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Antitumor activity of BCG for transitional cell carcinoma of the urinary bladder was evaluated in 103 patients from October, 1983 to October, 1989 at Hirosaki University Hospital. At the same time, the role of various inflammatory cells infiltrating in the bladder wall after intravesical BCG instillation as mechanism of action of BCG was studied. Of 72 patients with superficial bladder cancer, 19 showed a complete response and 28 showed a partial response. The effective rate was 65.3 percent. Significant efficacy was obtained in patients received more than 5 times instillation of BCG. Before intravesical BCG instillation, a small number of lymphocytes or plasma cells infiltrated in the stroma of the tumor. But histiocytes, neutrophils or eosinophils were hardly found. After BCG instillation, the degree of infiltration of each of them tended to increase. The mean degree of infiltration of those inflammatory cells almost all significantly increased in the stroma of the tumor, while only lymphocyte and histiocyte counts significantly increased in both the basal areas of the advancing margin of tumor cells and the tumor free submucosa after BCG instillation. Epithelioid granulomas were recognized almost in the basal areas of the advancing margin of tumor cells and the tumor free submucosa after BCG therapy. Langhans' giant cells were occasionally found within these lesions. In 2 patients marked central necrosis (caseation) was noticed in epithelioid granulomas. In BCG effective cases with superficial bladder cancer lymphocytes and histiocytes increased significantly in all of the stroma of the tumor, the basal areas of the advancing margin of tumor cells and the tumor free submucosa. On the other hand, in BCG noneffective cases they increased significantly only in the stoma of the tumor. Subsets of lymphocytes which increases after intravesical BCG instillation were mainly T pan cells with the predominance of T helper/inducer cells (Th/Ts ratio always > 1).

Side effects and serious complications of intravesical bacillus Calmette-Guerin (BCG) therapy were reviewed in 120 patients with transitional cell carcinoma of the urinary bladder from October, 1983 to June, 1989 at Hirosaki University Hospital. As local side effects, 102 patients (85.0%) had bladder irritability with frequency and/or micturition pain, and 46 patients (38.3%) had hematopyuria. As systemic side effects, fever in 43 patients (35.8%), elevation of serum GOT, GPT in 9 patients (7.5%), and malaise in 3 patients (2.5%) were seen. Serious complications were observed in 7 patients. 4 patients had a severely contracted bladder with decreased compliance less than 50 ml, 2 patients had persistent arthritis and one patient had interstitial pneumonia. In all 4 patients with a contracted bladder partial cystectomy was performed before or after intravesical BCG therapy, and three of them received more than ten times instillation of BCG. It was suggested that contracted bladder most likely occurred after frequent BCG instillations in addition to decreased bladder compliance. Contracted bladder was irreversible in 2 patients. Histopathologically, there was marked fibrosis in the muscular layer of the bladder without tuberculous inflammatory changes. It might depend on the severity of fibrosis in the muscular layer whether contracted bladder was reversible or not. Persistent arthritis was nonspecific inflammation with negative culture results for mycobacteria in the joint fluid in 2 patients. In one patient with interstitial pneumonia, fiberoptic bronchoscopy with transbronchial lung biopsy demonstrated marked fibrosis of alveolar septums and increased lymphocyte count without tuberculous inflammatory changes. The pathogenesis of this complications is considered to be a hypersensitivity reaction to BCG.

We have used the continent ileal bladder as a bladder replacement after radical cystectomy. The ileal bladder is an ileal pouch which is anastomosed to the urethral stumps. The ureters are implanted by a free end ureteroileostomy. The long term results with 26 patients who underwent this procedure are reported. In the early postoperative period, urodynamic and radiographic studies revealed small capacity and high intravesical pressure of the ileal bladder. However, it became a low pressure reservoir with increased capacity gradually. The average bladder capacity was about 250 ml and average residual urine was 30 ml. Most of the patients were continent in the daytime if the voiding intervals were less than 3 hours at night, some patients were incontinent. Urinary leakage was the most frequent complication. VUR and hydronephrosis were still the problems to be solved. The ileal pouch bladder is a valuable procedure in properly selected cases.