Endourological evaluation and management of leukoplakia of the renal pelvis.

Since August 1989, we have seen 4 patients with leukoplakia of the renal pelvis associated with a longstanding renal stone. In 2 of them, excretory or retrograde pyelography revealed multiple filling defects in the left renal pelvis as well as a renal stone, although urine cytological examination was negative. One of the other 2 patients underwent extracorporeal shock wave lithotripsy (ESWL) for the renal stone, but this was not followed by the passage of stone fragments. The renal stone in the remaining patient was associated with staghorn calculi. For stone extraction as well as endoscopic evaluation of the intrapelvic lesion, percutaneous nephroscopy was performed. A small to large amount of tissue-like white debris in sheets characteristic of leukoplakia was found in the renal pelvis with stones embedded in it and was removed directly by forceps or suction and then by irrigating with saline. We propose that 1) the endourological approach should be recommended for patients with renal pelvic lesions associated with longstanding renal stones or for patients who show difficulty in passing stone fragments after ESWL and 2) this entity of leukoplakia should be kept in mind for the differential diagnosis of renal pelvic lesions associated with renal stones.

[Endourology update].

In urology, endoscopic surgery and laparoscopic surgery are generally named as endourology. Transurethral endoscopic surgery was originated in mid 19th century, and established by 1950s. At present, transurethral resection of the prostate, transurethral resection of the bladder tumor, transurethral incision of the urethral stricture, transurethral vesicolithotripsy, and transurethral ureterolithotripsy, were commonly performed in many urological clinics. Percutaneous nephrolithotripsy and extracorporeal shock wave lithotripsy were introduced in 1980s, and now, open operation for urolithiasis are rarely performed. In 1990s, as a new endourologic procedure, laparoscopic operations are being increasingly applied to the treatment of urological diseases; for example, laparoscopic pelvic lymphadenectomy, laparoscopic varicocelectomy, laparoscopic exploration of non-palpable testis, laparoscopic nephrectomy, and laparoscopic adrenalectomy etc. Of the variety of treatment modalities available, the most effective and least invasive method should be selected appropriately. So, we anticipate the further advancement in minimally invasive therapy, interdependently with our sufficient experience and skills.

Preoperative cystometrography in patients with clinical benign prostatic hypertrophy.

Preoperative water cystometrograms obtained from 437 patients with benign prostatic hyperplasia (BPH) were examined in a retrospective study. The cystometrographic results were analyzed regarding the preoperative clinical features: the patients' age, presence or absence of urinary incontinence, history of urinary retention, and rate of residual urine. Their prognostic value in terms of improvement in voiding difficulty and postoperative urinary incontinence was also analyzed at 1 and 6 months after elective transurethral resection of the prostate (TURP). Of these patients, 263 (60.2%) had detrusor instability (group I), whereas 174 did not (group II). Vesical denervation supersensitivity (Vds) to bethanecol chloride was noted in 47 (12.5%) of 375 patients. The observed difference in clinical features was significant between the two groups, with group I being older (P < 0.01) and showing a greater incidence of urinary incontinence (P < 0.001) and retention (P < 0.001). The difference seen between groups I and II in terms of mean bladder capacity (P < 0.01), compliance (P < 0.01), and a greater positive rate of Vds (P < 0.001) was also significant. The clinical and cystometrographic parameters studied worsened with advancing age of the patients. Although the majority of the patients (94.7%) were relieved of obstructive symptoms after TURP (6 months later), 113 (25.9%) showed no relief at 1 month.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bladder calculus after augmentation ileocystoplasty in children].

Of 12 children who had undergone augmentation ileocystoplasty for treatment of neurogenic bladder, 3 developed bladder calculi 9 to 19 months after the operation. All these 3 children had simultaneously undergone procedure to ensure urinary continence together with ileocystoplasty, and postoperative persistent bacteriuria was found in these 3 children. Component of bladder calculi was magnesium-ammonium phosphate in 2 and calcium phosphate in the other child, and all were successfully removed by endoscopic lithotripsy. These data suggest that postoperative persistent bacteriuria as well as procedures to ensure urinary continence might play a role in the formation of bladder calculus after augmentation cystoplasty.

The relevance of preoperative cystometrography in patients with benign prostatic hyperplasia: correlating the findings with clinical features and outcome after prostatectomy.

Preoperative water cystometrograms in 437 patients with benign prostatic hyperplasia (BPH) were examined in a retrospective study. The cystometrographic results were analyzed regarding the preoperative clinical features: patient age, presence or absence of urinary incontinence, history of urinary retention and rate of residual urine. The prognostic value in improvement in voiding difficulty and postoperative urinary incontinence was also analyzed at 1 and 6 months after elective prostatectomy. Subjective symptoms of the patients were the primary reasons for prostatectomy, the majority of which were performed by a single competent resectionist (K. T.) who evaluated the outcome but was blinded to the cystometric findings. Of these patients 263 (60.2%) had detrusor instability (group 1), while 174 did not (group 2). Vesical denervation supersensitivity to bethanechol chloride was noted in 47 of 375 patients (12.5%). The difference in clinical features was significant between the 2 groups, with group 1 showing older patient age (p < 0.01), and a greater incidence of urinary incontinence (p < 0.001) and retention (p < 0.001). The difference between groups 1 and 2 in mean bladder capacity (p < 0.01), compliance (p < 0.01) and a greater positive rate of vesical denervation supersensitivity (p < 0.001) was also significant. The clinical and cystometrographic parameters studied worsened with advancing patient age. Although the majority of the patients (94.7%) were relieved of obstructive symptoms after transurethral prostatectomy (6 months later), 113 (25.9%) were not at 1 month. Compared to 324 patients with early improvement (74.1%), those without improvement at 1 month were characterized by older age (p < 0.01), greater prevalence of preoperative incontinence (p < 0.05), retention (p < 0.01), greater residual rate (p < 0.05), a less compliant bladder (p < 0.01) and a higher positive rate of vesical denervation supersensitivity (p < 0.05). Cystometrographic findings, however, had no relevance to late (6 months) outcome of voiding difficulty. On the other hand, postoperative incontinence was noted in 100 patients (22.9%) at 1 month after transurethral prostatectomy, with the majority having episodes similar to those experienced preoperatively (70.0%) as well as detrusor instability (87.0%). They also were older (p < 0.01), and had a less compliant bladder (p < 0.01) and a higher positive rate of vesical denervation supersensitivity (p < 0.01) than did continent patients. Only 18 elderly patients (4.1%) remained incontinent 6 months later, all with a less compliant (p < 0.01) and more unstable (p < 0.01) bladder initially. The genesis of this detrusor dysfunction was believed to be aging in male patients, in whom BPH evolves and progresses. In conclusion, preoperative cystometrography in patients with BPH is valuable in that it correlated well with the clinical features and it can predict to some extent the outcome of obstructive symptoms and urinary incontinence after transurethral prostatectomy.

[Preoperative cystometric analysis of benign prostatic hyperplasia--special reference to the natural history and postoperative outcomes].

Four hundred and thirty-seven patients with benign prostatic hyperplasia selected for elective prostatectomy underwent preoperative cystometry. Of these patients 263 (60.2%) had bladder instability, who tended to be more irritative and more obstructive in their preoperative objective assessment than the others. Forty-seven patients (12.5%) revealed vesical denervation supersensitivity, of these patients all but one had bladder instability. Significant correlation was found between occurrence of the bladder dysfunction and the severity of obstruction. The occurrence of both bladder dysfunction developed with age. Four hundred and fourteen patients (94.7%) had successful outcome in voiding postoperatively, but elderly patients with low bladder compliance and severe emptying failure tended to need several months in their recovery. Postoperative incontinence was found in 100 patients (22.9%) with high incidence of preoperative bladder instability in the early phase, but was reduced in most cases 6 months later. Eighteen prolonged incontinent cases showed high incidence of low bladder capacity and low compliance with instability at preoperative cystometry. In these cases, the incidence of elderly patients was higher than that of dry cases. It is concluded that most of these bladder dysfunction is secondary to the infravesical obstruction which depends upon severity and duration of the disease, but aging also appears to play a role in its appearance. We assume that detrusor instability represents a kind of compensation for infravesical obstruction, and that the development of denervation supersensitivity indicates that the bladder damage is severely progressing.

Detection of missing vesicoureteral reflux with bethanechol chloride-aided voiding cystourethrography.

Experience in the detection of absent vesicoureteral reflux with bethanechol-aided voiding cystourethrography is presented. The detection rate with conventional contrast-enhanced voiding cystourethrography among 9 study subjects, in whom vesicoureteral reflux otherwise was highly suspected from accompanying clinical, urographic and endoscopic features, and in whom it was absent contralaterally or bilaterally, was improved from 33 per cent (only 3 of 9 patients were positive for reflux) to 100 per cent (all 9 were proved to have vesicoureteral reflux) after bethanechol stimulation. Some representative cases are presented and the mechanisms of inducing vesicoureteral reflux with bethanechol are discussed as well as its clinical relevance. Bethanechol-aided voiding cystourethrography is suggested as a highly sensitive method to detect absent vesicoureteral reflux.

[Clinical evaluation of ofloxacin in the treatment of acute cystitis].

Ofloxacin (OFLX) was administered to 236 female patients with acute cystitis. Of them 164 patients who satisfied the criteria proposed by the UTI Committee, Japan were examined for the efficacy of the treatment, but all cases were included in the study of the side effects of the drug. In the 65 patients who received 300 mg (3 divided doses) of OFLX per day, the overall clinical efficacy was excellent in 66.2% and moderate in 33.8% of the patients. In the 99 patients who received 600 mg (3 divided doses) of OFLX per day, the overall clinical efficacy was excellent in 79% (P less than 0.076) and moderate in 18.2% of the patients. No failure of the treatment was observed in the two groups. Of 164 bacterial strains isolated from the urine of the patients, 132 strains were identified as E. coli. All bacterial strains were eradicated in the urinary specimens by the treatment. Subjective side effects were observed in 8 (3.4%) of the 236 patients. Gastrointestinal disturbance was complained by 6 patients. No drug-related aggravation in the laboratory test was observed except for one patient who showed mild leukopenia reduced from 3700/mm3 to 2200/mm3. These results showed that the oral administration of OFLX was excellent and satisfactory in the treatment for acute cystitis.

[Assessment of prostatic weight by means of computed tomography and urethroscopy].

Preoperative determination of prostatic weight in patients with prostatic hyperplasia is important in determining the choice of the surgical technique used. Prostatic volume determination with CT scans, using the ellipsoid formula, appears to be quite accurate. CT scanning of the prostate gland was performed in 34 patients with prostatic hyperplasia (2 cases with cancer). All scans were performed with a Toshiba TCT-60A-30 scanner, and were made for 10 mm slices as follows. From the CT image the maximum transverse diameter (a) sagittal diameter (b), and the maximum transverse area (S) were easily determined. The long axis was calculated from the bladder neck to the distal edge of the vermontanum by urethroscopy (Fig.1). A rough calculation was given by formula V1 or V2. V1 = pi abc/6 or V2 = 2/3 Sc. Calculated volumes of the prostate were compared with the weight of surgical specimens (TUR-P 27 cases, open surgery 7 cases). A good correlation was obtained by this method, i.e., regression equation V1: y = 1.21x + 9.68 (gamma = 0.9376); V2: y = 1.31x + 10.58 (gamma = 0.9471). This method is considered valuable for preoperative measurement of prostatic size, and is useful when evaluating changes in prostatic volume during non-surgical treatment.

[Clinical and pathological study of renal pelvic and ureteral tumors].

This report is on 25 patients with primary urothelial tumor in the upper urinary tract who were admitted to our hospital from February, 1969 through January, 1983. The patients were 18 males and 7 females with a mean age of 66 years. The affected side was the right side in 11 cases, the left side in 12 and bilateral in 1 case (bilateral asynchronous ureteral tumor). The major symptoms were hematuria (69%) and flank pain (25%), with rare signs of fever. Total nephroureterectomy with bladder cuff was employed as the surgical method in 19 out of 25 cases. We performed conservative surgery in the case of non-infiltrating bilateral ureteral tumor. Pathologically, all 25 patients had transitional cell carcinoma. Over-all survival rate at 3 and 5 years was 64% and 51%, respectively. Our findings coincided with earlier reports by others that the prognosis of primary tumors in the upper urinary tract is related to the grade and stage of the tumor.