In order to evaluate the relative importance of clinicopathological factors for survival of patients with urinary bladder cancer, two multivariate analyses were undertaken on 121 patients initially treated at Nagoya University Hospital from 1973 to 1982. The factors included in the analyses were sex, age, symptoms, interval between the onset of symptoms and first consultation, and six tumor characteristics such as location, size, number, shape, grade and stage.
Using Hayashi's quantification theory (type II), the authors found that the three major determinants of prognostic importance were stage, tumor size and grade in this order. At the same time multiple regression analysis demonstrated that approximately 40 percent of variability in the prognosis could be explained by stage alone. When the remaining nine factors listed above were included, the accuracy increased only to about 50 percent, indicating that stage is the single major determinant of prognostic significance in urinary bladder cancer. Grade seemed to be less important for prognosis in multiple regression analysis, since grade was closely associated with stage, with a significant positive correlation coefficient of 0. 689. The contribution of stage to survival was relatively large for the first and third post-operative years, and decreased slightly thereafter. As the contribution of stage decreased, the prognostic importance of grade and tumor location tended to increase.
The authors believe that the overall results of the present multivariate analyses confirm the prior clinical impressions both quantitatively and objectively. It is therefore concluded that improved prognosis of patients with bladder cancer requires accurate staging of the tumors, together with selection of appropriate treatment procedures based on this staging.

View full abstract

During the past 4 years, we have adopted tubeless ureterostomy as a main urinary diversion method on patients with maligmant disorders.
Twenty-five cases (34 ureters) were operated on by this tubeless ureterostomy method. Operative success was achieved in 84% of the cases. (excellent 65%, fair 15%)
Two major complications leading to failure of the treatment were stomal and ureteral stenosis. Although leakage at the junction of uretero-ureterostomy occurred in 4 cases, we could manage all of them successfully by the conservative catheter indwelling.
However, problems of ureteral stenosis remained unsolved.

View full abstract

From January 1957 to March 1984, 713 patients with bladder tumor were treated at Osaka University Hospital and the clinical statistics of the first occuring tumors were herein described. These 713 cases included 10 of adenocarcinoma of urachal origin, 41 of flat carcinoma, 7 of inverted papilloma 4 of diverticulum tumor and 4 of non-epithelial neoplasms. The results were summarized as followings:
1. Age distribution was from 14 to 88 years old with the average±standard deviation of 58.7±12.2. In female patients, the tumors were found at older ages than in male patients. The male to female ratio was 4.1:1.
2. Subjective complaints were gross hematuria, symptomatic or asymptomatic, in 88.8%, pain at micturition in 20.3%, frequency of urination in 22.2%, disturbance of urination in 6.6% and others in 4.4%.
3. Endoscopically multiple bladder tumors were observed in 42.5%. Small tumors (below 1cm in diameter) constituted 8.9%, medium sized ones (1 to 3cm) 41.7% and large mass (more than 3cm) 49.4%. Papillary tumors with stalk were found in 44.0%, papillary sessile tumors in 31.7%, non-papillary with stalk in 2.6% and non-papillary sessile ones in 21.7%. The main tumors located at lateral wall in 42.9%, trigonal area including ureteral orifice in 27.7%, posterior wall in 17.9%, vault in 6.6%, bladder neck in 3.1% and anterior wall in 2.8%.
4. Apparent metastasis at distant organs were revealed in 13 cases and lymph node involvements in 31 cases.
5. Histologically 93.6% of the tumors was transitional cell type. Adenocarcinoma and squamous cell carcinoma constituted 3.2% and 1.6%, respectively. Others included non-epithelial type and inflmmatory lesions, the latters were certainly misdiagnosed due to inadquate pathological specimens.
6. From comparative study of clinical and pathological stage, it could be said that there was a tendency of overstimation at preoperative diagnosis.
7. Between pathological stage and grade of malignancy, there was significant correlation by chi-square test.
8. Correlation of stage or grade of the tumors and chief complaints, size, multiplicity, shape and location was studied by chi-square test. With the progress of the stage or grade, the patients noticed cystitis-like symptomes, the size of the tumors increased, multiple tumors became frequent, and all these findings were statistically significant.
9. The treatments applied to the first tumors were total cystectomy for 173 cases, partial cystectomy, for 148 cases, tumor resection or mucosal denudation by cystotomy for 30 cases, transurethral resection for 259 cases and transurethral coagulation for 34 cases. In 68 cases, the treatments were non-surgical procedures. Irradiation was performed in 58 patients, as a definite treatment for the tumors in 25 cases, as preoperative irradiation in 8 cases, for prophylaxis to intravesical recurrence in 20 cases. The procedures were for the treatment of metastatic lesions in 3 cases and for postoperative prophylaxis of intrapelvic regrowth in 2 cases. Bladder instillation of cytotoxic agents was performed in 83 cases, most of them were to prevent intravesical recurrence. General administration of anti-cancer agents was also applied in 44 cases, for prevention of intravesical recurrence or distant metastasis in most of the cases, but in 12, the administration was as the main therapeutic modality.
10. The relative survival rates after the first treatments were 75.3%, 71.9%, 64.7% at 3, 5 and 10 years, respectively. These rates, of couse, depend on the character of the tumors and the treatments. Detailed description of this problem will be given elsewhere.
11. Intravesical recurrence rate after bladder sparing operation was calculated by actuarial method. The cumulative recurrence rates were 50.9% at 3 years, 61.5% at 5 years and 73.9% at 10 years, regardless of the application of intravesical instillation or external irradiation for prophylaxis.

View full abstract

Clinical and pathological studies were performed on 37 autopsy cases of bladder tumor encountered at bur hospital from February 1965 to December 1983.
Histological examination revealed transitional cell carcinoma in 26 patients (70.3%), squamous cell carcinoma in 6 (16.2%), adenocarcinoma in 2 (5.4%), anaplastic cell carcinoma, primary malignant lymphoma and metastatic bladder tumor each in 1 patient each (2.7%).
Metastasis was noted in 30 of the cases (81.1%), and occurred frequently in lymph nodes (56.7%), liver (50.0%), bones (40.0%), lungs (36.7%) and colon (23.3%).
In 17 lymph node metastasis, the most frequent sites of occurrence were paraaortic nodes (11 cases), pelvic nodes (8 cases) and tracheo-bronchial nodes (5 cases). Eight cases which had lymphvascular invasion in resected tumor had distant metastasis at autopsy. A patient receiving curative operation died of metastasis of bladder tumor 37 months postoperatively. This case indicated the importance of long term clinical follow-up.
Only 27 of the deaths were attributed to carcinomatosis, other reasons including sepsis, uremia, pneumonia, fruminant hepatisis in 2 patients each, and acute myocardial infarction and gastro-intestinal bleeding in one patient each. Seven patients had multiple cancers.

View full abstract

In cumulative dose-response studies, spontaneous contractions of muscle strips from bladder detrusor and bladder base of the rabbit were significantly inhibited by isoproterenol, β-adrenoceptor agonist and terbutaline, β2-adrenoceptor agonist. There was no difference between the two regions in sensitivity to isoproterenol or terbutaline. There was no difference between isoproterenol and terbutaline in responses from detrusor and bladder base muscle strips, either. Dobutamine, β1-adrenoceptor agonist caused small relaxant response in bladder base muscle strips at the dose of 10^-4M, which was similar to the effect of isoproterenol at the dose of 10^-7M. The results suggest that there is no significant difference in distribution of β-adrenoceptor between detrusor and bladder base and that β2-adrenoceptor predominantes in the urinary bladder smooth muscle.

View full abstract

Scanning electron microscopic exfoliative cytology (SEM cytology) was performed on 147 urine specimens from 78 patients with malignant or non-malignant urothelial diseases (17 well-differentiated bladder tumors, 3 poorly-differentiated bladder tumors, 24 followed-up patients previously undergone TUR-Bt, 13 prostatic carcinomas and benign urothelial diseases). Urinary exfoliated cells could be classified into 8 types by their shapes and surface features-namely, superficial transitional cell, immature superficial transitional cell, atypical transitional cell (ATC) with pleomorphic microvilli, superficial squamous cell, immature superficial squamous cell, atypical squamous cell, smooth surfaced cell and bleb-forming cell. About 100 exfoliative cells were observed on each urine specimen, and percentages of each cell type were calculated.
Supposing that more than 3% of ATC is positive in SEM cytology, this method's specificity and sensitivity for bladder tumor were 89% and 58%, respectively. However, if its sensitivity was confined to the well-differentiated bladder tumor, its sensitivity was 71%. After the comparison of results between SEM cytology and Papanicolaou cytology (LM cytology) on urine specimens from the same patients, the sensitivity of LM cytology was high (78%) for poorly-differentiated tumor, and the sensitivity of SEM cytology was also high (77%) for well-differentiated tumor. In the followed-up cases who had formerly undergone TUR-Bt, 46.7% of patients who showed positive SEM cytology had recurrence, and on the contrary only 7.1% of those who showed negative results had recurrence. In conclusion, this study suggests that SEM cytology is superior to LM cytology in the cases of well-differentiated bladder tumor. Moreover, this may be a useful screening method for early detection of recurrent bladder tumor of well-differentiated type in followed-up cases.

View full abstract

The clinical usefulness of TPA as a tumor marker for bladder tumors was investigated in serum (S-TPA) and urine (U-TPA) by comparing with carcinoembryonic antigen (CEA) and Carbohydrate antigen 19-9 (CA19-9). TPA levels were evaluated using RIA-kit by the two-antibody technique. The positive rate for bladder tumors was 56% (19/34) in S-TPA. This diagnostic rate was superior to that of CEA, CA19-9 (in S and U). S-TPA was useful for assessment of clinical course and early detection of metastases in patients with urinary diversion following total cystectomy.
On the other hand, although diurnal variation of U-TPA was present, there was a good correlation in U-TPA levels between 24hr-urine and morning spot urine. Therefore, U-TPA levels of morning spot urine were utilized for this study. U-TPA levels in patients with bladder tumors were significantly higher than those of non-malignant groups. Although U-TPA levels were elevated by infected urine among 22% of patients with benign diseases, positive rate of U-TPA for bladder tumors was 96% (24/25), which was superior to that of S-TPA and urinary cytology. While the values of U-TPA before and after TUR-Bt were compared, post operative U-TPA levels decreased significantly and a good correlation was found between U-TPA levels and tumor growth. U-TPA was available for screening of bladder tumors, diagnosis of histological biology and surveillance of patients following TUR-Bt.
Although further studies are required to assess the values of TPA, combined studies of TPA in serum and urine should be used for better monitoring of bladder tumors.

View full abstract

We studied 44 over 80 years old patients with benign prostatic hyperplasia who underwent surgical treatment during the past 8 years from 1978 to February 1985. Various surgeries were performed in the 44 patients: TUR in 25 patients, retropubic prostatectomy (RPP) in 9, and the combined method in 6 and cryosurgery in 4. The average operation times were 123.6, 87.8, 82.7 and 15 minutes in RPP, TUR, combined method and cryosurgery, respectively. The average blood losses during RPP, combined method, TUR and cryosurgery were 1063, 750, 400 and 27ml, respectively. Drug induced hepatitis which was recognized in 4 cases of TUR was the most frequent postoperative complication. There was no postoperative complication in combined method prostatectomy and cryosurgery. There was no postoperative death. The average postoperative admission periods were 28.5, 25.1, 22.2 and 18 days in TUR, RPP, combined method and cryosurgery, respectively. The average weight of the resected adenoma was 55.4, 50.3 and 22.4 gm in RPP, combined method and TUR, respectively. There were 2 patients with the resected adenoma weighing more than 100gm. The average duration of postoperative indwelling catheter was 13.5, 9.3, 7.3 and 7.2 days in cryosurgery, RPP, combined method and TUR, respectively. The average duration of post-operative hematuria was 5.5, 4.8, 4.7 and 2.8 days in TUR, cryosurgery, RPP and combined method, respectively. The average duration of wound drainage was 6.8 and 3.8 days in RPP and combined method, respectively. There was only one incidental carcinoma found in the resected adenoma in pathological examination (2.3%). We conclude from these data that combined prostatectomy is a favorable surgical procedure for over 80 years old patients with benign prostatic hyperplasia.

View full abstract

In our hospital 39 patients who had histologically made diagnosis of carcinoma in situ of the urinary bladder had been followed up. Of 39 patients, 25 were primary carcinoma in situ and 14 had past history of bladder carcinoma. Of 39 patients with carcinoma in situ, 33 were men and 6 were women. They ranged in age at the time of diagnosis from 33 to 77 years, with average of 59.5 years. Of 25 patients with primary carcinoma in situ, 22 (88%) complained of symptoms of bladder irritation (pain on urination and/or pollakiuria), and eight patients complained of gross hematuria, but one patient had no symptom, except for positive cytology. Urinary cytology was positive in 37 (95%) of 39 patients with carcinoma in situ. Cystoscopic examination revealed no overt tumor in any patient. But cystoscopic abnomalities which were erythematous and slightly raised velvety lesions with poorly defined margins were noted in 35 patients (90%). Total cystectomy was performed in 25 (64%) of 39 patients as primary treatment. In addition, 8 patients underwent total cystectomy after failure of other primary treatment. Of 33 patients received total cystectomy, the tumors were entirely in situ in only 12 (37%) histologically, and the tumors showed microinvasion or massive invasion in 21. Five-year and ten-year survival rates of 39 patients with carcinoma in situ were 64.4% and 48.3%, respectively.

View full abstract

Sixty-two patients underwent catheterless ureterocutaneostomy as the method of urinary diversion at the Department of Urology, Wakayama Medical College in the 11 years from 1972 to 1982. The follow-up period ranged from 4 days to 108 months, median 16 months. The primary pathological condition was bladder cancer in 30 patients, uterine cancer in 22 patients, other pelvic malignancies in 7 patients and benign disease in 3 patients. We used 4 types of ureterocutaneostomy. Transuretero-ureterocutaneostomy was done in 3 cases, bilateral ureterocutaneostomy through a single stoma in 15 cases, bilateral ureterocutaneostomy with two stomas in 5 and unilateral ureterocutaneostomy for one available kidney in 39 cases.
Stomal stricture developed in 19 cases (31%) which necessitated periodic dilatation, stomal revision or catheter drainage. Eight of these patients required ureteral intubation. Catheterless drainage was maintained in 48 patients. Twenty-one patients (34%) were completely free from stomal trouble, deterioration of renal function and urinary tract infection.
Postoperative complications except for stomal stricture occurred in 38 patients (62%). These complications included wound infection, pyelonephritis, gastrointestinal bleeding and so forth.
Long-term results of ureterocutaneostomy in 9 cases were compared to those of ileal conduit urinary diversion in 24 cases. The urographic deterioration was not seen in the ureterostomy group, while 14.4 percent of renal units deteriorated in the ileal conduit. Pyelonephritis occurred in both groups and it was associated with stomal stricture in the ureterostomy group. Renal calculus developed in the ileal conduit group but not in the ureterostomy group. In ureterocutaneostomy stomal stricture was the only main problem.
Although patients with a dilated and thickened ureter are good candidates for catheterless ureterocutaneostomy, it should be challenged for normal ureter after suitable improvement in the future.

View full abstract

Herein 35 cases of congenital mechanical obstruction of lower urinary tract experienced in these 16 years were reported. I. Posterior urethral valve (7 cases) was treated by TUR in all with satisfactory result. In a few cases ureteroneocystostomy was necessary for VUR. II. Anterior urethral valve or diverticulum (6 cases) was treated by urethroplasty in 2 and by TUR in 4 both with satisfactory result. In 2 re-TUR was necessary for incomplete resection of distal lip. III. Anterior urethral stricture (20 cases) was found predominantly in bulbous urethra (“ring”). TUR was performed in most of them with satisfactory result. Re-TUR was added in 4. In a case Johanson's operation was performed for tight stricture. IV. Female distal urethral stenosis (DUS, 2 cases) was treated by bougie with satisfactory result including disappearance of unihibited contraction of bladder.
Although prevalence of VCU, urodynamics and development of miniature endoscope made it easier to diagnose and to treat these diseases, evaluation of examinations and TUR need prudence and experience. Furthermore, in some cases, it must be noted that staged operations were also necessary.

View full abstract

To find whether computer tomography (CT) can determine the composition of urinary calculi, we measured the CT values of 47 calculi in vitro and 26 calculi in situ.
The results are as follows;
1) CT values (Hounsfield Unit) of various stones which were measured in vitro (mean ±s. d.) were as follows; mixed calcium oxalate and calcium phosphate (the mixed stone) 1555 ±193H, magnecium ammonium phosphate (MAP) 1285±248H, cystine 757±114H, uric acid 480H.
2) In situ the peak CT values of various calculi were almost the same as those in vitro, but the mean CT values were slightly less.
3) From these results we concluded that cystine and uric acid stones can be identified by the CT value. With regard to the mixed stone and MAP, it is almost impossible to identify these stones especially when they reveal the CT values of 1100-1500H. However, stones with the peak CT values of more than 1500H were rarely MAP and often the mixed stone, and those with the mean CT values of 1000-1100H were rarely the mixed stone and often MAP.

View full abstract

Forty cases of primary hyperparathyroidism were operated from October, 1968 to September, 1984. There were 25 males and 15 females with the highest age incidence (11 cases) at thirties. Thirty-seven of them were of the stone type, two of the bone type and one of the chemical type. In the stone type, the preoperative laboratory data often showed borderline values of serum calcium (or ionized calcium) and phosphorus. The neck exploration was indicated if the higher value of serum calcium and/or the lower serum phosphorus concentration were noted more than a few times in several estimations and additionally the abnormal result was obtained in at least one of the examinations including parathormone in blood, %TRP, serum alkaline phosphatase, calcium loading test and urinary excretion of calcium and/or phosphorus. CT and ²⁰¹T1-chloride scintiscan were valuable in the preoperative localization of the parathyroid lesions.
At the operation, it was extremely important to get aquainted with surgical anatomy of the parathyroid glands. It should be noted that the upper parathyroid gland is usually located at the periphery of the inferior thyroid artery flowing into the thyroid lobe at the posterior and extremely medial aspect-just adjacent to the trachea or the esophagus. Therefore, the thyroid lobe must be adequately exposed and pulled away meddially so that one can fully explore the posterior medial aspect of the thyroid lobe.
Among the 37 cases of the stone type, abnormal parathyroid lesions were found in 31 cases, in which only one stone recurrence was observed postoperatively. In the remaining 6 cases, parathyroid disorders were missed either because of inadequate exploration or abnormal anatomy of the parathyroid glands. Stone recurred in the postoperative follow-up in 4 out of these 6 cases.
The bone type required the longest postoperative period before normalization of calcium and phosphorus metabolism, while the stone formers due to parathyroid hyperplasia revealed the quickest recovery in this respect. The case of parathyroid adenoma causing urinary calculi was situated intermediately between the above-mentioned two types in the recovery of metabolism of calcium and phosphorus.

View full abstract

A combined therapy of irradiation and 8MHz radiofrequency hyperthermia using Thermotron-RF Model 8 was carried out in a total of 26 patients with urological malignancies; 9 renal cancers, 1 renal capsular tumor, multiple liver metastatic lesions of renal cancer, a postoperative mediastinal metastasis of renal cancer, 2 ureteral cancers associated with bladder cancers, 4 bladder cancers, 4 prostatic cancers, a postoperative local recurrent tumor of an adult type Wilms' tumor, and multiple skin metastatic lesions of a penile cancer. Previous therapies were unsuccessful, or surgical interventions were not indicated because of poor general conditions. They were irradiated with daily 1.8 to 2.0Gy, 5 times a week, or daily 2.0 to 4.0Gy twice a week. Hyperthermia was induced twice a week within one hour after each irradiation, in total 10 times for 5 weeks. Intratumoral temperature was kept between 42.0 to 44.0°C. Clinical efficacy was evaluated by CT, ultrasound and biochemical data. Partial tumor regression, defined as the regression of 50% or more, was obtained in one of the 9 renal cancers, in the mediastinal metastasis of renal cancer, 2 of the 4 prostatic cancers, one of the 4 bladder cancers and the 2 ureteral cancers, CR was obtained in the 2 associated bladder cancers. As side effects, a mild skin burns and anorexia were observed in approximately 50% of the cases. Subcutaneous fat tissue indurations occurred in 6 of the 30 patients, who had 15 mm or more thickness of subdermal fat tissues, after treatment.

View full abstract

Observations by computerized tomography (CT) of parenchymal changes following nephrolithotomy using one-layer interrupted parenchymal suture (Taguchi) revealed the site of incision and suture to have undergone changes that could be divided into the following three types; no change or a linear low density area in the parenchyma (Type I); a long, narrow strip of low density area (Type II), and a wedgeshaped low density area or depression of the parenchyma (Type III). The present study deals with measurements of variations of serum lactic dehydrogenase (LDH) activities and isoenzyme patterns in 14 cases after nephrolithotomy to see their relationship, if present at all, with renal parenchymal disorder in a late stage. For controls, 11 cases of coagulum pyelolithotomy and open renal biopsy were used. In the group of nephrolithotomy, postoperative serum LDH activities rose transiently with a peak on the 3rd postoperative day, returning to within normal range by two weeks. LDH₁/LDH₂ ratio also reversed temporarily (infarct pattern), but returned to normal in one week. There was no significant correlation noted between variations of LDH activities and the clamping time of renal pedicle and the length of the parenchymal incision. In each CT pattern studied, LDH activities and LDH₁/LDH₂ ratio tended to attain higher levels in Types II and III than in Type I, but without statistical significance. Thus, we have reached a conclusion that both serum LDH activities and LDH₁/LDH₂ ratio cannot be a valid indicator for the delayed development of parenchymal damage after nephrolithotomy despite their evident increase as compared to controls. Among cases in the group of coagulum pyelolithotomy, a few showed an increase in LDH activities and a reverse in LDH₁/LDH₂ ratio, presumably due to manual compression applied to the parenchyma prior to the removal of the coagulum.

View full abstract

Congenital neurogenic bladder, not associated with meningomyelocele, is a relatively rare entity, distinctly different from the latter in its diagnosis, treatment, and complications. Herein, some problems of treatment and complications of our 21 cases, experienced in the last eight years, are reported. Of the 21 cases, 18 had spina bifida occluta, 11 sacral dysgenesis, 3 congenital scoliosis. There were 9 cases that had so-called “tethered cord syndrome” with occult spinal dysraphism. The chief complaints were urinary incontinence and symptoms of urinary tract infection. The cases of tethered cord syndrome were urologically managed like those of meningomyelocele, although the indication and timing of operation must be decided carefully. In the cases of sacral dysgenesis, association of various genitourinary and anorectal anomalies were characteristic. Urological management of these cases were more complicated than in meningomyelocele, since these assosiated anomalies often dictate the treatment plans.

View full abstract

During a recent 6-year period 74 male patients underwent cystectomy for bladder carcinoma. Of these 74 patients, simultaneous urethrectomy was done on 9 patients. Of the remaining 65 patients who had only total cystectomy, 7 (10.8%) had clinically suspected urethral reccurrence. Five of the 7 patients died of cancer 2 to 26 months (mean 9.6) after urethral reccurrence. Four of the 5 patients died of metastatic disease, only one death was directly related to the urethral reccurrence. We considered prophylactic urethrectomy in all male patients undergoing cystectomy may be avoided. We discussed the management of the urethra in male patient who have undergone cystectomy.

View full abstract

Successful management of advanced retroperitoneal fibrosis by a ureteral substitution in a 56-year-old female is described. She had taken Senna as a purgative every day for over 10 years. She had dull pain in the left flank since February 1982 and in the right flank since January 1983. Her doctor diagnosed bilateral hydronephrosis in February 1982, but she had no further examination or treatment. In October 1983 the patient was transfered to our clinic because of non-functioning left kidney and marked right hydronephrosis. Right nephrostomy was performed for improvement of renal function. Antegrade pyeloureterography demonstrated a tapering stricture of the right ureter near the crossing of the iliac artery. A No 5 French ureteral catheter could not be passed through the narrowing of the ureter at 10cm proxymal from the ureteral orifice. On computerized tomogram the contrast material in the right ureteral leumen was surrounded by thick tissue. In February 1984 right uretero-ileocystostomy was performed. AT the operation the right ureter was enveloped by tough fibrous tissue, and was felt so hard like a string at the area of the obstruction that the obstructive portion of the right ureter was resected. On histological examination the fibrous tissue covering the ureter consisted of fibrosis with round cell infiltration. The ureteral mucosa exhibited a squamous metaplasia. The musclaris of the ureter was also affected by chronic inflammatory process and marked fibrosis. Convalescence was uneventful. The patient was well without obstruction 8 months after the operation.

View full abstract