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Summary To evaluate the effects of ligature of the internal spermatic artery at varicocelectomy on fertility, we conducted a prospective randomized study for comparison of two surgical methods (artery-ligated and artery-preserved). A total of 66 infertile patients with palpable varicocele was randomly assigned to an artery-ligated or artery-preserved group at varicocelectomy and the change in seminal characteristics and testis volume was prospectively investigated. Sperm density and motility improved significantly in the artery-ligated group. There was significant improvement in sperm density in the artery-preserved group, but motility did not reach the level of statistical significance in this group. The significant change in testis volume was not observed in both groups. Seven (23.3%) of 30 patients in the artery-ligated group and 5 (13.9%) of 36 men in the artery-preserved group managed to impregnate their partners. The difference was not statistically significant. In spite of the advocative advantage of artery preservation, our present study did not show any significant difference between artery-ligating and artery-preserving varicocelectomy when improvements in semen quality and pregnancy rate were assessed. Thus, artery-ligated varicocelectomy is warranted with regard to postoperative fertility in the patients with clinical varicocele.

Direct transrectal infiltration of the prostate with antibiotics was performed in 25 selected patients with refractory chronic prostatitis, and sequential samples of urine and prostatic secretion were studied at 3-monthly intervals thereafter. The criterion for cure of chronic bacterial prostatitis was persistently sterile cultures of urine and prostatic secretion for at least 12 months after completion of treatment. Complete cure was obtained in 14 patients (56%) after one or two infiltrations. In seven other patients clinical and bacteriologic remission was obtained after several injections but the follow-up period was too short to judge the efficacy of the intraprostatic antibiotic administration. The remaining four patients (16%) had sterile specimen cultures 3 months after one injection, but were lost to further follow-up. The results suggest that local antibiotic treatment of chronic bacterial prostatitis is useful, although careful randomized studies with long follow-up are required to evaluate the merits of the method.

PURPOSE AND METHODS Diagnostic values and limitation of conventional urodynamic study (UDS) were assessed in 380 patients with benign prostatic hypertrophy (BPH), in terms of uroflowmetry, measurement of postvoid residual urine and cystometry. RESULTS Maximum and average flow rate on uroflowmetry improved with increasing voided volume. Neither maximum nor average flow rate correlated with size of the prostate, subjective symptom (International Prostate Symptom Score) and bothersomeness for prostatism. Pre-TUR maximum flow rate did not predict outcomes on postoperative flow rate and surgical treatment failures. Uroflowmetry did not differentiate between obstruction and weakness of detrusor contraction. The intraindividual variation of postvoid residual urine was great and the volume of residual urine correlated poorly with subjective symptom, size of the prostate, maximum and average flow rate. On filling cystometry, although uninhibited detrusor contraction was much more frequently observed in patients with urge incontinence as compared with continent patients, there was no significant difference in other parameters between the two groups. Every parameter on cystometry did not correlate with nocturnal frequency. Postoperative persistence of urge incontinence did not correlate with the bladder volume at the first desire to void or at the maximum desire to void, an amplitude of uninhibited detrusor contractions, or bladder compliance. In some cases, evaluation of the intravesical pressure on voiding phase and uroflowmetry was diagnostic of apparent obstruction. CONCLUSIONS In diagnosis of BPH, conventional UDS has limitation for certain and some caution showed be taken in interpretation of the data. However, since conventional UDS provides important and objective information on obstruction and detrusor function, which are independent of subjective symptom and prostate size, these should be necessary in diagnosis, determination of treatment options and evaluation of treatment outcomes in BPH.

To examine whether intravesical instillation of low-dose bacillus Calmette-Guérin (BCG) therapy is effective with low toxicity, we reviewed data for 111 patients with superficial bladder cancer (stages Ta and T1). Among them, 74 received the BCG treatment for prophylaxis of intravesical recurrence after transurethral resection, and the remaining 37 therapeutically for Ta or T1 tumours. The patients were divided into two groups by instillation dose of BCG (Tokyo 172 strain): 40 mg (n = 55) and 80 mg (n = 56), and statistically compared for recurrence, antitumour effect and toxicity. The mean instillations were done 8.4 times in the 40 mg dose group and 8.6 times in the 80 mg dose group. Among the 74 patients with BCG therapy for prophylaxis those with a previous episode of bladder cancer treatment (n = 47) experienced a significantly (p = 0.006) shorter recurrence-free interval than those with no episode (n = 27). Among 47 patients with a previous treatment episode, those receiving the 80 mg dose demonstrated a significantly longer recurrence-free interval than those given the 40 mg dose (p = 0.03). Among the 27 patients without previous treatment no significant difference in recurrence-free intervals was found between the two dose groups. Univariate and multivariate analyses using Cox's proportional hazards model confirmed the above findings. The recurrence index was also significantly reduced after BCG therapy in the 80 mg and 40 mg groups and similar antitumour effects for Ta or T1 tumours were observed in the two dose groups. The degree of toxicity due to BCG therapy was significantly (p = 0.02) lower with the 40 mg dose. The present study suggests that (1) a 40 mg BCG low-dose (Tokyo 172 strain) regimen is useful for preventing recurrence, with sufficient therapeutic efficacy and low frequency of toxicity, among patients without a previous treatment, and (2) prophylactic effects with the 80 mg dose regimen are much superior for previous treatment cases.

We have developed a new sperm collection method by epididymal micropuncture in conjunction with perivascular nerve stimulation to obtain as many uncontaminated spermatozoa as possible for IVF for patients with surgically unreconstructable vasal obstruction. Fifteen azoospermic men with congenital absence of the vas deferens or vasal obstruction not amenable to surgical repair enrolled in this study. Under general anaesthesia the testis and epididymis were retrieved and stabilized in a testicular holder with the aid of 2% agar. The epididymal micropuncture was performed using a micropipette placed in a micromanipulator. A pair of Ag-AgCl ring electrodes were placed around the spermatic cord for perivascular nerve stimulation with DC (intensity 136 V, frequency 20 Hz) for 30 s. Electrical stimulation was repeated every 1 min until no further fluid was obtained. Epididymal fluid obtained ranged from 78 to 980 microliters (mean 169 microliters). Sperm concentration ranged from 0.7 to 200 million (mean 53.5 million). Sperm motility ranged from 0.5% to 70% (mean: 19.9%). The percentage of spermatozoa with normal morphology ranged from 3% to 32% (mean 16.4%). Of 16 cycles in which spermatozoa and oocytes were retrieved, 56% (9/16) resulted in fertilization and 18.8% (3/16) developed clinical pregnancies. The clinical pregnancy rate per couple was 20% (3/15). This is the first clinical experience of the bulk sperm collection system for IVF for the treatment of unreconstructable obstructive azoospermia. Our results indicate that our new technique, in conjunction with IVF, is clinically useful for patients with surgically irreparable vasal obstruction.

A case report describes successful microfertilization of oocytes of a 27-year-old woman with epididymal sperm retrieved by micropuncture technique from the patient with congenital absence of the vas deferens. Microfertilization treatment resulted in a singleton pregnancy; the child has since been born. Treatment of couples involving men with surgically unreconstructible obstruction is now possible. Our experience indicates that sperm retrieved with this new technique, when combined with assisted reproductive technologies, permits fertilization for the men with surgically irreparable vasal obstruction.

To clarify the clinicopathological characteristics of small renal cell carcinomas (RCCs) the authors reviewed data for 154 RCC patients treated between January 1980 and September 1992. Of 20 patients with tumours of 3 cm or less in diameter, 12 (60%) had no related symptoms: 6 (30%) were found during routine physical check-ups and 6 (30%) were incidentally detected during examinations for diseases other than RCC. The remaining 8 (40%) patients demonstrated indicative symptoms. Most small tumours showed expansive growth and nuclear atypia was minimal or moderate. In all 20 cases, the lesions of 3 cm or less were confined to the kidney (pT1 to pT2b) and no lymph node metastasis was found. Only one (5%) had a distant metastasis, and venous involvement was also microscopically observed in only one patient (5%). The 5-year survival rates were 95% for patients with tumours of 3 cm or smaller, 74% for those of 3.1 to 5 cm, and 68% for those of greater than 5 cm. These findings revealed small RCC to demonstrate biologically less malignant behaviour. Early detection of such small lesions by ultrasonography should therefore improve the overall survival of patients with RCC.

To examine the effectiveness of micromanipulation on the treatment of the patients with obstructive azoospermia, subzonal insemination or partial zona dissection was performed using epididymal sperm of the 23 patients, and the in vitro fertilization and embryo transfer (IVF-ET) outcomes were analyzed.Fertilized oocytes were obtained in 11 cycles of the 25 treated cycles, and six pregnancies were established by the subsequent ET. Through the analysis of 13 cycles in which both the micromanipulation and usual IVF insemination were performed, the fertilization rate per oocyte with the micromanipulation [25% (28/113)] was significantly higher than that with the usual insemination method [4% (4/102)]. The micromanipulation was most useful for the treatment of the patients with congenital absence of the vas deferens. Moreover, there was no need to aspirate a large volume of the epididymal fluid, but it was essential to prepare more than 10 mature oocytes retrieved.These results indicate that micromanipulation with epididymal sperm is an effective treatment for obstructive azoospermia, and careful preparations of sperm and well-controlled ovarian hyperstimulation are necessary for successful IVF-ET.

We treated 13 patients with unilateral ureteropelvic junction obstruction by percutaneous endopyelotomy, and they were urodynamically evaluated by the Whitaker test and diuresis renography, in addition to excretory urography (IVP). Surgery was uncomplicated in all patients except 1 who required repeat incision 4 weeks later. Obstruction was diagnosed preoperatively by the Whitaker test and diuresis renography in 10 cases, and by IVP in 13. Postoperatively, all 10 patients (100%) with a positive Whitaker test were free of obstruction with a significant reduction in the relative renal pelvic pressure from 35.0 to 8.1 cm. water (p0.01). Diuresis renography revealed no obstruction in 8 patients (80%) and persistent obstruction in 2. IVP demonstrated reduced hydronephrosis in 8 of 13 patients (62%) 12 weeks after surgery and in 11 of 13 patients (85%) 19 months later. However, a marked reduction in renal pelvic size was noted in only 3 patients (23%). Flank pain disappeared in 10 of 11 patients (91%) postoperatively. Overall, surgery was successful in 11 of the 13 patients (85%). Percutaneous endopyelotomy was effective in relieving obstruction at the ureteropelvic junction with minor morbidity. The Whitaker test was more sensitive for evaluating the results of surgery than diuresis renography and IVP, although diuresis renography appears to be useful in followup evaluation of hydronephrosis.

Summary— The in vitro pharmacological responses of the human neurogenic bladder to KCl, carbachol, ATP and CaCl2 have been analysed. The contractility (contractile strength and ED50) of neurogenic bladders was significantly increased when treated with carbachol, ATP and CaCl2. In contrast, there was no apparent difference in the responsiveness of neurogenic bladders when treated with KCl. There was no apparent correlation between pharmacological responsiveness and clinical parameters, such as gender, age or cystometric data, in the neurogenic bladders.

Summary The localization of calmodulin in testes of patients with idiopathic male infertility was studied using the indirect immunoperoxidase method. Specimens were obtained by testicular biopsy from 55 patients. They were divided into 26 cases of hypospermatogenesis, 11 cases of maturation arrest (8 of primary spermatocyte arrest and 3 of spermatid arrest) and 18 cases of Sertoli cell-only syndrome. Regardless of the type of testicular pathology, the types of immuno-reactive cell and the intensities of staining were the same as those in the normal testis. That is, staining for calmodulin was first found to be positive in early pachytene primary spermatocytes. It became intense in late pachytene primary spermatocytes and round spermatids. By contrast, elongated spermatids and spermatozoa were not stained. Sertoli cells were stained slightly or not at all. A calmodulin-staining index (CaM-S index) was defined as the proportion of primary spermatocytes that were stained intensely for calmodulin relative to the total number of primary spermatocytes. The indices for the testes of men with complete spermatocyte maturation arrest were significantly lower than those for the testes of normal controls and of men with hypospermatogenesis. Degenerating late pachytene spermatocytes observed in the testes of men with spermatocyte arrest showed low calmodulin-specific immunoreactivity. Such a decrease in numbers of normal late pachytene spermatocytes might be responsible for the low CaM-S index in cases of complete spermatocyte arrest.

Early and longterm results of transurethral incision of the prostate and bladder neck (TIPBn) were compared with those of transurethral resection of the prostate (TURP) in treatment of 36 patients with outflow obstruction caused by small benign prostatic hypertrophy. Seventeen patients underwent TIPBn and 19 TURP. Parameters on uroflowmetry (maximum flow rate, average flow rate, voiding time and residual rate) were significantly improved postoperatively in both groups. There was no significant difference in the improvement on uroflowmetry both at early (3 months) and longterm (TIPBn: 12-48, mean 20.1 months, TURP: 12-48, mean 22.2 months) postoperative periods, between the two groups. Subjective symptom of voiding difficulty was remarkably improved in all patients of both groups during early postoperative period. However, at longer follow-up, subjective improvement was preserved in 88.2% in the TIPBn group and 73.7% in the TURP group. A re-operation was needed in 4 cases (21.5%) in the TURP group because of recurrence of obstructive symptom due to postoperative bladder neck contracture, while a second operation has not been performed in the TIPBn group. We conclude that TIPBn can be the preferred surgical treatment of outflow obstruction caused by small benign prostatic hypertrophy.

Objective To determine if the mast cell subclass changes in diseased testes. Design Retrospective. Setting University hospital urology clinic and anatomy laboratory. Patients, Participants Fourteen normal men and 50 patients with idiopathic male infertility. Interventions Histochemical techniques to identify proteoglycans of mast cells were applied to the obtained testicular biopsy specimens. Main Outcome Measures The numbers of the heparin containing mast cell and the chondroitin sulfate containing mast cell were measured with light microscopy. Results The total number of mast cells and the ratio of chondoroitin sulfate containing mast cells were significantly increased in the testes from patients with idiopathic male infertility. Conclusion These results suggest that mast cells may play a certain role in the etiology of idiopathic male infertility.

Of 113 patients with bladder cancer who underwent total cystectomy from January 1980 to December 1990, 30 (27%) had superficial tumours (pTa, pTis, and pT1). Nineteen of these 30 patients (63%) were primarily treated by total cystectomy and the remaining 11 (37%) had a past history of treatment for bladder cancer. Major reasons for choice of total cystectomy were multifocal tumours, frequent recurrence, and diffuse carcinoma in situ. Histologically stage pT1, grade 3 tumours were frequently accompanied by carcinoma in situ and often by lymphatic invasion. None of the 24 patients undergoing pelvic lymphadenectomy had lymph node metastasis. Of 25 male patients 15 (60%) underwent simultaneous prophylactic urethrectomy. Two of the remaining 10 males (20%) not undergoing this additional operation died of subsequent urethral recurrence. The 5-year actuarial survival rate was 80% for the 30 patients when all causes of death were considered. It was concluded that patients with superficial bladder cancer who undergo total cystectomy without prophylactic urethrectomy require close follow-up with urethral washings for cytology to detect early urethral recurrence, an important determinant for survival.

We report two cases of small renal adenocarcinoma and one case of small angiomyolipoma, which were identified as hyperechoic tumors by ultrasonography. None of the three tumors displayed fat content on plain CT. Since CT cannot reliably identify the intratumoral structure of small hyperechoic renal tumors, we recommend intraoperative pathological examination when CT findings do not correspond with the results of ultrasonography.

A sandwich-type enzyme immunoassay for human 28 kDa vitamin D-dependent calcium binding protein (calbindin-D) was established with a sensitivity of 1 pg/tube. Antisera were generated in rabbits injected with highly purified human kidney calbindin-D, and specific antibodies to calbindin-D were purified by the use of a column of calbindin-D-coupled Sepharose. The purified antibodies showed a single band at the position corresponding to calbindin-D on an immunoblotting test with a crude extract of human kidney. The assay system consisted of polystyrene balls with immobilized F(ab')2 antibodies and the same antibodies labeled with beta-D-galactosidase from Escherichia coli. The assay was specific to 28 kDa calbindin-D, showing no cross-reactivity with other calcium binding proteins such as S-100a0 (alpha alpha), S-100b (beta beta), parvalbumin and calmodulin. The assay was also reproducible (coefficients of variation between assays were less than 10%). With the present method, immunoreactive calbindin-D could be detected in various human tissues, with major concentrations in kidney and brain. The values for immunoreactive calbindin-D in various body fluids of healthy subjects varied from undetectable in serum and semen to 3.8 +/- 2.0 (SD) micrograms/g creatinine in urine and 2.9 +/- 0.8 (SD) micrograms/l in cerebrospinal fluid. Immunohistochemically, the calbindin-D in human kidney was localized in epithelial cells of distal tubules.

As a prospective study on asymptomatic microhematuria, complete urological examinations including cystoscopy, IVP, ultrasound and urinary cytology were performed on 422 patients over 40 years old between January 1987 and December 1988 (group A). The results of group A was compared with that of retrospective study on 266 patients, who had incomplete urological examination between January 1984 and December 1985 (group B). Cystoscopy was performed on 321 patients (87.2%) in group A and on 108 patients (40.6%) in group B. Bladder tumor was found in 10 cases (2.4%) in group A, including 7 cases of male patients (5.7%), but in only 1 case (0.4%) in group B. Since the negative rate of abnormal urinary cytology was 50% and that of abnormal IVP was 90% in 10 cases of bladder tumor in group A, cystoscopy was considered to be an essential examination for the screening of patients with asymptomatic microhematuria over 40 years old patients.

Purpose To analyze the horizontal rectus extraocular muscles (EOMs) by orbital magnetic resonance imaging (MRI) in patients with congenital cranial dysinnervation disorders that arises from abnormal development of cranial nerve nuclei or their axonal connections. Design Case series, retrospective analysis. Methods The morphology of the horizontal rectus EOMs was analyzed in orbital MRI on 4 patients with congenital oculomotor palsy, 26 with congenital superior oblique palsy, and five with Duane syndrome. Orbital imaging was performed by 1.5 tesla (T) and 3T MRI, and quasi-coronal and sagittal images perpendicular and parallel to the long axis of the orbit were obtained at slice thicknesses of 3 and 2 mm. Results The horizontal rectus EOMs were split in 4 of the 35 patients (11%). Splitting was observed in 2 of the five patients (40%) with Duane syndrome, one of the 26 patients (4%) with congenital superior oblique palsy, and 1 of the 4 patients (25%) with oculomotor palsy, but in none of the 6 normal subjects and 12 patients with acquired cranial nerve palsy. Conclusion Since splitting of the horizontal rectus EOMs was noted in patients with congenital dysinnervation disorders, including Duane syndrome, Sevel's theory that the horizontal rectus EOMs develop from the superior and inferior mesodermal complexes is considered to be reasonable.

We used an immunohistochemical technique with the monoclonal antibody Ki-67, which recognizes nuclear antigen expressed in proliferating cells to determine the growth fractions of 5 normal mucosa specimens and 55 transitional cell carcinomas of the bladder. Normal mucosa had a mean value of 0.37 +/- 0.35% cells positive for Ki-67, whereas 9 histological grade 1 tumors showed 2.2 +/- 1.5%, 31 grade 2 tumors averaged 10.1 +/- 7.5% and 15 grade 3 tumors yielded 19.5 +/- 9.0%. These values were significantly different from each other (p less than 0.01), with Ki-67 indexes for grade 2 varying from 0.3 to 24.6%. Nonpapillary tumors had significantly higher indexes than papillary tumors (20.1 +/- 8.0 versus 6.7 +/- 5.9, p less than 0.01). The Ki-67 indexes were 4.6 +/- 4.5% for stage Ta (20 cases), 7.8 +/- 4.7% for stage T1 (14) and 20.2 +/- 7.8% for stages equal to or higher than T2 (21). Significant differences were noted between stages Ta and T1 (p less than 0.05) and between stages T1 and T2 or greater (p less than 0.01). Tumors with muscle layer invasion often showed more than 15% Ki-67 positive cells. Our results imply that Ki-67 indexes not only provide objective information to determine a malignant potential but also help to select the treatment.

We reviewed data from 62 patients with epithelial tumors of the renal pelvis and ureter who were hospitalized and treated at Nagoya University Hospital between July, 1970 and June, 1988. Of the 62 patients, 50 were males and 12 were females, the ratio being 4.2:1. The mean age was 62.1 years, the ages ranging from 41 to 87 years. The peak incidence of tumors was marked in the sixth decade for the males and in the seventh decade for the females. Eighty-two percent of the patients were 50 years of age or older. Smoking habits were noted in 76.0 percent of the males and in 16.7 percent of the females. Asymptomatic macrohematuria, found in 43 patients, was the most frequent symptom. Ninety percent of the 62 tumors were transitional cell carcinoma. Twenty-five patients (40.3%) had concomitant bladder cancer, which was previously diagnosed in 3, simultaneously found in 9, and subsequently developed in 16. Twenty-nine patients had tumors localized in the renal pelvis and eighteen in the ureter; the remaining fifteen had tumors localized in two or three organs, including the renal pelvis, ureter and bladder. Histological grades of ureteral tumors were significantly higher than those of renal pelvic tumors. The sensitivity of urinary cytology was 57.8 percent. High-grade tumors had higher sensitivity than low-grade tumors. Larger tumors (greater than 3 cm in diameter) were significantly associated with high-stage tumors, whereas no apparent correlation was found between tumor size and histological grade. Nonpapillary growth of tumor and vascular invasion were significantly related with high-stage and high-grade tumors; diffuse pattern of tumor infiltration was associated with high-stage tumors.

Transurethral incision of the prostate and bladder neck (TIPBn) was compared with transurethral resection of the prostate (TURP) followed by bladder neck incision in the treatment of 22 patients with outflow obstruction caused by a small prostate adenoma (below 15 gm). Eleven patients underwent TIPBn and another 11 TURP. An evaluation of the urodynamic findings and subjective symptoms was undertaken before the operation and 3 months afterwards. Urodynamic findings were evaluated, based upon uroflowmetry, i.e., in terms of maximum flow rate, average flow rate, voiding time, initiation time and residual rate. All patients in the TIPBn group revealed an improvement in every urodynamic parameter (MFR: from 6.1 to 10.8 ml/sec, AFR: from 3.1 to 5.8 ml/sec, Voiding time: from 95.5 to 24.2 sec/100 ml, Initiation time: 34.3 to 10.2 sec, Residual rate: 31.6 to 17.8%, in mean value). Ten out of the 11 in the TIPBn group subjectively considered the result to be good. The improvements in the urodynamic parameters in the TIPBn group were statistically comparable to those in the TURP. The improvements in voiding time and initiation time, however, tended to be much better in the TIPBn group. We conclude that TIPBn can be the operation of choice in the treatment of outflow obstruction caused by a small prostate.

Purpose: We investigated the preliminary surgical results of endoscopic trigonoplasty in pediatric patients with primary vesicoureteral reflux.Materials and Methods: We performed endoscopic trigonoplasty in 6 pediatric patients (11 refluxing ureters). Reflux was grade II in 4 reno-ureteral units, grade III in 5, grade IV in 1 and grade V in 1 (international classification). Surgery was done using laparoscopic and endoscopic instruments.Results: Vesicoureteral reflux disappeared 3 to 12 months postoperatively. Analgesics were administered postoperatively to 4 patients for 24 hours and to 2 for 48 hours. No bladder irritability or postoperative upper urinary tract dilatation was observed in the early postoperative period.Conclusions: Minimally invasive endoscopic trigonoplasty can be an effective surgical procedure for pediatric patients with vesicoureteral reflux.

We report an initial case of intraperitoneal testicular cancer with ascites. Although the cytology of aspirated ascites revealed no tumor cells, the beta-HCG and AFP values were high. Preoperative cisplatin-based combination chemotherapy was used without any pathological diagnosis. Following 2 cycles of chemotherapy, the beta-HCG and AFP values normalized. Furthermore, no ascites was observed on CT scan. Although an accurate histological diagnosis was not established before treatment, it was thought that the ascites originated from the disseminated testicular cancer cells in the peritoneum.

Objective To determine whether mast cell blocker (tranilast) improves fertility and/or semen parameters in severe oligozoospermia. Design Placebo-controlled single-blind clinical study. Setting Nagoya University Hospital Andrology Clinic, Nagoya, Japan. Patients Fifty men with sperm density 6 sperm/mL, normal serum gonadotropins, and T, and a fertile partner were enrolled in this study. Interventions Patients were prescribed randomly 300mg/d tranilast or a placebo, three tablets per day, for 3months. Semen and blood samples were collected before and after therapy. Semen parameters, serum gonadotropins, T, and PRL were evaluated before and after therapy. Results The pregnancy rate (PR) in the mast cell blocker group was 28.6% compared with 0% in the placebo group. There was a statistical difference in the PR between groups. The mast cell blocker group had significantly higher levels of sperm density, sperm motility, and total motile sperm count. There were no differences between the mast cell blocker and placebo groups in seminal volume and normal sperm morphology. Conclusions The authors conclude that mast cell blocker is clinically useful for the treatment of idiopathic severe Oligozoospermic men.

Serum estradiol levels were measured in 360 men attending an infertility clinic and 68 proven fertile men to determine whether estradiol measurements are clinically useful. The normal range of estradiol levels found in fertile men was 10-82 pg/ml. Serum concentrations of estradiol in azoospermic or oligozoospermic patients were significantly lower than those in normozoospermic men (p < 0.021). Serum concentrations of testosterone were also significantly decreased in infertile patients (p < 0.025). This decrease in serum estradiol may be partly due to reduced testosterone levels in these men because estradiol is mainly formed by peripheral aromatization of testosterone in fatty and muscle tissues. However, the exact mechanism for the decrease in the serum estradiol levels remains undetermined. It is concluded that serum estradiol levels are significantly low in the men with various testicular disorders.

The treatment of patients with chronic unilateral or bilateral orchialgia, defined as intermittent or constant testicular pain of greater than 3 months and of unclear cause, is difficult. This pain significantly interferes with the daily activities of the patient. We have seen 12 patients with chronic orchialgia of unknown etiology and each had a normal history, physical examination and normal scrotal sonogram. Three patients were treated with nonsteroidal anti-inflammatory drugs and obtained partial pain relief. Three patients underwent spermatic cord nerve blockade using a combination of 1% lidocaine and 40 mg methylprednisolone and experienced partial pain relief. Four patients underwent inguinal orchiectomy after failing conservative management: three reported complete relief of pain, and the other partial relief. Two patients had bilateral transrectal injections of local anesthetic (5 ml bupivacaine) and methylprednisolone into the region of the pelvic plexus under transrectal ultrasound guidance. They were successfully treated with this injection technique. On the basis of our results, we recommend transrectal blockade of nerves from the pelvic plexus or inguinal orchiectomy as the procedure of choice for patients in whom medical treatment fails.

Extremely rarely renal cell carcinoma metastasizes to the contralateral renal pelvis or ureter. The present report concerns a case where a metastatic tumor could be successfully removed from the left renal pelvis 3 years after right nephrectomy for the primary tumor. A review of the literature revealed this to be only the fourth such case documented.

A novel sperm collection method by epididymal micropuncture combined with perivascular nerve stimulation has been developed to obtain as many clean sperm as possible for IVF for patients with surgically irreparable vasal obstruction. To assess whether the new technique could improve the fertilization and pregnancy rates obtained when attempting microsurgical epididymal sperm aspiration (MESA) to retrieve epididymal sperm from such patients, a prospective randomized comparative study was conducted. Twenty-nine cycles of conventional MESA with ICSI were performed on 25 couples with congenital bilateral absence of the vas deferens (CBAVD) and four failed vasovasostomy cases (group 1). Thirty cycles of epididymal micropuncture with nerve stimulation with ICSI were performed on 28 couples with CBAVD and two failed epididymovasostomy cases (group 2). The mean volume of epididymal fluid and sperm motility in group 2 was significantly higher than that in group 1 (p.001). Both fertilization and pregnancy rates in group 2 were significantly higher than those in group 1 (p.001 and p.03). This novel epididymal sperm collection method for ICSI can provide significantly higher fertilization and pregnancy rates than conventional MESA for ICSI.

Testicular sperm was retrieved from a man with an epididymal obstruction, and an intracytoplasmic sperm injection was made into his wife's oocytes. In 4 mature oocytes treated, 2 fertilized eggs were obtained, and a clinical pregnancy was established with embryo transfers. Our experience demonstrated the possibility of fertilization and conception with testicular sperm.

The urodynamics of pouch-urethra function were investigated in patients with a urethral Kock pouch to understand mechanisms involved in the storage and evacuation of urine, and elucidate any problems of long-term outcome.Urodynamic evaluation was performed in 18 male patients who underwent bladder replacement with a urethral Kock pouch following radical cystectomy.Good urinary continence was achieved with normal frequency of voiding. On urodynamics pressure within the pouch remained low during the storage phase (mean 33.2 cm. water) but markedly increased during the evacuation of urine (mean 77.3 cm. water). In 8 patients (44%) extremely high pressure within the pouch (80 to 150 cm. water) was noted at voiding. Clean intermittent self-catheterization was initiated in a patient with high pressure within the pouch at voiding in whom pouch-ureter reflux developed 7 months postoperatively. The external urethral sphincter was impaired to some extent postoperatively but it contracted in response to filling of the pouch with a marked increase in urethral pressure from a mean of 31.6 to 66.3 cm. water.Urodynamic and radiological studies will be necessary periodically since high pressure within the pouch at voiding might jeopardize the antireflux mechanism, leading to reflux and renal impairment.

The authors treated 135 men who underwent varicocelectomy, but had sustained Leydig cell dysfunction disclosed by LHRH test with human chorionic gonadotropin (hCG). hCG was administered for 10 weeks: 50,000 units were given in 10 divided doses intramuscularly. Semen analysis and measurement of serum hormone level were obtained 8 weeks after the completion of treatment, and every 3 months after that. All patients were followed up for 2 years to confirm pregnancy. Fifty-five percent of patients achieved pregnancy and they showed significant increase in sperm density, percentage of sperm motility, normal form sperm, and serum testosterone level. It is recommended that hCG be administered to patients who undergo varicocelectomy but have persistent subtle Leydig cell dysfunction disclosed by LHRH test to stimulate the intratesticular testosterone production.

Objective To investigate the surgical results of endoscopic trigonoplasty in patients with primary vesico-ureteric reflux. Patients and methods Records were reviewed for 12 patients who underwent endoscopic trigonoplasty between February 1992 and February 1994. Of the 12 patients, 11 were female; one was a child and nine had unilateral disease. From 15 renoureteric units, grade I vesico-ureteric reflux was demonstrated in five, grade II in six and grade III in four. The ureteric orifices were approximated close to the midline via the urethral route and two trocars on the abdomen achieved pneumobladder. Results The mean surgical time was 178 ± 52 min; this lessened as the learning curve developed. Intra-opera-tive complications in three patients were all caused by trocar placement. Eleven patients required analgesics for one post-operative day only. No post-operative dilatation of the upper urinary tract was demonstrated. Vesico-ureteric reflux was eradicated in all patients. Conclusions Endoscopic trigonoplasty is a minimally invasive procedure with a high cure rate. By not destroying the normal vesico-ureteric junction, postoperative obstruction cannot occur. We believe that endoscopic trigonoplasty is a feasible procedure for patients with vesico-ureteric reflux.

Objective To determine whether α -blocker (bunazosin) improves fertility and/or semen parameters in oligozoospermic men. Design Placebo-controlled, double-blind clinical study. Setting Nagoya University Hospital Andrology Clinic, Nagoya, Japan. Patients Thirty-four men with sperm density between 5 and 20 X 10 6 sperm/mL, normal serum gonadotropins and T, and a fertile partner were enrolled in this study. Interventions After a 3-month control period, patients randomly were prescribed bunazosin 2 mg/d or a placebo, two tablets per day, for 6 months. Semen and blood samples were collected before and after therapy. Semen parameters, serum gonadotropins, T, PRL, and E 2 were evaluated before and after therapy. Results The pregnancy rate (PR) in the α -blocker group was 25%, compared with 6.7% in the placebo group. There was no statistical difference in the PR between groups. The α -blocker group had significantly higher levels of sperm density and total motile sperm count. There were no differences between the placebo and α -blocker groups in seminal volume, the percentage of motile sperm, and normal morphology or hormone levels. Conclusions The authors conclude that α -blocker is a useful drug in the treatment of idiopathic moderate oligozoospermic men.

Prostate-specific antigen (PSA) is a kallikrein-like serine protease that is secreted exclusively by the epithelial cells of all types of prostatic tissue, benign and malignant. Its serum concentration is raised in men with prostatic disease including cancer. We have evaluated its usefulness in the diagnosis of prostate cancer by measuring serum PSA concentrations in 260 men aged 50 years or over. All had abnormalities at digital rectal examination (DRE) involving suspected cancer, signs and symptoms of benign prostatic hyperplasia and equivocal findings on DRE, and miscellaneous other conditions, including hematospermia, chronic prostatitis and microscopic hematuria. Transrectal prostatic needle biopsies were performed in the men with abnormal findings on DRE or elevated serum PSA (above 4 ng/ml). Serum PSA ranged from 4.0 to 9.9 ng/ml in 14 (5%) of the 260 men. Four of the men in this group (31%) who underwent prostatic biopsy had prostate cancer. Serum PSA levels greater than or equal to 10.0 ng/ml were found in 8 (3%) of the 260 men. 5 of these 8 (63%) who underwent prostatic biopsy had cancer. If DRE alone had been used to screen the men having biopsies, 4 of the 10 cancers (40%) would have been missed. If PSA alone had been used to screen these men, only 1 of the 10 cancers would have been missed. Serum PSA measurement was more reliable than DRE for detecting prostate cancer. Since these two methods do not always detect the same malignant tumor, the combined use of DRE and PSA testing affords a more complete evaluation of the prostate gland for malignant involvement.

From 1980 to 1990, we treated 45 patients with non-seminomatous germ cell tumors of greater than or equal to stage II according to the Japanese general rule for clinical and pathological studies on testicular tumors. The patients were divided into 2 groups based on the Indiana University Classification: 26 good risk patients (scoreor = 6) and 19 poor risk patients (scoreor = 7). The clinical results, the % dose intensity of Cisplatin and half-lives of tumor makers were analyzed in the two groups. The per cent dose intensity of Cisplatin of the induction chemotherapy was 61 +/- 24% in 1980-1985 and 87 +/- 18% in 1986-1990. The NED rate improved from 66.7% (10/15) to 81.8% (9/11) in the good risk patients and from 33.3% (3/9) to 50.0% (5/10) in the poor risk patients between the above two periods. When the % dose intensity of Cisplatin exceeded 80%, the NED rate increased from 66.7% (10/15) to 90.0% (9/10) in good risk patients and from 33.3% (2/6) to 45.5% (5/11) in poor risk patients. The NED rate was only 25.0% (4/16) in the poor risk patients whose residual tumors were not resected. The half-lives of AFP and beta-HCG from the latter part of the first course to the second course were 6.8 +/- 1.9 days and 4.4 +/- 1.4 days, respectively, in the patients with a good prognosis, while they were 6.5 +/- 1.5 days and 4.4 +/- 2.9 days, respectively, in with a poor prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

We studied 41 testicular germ cell tumors (TGCT) using DNA flow cytometry and argyrophilic (silver staining) nucleolar organizer region (Ag-NOR) quantitation to evaluate the proliferative characteristics of TGCT and the significance of those analytical techniques. In nonseminomatous germ cell tumor (NSGCT), the percentage of S + G2M phase cells (% S + G2M) in DNA aneuploid tumor was higher than in DNA of diploid tumors. Likewise, in NSGCT the aneuploid Ag-NOR sites per nucleus (Ag-NOR count) were significantly higher in DNA aneuploid than in DNA diploid tumors. There was also a significant linear correlation between % S + G2M phase cells and the Ag-NOR count in TGCT. However, the DNA ploidy pattern and the % S + G2M phase cells, and Ag-NOR counts, did not correlate significantly with the patient survival rate or clinical stage. In conclusion, our study suggests that Ag-NOR enumeration is an effective technique for assessing cellular proliferative activity that is somewhat less expensive than DNA flow cytometry. © 1994 Wiley-Liss, Inc.

Twenty patients with testicular hydrocele were treated with a new sclerosing therapy consisting of intrascrotal injection of OK-432 (group A Streptococcus pyogenes of human origin). The median observation period after treatment was 6 months (range 2-13 months). Eighteen patients required only one treatment. Two patients had recurrences and received repeat injection. There have been no serious side effects except for fever of 2-3 days' duration and local inflammatory reaction. Sclerotherapy with OK-432 is an efficient and easy method which can be recommended as a primary treatment for hydrocele.

Calbindin-D 28 kDa. is a vitamin D-dependent calcium binding protein that is found mainly in the distal renal tubules and central nervous tissue in humans. Calbindin-D was measured in the serum and urine before, and immediately, 2 hours or 24 hours after extracorporeal shock wave lithotripsy (ESWL*) in 83 consecutive patients. ESWL was performed with the Siemens Lithostar device in 61 patients and with the Dornier MPL9000 lithotriptor in 22. The serum 28 kDa. calbindin-D level was undetectable (less than 20 pg./ml.) in many samples, whereas urinary 28 kDa. calbindin-D could be detected in every sample. The serum 28 kDa. calbindin-D level was usually elevated after ESWL and the concentration in patients treated with the MPL9000 device was greater than in those treated with the Lithostar instrument. Urinary 28 kDa. calbindin-D levels were elevated significantly immediately and at 2 hours after ESWL, and they decreased to the baseline level within 24 hours after ESWL in the Lithostar group but remained consistently significantly elevated after ESWL in the MPL9000 group. This fact may be because the MPL9000 lithotriptor produces a stronger shock wave than does the Lithostar device during ESWL. These results suggest that 28 kDa. calbindin-D is released from damaged distal renal tubule cells into the serum and urine during ESWL and that 28 kDa. calbindin-D is a specific marker for renal damage by ESWL. To our knowledge this is the first clinical study using a sensitive enzyme immunoassay for human 28 kDa. calbindin-D to estimate renal damage during ESWL.

The detrusor contraction induced by intramural nerve stimulation in human neurogenic bladders was investigated in comparison with control bladders. All the cases with the neurogenic bladder underwent ileocystoplasty in order to resolve intractable incontinence and/or vesicoureteral reflux due to low bladder compliance or severe detrusor uninhibited contraction. 1. The dose-response curve and ED50 value for KCl were not different between neurogenic and control bladders. 2. The response of neurogenic bladders induced by intramural stimulation was significantly stronger than that of control bladders. 3. After application of 10(-6) M atropine remaining contraction of neurogenic bladders was significantly greater than that of control bladders, i.e. 28.4% and 3.7% respectively. However, 10(-6) M tetrodotoxin almost completely inhibited the detrusor contraction in both groups. 4. The subthreshold KCl (5 mM or 10 mM) enhanced the detrusor contractility significantly in control bladders compared to neurogenic bladders. 5. After bathing medium was replaced into Ca-free Krebs' solution, the contractile response was decreased. The contraction of neurogenic bladders in Ca-free solution persisted longer than that of controls. In conclusion, though there was no intrinsic difference in detrusor contractility, contractile response to electrical field stimulation, atropine resistance, enhancement of response by potassium, and contractility in Ca-free solution were significantly different between neurogenic and control bladders.

Urodynamic evaluation was performed in 11 male patients, who underwent radical cystectomy with pelvic lymph node dissection for bladder cancer followed by bladder replacement with a urethral Kock pouch, 3 to 21 months after the operation. Frequency of micturition were 4.9 +/- 1.5 times (mean +/- S.D.) during the day-time and 1.5 +/- 1.2 times during the night-time. Tidal volume of micturition ranged from 300 to 550 ml and residual volume from 10 to 30 ml. Urinary continence was completely preserved in all patients (100%) during the day-time and 8 (72.7%) during the night-time. On pouchmetry, maximum capacity of the pouch was 429.2 +/- 82.4 ml, and intra-pouch pressure was 16.2 +/- 5.4 cmH2O at the capacity of 200 ml and 38.7 +/- 11.5 cmH2O at the maximum capacity. Maximum intra-pouch pressure on voiding was 80.0 +/- 19.4 cmH2O. Uroflowmetry demonstrated intermittent voiding curves in all the patients, with maximum flow rate of 15.2 +/- 6.5 ml/sec, voided volume of 405.9 +/- 80.7 ml and residual rate of 4.5 +/- 2.6%. Maximum intra-urethral pressure at the external urethral sphincter was 28.0 +/- 11.3 cmH2O when the pouch was empty and increased in response to pouch filling up to 64.7 +/- 27.0 cmH2O. Maximum urethral closing pressure and total profile length on the urethral pressure profile were 30.2 +/- 12.4 cmH2O and 20.9 +/- 9.0 mm, respectively, with the pouch empty, and 23.2 +/- 14.5 cmH2O and 20.0 +/- 7.6 mm, respectively, with the pouch full.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnosis and treatment of urinary incontinence in the elderly out-clinic patients were reviewed. Sixty-three patients (24 males and 39 females) over 60 years old, who consulted our clinic complaining urinary incontinence, were subjected to the present study. The patients' ages ranged from 60 to 91, with the mean age of 72.9 years old. The types of the incontinence were urge in 44 cases (69.8%), stress in 10 (15.9%), outflow in 5 (7.9%) and mixture of urge and stress in 4 (6.4%). Urge incontinence resulted from unstable bladder in 63.6% and from neurogenic bladder (overactive detrusor) in 36.4%. Cerebrovascular diseases were the most common cause of the neurogenic bladder. Fifty-four patients (85.7%) were out-patients and 9 (14.3%) were hospitalized for other diseases. Thirteen patients (20.6%) with dementia were included. Diagnosis was made on the basis of a detailed questionnaire, physical examination and voiding chart, and confirmed by urodynamic study. Treatment was positively made by means of drug therapy, operation, clean intermittent catheterization and/or behavior training. As results, incontinence disappeared in 52.4% (frequency of incontinence/day: 5.0 +/- 2.6 times/day to 0), was fairly improved in 30.2% (5.1 +/- 2.3 to 1.2 +/- 0.8), was slightly improved in 7.9% (3.4 +/- 1.4 to 2.4 +/- 1.4) and unchanged in 9.5% (8.2 +/- 2.3 to 8.3 +/- 2.2). Severe neurogenic bladder (overactive), dementia and physical disability were proposed to be important factors responsible for treatment failure. Aggressive therapy should be tried to treat the urinary incontinence in the elderly, since favourable results can be expected in most of the cases.

Pelvic floor muscle training is the mainstream of the non-operative treatment for female stress urinary incontinence. However, in order to make this method effective, it is mandatory to learn how to correctly contract pelvic floor muscles. Thirty adult women suffering from mild stress incontinence were instructed to train their pelvic muscles using vaginal cones. They retained cones of increasing weight in the vagina by contracting pelvic floor for 15 minutes twice a day. Twenty-seven of 30 (90%) patients could complete the training in five weeks. Both incidence and degree of incontinence decreased significantly after the training. The subjective improvement rate (incontinence cured or decreased by 50%) was 70%. The cone weights which they could hold over one minute and the voluntary pelvic floor contractions measured with the perineometer increased significantly, which indicated strengthening of pelvic floor muscles. Vaginal cones have a shape similar to tampons and are accepted by Japanese women with little psychological resistance. This device helps the patients to understand how to contract pelvic floor muscles and to motivate them to continue training, thus contributing for the treatment of stress incontinence.

In order to demonstrate that the extracorporeal shockwave lithotripsy (ESWL) for urolithiasis causes a renal damage, we immunoassayed S100a0 protein and creatine kinase isozymes (CK-B & CK-M) in the serum and urine from patients with renal stone (N = 21) and those with ureteral stone (N = 18) before and after ESWL. S100a0 protein and CK-B, which are localized in the proximal renal tubules at relatively high concentrations, were enhanced more or less both in the urine and serum samples after the treatment in both groups of patients. Since CK-M, which is mainly localized in muscle tissue, also increased in both groups of patients, S100a0 protein and CK-B may be derived not only from kidney, but also from muscle tissues.

To assess changes in aldolase isozyme patterns (A, B, and C) in renal cell carcinoma (RCC) tissues and to evaluate whether serum aldolase A might be a useful marker for RCC, quantitative analysis by enzyme immunoassay and immunohistochemical localization were performed. Concentrations of aldolase A in RCC (7300 +/- 6300 ng./mg. protein n = 26) were significantly higher than those of normal cortex (720 +/- 410 ng./mg. protein, n = 14, p less than 0.01); concentrations of aldolase C in RCC (48.0 +/- 8.0 ng./mg. protein) were also significantly higher than those of normal cortex (8.7 +/- 4.7 ng./mg. protein, p less than 0.01). On the other hand, concentrations of aldolase B in normal cortex were 18,100 +/- 10,100 ng./mg. protein (n = 14), whereas the values in RCC were only 130 +/- 270 ng./mg. protein, a significant lowering (p less than 0.01). Immunohistochemically, aldolases A and C were found localized in all RCC tissues (n = 10); aldolase B was faintly stained in only a few tumor cells of two cases (20%). Levels of serum aldolase A were elevated (greater than 300 ng./ml.) in 30 (75%) of 40 patients with RCC as compared to three (6.3%) of 48 individuals with urogenital benign diseases and in seven (21%) of 34 cases with non-RCC urogenital malignancies. Since it is generally accepted that RCC are derived from renal proximal tubules, these findings indicate that aldolase B, the predominant isozyme in the normal case, changes into aldolases A and C during carcinogenesis and that serum aldolase A could be a new useful biomarker for RCC.

We determined the serum concentrations of IgA and IgG antibodies specific for Chlamydia trachomatis (C. trachomatis) by an indirect immunoperoxidase assay (IPAzyme kit, Savyon Diagnostics, Ltd., Bee, Shova, Israel) to evaluate their diagnostic significance in latent infections in males. Forty-five asymptomatic males whose wife or partner was suspected to be infected with C. trachomatis were studied and the incidence of serum IgA (titer greater than or equal to 16) and IgG (titer greater than or equal to 64) antibodies for C. trachomatis was compared with that in a healthy group, a group with non-gonococcal urethritis (NGU) patients. Changes in IgA titer during treatment were also examined. The incidence of IgA and IgG antibodies in the healthy group was found to be 2.4% and 11.9% in males, and 4.8% and 18.1% in females, respectively. In patients whose wife or partner who was positive to C. trachomatis, the incidence of IgA and IgG antibodies was 42.2% and 75.6%, respectively. In the NGU patients the incidence of IgA and IgG antibodies was 56.3% and 62.5%, respectively. The incidence of IgA and IgG antibodies in patients whose wife or partner was antibody-positive were significantly higher (p less than 0.01) than the corresponding value in healthy men and women, but there was no significant difference from NGU patients or the elderly group. The IgA antibody titer during treatment of C. trachomatis infection showed no reduction in some cases. This study revealed frequent latent incidence of C. trachomatis infection in male patients. Determination of C. trachomatis IgA and IgG antibodies is considered to be supplemental for diagnosis of chlamydial latent infections.

We report a case of benign mixed mesenchymal tumor consisting of spindle cells and an area involving osseous elements. Immunohistochemical investigation revealed the spindle tumor cells to express vimentin and the alpha-subunit of S100 protein, but no staining for other specific antigens. The findings thus suggest that the spindle tumor cells are undifferentiated in nature and derived from mesenchyma, the osseous component being interpreted as evidence of a specific differentiation.

Effects of adrenergic alpha-1-blocking agent, prazosin, in the treatment of detrusor external-sphincter dyssynergia (DSD) were evaluated in both experimental and clinical aspects. Experimentally, in the urethral pressure profile in dogs, the maximum urethral closing pressure was depressed after intravenous injection of 1 mg prazosin. When experimental DSD was obtained in dogs by stimulating electrically the unilateral 2nd sacral root, intra-venous injection of 1 mg prazosin inhibited contraction of the external urethral sphincter. Clinically, 74 patients with DSD based on neurogenic bladder from cerebral vascular attack (CVA) (13 cases) and spinal cord injury (61 cases) were retrospectively surveyed in terms of therapeutical effects of prazosin for DSD. Spinal cord injury was subdivided to 4 groups for clinical evaluation; cervical cord injury (C) with complete paralysis, thoracic cord injury (Th) with complete paralysis, lumbar cord injury (L) with complete paralysis and spinal cord injury with incomplete paralysis. Patients with CVA and spinal cord injury with incomplete paralysis showed good response rates in subjective improvement, 69% and 60% respectively. However, those with spinal cord injury with complete paralysis showed a poor response (28% for C, 23% for Th and 14% for L). The amount of residual urine significantly decreased after treatment, in all the groups except that of lumbar cord injury with complete paralysis. In all the groups, however, even after the drug treatment the amount of residual urine ranged from 80 to 170 ml and the rates of needing clean intermittent catheterization unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of transitional cell carcinoma of the periurethral prostatic ducts received neoadjuvant chemotherapy consisting of methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC), which eradicated pelvic lymph node metastasis, followed by cystoprostatectomy. M-VAC therapy may be indicated for metastatic transitional cell carcinoma of the periurethral prostatic ducts.

To investigate the role of microhematuria for the diagnosis of bladder tumor, the retrospective study of 156 patients with bladder tumor was done. Among the 156 cases, asymptomatic microhematuria was observed in 15 cases (9.6%) as an initial sign of the disease. According to the process to the final diagnosis, these 15 cases were classified into 4 groups; the Group 1 comprised 4 patients who consulted the urologist just after health examination; the Group 2 comprised 6 patients who consulted the urologist by the introduction of the general practitioner; the Group 3 comprised 2 patients who disregarded the sign and consulted the urologist after the appearance of symptoms; the Group 4 comprised 3 patients whose general practitioner overlooked the sign and who consulted the urologist after the appearance of the symptoms. The mean duration between the initial sign and the final diagnosis of each group was 2, 2, 8 and 62 months, respectively. Three of the 5 patients (60%) in groups 3 and 4 were treated by total cystectomy, while only 2 of the 10 patients (20%) in groups 1 and 2 totally cystectomized. High grade tumor was observed more frequently in groups 3 and 4 than in groups 1 and 2. Since the negative rate of urinary cytologic examinations of these 15 cases was 33.3%, cystoscopic examination was necessary for screening of bladder tumor.

To evaluate clinical and pathological factors present at the initial consultation which affect disease progression, we reviewed data from 223 patients with superficial bladder cancer (pTa and pT1) who were initially treated at Nagoya University Hospital between January 1973 and December 1987. The factors included in the present analysis were age, sex, symptoms, interval between initial symptoms and first consultation, location of tumor, size, number, endoscopic shape, histological pattern of growth, grade and stage. The median duration of the follow-up after initial treatment was 46 months. Of the 223 patients, 17 died: 8 (3.6%) of bladder cancer and the remaining 9 (4.0%) of unrelated causes. Disease progression developed in 12 patients (5.4%): muscle invasion of the bladder wall in 11 and lung metastasis in one. The interval between initial treatment and progression ranged from 4 to 108 months, with a median of 11.5 months. Of the 12 patients, 9 (75%) had disease progression within 2 years. Progression was significantly associated with poor prognosis (p less than 0.001): the 5-year actuarial survival rates were 47.1% and 92.8% in patients with and without progression, respectively. Univariate analysis by Cox's proportional hazards model demonstrated that characteristics such as irritative bladder symptoms, higher-grade tumors, invasion into lamina propria, and nonpapillary growth seen at initial consultation were significantly related to disease progression. Cox's proportional hazards model produced hazard ratios of 10.2 in irritative bladder symptoms (yes vs. no), 6.3 in histological grade (grade 3 vs. grades 0-2), 4.9 in stage (pT1 vs. pTa), and 4.7 in pattern of growth (papillary vs. nonpapillary).(ABSTRACT TRUNCATED AT 250 WORDS)