 12 cases was 2248.1±3197.1 (ranged from 80 to 10500) mg.
2) As postoperative complication, recurrent nerve injury was noticed in 2 cases and pretetanic symptoms in 5 cases.
3) In 9 of the 12 cases, remarkable improvement of symptoms was noticed and in 7 of these 9 cases complete rehabilitation was achieved, but no improvement of symptoms was noticed in the other 3 cases.
4) The average weight of removed parathyroid glands in cases in whom satisfactory postoperative course was noticed (2961.2±3429.6mg) was much greater than that in cases of unsatisfactory results (107.3±24.2mg).
5) Serum PTH values measured preoperatively were useful for diagnosis of secondary hyperparathyroidism in chronic hemodialysis patients.

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