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Study Design: retrograde neurotracing and immunohistochemistry were used to investigate the effect of the tumor necrosis factor (TNF)-α inhibitor, etanercept, on calcitonin gene-related peptide (CGRP) expression in dorsal root ganglion (DRG) neurons innervating intervertebral discs in rats., Objective: to clarify the action of a TNF-α inhibitor on a sensory neuropeptide in DRG neurons innervating intervertebral discs., Summary of Background Data: degeneration of lumbar intervertebral discs is a cause of low back pain. TNF-α in the intervertebral disc is a major contributor to discogenie pain. Effects of TNF-α inhibition on CGRP expression in DRG neurons were evaluated., Methods: the neurotracer FluoroGold was applied to the surfaces of L4/5 discs to label their innervating DRG neurons (n = 30). Of 30 rats, 10 were in a nonpunctured disc sham surgery control group, whereas the other 20 were in experimental groups in which intervertebral discs were punctured with a 23-gauge needle. Etanercept or saline was applied into the punctured discs (n = 10 each treatment). After 14 days of surgery, DRGs from L1 to L6 were harvested, sectioned, and immunostained for CGRP. The proportion of FluoroGold-labeled CGRP-immunoreactive DRG neurons was evaluated in all groups., Results: FluoroGold-labeled neurons innervating the L4/5 disc were distributed throughout L1-L6 DRGs in all groups. Of the FluoroGold-labeled neurons, the proportion of CGRP-immunoreactive neurons was 21% ± 4% in the sham surgery control group, 32% ± 7% in the puncture + saline group, and 23% ± 4% in the puncture + etanercept group. The proportion of CGRP-immunoreactive neurons was significantly greater in the puncture + saline group compared with the sham control and puncture + etanercept groups (P < 0.01)., Conclusion: in this model, CGRP was upregulated in DRG neurons innervating damaged discs. However, direct intradiscal application of etanercept immediately after disc puncture suppressed CGRP expression in DRG neurons innervating injured discs. This finding may further elucidate the mechanism for the effectiveness of etanercept in upregulation of neuropeptide in DRG neurons innervating intervertebral discs.

Study Design: Prospective cohort study., Objective: To examine the utility of 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) to diagnose pyogenic spondylitis in patients showing Modic change., Summary of Background Data: Vertebral bone marrow infection may appear as Modic type 1 signal on magnetic resonance imaging, so it is difficult to distinguish between common Modic change and infection. In the current study, we aimed to examine the utility of 18F-FDG-PET to diagnose pyogenic spondylitis in patients showing Modic change., Methods: In a prospective assessment of 312 patients showing low back pain, 18 patients were suspected of having pyogenic vertebral osteomyelitis because of their symptoms, biopsy results, blood analysis, x-ray examination, magnetic resonance imaging, and FDG-PET during a 1-year follow-up., Results: Observers ultimately diagnosed 11 patients with pyogenic spondylitis (group 1 observers). FDG-PET evaluation by 2 radiologists (group 2 observers) showed isotope accumulation in the lumbar spine in 11 patients, and no accumulation in 7 patients. The evaluation by group 1 observers, who did not see the FDG-PET findings, was compared with the evaluation by group 2 observers. No patients were evaluated differently by group 1 and group 2 observers., Conclusion: In conclusion, the rate of detecting spondylodiscitis infection was very high if FDG-PET was additionally used. FDG-PET is recommended to distinguish between common Modic change and spinal infection.

Nerve growth factor (NGF) and its dual structurally unrelated receptors, tropomyosin-related kinase A (TrkA) or p75 neurotrophin receptor (p75(NTR)), cause the pathogenesis of discogenic pain. To investigate the sensory innervation of injured rat lumbar intervertebral disc (IVD), we examined the expression of neuropeptides such as calcitonin gene-related peptide (CGRP) at dorsal root ganglia (DRG) by inhibiting NGF or its dual receptors. Sprague-Dawley rats with multiply punctured L5-L6 IVD were used. Six experimental groups were prepared: naïve, sham control, and four agent-treated groups with punctured IVD (vehicle, anti-NGF antibody, anti-TrkA antibody, and anti-p75(NTR) antibody). Retrograde neurotracer Fluoro-Gold (FG) was applied together except for the naïve group. Their lumbar DRG were harvested and immunolabeled for CGRP. FG-labeled DRG neurons were most prevalent at L1 and L2 DRG, and the proportion of FG-labeled CGRP-immunoreactive DRG neurons in the vehicle group was significantly elevated (p < 0.05) compared with the sham group, while those of antibody-treated groups, especially in the anti-p75(NTR) group, significantly decreased compared with the vehicle group (p < 0.05). Direct intradiscal application of antibody to NGF or its receptors suppressed CGRP expression, and p75(NTR) antagonism induced the most profound suppression., (© 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Background: It has been reported that rat L5/6 lumbar discs are innervated mainly by L2 dorsal root ganglion neurons. We previously reported that L2 spinal nerve infiltration was effective for discogenic low back pain (DLBP) patients, although the diagnosis was based only on the results of physical examination, plain films, and magnetic resonance imaging (MRI). The purpose of the current study was to evaluate L2 spinal nerve block for DLBP patients retrospectively based on MRI findings and surgical results., Methods: A total of 62 patients with only LBP and no accompanying radicular pain were investigated. Patients had only one level of disc degeneration on MRI. When pain was provoked during discography, we performed surgery at the next stage (40 patients). In all, 22 patients were excluded owing to negative discography results. Of the 40 patients, we evaluated 25 strictly selected patients suffering from DLBP. DLBP was diagnosed when the patient experienced pain relief at least 2 years after anterior lumbar interbody fusion. Fifteen patients who did not show pain relief after surgery were used for the non-DLBP group. L2 spinal nerve infiltration using 1.5 ml of lidocaine was performed in all 40 patients before surgery. The visual analogue scale (VAS) score after L2 spinal nerve infiltration was recorded, and an association of L2 spinal nerve infiltration and DLBP was explored., Results: Low back pain scores assessed using the VAS score, the Japanese Orthopedic Association score, and the Oswestry Disability Index score in the two groups were not significantly different. L 2 spinal nerve infiltration was effective for 27 patients but not effective for 13 patients; the VAS score after 15 min and 2 h improved in the DLBP group compared with that of the non-DLBP group (P < 0. 05). L2 spinal nerve infiltration was more effective in DLBP patients (21 patients, 84%) than in the non-DLBP group (6 patients, 40%) (P < 0.05)., Conclusions: In the current study, L2 spinal nerve infiltration was effective in 84% of selected DLBP patients and is thought to be a useful tool for diagnosing DLBP. However, we should take into consideration that the L2 spinal nerve infiltration was effective in 40% of non-DLBP patients as well.

Diffusion-weighted imaging (DWI) can provide valuable structural information about tissues that may be useful for clinical applications in evaluating lumbar foraminal nerve root entrapment. Our purpose was to visualize the lumbar nerve root and to analyze its morphology, and to measure its apparent diffusion coefficient (ADC) in healthy volunteers and patients with lumbar foraminal stenosis using 1.5-T magnetic resonance imaging. Fourteen patients with lumbar foraminal stenosis and 14 healthy volunteers were studied. Regions of interest were placed at the fourth and fifth lumbar root at dorsal root ganglia and distal spinal nerves (at L4 and L5) and the first sacral root and distal spinal nerve (S1) on DWI to quantify mean ADC values. The anatomic parameters of the spinal nerve roots can also be determined by neurography. In patients, mean ADC values were significantly higher in entrapped roots and distal spinal nerve than in intact ones. Neurography also showed abnormalities such as nerve indentation, swelling and running transversely in their course through the foramen. In all patients, leg pain was ameliorated after selective decompression (n = 9) or nerve block (n = 5). We demonstrated the first use of DWI and neurography of human lumbar nerves to visualize and quantitatively evaluate lumbar nerve entrapment with foraminal stenosis. We believe that DWI is a potential tool for diagnosis of lumbar nerve entrapment.

Study Design: Investigation of sensory innervation of rat osteoporotic lumbar vertebrae using in vitro and in vivo models., Objective: To investigate (1) sensory innervation of osteoporotic rat vertebrae, (2) effects of risedronate on sensory neurons, (3) effects of osteoporosis treatment on bone mineral densities (BMDs) and the sensory innervation., Summary of Background Data: Osteoporotic patients without fractures sometimes experience vague low back pain of unknown origin. The mechanisms of osteoporosis treatments against the pain are unclear., Methods: (1) The expression of calcitonin gene-related peptide (CGRP) immunoreactive (-ir) or transient receptor potential vanilloid 1 (TRPV1)-ir nerve fibers in vertebrae and dorsal root ganglions (DRG) innervating L3 vertebrae of Sprague Dawley rats labeled with neurotracer were examined in control, sham, and ovariectomized (OVX) rats. (2) Cultured rat neonate DRG neurons in media containing different concentrations of risedronate were immunostained for CGRP, and we measured its activity using axonal length and proportion of CGRP-ir neurons. (3) BMDs and CGRP expression in DRG neurons innervating L3 vertebrae were examined in the following 5 groups: sham (treated with saline), OVX (saline), OVX+EXE (treadmill exercise), OVX+RIS (risedronate), and OVX+RIS+EXE (risedronate and exercise)., Results: (1) A few CGRP-ir or TRPV1-ir nerve fibers were observed in the bone marrow. CGRP or TRPV1 expression in DRG was elevated in the OVX group (P < 0.05). (2) The axonal length and proportion of CGRP-ir neurons were dose-dependently suppressed (P < 0.05). (3) BMDs improved and the CGRP expression decreased in the risedronate-treated groups (P < 0.05), especially in the OVX+RIS+EXE group., Conclusion: Sensory innervation of osteoporotic rat vertebrae showed increased expression of CGRP and TRPV1 in DRG neurons. Risedronate suppressed activity of CGRP-ir neurons in vitro, improved BMD, and decreased CGRP expression, especially together with exercise in vivo.

Study Design: Prospective radiographic outcome analysis., Objective: Radiographic evaluation of the rigidity of monocortical and tricortical purchase in lumbosacral fixation., Summary of Background Data: The lumbosacral junction continues to be a difficult region to obtain a successful spinal arthrodesis and is one of the primary regions for construct failure. In inserting sacral screws, 3 types of purchase are known: monocortical, bicortical, and tricortical. Among them no clinical or basic studies have compared monocortical with tricortical purchase., Methods: Ninety consecutive patients diagnosed with spondylolisthesis who underwent lumbosacral fixation were evaluated. Fifty-three patients were treated with a monocortical approach and the other 37 patients were treated with a tricortical approach. Patients underwent surgery for posterolateral fusion or transforaminal lumbar interbody fusion (TLIF) according to their diagnosis. Their radiologic findings, radiolucent zones around sacral screws, and lumbosacral instability of more than 2° flexion just after the surgery and 1 year later were compared. The angulation and length of the inserted screw were also measured and evaluated., Results: There were no significances in the distributions of gender, average age, proportion of fixation method, and fusion range between the monocortical and tricortical groups (P > 0.05). Radiolucent zones and lumbosacral instability were more prevalent in the monocortical group than were in the tricortical group. Smaller angulation also affected the outcome in the monocortical group while screw length did not. Multivariate logistic regression analysis of possible risk factors revealed that female gender (odds ratio [OR]: 3.56, 95% confidence interval [CI]: 1.18-10.8), TLIF operative method (OR: 5.54, 95% CI: 1.08-8.2), number of fusion levels (OR: 1.84, 95% CI: 1.05-3.18), and monocortical purchase (OR: 7.11, 95% CI: 1.58-31.9) were statistically significant., Conclusion: More loosening of sacral screws was radiographically observed in the monocortical purchase group than in the tricortical group 1 year after the lumbosacral fixation surgery. A statistical analysis indicated that the tricortical approach should be used for patients undergoing multilevel fusion including lumbosacral junction by TLIF.

Pathomechanisms of injured-nerve pain have not been fully elucidated. Radicular pain and chronic constriction injury models have been established; however, producing these models is complicated. A sciatic nerve-pinch injury is easy to produce but the reliability of this model for evaluating pain behavior has not been examined. The current study evaluated pain-related behavior and change in pain markers in the dorsal root ganglion (DRG) of rats in a simple, sciatic nerve-pinch injury model. In the model, the sciatic nerve was pinched for 2 s using forceps (n = 20), but not injured in sham-operated animals (n = 20). Mechanical and thermal hyperalgesia were measured every second day for 2 weeks using von Frey filaments and a Hargreaves device. Calcitonin gene-related peptide (CGRP), activating transcription factor-3 (ATF-3), phosphorylated p38 mitogen activated protein (Map) kinase (p-p38), and nuclear factor-kappa B (NF-κB; p65) expression in L5 DRGs were examined at 4 and 7 days after surgery using immunohistochemistry. The proportion of neurons immunoreactive for these markers was compared between the two groups. Mechanical (during 8 days) and thermal hyperalgesia (during 6 days) were found in the pinch group rats, but not in the sham-operated animals (p < 0.05); however, hyperalgesia was not significant from days 10 to 14. CGRP, ATF-3, p-p38, and NF-κB expression in L5 DRGs was upregulated in the nerve-injured rats compared with the sham-operated rats (p < 0.01). Our results indicate that a simple sciatic nerve pinch produced pain-related behavior. Upregulation of the pain-marker expression in the nerve-injury model suggested it could be used as a model of pain. However, it was not considered as suitable for long-term studies.

Purpose: Mullerian duct cyst is a rudiment of a Mullerian duct in the fetal period which causes ejaculatory duct obstruction and male infertility., Case Report: We report two patients with Mullerian duct cyst that presented with low ejaculate volume, oligoasthenoteratozoospermia and azoospermia syndrome. Transrectal ultrasound (TRUS) and magnetic resonance image (MRI) revealed a midline prostatic cystic structure. In each case, we performed a TRUS guided transperineal aspiration of the cyst. Seminograms of the patients improved and one of their wives got spontaneously pregnant 3 months after the surgery., Conclusion: We should assume the TRUS guided aspiration of Mullerian duct cyst.

The relationship of Modic change to pain and inflammation remains to be unclear. Recently, some authors have reported that Modic type 1 signals are closely related to infection. However, if the patients do not have severe back pain, fever, or an abnormal blood profile, it is difficult to distinguish between common Modic change and infection. The purpose of this study was to examine the prevalence of pyogenic spondylitis in patients who showed Modic type 1 change without other signs of infection. Seventy-one patients with Modic type 1 change were evaluated (average age 55, 32 males and 39 females). X-ray and magnetic resonance imaging (MRI) were performed to investigate low-back pain and leg pain. Body temperature was measured and blood analysis (including white blood cell count and level of C-reactive protein) was conducted for all patents. All 71 patients with Modic type 1 change, but without other signs of infection were followed for 2 years. Low-back pain, X-ray, and blood analyses were performed every 3 months; and MRI was performed every year. Severe low-back pain or abnormal signs developed in four patients during the follow-up. Pyogenic spondylitis was diagnosed in three patients by symptoms, blood results, and imaging, and confirmed by biopsy. Two of the three patients were diabetic. A total of 4.2% of patients with Modic type 1 change, but without other signs of infection were diagnosed as having pyogenic spondylitis during the 2-year follow-up, therefore, it is important to consider this before treating Modic type 1 change.

The number of patients showing lumbar degenerative scoliosis, including disc wedging, has increased, and examination of the mechanism of spinal nerve compression due to lateral and rotational mobility of the lumbar spine is necessary. Thirty-two patients with L4-L5 disc wedging but without antero- or retrospondylolisthesis and ten age-matched controls were examined. The angle of disc wedging and change in the angle between left and right bending were evaluated by anterior-posterior X-ray images of patients while they were in a standing position. The degree of disc degeneration and existence of vacuum phenomena were evaluated at the L4-L5 discs. Rotational mobility between maximal right and left rotation was examined by computed tomography (CT). Rotational mobility was measured using the spinal transverse processes of L4 and L5. The relationship between these factors was statistically evaluated using multivariate analysis and Spearman's correlation test. There was a significant increase in the average rotational mobility of the L4-L5 disc-wedging group. In the L4-L5 disc-wedging group, the increased angle of disc wedging and change in the angle between left and right bending correlated with increased rotational mobility. The degree of disc degeneration did not affect rotational mobility. However, existence of vacuum phenomena increased the rotational mobility of the L4-L5 disc-wedging group. This is the first study to evaluate the rotational hypermobility of L4-L5 disc wedging in patients without antero- or retrospondylolisthesis using kinematic CT. Increases in the wedging angle and abnormal instability of lateral bending correlated with increased rotational mobility. For surgical planning of degenerative L4-L5 disc wedging, it is important to consider rotational hypermobility using kinematic CT or X-ray imaging findings of lateral bending.

Study Design: Prospective cohort study., Objective: To examine the relationship between low back pain after discectomy for disc herniation and Modic type 1 change., Summary of Background Data: Lumbar vertebral bone marrow change is divided into Modic types. Some reports indicate that Modic type 1 is related to low back pain, but the reliability of this assertion is unclear. The current study examines changes in low back pain in patients with lumbar disc herniation and Modic type 1 change after lumbar discectomy without fusion surgery., Methods: Forty-five patients with lumbar disc herniation showing normal or Modic type 1 signals in their bone marrow were selected (mean age 35 years). All patients suffered low back and leg pain because of lumbar disc herniation, and underwent a discectomy without fusion. We evaluated change in low back pain [Visual analogue scale (VAS) score, Japanese Orthopedic Association score (JOAS), and Oswestry Disability Index (ODI)] before, 12 and 24 months after surgery., Results: Twenty-three patients showed Modic type 1 signals and 22 patients showed normal intensity before surgery. VAS score, JOAS, and ODI were not significantly different between the normal and Modic type 1 groups. VAS score, JOAS, and ODI improved after surgery in both groups (P>0.05). Low back pain after surgery evaluated from the 3 scores was not significantly different in the 2 groups 12 or 24 months after surgery (P>0.05)., Conclusion: Discectomy improved low back pain in patients suffering from lumbar disc herniation. Patients with or without Modic type 1 change showed a similar improvement of low back pain score. Low back pain in patients with disc herniation appears to mainly originate from disc or nerve root compression, and decompression surgery without fusion is an option for these patients, even those with Modic type 1 changes.

Study Design: Prospective cohort study., Objective: To examine the change of Modic Type 1 to Type 2 after posterolateral fusion surgery., Summary of Background Data: Lumbar vertebral bone marrow change is divided into Modic types. Magnetic resonance imaging reveals Modic Type 1 and 2 signals. Some reports indicate that with time, Type 1 signals (intervertebral instability) change to Type 2 (restabilization), but the reliability of this assertion is unclear. The current study examines the change of Modic Type 1 signals to Type 2 after posterolateral fusion surgery., Methods: Patients with Modic Type 1 and 2 signals were selected (mean age, 65 years). All patients suffered low back pain and leg pain due to lumbar spinal canal stenosis, and underwent decompression and posterolateral fusion surgery. We evaluated change in Modic signal and severity of low back pain (Visual analogue scale score, Japanese Orthopedic Association score, and Oswestry Disability Index before and 24 months after surgery., Results: Of 21 patients with Modic Type 1 signals before surgery, 2 cases changed to normal bone marrow, 9 to Type 2, and 12 remained Type 1. Of 12 patients with Type 2 signals, none changed to Type 1, 2 changed to normal bone marrow, and 10 remained Type 2. Visual analogue scale score, Japanese Orthopedic Association score, and Oswestry Disability Index improved after surgery; however, low back pain was not significantly associated with signal change after surgery (P > 0.05)., Conclusion: In the current study, Modic Type 1 signals changed to Type 2; however, Type 2 did not change to Type 1, suggesting that Type 2 signals indicate a stabilized stage. For Modic Type 1 and 2 signals, there were changes to normal bone marrow signals in 4 cases. Therefore, degenerated bone marrow may be able to regenerate after surgical stabilization. We did not show a significant difference between low back pain and signal type.

Background: Recent studies have revealed that the low-affinity nerve growth factor receptor, p75 neurotrophin receptor (p75NTR), is important in inflammatory pain. Moreover, p75NTR immunoreactive sensory nerve and dorsal root ganglion (DRG) neurons have been found to innervate lumbar intervertebral discs. The purpose of the current study was to investigate the effect of p75NTR saporin, a toxin used to destroy p75NTR, on calcitonin gene-related peptide (CGRP), an inflammatory neuropeptide associated with pain, in DRG neurons innervating punctured intervertebral discs in rats., Methods: The neurotracer fluorogold (FG) was applied to the surfaces of L5/6 discs to label their innervating DRG neurons (n = 30). Of 30 rats, 10 were in a nonpunctured disc sham surgery control group (nonpuncture group), and the other 20 were in experimental groups in which intervertebral discs were punctured with a 23-gauge needle. p75NTR saporin was applied to the discs of 10 rats (puncture + p75NTR saporin group) and the other 10 received the same volume of saline (puncture + saline group). At 14 days after surgery, DRGs from L1 to L6 were harvested, sectioned, and immunostained for CGRP, and the proportions of CGRP-immunoreactive DRG neurons was evaluated., Results: Of the FG-labeled neurons innervating the L5/6 disc, the proportion of CGRP-immunoreactive neurons was 32% +/- 6% (mean +/- SE) in the nonpuncture group, 47.2% +/- 8% in the puncture + saline group, and 34.6% +/- 9% in the puncture + p75NTR saporin group. The proportion of CGRP-immunoreactive neurons was significantly greater in the puncture + saline group compared with the nonpuncture and puncture + p75NTR saporin groups (P < 0.01)., Conclusions: Half of the DRG neurons innervating the discs were positive for CGRP in the puncture + saline group. CGRP is important for mediating inflammatory and nerve-injured pain and may be important in discogenic pain. However, p75NTR saporin suppressed CGRP expression in DRG neurons. Therefore, p75NTR may be an important receptor for mediating discogenic pain via CGRP expression.

Background: Clinically, the origin of low back pain is unknown. The pain may originate from the lumbar muscles directly, or it may be referred pain from the spine. Dorsal root ganglion (DRG) neurons with dichotomizing axons have been reported in several species and are thought to be related to referred pain. However, these neurons, which have dichotomizing axons to the lumbar facet joints and to the lumbar muscle, have not been fully investigated., Methods: Two neurotracers - 1,1'-dioctadecyl-3,3,3',3'- tetramethyl-indocarbocyanine perchlorate (DiI) and fluorogold (FG) - were used in the present double-labeling study. DiI crystals were placed in the right L5/6 facet joint, and FG was applied to right multifidus muscles at the L5 level in 10 rats. Two weeks later, bilateral DRGs from L1 through L6 were harvested, sectioned, and observed under a fluorescence microscope., Results: DiI-labeled DRG neurons innervating the L5/6 facet joint (5.17% of the total DRG neurons) were distributed from L1 to L6. FG-labeled DRG neurons innervating the lower back muscle (15.9% of the total) were also distributed from L1 to L6. Double-labeled DRG neurons were found from L1 to L6. The ratio of total double-labeled/total DiI-labeled DRG neurons was 17% and that of total double-labeled/total FG-labeled DRG neurons was 7%. Approximately 17% of all DRG neurons innervating the facet joints had other axons that extended to the lower back muscle., Conclusions: This finding provides a possible neuroanatomical explanation for referred low back muscle pain from the lower facet joints.

Objective: This study aimed to investigate the level of vascular endothelial growth factor (VEGF) in the temporomandibular joint (TMJ) synovial fluid (SF) and the severity of arthroscopically observed synovitis before and after visually guided TMJ irrigation (VGIR) in patients with chronic closed lock (CCL). In addition, the findings were correlated with the clinical outcome., Study Design: Twenty-four patients with unilateral CCL, who underwent a second VGIR either as a repeated therapeutic TMJ irrigation or as a follow-up arthroscopy, were enrolled in the study. They were divided into either successful (s-group; n = 11) and unsuccessful (u-group; n = 13) groups. The VEGF level in the aspirated SF and the severity of synovitis were compared between the s- and u-groups. In each group, the same parameters were compared before and after VGIR. The correlation of the VEGF level with the severity of synovitis was also studied., Results: At the first VGIR, the VEGF levels showed no significant differences when comparing s- and u-groups. At the second VGIR, the VEGF level was significantly higher in the u-group. The VEGF level significantly decreased after the first VGIR in the s-group but remained unchanged in the u-group. There was no significant correlation between the VEGF level and the severity of synovitis., Conclusions: The level of VEGF in TMJ SF seems to reflect the clinical status in patients with CCL. Moreover, VEGF may be an important target molecule in future chemotherapy of TMJ CCL., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

STUDY DESIGN.: Immunohistological analysis of punctured disc after application of a p38 MAP kinase inhibitor. OBJECTIVE.: To examine effect of direct application on dorsal root ganglion (DRG) neurons innervating damaged rat discs. SUMMARY OF BACKGROUND DATA.: Degeneration of lumbar discs is one cause of low back pain. Pathogenesis may involve sensory nerve ingrowth into disc inner layers; tumor necrosis factor-alpha (TNF-alpha) is thought to be a major inducer of ingrowth. Because p38 mitogen-activated protein kinase (p38) upregulates TNF-alpha expression and may play a crucial role in pain sensation, we investigated the effect of one injection of inhibitor on expression of the pain-related neuropeptide calcitonin gene-related peptide (CGRP). METHODS.: The neuro-tracer fluoro-gold was applied to the surfaces of L4/5 discs to label the innervating DRG neurons (n = 30). Of 30 rats, 10 were controls, whereas the other 20 were the experimental model (i.e., discs were punctured with 23-gauge needle). P38 specific inhibitor or saline was applied simultaneously (n = 10 each, Puncture + inhibitor and puncture + saline groups). Fourteen days postsurgery, DRGs from L1 to L6 were harvested, sectioned, and immunostained for CGRP. Proportion of CGRP-immunoreactive DRG neurons was evaluated in all groups. RESULTS.: Fluoro-gold-labeled neurons innervating the L4/5 disc were distributed throughout L1 to L6 DRGs in all groups. Proportions of labeled neurons positive for CGRP were 15.2% +/- 8% (controls), 27.2% +/- 10% (puncture + saline), and 25.2% +/- 8% (puncture + inhibitor). Proportion of immunoreactive neurons was significantly increased in the puncture groups compared with controls. However, there was no significant difference between the 2 puncture groups (P > 0.1). CONCLUSION.: In this model, CGRP was upregulated in DRG neurons innervating the damaged disc. However, a direct single application of p38 inhibitor did not suppress CGRP expression in innervating DRG neurons. Future research with p38 inhibitor in this model should evaluate multiple or systemic administration of inhibitor.

Objective: This study aimed to investigate the changes of joint effusion (JE) on the MRI and arthroscopically observed pathology after visually guided TMJ irrigation (VGIR) in patients with chronic closed lock. The correlation of these findings to the clinical outcome was also studied., Study Design: Forty patients with unilateral chronic closed lock who underwent 2-time VGIR, were divided into either the good outcome (g-) group (n = 29) or poor outcome (p-) group (n = 11) after the first VGIR. Before each VGIR, the each severity of JE, osteoarthritis, synovitis, and fibrous adhesion were assessed. They were compared between the g- and p-groups, or between the first and second VGIR., Results: The severity of JE at the first VGIR was significantly worse in the p-group. In both groups, JE significantly improved after the first VGIR. In the g-group, synovitis significantly improved after the first VGIR, but fibrous adhesion significantly became worse., Conclusions: JE may be predictive for the clinical outcome of TMJ irrigation in chronic closed lock patients. Moreover, the severity of JE and arthroscopically observed synovitis could reflect the clinical state to some degree.

An 86-year-old man with a serum prostate-specific antigen level of 93.33 ng/ml was diagnosed as having cT3aN0M0 prostatic adenocarcinoma of Gleason score 9. Although the serum prostate-specific antigen responded well to combined androgen blockade, the cancer spread and lead to death 6 months after diagnosis. The patient had leukocytosis during the clinical course with no sign of localized infection, especially after manipulation of the prostate. Enzyme immunoassay demonstrated elevated serum levels of granulocyte colony-stimulating factor (G-CSF) and macrophage colony-stimulating factor. To our knowledge, this is the first case of prostate cancer with G-CSF production, which was confirmed immunohistochemically., ((c) 2009 S. Karger AG, Basel.)

Objective: To survey practice patterns in surgical treatment for urethral distraction defect associated with pelvic fracture (PFUDD) and to analyze outcomes of the treatment in Japan., Methods: A questionnaire on surgical treatment for PFUDD to 3307 Japanese consultant urologists was sent. Responses were collected and statistically analyzed., Results: The number of respondents was 1290 (39%). Patients surgically treated for PFUDD in the previous 5 years totaled 0 for 919 urologists (71%), one to two for 283 (22%), and three to ten for 83 (7%) urologists. Realignment for PFUDD was carried out within 2 weeks in 205 patients (23%), after 2-6 months in 607 (69%) patients, and after more than 6 months in 72 (8%) patients. Urologists operated on 361 (61%) patients endoscopically (ES), 108 (18%) by open anastomosis (OA) and 101 (17%) by pull-through operation (PT). According to the operator's impression, success rates were 65% for ES, 79% for PT and 69% for OA. Re-operation (RO) rates were 43%, 25% and 26% for ES, PT, and OA, respectively, (ES vs PT or OA; P < 0.05). Postoperative repeated urethral dilatation (PORUD) was required in 71% of ES, 77% of PT and 38% of OA cases (OA vs ES or PT; P < 0.05)., Conclusions: PFUDD represents a rare disorder for Japanese urologists. Deferred endoscopic realignment is the preferred treatment option. Success rates were not different among three surgical treatments. OA was superior to ES and PT in terms of PORUD and RO.

We report a rare case of primary signet-ring cell carcinoma of the prostate in an advanced stage. A 62-year-old man with serum level of prostate-specific antigen at 364.70 ng/ml was diagnosed as having cT4N1M1c prostatic signet-ring cell carcinoma of Gleason score 5 + 4 = 9. Immunohistochemical examination demonstrated cytoplasmic immunoreactivity to prostate-specific antigen in signet-ring cancer cells. The intracytoplasmic vacuoles in the signet-ring cells showed mucin production with a positive staining with periodic acid-Schiff. Although the patient received hormonal therapy, the disease progressed and lead to death 15 months after the diagnosis. The clinical and immunohistochemical characteristics of this malignancy are also reviewed.

Objectives: To explore an optimal combination of sampling sites to detect prostate cancer in a repeat biopsy setting., Methods: A transrectal ultrasound-guided systematic three-dimensional 26-core biopsy (3D26PBx), a combination of transrectal 12 and transperineal 14 core biopsies, was performed in 235 Japanese men with prior negative biopsy. Using recursive partitioning, we evaluated cancer detection of all possible combinations of sampling sites and selected the combination that provides the highest cancer detection rate at a given number of biopsy cores., Results: Prostate cancer was detected in 87 of the 235 (37%) men. The 3D26PBx improved cancer detection by 89% relative to the conventional transrectal sextant biopsy. Neither Gleason score nor percentage of Gleason 4/5 cancers differed between cancers with and without positive cores within the transrectal sextant-sampling sites. A three-dimensional combination of transrectal and transperineal approaches outperformed either transrectal or transperineal approach alone. Recursive partitioning revealed that a three-dimensional 16-core (transrectal eight cores plus transperineal eight cores) biopsy could detect all the cancers with the minimum number of cores., Conclusions: We propose a three-dimensional combination of transrectal eight cores taken from the far lateral peripheral zone and the parasagittal base, and transperineal eight cores taken from the anterior and posterior apex and the transition zone as an optimal set of sampling sites for repeat biopsy.

In a case of renal cell carcinoma extending into the vena cava, a temporary intracaval filter was applied before surgery to prevent pulmonary artery thrombosis. Two days later, the filter accidentally migrated into the right ventricle during defecation. Fortunately, it was successfully removed without damaging cardiac musculature under fluoroscopy.

Fistula formation between the upper urinary tract and bowel is an uncommon complication in urogenital diseases. We present a rare case of focal xanthogranulomatous pyelonephritis with a renocolic fistula. This is the first case where a parapelvic cyst obstructs the caliceal outflow and leads to the formation of a renocolic fistula in renal inflammatory disease. It is difficult to make a preoperative diagnosis of focal xanthogranulomatous pyelonephritis with widespread involvement that is caused by non-calculous urinary tract obstruction.

We report a case of invasive renal pelvic tumor with high serum levels of carcinoembryonic antigen (CEA) and carbohydrate antigen (CA 19-9). An 86-year-old man presented with macrohematuria. Retrograde pyelography demonstrated a filling defect in right upper calyx, suspected of renal pelvic tumor. The levels of serum CEA and CA 19-9 were elevated to 28.0 ng/ml and 122 U/ml, respectively. No abnormalities were found in the gastrointestinal tract. Right nephroureterectomy was performed, and histopathological diagnosis was transitional cell carcinoma, grade 2>grade 3, accompanied with adenocarcinoma immuno-stained for CEA and CA19-9. A part of the tumor showed a tubular growth pattern. Both serum levels of CEA and CA 19-9 immediately decreased to the normal range after the operation, but increased again with lung and hepatic metastases.

Objectives: To examine the possibility of nerve grafting to repair the sympathetic pathway projecting to the prostate, as contraction of the prostate is known to be controlled by the sympathetic pathway via the hypogastric nerve (HGN), and injuries to the pathway cause significant disturbances in prostatic secretion., Materials and Methods: In six dogs both of the HGNs were partly removed and immediately repaired with an autologous nerve graft. The left HGN was repaired with a colonic (autonomic) nerve graft and the right with a genitofemoral (somatic) nerve graft. Twenty months after surgery the reconstruction of the sympathetic pathway was assessed by measuring contraction of the prostate after stimulating the lumbar splanchnic nerves (LSNs)., Results: Nine of the 17 right LSNs stimulated elicited prostatic contractions. After transecting the left HGN five of these nine responses were restored. Seven of the 11 left LSNs stimulated elicited prostatic contractions; after transection of the left HGN four of these seven responses were preserved., Conclusion: The sympathetic pathways via the HGN to the canine prostate can be reconstructed by nerve grafting, regardless of the use of autonomic or somatic nerve grafts, and the cross-innervation mechanism from the LSN to the prostate can also be repaired.

We investigated the clinical risk factors and bacteriological examination for surgical site infection (SSI) in 144 portless endoscopic surgeries consisting of 66 clean and 78 clean-contaminated surgeries in urological diseases from April 2000 to December 2001. There were no cases of SSI in the clean surgeries. SSI occurred in 5 cases (3.5%) of clean-contaminated surgeries including total cystectomy and ileal conduit in 4 cases and total prostatectomy in 1 case. Multivariate statistical studies revealed that usage of ileum during operation and preoperative hypo-albuminemia were significant risk factors for SSI. Gram-negative rods and anaerobic bacteria were isolated from the operative wound in the total cystectomy and ileal conduit, suggesting that SSI in the operation with usage of the ileum was partially derived from contamination with endogenous bacteria, while, normal flora of the skin in the wound did not cause any post-operative SSI.

To investigate the feasibility of preoperative low-dose chemoradiotherapy, 50 patients with localized muscle-invasive bladder cancer (T2-T4) were treated with concurrent cisplatin (100 mg/body x 2 courses) and pelvic irradiation (40 Gy). Among 20 patients (40%) who achieved clinical complete regression, 11 with solitary tumor underwent partial cystectomy because of advanced age, poor condition of the patients, or a reluctance to have radical surgery. Radical cystectomy was carried out in the remaining 39 cases (complete regression 9, partial regression 30). Pathologic T0 response (no residual tumor) was achieved in 18 (36%) of all the cases. Median follow-up was 19 months (range 2-59 months). Estimated 3-year disease-free survival was 75% for all patients and 100% for T0 responders. Local recurrence (2 patients) or distant metastasis (6 patients) developed in 8 of 32 patients with pathologic persistent tumor. All of the 11 patients (9 with T0 response and 2 with a small residual tumor nest) who underwent partial cystectomy were recurrence free for observation periods up to 59 months. Low-dose chemoradiotherapy is as effective as other neoadjuvant protocols and is applicable to high-risk patients. The bladder can be preserved by partial cystectomy in selected cases with clinical complete regression.

The membranous urethral muscles, bulbocavernosus muscle (BCM) and ischiocavernosus muscle (ICM) play a significant role on expulsion at ejaculation. Projection of the sympathetic pathways in the retroperitoneum to these muscles was investigated in the dog. Intraluminar pressure of the membranous urethra and contractions of the BCM and ICM to electrical stimulation of the lumbar splanchnic nerve (LSN) or the lumbosacral sympathetic chain (LSC) were examined. Stimulation of the LSN was performed after transection of the unilateral hypogastric nerve (HGN) to clarify its cross-innervation. Stimulation of each of the 2nd to 4th LSNs elicited elevation of the intraluminal pressure of the membranous urethra. In eight dogs whose right HGNs were transected, 15 of the 19 right LSNs, and 12 of the 16 left LSNs examined elicited elevation of the membranous urethral pressure, respectively. In five dogs whose left HGNs were transected, 6 of the 9 right LSNs and 10 of the 12 left LSNs stimulated elicited elevation of the pressure. Stimulation of the HGN caused no detectable contractions of the BCM and ICM in all six dogs examined. Stimulation of the LSC elicited responses of the BCM and ICM in all six dogs examined and the membranous urethra in three of six dogs. The maximum value of the response of the BCM was greater than that of the ICM. After consecutive transection of the ipsilateral pelvic nerve, stimulation of the LSC showed no significant changes in the responses of the BCM and ICM. The above results indicate the following: (1). each of the L2-L4 LSNs sends signals to the membranous urethra via two routes, passing through the ipsilateral or contralateral HGN; (2). the above nerve does not send effective signals to the BCM and ICM; (3). the LSC sends signals to the membranous urethra, BCM and ICM; (4). the signals from the LSC mainly pass through the pudendal nerve to the BCM and ICM; and (5). the signals were dominant to the BCM compared with the ICM.

p63, a homologue of the p53 gene, is considered to be essential for the normal development of stratified epithelia including urothelium. To examine possible roles of p63 in urothelial tumorigenesis, p63 expression was systematically examined in normal urothelium, low-grade papillary noninvasive (LPN) urothelial tumours, and high-grade or invasive carcinomas, using either an isoform-nonspecific or a Delta N-isoform-specific antibody. Expression profiles of p63 were also analysed in cultured cells. Immunoreactivity with the two antibodies was virtually identical in tissue samples examined. Basal and intermediate cell layers of normal urothelium showed intense nuclear p63 immunostaining. This normal staining pattern was preserved in a majority of LPN tumours, whereas it was frequently impaired in high-grade or muscle-invasive carcinomas. At the mRNA level, Delta Np63 expression predominated over TAp63, and amounts of Delta Np63 mRNA correlated with p63 immunoreactivity, confirming that Delta Np63 accounts for p63 expressed in urothelial tissues. In cultured cells, Delta Np63 was also expressed in low-grade tumour cells as well as normal urothelial cells, but undetectable in high-grade aggressive carcinoma cells. Interestingly, impaired Delta Np63 expression significantly associated with reduced beta-catenin expression that was possibly related to progression of urothelial neoplasms. Thus, impaired Delta Np63 expression characterises aggressive phenotypes of urothelial neoplasms.

A 24-year-old man complaining of asymptomatic gross hematuria was referred to our hospital for treatment of bilateral hydronephroses (left > right) diagnosed at a previous clinic. Radiological examinations demonstrated a filling defect at the left uretero-pelvic junction. Cytological examination of the urine was negative. With the diagnosis of suspected benign ureteral polyp, the patient underwent endoscopic-assisted partial ureterectomy and pyeloplasty through a 5 cm flank incision. Histological examination revealed that the villous tumor in the ureter was a fibroepithelial polyp.

Objective: To assess the roles of RhoA small GTPase (RhoA) in upper urinary tract cancer by analysing the mRNA and protein levels of RhoA., Patients and Methods: The mRNA and protein levels of RhoA in matched sets of tumour, non-tumour and metastatic lymph node tissues of surgical specimens were analysed in 47 consecutive patients with renal pelvic/ureteric cancer, using the polymerase chain reaction after reverse transcription and Western blotting. The relationship between mRNA and protein levels of RhoA in tumour tissues and the clinicopathological features of the patients was also assessed., Results: The mRNA levels of RhoA and RhoA protein were greater in tumour and metastatic lymph node tissues than in non-tumour tissues (all P < 0.001). The expression levels of RhoA mRNA and protein levels in primary tumours was related to poorly differentiated grade (both P < 0.05) and muscle invasion (P < 0.01 and < 0.001, respectively). Kaplan-Meier plots of survival in patients with low or high RhoA showed that high mRNA and protein levels were associated with a shorter disease-free (P < 0.01) and overall survival (P < 0.001). Multivariate analysis using the Cox proportional hazards model showed that a high RhoA protein level was an independent prognostic factor, second to stage, in disease-free and overall survival (both P < 0.05)., Conclusions: These findings suggest that RhoA is involved in the invasion and metastasis of upper urinary tract cancer, indicating that RhoA may be a useful prognostic factor in this disease.

Background: For small, incidentally discovered renal cell carcinoma, partial nephrectomy is becoming more widely accepted as an alternative to radical nephrectomy and the need for minimally invasive approach is increasing., Methods: We carried out endoscopic minilaparotomy partial nephrectomy in seven cases of solitary renal cell carcinoma smaller than 4 cm. Five of them were without renal pedicle clamping. All procedures were done through single skin incision (5-8 cm) using a 30 degrees telescope. Hemostasis was achieved with a harmonic scalpel, a microwave tissue coagulator, an argon beam coagulator and autologous fibrin glue., Results: There were no perioperative complications. All patients had negative surgical margins. The operating time was 157-275 min (average 209 min). The blood loss was 20-1200 ml (average 525 ml). Postoperatively, renal function as assessed by serum creatinine was within normal limits. Neither local recurrences nor metastases were observed during a follow-up of 6-15 months. The postoperative course was markedly improved over that expected from standard open surgery., Conclusions: With minimal morbidity and complications, endoscopic minilaparotomy partial nephrectomy is feasible for small renal cell carcinoma.

Expression of peroxisome proliferator-activated receptor (PPAR) gamma in the human urinary tract through embryonic development suggests its possible roles in the development, proliferation, and differentiation of uroepithelium. Little is known, however, about physiological roles of PPARgamma in the urinary tract. We investigated effects of PPARgamma ligands on the proliferation of normal human urothelial cells and stromal cells cultivated from surgical specimens. Active proliferation in vitro as well as high molecular weight cytokeratin expression indicated that cultured urothelial cells possess basal cell phenotype. PPARgamma protein, expressed predominantly in the epithelial layer of the normal human urinary tract in vivo, was abundantly expressed in urothelial cells but barely detectable in stromal cells in vitro. Natural ligand for PPARgamma, 15-deoxy-Delta(12,14) prostaglandin J(2) (15d-PGJ(2)), as well as synthetic ones, troglitazone and pioglitazone, suppressed proliferation of the urothelial cells dose-dependently. These effects were PPARgamma specific because clofibrate or PGF(2alpha) did not affect proliferation of urothelial cells. Neither 9-cis retinoic acid or all-trans retinoic acid (ATRA) at 1 microM showed any synergism on the antiproliferative effects of PPARgamma ligands. Urothelial cells treated with PPARgamma ligands showed drastic morphologic changes and cell cycle arrest at G0/G1 phase accompanied with increased mRNA level of a cyclin-dependent kinase inhibitor p21(WAF1/CIP1). Since 15d-PGJ(2) is present in vivo during the resolution phase of inflammation, these results indicated that PPARgamma might be involved in the terminal phase of urothelial re-epithelialization processes., (Copyright 2002 Wiley-Liss, Inc.)

We have been applying endoscope-assisted minilaparotomy (endoscopic minilaparotomy) to retroperitoneal operations with favorable outcomes. Here, endoscopic minilaparotomy through a single flank incision (4-7 cm) was performed in three cases of incidentally discovered retroperitoneal Schwannoma. Resection of the tumor was successfully completed. The postoperative course was uneventful. Wound pain was mild and full oral feeding and walk were resumed the day following operation. It is concluded that endoscopic minilaparotomy is applicable to retroperitoneal Schwannoma with excellent postoperative recovery.

Background: To assess the feasibility of laparoscope-guided minilaparotomy (endoscopic minilaparotomy) for renal cell carcinoma in patients on chronic dialysis., Methods: Endoscopic retroperitoneal minilaparotomy using a 30 degrees telescope was carried out through single skin incision (5-8 cm) in eight patients with renal cell carcinoma who were on chronic dialysis. Outcomes of the operations were compared to those in eight patients on chronic dialysis with renal cell carcinoma who underwent standard translumbar radical nephrectomy., Results: Resection of the tumor was successfully completed without complication and the postoperative course was uneventful in both of the treatment groups. No significant difference in mean operative time or mean blood loss was observed between the treatment groups. Wound pain was minimal and analgesics were generally not required in the minilaparotomy group. The endoscopic laparotomy group resumed full diet and began walking earlier than the group that underwent standard radical nephrectomy., Conclusions: Endoscopic minilaparotomy seems to be a valuable alternative treatment for renal cell carcinoma in patients on chronic dialysis.

The intracavitary injection of OK-432 (a streptococcal preparation) with subcutaneous priming has been shown to be an effective immunotherapy for patients with malignant effusion. We applied this treatment in a case of advanced renal cell carcinoma with massive ascites. The patient received 0.2 Klinishe Einheit (KE) OK-432 in the subcutaneous injection twice (day 1 and day 7) followed by 10KE OK-432 intra-abdominal administration (day 9). The treatment was performed safely without major side-effects except for transient pyrexia. A significant reduction of ascites was noted 1 month after the treatment without subsequent re-accumulation. Intracavitary injection of OK-432 with subcutaneous priming seems to be a simple, safe and effective treatment for ascites in advanced renal cell carcinoma.

We compared the efficacy of naftopidil with that of tamsulosin hydrochloride for benign prostatic hyperplasia patients. Eighty-five patients without improvement of quality of life (QOL) score by the administration of 50-75 mg naftopidil for more than four weeks were assigned to receive doses of 0.1-0.2 mg tamsulosin hydrochloride and 89 patients without improvement of QOL score by the administration of 0.1-0.2 mg tamsulosin hydrochloride for more than four weeks were assigned to receive doses of 50-75 mg naftopidil once a day for 8 weeks. International prostate symptom score, maximum flow rate, residual urine volume and side effect profile were determined before the administration of the first medicine, before the administration of the second medicine and after 8 weeks of treatment with the second medicine. In the group without improvement of QOL score by naftopidil, significant improvements in symptoms of urgency, weak stream and straining were observed after 8 weeks of treatment with tamsulosin hydrochloride. In the group without improvement of QOL score by tamsulosin hydrochloride, significant improvements in symptoms of incomplete emptying, intermittency and nocturia were observed after 8 weeks of treatment with naftopidil. In conclusion, improvement of symptoms by each alpha 1-blocker differs symptom by symptom. Tamsulosin hydrochloride was superior to naftopidil for the symptoms of urine flow and naftopidil was superior to tamsulosin hydrochloride for the symptom of nocturia.

The clinical efficacy of a single-day oral administration of levofloxacin (LVFX) for the prevention of urinary tract infections (UTI) after urogenital examinations and treatments for outpatients was assessed. A single-day oral administration of LVFX, 100 mg three times a day, was compared to a single dose intra-muscular injection of 100 mg netilmicin sulfate or 100 mg dibekacin sulfate. Three of 219 cases (1.4%) and 7 of 304 cases (2.3%) contracted UTI in the single-day oral administration group and the single dose intra-muscular injection group, respectively. Adverse reactions were observed in 3 of 219 cases (1.4%) and 27 of 304 cases (8.8%) in the single-day oral administration group and the single dose intra-muscular injection group, respectively. In the single dose intra-muscular injection group, UTI and adverse reactions were more severe than in the single-day oral administration group. Therefore, a single-day oral administration of LVFX was superior to a single dose intra-muscular injection of netilmicin sulfate or dibekacin sulfate in the prevention of UTI with less probability of the adverse effects. A single-day oral administration of LVFX was concluded to be sufficient for the prevention of UTI caused by examinations and treatments for outpatients.

Metastatic urachal cancer is often considered lethal. We report 2 cases of metastatic urachal carcinoma successfully treated with surgical excision followed by combinations of surgery, radiation, and chemotherapy against local recurrence and/or distant metastases, with a recurrence-free survival period of more than 10 years. These cases provide support for multimodal treatments of metastatic urachal cancer.

Objectives: The pathologic complexity of the testicular tumor makes it difficult to demonstrate exactly the relationship between the impaired spermatogenesis in patients with a testicular tumor and the serum level of the human chorionic gonadotropin beta subunit (beta-hCG). Therefore, we performed quantitative evaluation of spermatogenesis in ipsilateral and contralateral testicular tissues of seminoma to simplify the relation pathologically and endocrinologically and to demonstrate the exact correlation between spermatogenesis and serum beta-hCG levels., Methods: Fifty-three biopsy specimens from ipsilateral and contralateral testicular tissues of seminoma were analyzed histologically. The quantitative evaluation of spermatogenesis was performed by the mean Johnsen's score count (MJSC). Beta-hCG expression in seminoma was examined immunohistochemically. Serum beta-hCG, testosterone, estradiol, luteinizing hormone, and follicle-stimulating hormone levels were analyzed before orchiectomy., Results: A significant linear relationship (r = -0.82; P <0.005) was found between the serum level of beta-hCG and the MJSC in contralateral testicular tissues but not in ipsilateral ones, although the suppression of spermatogenesis was observed in both sides without suppression of luteinizing hormone and/or follicle-stimulating hormone production., Conclusions: A clearcut fall in the MJSC with an associated rise in the serum level of beta-hCG was demonstrated in the contralateral testicular tissues but not in the ipsilateral ones of seminoma. It seems most likely that serum beta-hCG suppresses spermatogenesis in both ipsilateral and contralateral testicular tissues without the suppression occurring through the hypothalamus-pituitary-gonadal system, and also that some less well recognized factors affect spermatogenesis, making the relation between serum beta-hCG and MJSC obscure in ipsilateral testicular tissues.

Physicians' attitudes towards the disclosure of a cancer diagnosis to 114 consecutive patients (age range, 65-93 years; median 78 years) admitted to the Tokyo Metropolitan Tama Geriatric Hospital from April 1994 to May 1995 were analyzed utilizing a questionnaire administered to the attending physicians. Eighty-seven patients (76%) had been informed of their diagnosis before the initiation of cancer treatment, while 27 patients (24%) were not told. 'To carry out the treatment under patient's understanding' and 'consideration for patient's quality of life' were the major reasons for diagnosis disclosure, while 'lack of patient's ability to understand the information' and 'family's wish that the patient not be informed of the truth' were the major reasons for non-disclosure. Dementia, deteriorated performance status, and non-curability were major factors related to non-disclosure. Even with decisional ability, 15% of patients were not told their cancer diagnosis because wishes of their families were preferred. The current results suggest that telling cancer diagnosis to the elderly patients will not yield negative attitude of the patients and that there is no rationale for physicians to hesitate to disclose cancer diagnosis merely because of patient's high age.

Background: Good local control has been reported in cases of muscle-invasive bladder cancer treated by chemoradiotherapy and transurethral resection (TUR). However, definitive irradiation or extensive chemotherapy is often intolerable for elderly or poor-risk patients. We report here benefits of partial cystectomy after concurrent low-dose chemoradiotherapy for high-risk patients., Methods: Thirty-seven patients with localized muscle-invasive bladder cancer (T2-T4) were treated with concurrent cisplatin (50-100 mg/body x 2 courses) and pelvic irradiation (40 Gy) preoperatively. Among 17 patients (46%) who achieved complete response (CR), 10 were not suitable for radical cystectomy and underwent partial cystectomy. Radical cystectomy was performed in 24 cases [CR = 6, partial response (PR) = 18]. Two patients (one CR and one PR) rejected open surgery and were treated by TUR of the primary site. One no change (NC) patient received no further treatment because of mental disorder., Results: Median follow-up was 12 months (range 2-37 months). Fifteen of 36 evaluable cases (42%) achieved a pathological T0 response (no residual tumor). Estimated 3-year disease-free survival was 56% for all patients and 100% for T0 responders. Seven of 21 patients with pathological persistent tumor developed local recurrence (three patients) or distant metastasis (four patients). All of the 10 patients (eight with T0 response and two with a small residual tumor nest) who underwent partial cystectomy were recurrence-free for an observation period of up to 3 years., Conclusions: Bladder preservation by partial cystectomy may be a choice for patients who show a good response to preoperative chemoradiotherapy and are not suitable for radical cystectomy.

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: The durability of pubovaginal sling procedure for type 2 stress urinary incontinence was evaluated by a questionnaire survey., Materials and Methods: From 1989 to 1996, 48 patients with type 2 stress urinary incontinence were treated with a polytetrafluoroethylene patch sling. Tightness of the sling was adjusted by setting the posterior urethrovesical angle at about 90 degrees under ultrasound monitoring. Study inclusion criteria were no urine leakage for at least 24 months confirmed by questionnaire and no recurrent urinary incontinence during followup., Results: We received answers from 39 patients (81.3%), of whom 1 was excluded from study due to less than 24-month followup (18 months) without urine leakage. Of the 38 patients 32 (84.2%) reported no leakage of urine, 4 (10.5%) were subjectively improved, 2 (5.3%) were the same and none was worse, for an overall cure or improved rate of 94.7%. Followup of the 32 patients maintaining urinary continence averaged 65.9 +/- 29.4 months. Of the patients 6 (15.8%) had slight pelvic pain, 4 (10.5%) always and 10 (26.3%) sometimes had to strain to void, and 14 (36.8%) complained pollakisuria. Urge incontinence coexisted in 5 of 6 patients reporting improved or the same status. Of all patients 31 (81.6%) were satisfied with the decision to undergo the operation., Conclusions: Durability and safety of our procedure for stress urinary incontinence were confirmed by the survey questionnaire. Most of the patients complained of no or little difficulty voiding.

An 89-year-old man presented with urinary retention. Digital rectal examination was benign despite elevated serum prostate-specific antigen (PSA) level. Suprapubic prostatectomy was performed under the diagnosis of benign prostatic hyperplasia. Histopathological diagnosis was endometrioid carcinoma showing positive immunohistochemical staining for PSA. Postoperatively, estrogen was administered for 9 months. After 37 months, serum PSA level began to increase and a palpable nodule was detected on digital rectal examination. Biopsy showed coexistence of endometrioid carcinoma and acinar adenocarcinoma. Hormonal treatment was resumed and the disease has been well controlled for 65 months postoperatively.

A 62-year-old female was admitted to our hospital with left flank pain and weight loss. Computerized tomography revealed a large left adrenal tumor and a small right renal tumor. A left adrenalectomy was performed initially to confirm sparing the left kidney. The left adrenal tumor weighed 650 g and was renal cell carcinoma histologically, suggesting a contralateral metastasis of the right renal tumor. Two months after the adrenalectomy, the right kidney was excised. The right adrenal gland was preserved. Pathologically, the renal tumor was also renal cell carcinoma. The patient has remained well for 34 months after the operation. The literature concerning the adrenal metastasis of renal cell carcinoma is briefly reviewed.