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Thirty-eight patients with genuine stress incontinence underwent the Gittes procedures of the bladder neck suspension under ultrasonical monitoring. We performed the following two procedures. Original Gittes procedure: the puncture of the needle made twice through the different holes of the rectus fascia for each side and the bilateral helical suture was tied down separately above the rectus fascia. Modified Gittes procedure: the needle was passed through the rectus fascia once for each side and the both end of the helical suture was drawn up to suprapubic area, then the bilateral threads were tied over the rectus fascia. Original Gittes procedure was performed for twenty-nine patients and modified Gittes procedure for nine patients. Tightness of the suspension was decided by monitoring the posterior urethrovesical angle with use of the transrectal ultrasonography during the operation. A long term follow up survey was made up by means of a questionnaire by the phone or the mail. A total of thirty-six patients responded the questionnaire for a 94.7% response rate. The mean follow up was 33.1 months. 83.3% of the patients were cured and 5.6% were significantly improved. None of the patients claimed dysuria. There was no difference between the continent rates of the two procedures. We conclude that the Gittes bladder neck suspension with use of ultrasonography is effective for correction of female stress urinary incontinence.

Purpose: We investigated the female continence mechanisms by comparing directional differences of static and stress urethral pressure profiles (UPP) in urinary continent females with those in stress incontinent females. Also, the mechanisms of bladder neck suspension were investigated by comparing directional differences of UPP pre- and post-operatively., Methods: UPP at rest and under stress were recorded by means of double lumens microtip transducer catheter in 21 females without urinary incontinence (normal group) and 38 females with stress urinary incontinence (SUI group). And UPP were recorded pre- and postoperatively in 19-females of SUI group who had surgical cure of SUI (ope group). These measurements were performed on the urethral directions (anterior-direction of symphysis pubis, lateral and posterior) to which the pressure sensor in the catheter were pointed. Pressure transmission ratios (PTR) were calculated in each quartile dividing functional urethral length (FUL) into four equal lengths. We compared the parameters (the maximum urethral closure pressure = MUCP, FUL and PTR) when the sensor lies at the anterior, lateral and posterior direction in each group. The parameters in normal group were compared with those in SUI group in each direction and those in ope group were, compared pre- and postoperatively., Results: In all groups, MUCP is always highest in the anterior direction but FUL shows no differences in the three directions. In all directions, MUCP and FUI are higher in the normal group than in the SUI group and there is no significant change in MUCP and FUL following successful bladder neck suspension. In the normal group, PTR of anterior, lateral and posterior urethra were approximately equal, but SUI group patients demonstrated significantly decreased PTR in the lateral and posterior urethra in comparison with PTR observed in the anterior urethra. Also, PTR of the anterior urethra in the SUI group approximates that in the normal group but PTR of the lateral and posterior urethra are lower in the SUI group than in the normal group. In the ope group, in the proximal three-quarters of the FUL, PTR in the lateral and posterior urethra approximated to those in the anterior urethra postoperatively., Conclusion: These findings suggest that urethral support is destructed in the SUI group as mentioned in DeLancey's hammock hypothesis and lateral and posterior weakness were corrected by bladder neck suspension. Bladder neck suspension restored the continence by constructing posterior support of urethra as the substitution for destructed urethral support.

Operative results of ileal neobladder by the Hautmann procedure were studied in the patients with bladder cancer. From 1990 to 1993, 23 patients underwent total cystoprostatectomy for transitional cell carcinomas of the bladder. In 12 of these patients, an ileal neobladder was constructed for total bladder replacement under the following criteria; patients 1) with cancer confined in the bladder (T3b, M0, N0 or less), 20 without carcinoma in situ extending to more than half of urothelium of the bladder, 3) without cancerous lesion in the bladder neck or the prostatic urethra, 4) with performance status of 0 and the age of 75 or less. Pathologically, the disease was grade 2 in 3 patients, grade 3 in 9, stage pT1b in 3, stage pT2 in 4, stage pT3a in 1 and stage pT3b in 4. Two of 3 patients with the disease of stage pT1b had multiple papillary tumors. The remaining one patient had microinvasive cancer that carcinoma in situ infiltrated into submucosal area. Radical cystoprostatectomy and total bladder replacement by Hautmann procedure was performed in all patients. The maximum neobladder capacity was 349.5 +/- 58.1 ml (mean +/- SD). The intravesical pressure at maximum capacity was 30.6 +/- 6.2 cmH2O. At half maximum capacity, the intravesical pressure was 17.1 +/- 6.8 cmH2O. the maximum urethral closure pressure and the functional urethral length were 89.2 +/- 38.1 cmH2O and 25.5 +/- 7.0 mm, respectively. One patient had stress urinary incontinence. Slight nocturnal incontinence was found in 2 patients and nocturia was 1.86 +/- 0.55 times.(ABSTRACT TRUNCATED AT 250 WORDS)

We treated 42 females (26 with genuine stress urinary incontinence, 13 with incontinence and cystocele, and 3 with cystocele) with bladder neck suspension using transrectal ultrasonography during operation. The optimum tightness of suspension was decided by adjusting the posterior urethrovesical angle to about 90 degrees in 26 patients with genuine stress urinary incontinence accompanied with flattened posterior urethrovesical angles and by adjusting the angle of inclination of the upper urethra to about 10 degrees in 16 patients with cystocele accompanied with rotationally descended urethra. Urinary continence was achieved in 35 of 39 patients presenting with urinary incontinence. Three patients with cystocele without urinary incontinence remained dry after the operation. The average of maximum urinary flow rate significantly increased after operation. The angles of inclination of the upper urethra measured on the ultrasonogram during operation corresponded well with those measured on the post-operative lateral urethrocystogram. In 26 patients without cystocele, the angles of inclination of the upper urethra and the posterior urethrovesical angles were correlated significantly on the pre-operative urethrocystograms. Roentgenographic changes in pre- and post-operative urethrocystograms showed concomitant restoration in the angles of inclination of the upper urethra and in the posterior urethrovesical angles as well as significant elevation of the bladder neck. Present results indicate that the angles of inclination of the upper urethra measured by transrectal ultrasonography during operation as well as the posterior urethrovesical angles are useful and reliable to decide the optimum tightness of bladder neck suspension for the patients with stress urinary incontinence accompanied with rotationally descended urethra.(ABSTRACT TRUNCATED AT 250 WORDS)

The urethral pressure profiles (UPP) at rest and under stress, using double lumens microtip transducer catheter, in 17 females without urinary incontinence (normal group) were compared with those in 39 females with stress urinary incontinence (SUI group). And UPP were compared pre- and postoperatively in 21 females of SUI group who had surgical cure of SUI by bladder neck suspension (operative group). Pressure transmission ratios (PTR) were calculated in each quartile dividing functional urethral length (FUL) into four equal lengths. Maximum urethral closure pressure (MUCP) and Functional urethral length (FUL) in normal group were significantly higher than those in SUI group. In normal group, although bladder neck opening under stress (bladder neck incompetence) existed in 41% of them, the PTR in the distal three-quarters of the FUL were significantly larger than those in SUI group and urinary continence was remained in all of them. On the contrary, in SUI group, there was an almost linear decrease in the value of the PTR along the FUL. Therefore, it was suggested that SUI patients might lose distal urethral compensatory mechanisms. The results, obtained from the resting UPP, show that there is no significant change in MUCP or FUL following bladder neck suspension. In contrast, the stress UPP shows that successful operation generated a magnification of the PTR in the proximal three-quarters of the FUL. Only 1 case of post operative group showed bladder neck incompetence. Therefore suspending the bladder neck in a high position might produce the ability to occlude proximal three-quarters of the FUL.

From 1988 to 1992, 78 patients with genuine stress urinary incontinence underwent bladder neck suspension under ultrasonic monitoring. Tightness of suspension was adjusted by setting posterior urethrovesical angle to approximately 90 degree by transrectal ultrasonography during operation. Urinary continence was achieved in 68 of 78 patients. In the remaining 10 patients, slight incontinence recurred within 6 months after operation. In 60 patients undergoing postoperative chain cystourethrogram, the posterior urethrovesical angles set during operation were about the same as those after operation. In 39 patients undergoing uroflowmetry under the condition that micturition volume was 200 ml or more, urinary flow rate did not decrease after operation. In 20 patients whose posterior urethrovesical angles were measured by transperineal and transabdominal as well as transrectal ultrasonography, angles measured by each ultrasonography were almost identical and neither manipulation could change the configuration of the bladder neck. The posterior urethrovesical angles set during operation were kept postoperatively and provided proper tightness of the suspension suture to achieve urinary continence without any difficulty of urination. Therefore, a posterior urethrovesical angle can be set by transperineal and transabdominal ultrasonography as well as transrectal ultrasonography. While transrectal approach provides the clearest image among the three approaches, transperineal and transabdominal approach carried out with a transabdominal convex or sectorial probe are more convenient than transrectal approach which needed a special probe.

During 2 years and 10 months from November 1985 to September 1988, 50 patients with invasive bladder cancer (pT2-4, pN0-2, M0) were treated with total cystectomy followed by adjuvant combination chemotherapy including cis-platinum. In addition, so-called immunopotentiator (OK-432) and Kanpo (Juzentaihoto: TJ-48) were given to the patients in a random fashion to evaluate whether or not these agents had any significant effect on patients' prognosis. The 3- and 5-year survival rates for 48 evaluable patients were 71% and 67%, respectively. Histologic grade of primary tumors and number of cycles of adjuvant chemotherapy administered had a significant correlation to patients' survival: patients with grade 2 anaplasia had a better 3- and 5-year survival rates than those with grade 3 anaplasia, and patients receiving 3 or more cycles of chemotherapy had a better 3-year survival rate than those with 2 or less cycles. pT and pN categories also affected patients' survival, though not statistically significant. Administration of OK-432 or TJ-48 and pre-operative treatment such as irradiation and intra-arterial chemotherapy had no favourable effects on the survival. Side effects of the adjuvant chemotherapy were minimal to moderate and more than 70% of the patients tolerated at least 3 cycles of chemotherapy. It is likely that adjuvant chemotherapy, when given in a post-operative setting, should be repeated at least 3 cycles or more.

Ten patients with urinary stress incontinence were treated by suburethral sling procedure using a polytetrafluoroethylene tube as the sling. The tension of suspension was determined by the post-urethrovesical angle measured by transrectal ultrasonography in each patient. In nine patients, the post-urethrovesical angle ranged from 90 to 110 degrees, and urinary continence of the patients was completely obtained. The remaining one patient whose post-urethrovesical angle was determined as 120 degrees could not obtain complete continence. None of the patients had subjective post-operative disturbance in urination and the peak flow rate of post-operative uroflowmetry hardly decreased in 7 patients in whom this was performed. Although post-urethrovesical angles reduced as the tension which suspended the bladder neck increased, the tension reforming the post-urethrovesical angle was various in each patient. Since one of the aims of suspension of the bladder neck for patients with stress incontinence is reform of the post-urethrovesical angles, correct and reasonable tension of suspension is to be obtained by measuring the post-urethrovesical angle.

We performed percutaneous nephrolithotomy (PNL) on 49 patients between May, 1986 and March, 1987. To investigate acute renal damage from PNL, we measured urinary NAG (N-acetyl-beta-D-glucosaminidase) and gamma-GTP (gamma-glutamyl transpeptidase) activities before PNL and for 6 days after PNL in 24 patients. The NAG activities elevated beyond normal level in 23 patients and gamma-GTP activities in 15 patients. NAG activities showed a peak level in the third day after PNL and gamma-GTP activities in the next day of PNL. After the peak both enzyme activities got down gradually. There was no difference in NAG and gamma-GTP activities between nephrostomy and lithotripsy in 2 staged patients. And the intrapelvic pressure during operation was at the normal level in 5 patients. Therefore, we think that the cause of NAG and gamma-GTP activity elevation is a mechanical damage, not an influence of the irrigation fluid. Large stones, long operation time and 2 stage procedure were the factors that produced high enzyme activities, because, we guess, the frequency of mechanical damages to the kidney increase in such cases. Postoperative pyrexia caused a slight increase in enzyme activities but preoperative hydronephrosis exerted no influence on both enzyme activities. We also measured creatinine clearance before and after PNL but no significant change was obtained. PNL causes only slight mechanical damage to the operated kidney which is reversible when assessed by NAG and gamma-GTP activities and the glomerular function is not affected. Therefore, we conclude that PNL is a safe treatment for upper urinary tract stones.

In 46 patients treated with PNL in our hospital, the intervals from PNL to removal of a catheter indwelled in the nephrostomy were studied. The intervals were longer in the cases with ureteral stones than those with renal stones probably because of the different degrees of obstruction. To investigate the degree and the interval of upper urinary tract obstruction after PNL, Pressure-flow Studies were performed every or every other day after PNL in 5 cases with renal stones and 5 cases with ureteral stones, selected from 46 cases. In Pressure-flow Studies, intrapelvic pressures were measured while saline mixed with pigment was being dripping at a rate of 5 ml/min into the renal pelvis through the nephrostomy catheter. Saline initially reached into the urinary bladder at an average of 4.8 days after PNL (range 3 to 7 days) with a mean intrapelvic pressure of 37.6 cmH2O (range 28 to 52 cmH2O) in the cases with renal stones and at an average of 9.2 days (range 7 to 12 days) with a mean intrapelvic pressure of 27.0 cmH2O (range 9 to 43 cmH2O) in the cases with ureteral stones. Pressure-flow Studies were performed again a few days after the initial passage of saline into the urinary bladder in 2 of 10 cases. The intrapelvic pressures, 16 cmH2O and 13 cmH2O, respectively, several days after the initial passage of saline were lower than those, 35 cmH2O and 43 cmH2O, respectively, at the initial passage of saline. Therefore, it was likely that the proper interval of indwelling catheter after PNL was about 7 to 8 days, in the cases with renal stones and about 11 to 12 days in the cases with ureteral stones.