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Purpose: Recently, various types of radical surgery have been performed in Japan. To elucidate the surgical consequences, morbidity and mortality, and perioperative care, we conducted a nationwide survey., Materials and Methods: Assisted by the Japanese Society of Endourology, perioperative data from 156 hospitals participating in this survey in 2007 were analyzed. Using a spreadsheet database, data were collected from each institution., Results: Open radical prostatectomy was performed in 3,138 patients at 143 hospitals, minimum incision endourological radical prostatectomy in 361 at 15 hospitals, laparoscopic radical prostatectomy via transperitoneal approach in 143 at 11 hospitals and laparoscopic radical prostatectomy via extraperitoneal approach in 337 at 13 hospitals. For open and minimum incision endourological radical prostatectomy, the surgical duration was shorter but the bleeding volume was greater than that in laparoscopic radical prostatectomy via both approaches. As a whole, perioperatvie mortality rate was 0.05% and morbidity rate was 23.4%. Rectal injury was similarly infrequent among the four types of surgery. Superficial surgical site infection was most frequent in open radical prostatectomy. Perioperative management significantly varied among the four types of surgery. In laparoscopic radical prostatectomy via extraperitoneal approach, urethral catheter was removed earlier but acute urinary retention frequently occurred., Conclusions: In Japan, open radical prostatectomy was the most frequently performed surgery for prostate cancer. Surgical volume per hospital was small, however, mortality was low and morbidity was acceptable. Comparisons of complications and outcomes among the types of currently performed surgery should be useful to promote standardization of the perioperative care.

Purpose: Our previous study indicated that there was a great variety in the perioperative management of radical prostatectomy among hospitals. Therefore we conducted a multiinstitutional study in order to standardize the perioperative management using clinical pathways., Materials and Methods: The perioperative data on radical prostatectomy were collected between January and December 2004 (Period 1) from eight hospitals. These outcomes were discussed by researchers and the clinical pathway used at each hospital was constructed or revised. The outcomes using these pathways in Period 2 (January 2005 to March 2006) were compared with those in Period 1., Results: Three hundred seventy-eight men in Period 1 and 360 in Period 2 were enrolled in this study. The settings of perioperative management using the new pathways were relatively similar among hospitals. A majority of perioperative management procedures in Period 2 were conducted as described in the new clinical pathways, judging from the median days. The day of initiating the resumption of fluid intake, meals and removing the epidural anesthetic catheter and drain changed from 1.2 +/- 0.7 to 1.3 +/- 1.4 postoperative day, 1.9 +/- 1.2 to 1.8 +/- 1.7, 2.4 +/- 0.7 to 2.5 +/- 0.6, 3.8 +/- 2.5 to 3.8 +/- 2.8, respectively, without a significant difference. The postoperative day of initiating the walking and discontinuing continuous drip infusion and intravenous antibiotics were shortened from 1.9 +/- 0.9 to 1.5 +/- 0.6, 3.7 +/- 2.1 to 3.1 +/- 2.2 and 3.6 +/- 2.0 to 2.5 +/- 2.2, respectively, which did show a significant difference. The day of removing the urethral catheter was changed 9.1 +/- 4.9 to 8.6 +/- 5.4 without significant difference. But the durations of preoperative hospitalization, hospitalization after removing the urethral catheter and postoperative hospitalization were significantly shortened from 3.4 +/- 2.1 to 2.5 +/- 1.0 days, 8.9 +/- 10.1 to 5.6 +/- 3.8, and 17.9 +/- 10.9 to 14.4 +/- 9.1, respectively., Conclusions: The clinical pathways established or revised at these hospitals after discussing the perioperative management in multiple hospitals were similar, and using such pathways advanced the standardization of peri-operative management after radical prostatectomy.

Purpose: We investigated whether continuous bladder irrigation after Transurethral Resection of the Prostate (TURP) would prevent catheter obstruction by the clot., Materials and Methods: We analyzed data from 761 patients registered in "a multi-institutional study of TURP clinical pathway" sponsored by the Ministry of Health, Labor and Welfare between 2001 and 2003. The difference of clinical backgrounds of the cases, resected weight, operating time, risk of being feverish, risk of catheter obstruction and chance of postoperative Transurethral Fulguration (TUF) between each institution were investigated. The risk factor of catheter obstruction is characterized and the significance of continuous bladder irrigation is discussed., Results: The incidence of catheter obstruction in the four institutions, in which 90% or more of patients underwent continuous bladder irrigation, was significantly lower than that in the three institutions, in which continuous bladder irrigation was performed in selected patients whose hematuria was severe (4.4% VS 12.9%, p<0.001). There was no difference in the frequency of either pyrexia or postoperative TUF. Logistic regression analysis showed that significant factors for catheter obstruction are continuous bladder irrigation, resected tissue weight and preoperative urinary infection., Conclusions: Routine continuous bladder irrigation achieved a lower incidence of catheter obstruction. However, we recommend that urologists should decide whether to perform routine continuous irrigation, considering the frequency of catheter obstruction, safety, labor and cost.

Objectives: The perioperative management of radical prostatectomy in Japan has not been investigated previously. It would be significant to document present management practices., Methods: A questionnaire survey of 1,213 educational institutions of Japanese urological association was conducted by mail., Results: Questionnaires were returned from 722 (60%) institutions and responses indicated that radical prostatectomy was performed in 657 of these institutions (91%). Admission to hospital was most frequently scheduled on preoperative day 2; walking was most frequently planned to be initiated on postoperative day (POD) 1; beginning of food intake on POD 2; termination of continuous drip infusion and drain removal on POD 3, removal of the Foley catheter on POD 7; intravenous antibiotics for three days; oral antibiotics for 7 days; and discharge from hospital on POD 14. However, the duration of the indwelling drain and Foley catheter, antibiotic administration and hospitalization varied widely., Conclusion: There was great variety in the perioperative management of radical prostatectomy among hospitals. We need to obtain consensus on 1) the timing of drain removal, 2) duration of antibiotics, and 3) the timing of catheter removal, in order to uniformly provide medical care of good quality 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 = 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.

We experienced a case of advanced renal carcinoma that showed complete remission to interferon-alpha therapy. A 76-year-old male underwent radical nephrectomy for left renal cell carcinoma (pT3b pN0 M0, stage III). Two and a half months later, chest X-ray, computed tomographic (CT) scan and ultrasonography revealed multiple lung metastases and a hepatic metastasis simultaneously. We started the intramuscular administration of natural interferon-alpha (OIF, 5 MIU) combined with cimetidine everyday. It caused leukopenia, a possible side-effect of interferon-alpha. We reduced the dose to three times a week. The lung metastases and hepatic metastases disappeared after 5 and 12 months, respectively. After we reduced the dose to once a week, there was no evidence of disease for 21 months.

Objectives: We investigated perioperative management for transurethral resection of the prostate (TURP) in Japan., Methods: The questionnaire survey was conducted in 1,213 educational institutions for urology., Results: The questionnaires were returned from 722 (60%) institutions. Admission to hospital was most frequently scheduled on preoperative day 1; termination of continuous drip infusion, starting meal intake and walking on postoperative day 1; intravenous antibiotics for three days; removal of Foley catheter on postoperative day 4; oral antibiotics for 7 days; and discharge from hospital on postoperative day 7., Conclusion: Although hospitalization was 14 days or less at most institutions, several procedures, especially the administration of prophylactic antibiotics, were fairly varied. Discussions from various perspectives might be needed to standardize the perioperative management of TURP in Japan.

Objectives: We investigated the incidence of lower urinary tract symptoms (LUTS) in people consulting a general practice (GP) clinics., Materials and Methods: The questionnaire included 7 questions regarding LUTS and 1 question regarding QOL (QOL index) based on the International Prostate Symptom Score (I-PSS), 3 questions on the Overactive Bladder Symptom Score (OABSS) and 4 questions on the International Conference of Incontinence Questionnaire Short-form (ICIQ-SF) and the survey was conducted among 1,120 people aged 50 or older who consulted a GP clinic., Results: Questionnaires were collected from 958 persons (86%) and the data from 822 (73%) who completed all the above questions were analyzed. There were 364 men (mean age: 67 year-old) and 458 women (68 year-old). Moderate or severe grades on I-PSS and OABSS were indicated in 99 (27%) and 43 (12%), respectively, for men, and 55 (12%) and 40 (9%) for women. Moderately or severely impaired QOL was indicated in 206 (57%) men and 193 (42%) women. Fifty-five (15%) men and 185 (40%) women indicated that they had some type of urinary incontinence. There were 138 (38%) men and 165 (36%) women showing both moderate or severe I-PSS and moderate or severe impairment of QOL, and/or with an ICIQ-SF score greater than 1., Conclusion: When I-PSS and QOL score were used for LUTS screening, 38% of men and 36% of women aged over 50, consulting a GP clinic, had some LUTS which should be assessed to determine whether they need treatment.

Objectives: We conducted a preliminary study to examine the validity of assessment criteria of lower urinary tract symptoms (LUTS) severity for general practitioners (GPs)., Materials and Methods: This study included 194 patients with LUTS, who visited the urology clinics in three hospitals. In 177 who completed International Prostate Symptom Score (I-PSS), International Consultation on Incontinence Questionnaire : Short-Form (ICIQ-SF), frequency-volume chart, uroflowmetry and post-void residual urine measurement, three overall grades (mild, moderate and severe) of LUTS were determined using the newly-developed assessment criteria for GPs. The relationship between diagnoses and treatments by the urologists, and overall LUTS grades were examined., Results: All of the 70 patients with "severe" grade and 68 (94%) of 72 with "moderate" grade were diagnosed as having urination problems. Sixty-eight (97%) with "severe" grade and 64 (89%) with "moderate" grade were treated with fluid restriction, behavioral therapy, and/or drug therapy. Of 35 with "mild" grade, 17 (49%) were diagnosed as having normal urination. In this grade, eight patients (23%) were treated with fluid restriction and 15 (43%) with drug therapy., Conclusions: This preliminary study revealed that our criteria of LUTS severity for GPs were useful to determine whether the elderly patients should be treated or not. It is necessary to examine the validity of the criteria in a model in which GPs participate.

Purpose: We report a technique and outcome of endoscopic trigonoplasty II (ET II), anti-reflux surgery via a transvesicostomy transurethral approach and discuss its usefulness., Materials and Methods: Fifteen female patients, aged 5 to 64, with 23 refluxing ureters (grade I : 5, II : 2, III : 14, IV : 2) underwent the ET II. The principle of this surgery is tightening the muscular backing and elongating the intramural ureter. The operation consists of three steps: 1) two 5 mm locking trocars are placed into the bladder, 2) irrigating with 3% D-sorbitol solution, the bladder wall is incised upward along each side of the ureter using a resectoscope, to make a 2 to 3 cm U-shaped bladder flap including the ureter, 3) under a pneumobladder, the incised wall is sutured to make a muscular bed with a needle-holder via the urethra and forceps via the abdominal trocar. The U-shaped flap is fixed with two distal anchor sutures and four additional mucosal sutures. Urethral catheter is indwelled and the operation is finished. In recent four cases, we closed the tracts endoscopically., Results: The average operative time was 144 minutes per ureter. In one patient with unilateral reflux, we switched to open surgery because of bleeding. Of 22 refluxing ureters, the reflux disappeared in 18 ureters (82%) and improved grade III to I in 1 ureter (5%) after 3 months and disappeared in 19 ureters (86%) after 12 months postoperatively. Ureteral injury was occurred in 3 patients during the transurethral incision of the bladder. Though we repaired it by placing a double-J stent in the 2 patients, reflux recurred in 12 months postoperatively in one of them. In the other patient cystoscopy revealed a vesicoureteral fistula in the injured portion. She subsequently underwent successful open Politano-Leadbetter ureteroneocystostomy. The average duration of indwelling catheter was shortened from 4.3 to 3.0 days by closing the tracts endoscopically., Conclusions: The overall cessation rate of the ET II was inferior to those of open anti-reflux surgeries or laparoscopic extravesical ureteral reimplantation. We do not recommend ET II for vesicoureteral reflux.

Objectives: We performed a systematic review about whether high fluid intake can prevent cerebral and myocardial infarction., Materials and Methods: Previously published papers were searched for in PubMed using the combined terms of dehydration, hydration, water intake, fluid intake, cerebral infarction, cerebrovascular disease, apoplexy, myocardial infarction, angina pectoris, ischemic heart disease, blood viscosity and hemorheology., Results: Of 611 papers searched, twenty-two were selected. There was one prospective randomized study, four prospective non-randomized studies, eight epidemiologic (cohort or case-control) studies and nine retrospective descriptive studies, presenting the following points. Dehydration, which increases blood viscosity, is one of the causes of cerebral or myocardial infarction. Important factors other than dehydration can cause an increase in viscosity. Drinking water during the night can protect an increase in blood viscosity but there has been no evidence that drinking excessive amount of water prevents cerebral infarction. There was one report that the risk of myocardial infarction was lower in people drinking more than 5 glasses of water than those drinking less than 2., Conclusion: Since cerebral and myocardial infarction are primarily caused by atherosclerosis and atheroma plaque, it is essential to adjust life style for prophylaxis. There has been no direct evidence that decrease in viscosity due to high fluid intake can prevent cerebral infarction. Further studies regarding the relationship between fluid intake and ischemic diseases, and the appropriate fluid intake for the elderly to improve their QoL are needed.