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Purpose: Our objective was to evaluate the effect of the calcium (Ca2+) channel blocking agent nifedipine on bladder overactivity induced by middle cerebral artery (MCA) occlusion and determine its site of action., Materials and Methods: Seven days after implantation of a bladder catheter, a cannula for intracerebroventricular and intrathecal administration was implanted and the left MCA was occluded with 4-0 monofilament nylon thread in male SD rats. Twenty-four hours after the induction of cerebral ischemia, saline was infused into the bladder at a constant rate (200 microL/min.) and cystometrogram was measured in conscious state. Nifedipine was administered intracerebroventricularly (5 microL) or intrathecally (20 microL) at graded doses (0.15 ng.-0.15 microg., 0.15 microg. -1.5 microg., respectively)., Results: Bladder capacity in conscious rats was significantly reduced after the left MCA occlusion. Intracerebroventricular administration of nifedipine significantly increased bladder capacity in cerebral infarcted rats but not in sham operated rats. Furthermore there was no significant difference in bladder capacity between before and after intrathecal administration of nifedipine in cerebral infarcted rats., Conclusion: These results show that Ca2+ channel blocking agents can operate especially on the supraspinal central nervous system rather than on the spinal system in rats with neurogenic bladder overactivity following cerebral infarction.

This study was undertaken to determine if an AMPA (LY215490) or an NMDA (MK-801) glutamatergic receptor antagonist can reduce urinary tract dysfunctions related to detrusor hyperreflexia and detrusor-sphincter dyssynergia in awake, spinal cord-injured (SCI) rats. Experiments were performed on female Sprague-Dawley rats in which the spinal cord was completely transected at T(8-10) level, 2-3 weeks prior to performing an intravesical continuous infusion cystometrogram (CMG). Bladder volume threshold (VT) for inducing voiding and voiding efficiency (VE) were determined by measuring voided volumes and residual volumes (RV). After control CMGs were performed, cumulative intravenous doses of LY215490 (0.1, 1, and 10 mg/kg) or MK-801 (0.03, 0.3, and 3 mg/kg) were administered at 120-min intervals. Small doses of LY215490 (0.1 mg/kg) or MK-801 (0. 03 and 0.3 mg/kg) did not affect any parameters. A large dose (10 mg/kg) of LY215490 decreased maximal voiding pressure (MVP) by 27% and increased RV by 119% and VT by 58% but did not decrease VE. The highest cumulative dose (3 mg/kg) of MK-801 significantly increased RV by 134% and VT by 44% and markedly decreased VE by 60% and MVP by 18%. The effects of LY215490 to reduce MVP and increase VT without changing VE suggest that an AMPA receptor antagonist might be useful in treating detrusor-sphincter dyssynergia and bladder hypertrophy after SCI. The effect of MK-801 to markedly reduce VE indicates that NMDA receptor antagonists may exacerbate neurogenic bladder dysfunction in SCI patients., (Copyright 1999 Academic Press.)

Purpose: A causative relationship between stress urinary incontinence (SUI) and detrusor instability has been suspected but never proven. Many women with mixed incontinence have resolution of detrusor instability after surgical correction of SUI. We sought experimental support that stimulation of urethral afferent nerves can induce or change reflex detrusor contractions., Materials and Methods: Urethral perfusion pressure and isovolumetric bladder pressure were measured with catheters inserted through the bladder dome in urethane anesthetized female S.D. rats (250 to 300 grams; n = 12). The catheter assembly was seated securely in the bladder neck to block passage of fluid between the bladder and urethra without affecting the nerve supply to the organs. The external urethra was not catheterized. Responses were examined in the control state at a urethral saline perfusion speed of 0.075 ml. per minute. Intraurethral drugs were administered following blockade of striated sphincter activity with intravenous alpha-bungarotoxin (0.1 mg./kg.)., Results: Stopping the urethral saline infusion caused a significant decrease in micturition frequency in approximately 50% of the animals studied (n = 12). Intraurethral lidocaine (1%) infused at 0.075 ml. per minute caused a slight decrease in urethral perfusion pressure but no change in detrusor contraction amplitude. However, intraurethral lidocaine caused a significant (45%) decrease in the bladder contraction frequency (n = 5). The micturition frequency returned to baseline 30 minutes after stopping lidocaine infusion. Intraurethral infusion of nitric oxide (NO) donors (S-nitroso-N-acetylpenicillamine [SNAP] (2 mM) or nitroprusside (1 mM) immediately decreased urethral perfusion pressure by 30 to 37% (n = 5). A 45 to 75% decrease (n = 5) in bladder contraction frequency was also seen, which was similar to that observed following lidocaine. Neither NO donor changed the amplitude of bladder contractions., Conclusions: These results indicate that in the anesthetized rat activation of urethral afferents by urethral perfusion can modulate the micturition reflex. Thus in patients with stress urinary incontinence, leakage of urine into the proximal urethra may stimulate urethral afferents and facilitate voiding reflexes. This implies that stress incontinence can induce and/or increase detrusor instability. These findings have significant implications for the treatment of patients with mixed urge and stress incontinence. Correction of stress incontinence by surgery or pelvic floor exercise in patients with mixed incontinence may resolve the detrusor instability.

A 62-year-old male, who had undergone right nephrectomy to treat renal cancer 19 years earlier, was recently referred to our hospital to receive a detailed examination and treatment of mediastinal lymph node swelling. Biopsy of the swollen lymph nodes allowed a diagnosis of renal cell carcinoma (alveolar type, clear cell subtype, GI) to be made. The pathological features of his tumor were consistent with those of the renal tumor resected 19 years previously. Because there was a high probability of further growth of the swollen mediastinal lymph nodes and consequent high probability of compression of the superior vena cava, we performed mediastinal lymph node excision. Immediately after surgery, prophylactic interferon therapy was started. To date, five cases (including the present case) in which renal tumors recurred more than 15 years after surgical treatment have been reported in Japan.

The contribution of glutamatergic and dopaminergic mechanisms to bladder hyperactivity after left middle cerebral artery occlusion was evaluated by determining the effects of intravenous cumulative doses of an N-methyl-D-aspartate (NMDA) glutamatergic antagonist (MK-801) and D1-selective (Sch-23390), D2-selective (sulpiride), or nonselective (haloperidol) dopaminergic antagonists on bladder activity in sham-operated (SO) and cerebral-infarcted (CI) rats. MK-801 (1 and 10 mg/kg) or sulpiride (3-30 mg/kg) significantly increased bladder capacity (BC) in CI but decreased or had no effect, respectively, on BC in SO. Sch-23390 (0.1-3 mg/kg) decreased BC in both SO and CI. In both CI and SO, low doses of haloperidol (0.1-1 mg/kg) increased BC, but a higher dose (3 mg/kg) reversed this effect. Administration of haloperidol (0.3 mg/kg) or sulpiride (10 mg/kg) in combination with MK-801 (0.01-10 mg/kg) markedly increased BC in CI but produced small decreases or increases in BC depending on the dose of MK-801 in SO. These results indicate that the bladder hyperactivity induced by cerebral infarction is mediated in part by NMDA glutamatergic and D2 dopaminergic excitatory mechanisms.

A 53-year-old female patient with obstructive sleep apnea syndrome was reported. She had complained of enuresis as well as a 15-year history of snoring, but she had no complaint of sleep and awake disturbance. Polysomnographic study showed repeated obstructive apnea and hypopnea with an apnea/hypopnea index of 52.6, and severe oxygen desaturation during sleep. On cystometography during sleep, the changing amplitude of the spike wave corresponds to the changes of respiratory efforts against a closed upper airway. The patient was treated successfully with imipramine and acetazolamide for the obstructive sleep apnea and enuresis. Apnea/hypopnea index, nocturnal oxygen desaturation, and sleep architecture were improved, and enuresis completely disappeared. Cystometrography during sleep showed that the average amplitude of the spike wave tended to be low. Percentage urinary volume during sleep compared with 24 h volume was significantly reduced. We considered that the enuresis was mainly related to increased intra-abdominal pressure produced by respiratory efforts and enhanced nocturnal urine production.

A case of a single ectopic vaginal ureter in a 6-year-old girl with urinary incontinence is reported. Excretory urography and renal sonography failed to visualize the dysplastic kidney, but enhanced computed tomography clearly demonstrated a poorly functioning hypoplastic kidney, ectopic ureter and vagina filled with contrast medium., (Copyright 1999 S. Karger AG, Basel)

Purpose: Our objective was to evaluate the underlying mechanisms of neurogenic voiding dysfunction following cerebral infarction., Materials and Methods: The left middle cerebral artery (MCA) was occluded using 4-0 monofilament nylon thread in male S-D rats. Cystometric examination was performed in unanesthetized and urethane-anesthetized rats through a catheter chronically implanted in the dome of the bladder., Results: Bladder capacity of unanesthetized or urethane anesthetized rats was significantly reduced just after occlusion of the left MCA; 2 weeks after the occlusion, the capacity was less than half that in sham-operated rats. Intravenous administration of N-methyl-d-aspartate (NMDA) receptor antagonist MK-801 to the unanesthetized sham-operated rats led to a marked dose-dependent decrease in bladder capacity. Its administration to unanesthetized rats with cerebral infarction resulted in a slight decrease in bladder capacity. In the urethane-anesthetized state, the bladder capacity of the rats with cerebral infarction was significantly increased by MK-801, 0.1 mg./kg., without inhibiting the contraction pressure or increasing the amount of residual urine. A high dose (1 mg./kg.) of MK-801 was required to increase the bladder capacity of sham-operated rats. This led to an inhibition of contraction pressure and an increase in residual urine., Conclusion: Results in urethane anesthetized rats indicate that NMDA glutamatergic transmission is important in the overactivity of the bladder following a cerebral infarction. This model is useful in studying the neurogenic voiding dysfunction observed in patients with cerebrovascular disease.

Purpose: To evaluate the contractile properties of overactive bladder from rats in the chronic stage of experimental cerebral infarction., Materials and Methods: Cystometry was performed in conscious male S-D rats after inducing occlusion of the left middle cerebral artery. Bladder muscle strips were evaluated for force development in response to field stimulation, acetylcholine and KCl. By measuring the contractile response to field stimulation after adding atropine and alpha,beta-methylene-ATP, contributions of cholinergic and purinergic transmission were determined., Results: Bladder capacity of cerebral-infarcted rats was <50% of the capacity of sham-operated rats and significantly less than that of sham-operated rats even 4 months after surgery. There was no significant difference in bladder weight between sham-operated rats and cerebral-infarcted rats. No differences in the contractile response of detrusor strips to field stimulation and acetylcholine, or in the relative contribution of cholinergic and purinergic transmission to the contractile response, were observed over time or between strips from sham-operated rats and cerebral-infarcted rats. KCl induced significantly less contraction in strips from 4 month infarcted rats than in strips from 4 month sham-operated rats, 2 week infarcted rats and 2 month infarcted rats., Conclusions: This animal model will be useful for chronic studies on the mechanism of detrusor hyperactivity (DH).

The effect of anesthesia or an N-methyl-D-aspartate (NMDA) glutamatergic antagonist (MK-801) on bladder hyperactivity induced by unilateral middle cerebral artery (MCA) occlusion was examined in female rats. Before infarction, control bladder contractions were monitored in two groups of rats: 1) awake and 2) urethan anesthetized. The awake rats were then anesthetized with halothane, and MCA occlusion was performed in both groups. After recovery from halothane, bladder capacity in awake rats was significantly reduced (60.8 +/- 1.3%) 0.5-4.5 h after MCA occlusion but not changed in urethan-anesthetized rats. MK-801 (0.1 mg/kg i.v.) administered before MCA occlusion blocked the reduction in bladder capacity in awake rats 1.5-4.5 h after MCA occlusion. Bladder capacity was not changed by sham operation in either the awake or urethan-anesthetized rats. Urethan administered after recovery from halothane anesthesia increased bladder capacity in MCA-occluded awake rats but not in sham-operated awake rats. Infarct areas in halothane, urethan-anesthetized, or MK-801-treated rats were not significantly different. These results indicate that cerebral infarction induces bladder hyperactivity in awake rats and that urethan or MK-801 inhibits the development of this hyperactivity, most likely by blocking glutamatergic transmission in the brain.

Purpose: We evaluated the effects of intravesical administration of lidocaine on the overactive detrusor in patients with spinal cord injury and cerebrovascular disease., Materials and Methods: Cystometry was performed before and 15 minutes after intravesical instillation of 20 ml. of 1 and/or 4% lidocaine in 48 patients with spinal cord injury and 67 with cerebrovascular disease., Results: A significant increase in bladder capacity was observed following administration of 1 and 4% lidocaine in patients tested longer than 1 year after spinal cord injury. However, no significant increase was noted even with 4% lidocaine in those tested within 1 year after injury. A significant increase in bladder capacity was observed in patients with cerebrovascular disease with 4 but not 1% lidocaine. When comparing the percent increase in bladder capacity obtained with 4% lidocaine in the 2 groups, patients with spinal cord injury showed a significantly greater increase than those with cerebrovascular disease (91.6 versus 31.9%, respectively). Detrusor contractions disappeared in 37.5 versus 5.4% of patients, respectively., Conclusions: Intravesical administration of lidocaine appears to be useful in differentiating detrusor hyperactivity caused by lesions of the spinal cord versus those of the brain.

Factors influencing bladder compliance were examined in 116 patients with benign prostatic hyperplasia (BPH), by evaluating patients' histories, response of isolated bladder strips to acetylcholine, and the effect of prostatic urethral anesthesia. Patients' age, frequency of micturition, and duration of voiding difficulty were not correlated with bladder compliance. Bladder compliance was significantly low in patients within 30 days after urinary retention, as compared with bladder compliance in patients without an episode of retention. More than 30 days after retention, however, there was a tendency toward increased bladder compliance. Restricted to patients without an episode of retention, bladder compliance in the overactive detrusor group was found to be significantly lower than in the normal group. The responses to acetylcholine of bladder strips were compared between patients with low and normal-compliance bladders. The dose-response curve of patients with low-compliance bladders did not differ from that of those with normal compliance bladders, even when patients with an episode of retention were excluded. After prostatic urethral anesthesia, a significant increase of bladder compliance was observed in patients with an overactive detrusor, while the increase was not significant in patients with a normal detrusor. Our results strongly suggest that easy irritability of the anatomically altered prostatic urethra, as well as bladder over-distension caused by urinary retention, are important factors affecting bladder compliance in BPH patients.

Purpose: We assessed the usefulness of and indications for endoscopic treatment of vesicoureteral reflux in myelodysplasia patients., Materials and Methods: A total of 26 patients treated with intermittent catheterization was divided into 11 (16 ureters) with and 15 without vesicoureteral reflux. In 9 patients (13 ureters) endoscopic correction was performed with 3% atelo-collagen and without anesthesia at the outpatient clinic. In each ureter we obtained the sum of scores for 4 risk factors for upper urinary tract deterioration: bladder compliance less than 10 ml./cm. water, grade 2 to 3 bladder deformity, detrusor-sphincter dyssynergia and urethral closure pressure 50 cm. water or greater., Results: No reflux was demonstrated immediately after the initial collagen injection but cystography 3 to 6 months later showed recurrent reflux in 5 ureters (38%). Repeat injection cured the reflux, with results persisting for an average of 17 months. Mean risk factor score for patients without vesicoureteral reflux was significantly lower than that for patients with reflux. In patients treated with intermittent catheterization and anticholinergic agents the mean score for ureters with an increased or unchanged reflux grade was significantly greater than for those with a decreased grade., Conclusions: Endoscopic treatment of reflux appears to be safe and useful in patients with myelodysplasia. The treatment is preferable in those with high risk factor scores due to the possibility of increased reflux grade in such patients.

Nine patients with persistent urinary incontinence due to neurogenic bladder and intolerable systemic side effects on oral anticholinergic agents were treated with intravesical instillation of oxybutynin hydrochloride. Two tablets (6 mg) dissolved in 10 ml of physiological saline or sterile water were instilled into the bladder two times daily via self intermittent catheterization. The mean bladder capacity increased from 128 to 212 ml 1 month after intravesical instillation of oxybutynin hydrochloride, although this difference was not significant. The bladder was augmented more efficaciously in patients with overactive detrusor than patients with an underactive detrusor. Subjective improvement was recognized in 4 patients. Among 5 patients who discontinued therapy due to ineffective results, maximum urethral closure pressure below 50 cmH2O was seen in 4. Intravesical instillation of oxybutynin hydrochloride was considered to be ineffective clinically in patients with underactive detrusor and low urethral closure pressure. Although no systemic side effects were observed, a decrease of bladder capacity was recognized in 2 patients.

We present a case of colovesical fistula due to sigmoid colon diverticulitis. A 63-year-old woman was referred to our department with the complaints of dysuria, turbid and foul smelling urine. She was treated twice for acute cystitis at the referral hospitals. A diagnosis of colovesical fistula was confirmed on barium enema. She underwent partial resection of sigmoid colon with primary anastomosis and partial cystectomy with repair of bladder wall and covered with omentum. Retrograde cytography taken on the 20th post-operative day revealed no leakage of contrast medium. She was asymptomatic at 3 months of follow-up.

We examined the effects of prostatic urethral anesthesia on cystometrography in benign prostatic hyperplasia (BPH) patients with or without neurological disorders. Although cystometrography after anesthesia showed no disappearance of involuntary detrusor contraction, it did demonstrate significant increases in first sensation volume and maximum cystometric capacity in BPH patients without neurological diseases, as well as BPH patients with a history but no physical evidence of neurological disease. Furthermore, the bladder might be augmented more efficaciously in patients with involuntary detrusor contractions. No significant differences were found in first sensation volume or maximum cystometric capacity before and after anesthesia in patients without infravesical obstruction who had documented neurological disease with physical evidence. Our results demonstrated that prostatic urethral anesthesia can be used preoperatively in patients with infravesical obstruction to discriminate whether involuntary detrusor contractions are due to infravesical obstruction or to neurological disease.

A 24-year-old female with neurogenic bladder due to spina bifida consulted our department for further evaluation and treatment of a left renal stone. She innately voided urine by Crede's method. At the age of 15 years, intermittent self-catheterization was started because left severe hydronephrosis was found. At the age of 19 years, cystostomy was performed because of low compliance bladder and an aggravation of hydronephrosis in spite of intermittent catheterization. Thereafter, she was referred to our department for further evaluation and treatment of a left renal stone since the stone was increasing in size. First, left percutaneous nephrolithotomy was performed successfully. Secondly, clam ileocystoplasty using the ileum was carried out, followed by 1) increase of the bladder capacity, 2) improvement of the bladder compliance, 3) adequate intermittent self-catheterization, and 4) disappearance of urinous odor resulting from removal of the cystostomy catheter. Thus, the clinical effects were thought to be significant.

To determine the most effective parameter of functional electrical stimulation of the anal sphincter (FES), the present study was carried out in female mongrel dogs anesthetized with alpha-chloralose urethane. When spontaneous and rhythmic micturition contractions of the bladder were present, they were more effectively inhibited by the stimulation with low frequency (5 to 10 Hz). Based on the results of this experiment 18 patients with urge incontinence were treated by maximal electrical stimulation with the following parameters. The duration for each stimulus was 0.2 msec, frequency 5 Hz, amplitude 30 to 150 volts. Every patient received ten treatments for two weeks, each lasting for 30 minutes. A clinical cure for urge incontinence was noted in 12 patients. As for urodynamic studies, FES increased significantly the volumes of the first desire to void (FDV) and maximum desire to void (MDV); however, it did not increase significantly the maximum urethral closure pressure or residual urine volume. Eighteen patients were divided into two groups; an unstable bladder group and a neurogenic bladder group. In the latter, the increases in volumes of FDV and MDV were significant. Second, 18 patients were divided into two groups according to the administration of lack of anticholinergic agents. For subjective symptoms, the rate of improvement of urge incontinence was significantly higher in the group administered the agents. These findings suggested that FES was very useful for the treatment of urge incontinence, with its efficacy augmented by the administration of anticholinergic agents.

Bilateral renal cell carcinoma developing in a 55-year-old male receiving long-term dialysis is reported. The patient, who had undergone maintenance hemodialysis for 12 years, was admitted in July, 1986 for the purpose of extensive examination of a right renal mass. CT scan and ultrasonography demonstrated an enlarged bilateral kidney associated with multiple cysts, containing a solid mass in the right upper pole. The patients underwent right nephrectomy under the diagnosis of right renal tumor. The solid tumor 4 x 3 cm in size revealed a grade 1 to 2 renal cell carcinoma pathologically. Two small tumors were recognized in other portions of the kidney. Multiple cysts of varying sizes, the largest 2 cm in diameter, replaced the renal parenchyma. The cyst walls frequently contained hyperplastic changes. The patient has been subsequently followed up for 2 years and 9 months and underwent left nephrectomy for suspected left renal tumor. The surface of the left kidney was covered by numerous cysts. The result of pathological examination was renal cell carcinoma, which was recognized in a total of 7 regions of the left kidney. The patient remains well on hemodialysis, with no evidence of recurrence or metastasis.

A 42-year-old woman was admitted to our hospital complaining of dull left flank pain. Excretory urogram showed a downward compression above the left nephrogram. Computed tomographic scan and magnetic resonance imaging (MRI) revealed a left adrenal tumor with a non-homogenous inner density. The mass was hyperintense as compared to the liver on T2-weighted images of MRI. No endocrinological abnormalities were detected by laboratory examinations. We performed transperitoneal left adrenalectomy and nephrectomy under the diagnosis of non-functioning left adrenal tumor. The histological examination revealed adrenal cortical carcinoma without lymph node metastasis. The patient has been receiving 4.5g o,p'-DDD per day after the operation. There has been no evidence of recurrence or metastasis during the 7-month follow-up period.

Long-term dialysis patients frequently develop acquired cystic disease of the kidneys (ACDK). One hundred and sixty-seven dialysis patients were classified into two groups according to the presence or absence of ACDK, and the two groups were compared with regard to the dialysis period, laboratory findings, and so forth. Among the 167 dialysis patients, 37.7% showed ACDK and had an average dialysis duration of 10.3 years, which was significantly longer than the 5.0 years for patients without ACDK. The proportion of patients with ACDK rose with increasing duration of dialysis; 64.6% of the patients on dialysis for more than 10 years had ACDK. The values of hemoglobin and hematocrit of patients with ACDK were significantly higher than those without ACDK. Of 12 dialysis patients who were operated upon because of suspected renal tumor, pathological examination confirmed renal cell carcinoma in 8 and adenoma in one. One of these patients had been treated with chronic ambulatory peritoneal dialysis, and another had bilateral renal tumor. Among the 8 patients with renal cell carcinoma, ACDK was detected in 5 by means of CT and ultrasound tomography, and cystic changes were observed in two on light microscopic examination of the resected kidneys. Pathological examination of the non-tumorous renal tissues revealed hyperplastic or adenomatous changes in the cyst epithelium in 5 patients undergoing dialysis for more than 7.5 years. These changes were thought to be pre-neoplastic. The high incidence of ACDK and the development of renal tumors in long-term dialysis patients indicates the necessity of intensive monitoring.

During a period of 4.5 years, neurological and urodynamic evaluation was done on 12 patients with multiple sclerosis between 20 and 67 years old with an average age of 47.6 years. Pyramidal dysfunction (100%), sensory disturbance (100%) and brain stem dysfunction (60%) were common neurological signs. All patients were assessed by the Kurtzke's rating of neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Of the 12 cases 6 were diagnosed as severe multiple sclerosis (EDSS greater than or equal to 4.5) and the remainders were diagnosed as relatively mild (EDSS less than 4.5). Neurourologic evaluation was performed by rapid filling carbon dioxide cystometry and sphincter electromyography. Cystometry revealed overactive bladder in 4 (33%), underactive bladder in 3 (25%) and normoactive bladder in 5 (42%) of the 12 cases. Of the 6 severe cases of multiple sclerosis, 3 (50%) showed overactive bladder, while only 1 of the 6 (17%) mild cases showed overactive bladder. Detrusor sphincter dyssynergia (DSD) was observed in 4 of the 9 (67%) severe cases and none of the 6 mild cases. The presence of overactive bladder or DSD seems to correlate with the severity of multiple sclerosis.

We report a case of ectopic prostatic polyp preoperatively diagnosed as bladder tumor. Several examinations highly suggested the possibility of a bladder tumor invading prostatic tissue, but the exophytic lesion was located proximal to the verumontanum. Transurethral resection of the lesion was performed, and the histological examination revealed typical findings of benign prostatic hyperplasia. We reviewed 42 cases of ectopic prostatic tissue reported in the Japanese literature. Ectopic prostatic tissue should be considered in the differential diagnosis of hematuria in the male.

The clinical effectiveness and safety of propiverine hydrochloride (P-4, 20 mg tablet) were studied on 29 patients with nervous pollakisuria, neurogenic bladder or unstable bladder, whose chief complaints were urinary frequency and/or urinary incontinence. The clinical efficacy was "good" or better in 62.1% and "fair" or better in 86.2%. Patients' impressions were "good" or better in 79.3%. There were a total of 4 cases (13.8%) of adverse reactions, namely, two cases of decreased urinary stream, one dry mouth, and one dizziness. These reactions disappeared rapidly after the completion or discontinuance of drug administration, and therefore, did not constitute significant safety problems. The clinical efficacy in the treatment of subjective symptoms was 74.1% for diurnal pollakisuria, 50.0% for nocturnal pollakisuria, 83.3% for urinary incontinence and 69.0% for urgent feeling of micturition. For objective symptoms, P-4 increased significantly the volume of maximum desire to void (MDV); however it did not increase significantly the residual urine volume. The results of this study suggest that propiverine hydrochloride is very useful for the treatment of urinary frequency and/or incontinence.

A combined treatment of alpha interferon (INF), 8 MHz radiofrequency (RF) hyperthermia using Thermotron-RF Model 8 and/or irradiation was performed on a patient with advanced renal cancer. The patient was a 52-year-old male, who had received arterial embolization with a gelatin sponge and 60 mg of adriamycin for the right renal tumor in January, 1985. He was referred to our clinic in April, 1985. Computed tomography showed a right renal tumor, 120 x 105 x 80 mm. Histological examination revealed clear cell carcinoma of the right kidney. The tumor was unresectable because of the huge tumor size, invasion into the right lobe of the liver, multiple pulmonary metastases and severe dysproteinemia. From the beginning of May, 1985, administration of 3 x 10(6) units interferon-alpha (INF) daily and radiofrequency (RF)hyperthermia for one hour twice a week were started. By June 11, 1985, 10 sessions of RF-hyperthermia were performed. Thereafter, hyperthermia for the renal tumor was maintained once a week until June, 1986. From the middle of June, 1985, a gradual improvement of dysproteinemia and appetite loss, and a decrease of the right renal tumor size as well as disappearance of febrile attacks were attained. In November, 1985, mediastinal lymph node swelling developed. A combined therapy of RF-hyperthermia twice a week and irradiation with 2.0 Gy daily 5 times a week was started. A total of 14 sessions of RF-hyperthermia and 30 Gy of irradiation were delivered until January, 1986. Intratumoral temperature of the renal tumor reached 44.0 degrees C during the heating.(ABSTRACT TRUNCATED AT 250 WORDS)

We present three cases of benign prostatic hypertrophy associated with chronic renal failure for three years from 1982 to 1984. Endogenous 24-hour creatinine clearance (Ccr) on admission ranged from 8.7 to 29.4 ml/min. Temporary hemodialysis treatment was required in one patient at the beginning of hospitalization. Indwelling intraurethral catheterization for 3 months or more improved the renal function in one patient, but brought troublesome complications of gross hematuria, intractable urethral pain or recurrent pyelonephritis in the other patients. These complications might arise from strong uninhibited detrusor contractions triggered or accelerated by stimuli and/or urinary tract infection induced by urethra-indwelt catheters. Intermittent self catheterization reduced these complications in one patient. In two patients, Ccr increased beyond 30 ml/min as a desirable standard level for safe operations. Suprapubic prostatectomy was successfully performed in all the patients. However, severe gastric ulcer or fatal duodenal ulcer occurred in two patients. Hypoproteinemia and/or urinary tract infection was thought to be highly related to ulceration. In conclusion, we would like to emphasize that a Ccr of more than 30 ml/min is needed for safe operations concerning renal function in patients with benign prostatic hypertrophy associated with chronic renal failure.

The influence of prolonged bladder overdistension on the detrusor muscle was studied in female mongrel dogs. Two overdistending methods were employed, namely, constantly elevated hydrostatic pressure for one hour and bladder neck ligation for 48 hours. The cystometrogram and urinalysis at 2 weeks after release of overdistension were compared with the preoperative estimations. Using the in vitro isometric technique, the contractility of the detrusor muscle strip to acetylcholine was evaluated in the untreated control group and the two overdistended groups. Prolonged bladder overdistension for one hour as well as 48 hours resulted in a high incidence of urinary tract infection. There was no correlation between the cystometric findings before and after overdistension . An increase in contraction response to acetylcholine was observed in both overdistended groups. Besides, a small contraction response to acetylcholine at a lower concentration was observed in the group overdistended for 48 hours. It is suggested that the observed contraction response increase was probably due to axonal degeneration caused by a decrease in the blood supply to the overdistended bladder wall.

To investigate denervation supersensitivity of the detrusor muscle due to prolonged bladder overdistension, overdistended bladders were produced in female mongrel dogs by bladder neck obstruction for 48 hours and the dogs were sacrified 1, 2 and 4 weeks after overdistension. The sensitivity of the detrusor muscle to acetylcholine was measured using the isometric in vitro technique. The bladder wall tissues were examined with Masson's trichrome staining. The blood flow of the bladder wall was determined by the hydrogen gas clearance method. Sensitivity reached a maximum 2 weeks after overdistension, thereafter decreasing to a lower level 4 weeks after overdistension than that of the untreated detrusor muscle. A decrease of blood supply to the bladder wall, the rate being 63% immediately after overdistension, may result in a degeneration of the axon which is more fragile to ischemic changes. Subsequently axonal degeneration may be followed by denervation supersensitivity of the detrusor muscle. Remarkable fibrotic changes of the bladder wall 4 weeks after overdistension suggested a decrease of the detrusor muscle contraction to acetylcholine.

A case of benign retroperitoneal cystic teratoma in a 62-year-old female is reported. The patient was admitted to our hospital for the purpose of extensive examination of a left abdominal mass. Radiological examinations including CT scanning revealed a large retroperitoneal mass arising in the left upper quadrant superior to the left kidney, containing cystic areas. The mass was removed by the thoracoabdominal approach under the diagnosis of cystic teratoma or liposarcoma. The margin of the mass was well demarcated and completely separated from other adjacent structures. Histological examination confirmed the diagnosis of benign cystic teratoma. From the 6th postoperative day, the discharge from a drainage tube, placed in the left retroperitoneal space, increased gradually and the discharge fluid became lipemic. The amount of daily discharge had a peak of approximately 400 ml on the 15th postoperative day. Total parenteral hyperalimentation was started on the 17th postoperative day under a diagnosis of chylous ascites. The amount of the discharge decreased and the drainage tube was removed on the 21st postoperative day.

A case of inverted papilloma of the bladder with mild atypia in a 31-year-old male is reported. The patient was admitted complaining of macroscopic hematuria. An excretory urogram revealed a small filling defect in the center of the bladder. A 15 x 11 mm. exophytic lesion was noted at the center of the trigone by cystoscopy and ultrasonography. The patient underwent transurethral resection of the bladder tumor and selected-site mucosal biopsies. The result of a histopathological examination of the tumor was an inverted configuration with nuclear atypia, corresponding to transitional cell carcinoma, grade 1. No histopathological abnormalities in the normal-appearing bladder mucosa were observed. The patient has been subsequently followed up for 43 months and there was no evidence of recurrence.

A 3-year-old girl with an extrarenal nephroblastoma arising from the right retroperitoneal space is described. She was admitted to our hospital with the chief complaint of abdominal pain. On physical examination, she was found to have a large (12 X 10 cm in size), firm and nontender mass in the right upper quadrant of the abdomen. The mass did not extend beyond the midsagital line. The physical examination did not reveal any particular findings or any congenital anomalies. Urinalysis and hematological data were within the normal limit. Radiological examinations including CT scan showed that the solid tumor was related to the right kidney. Under the diagnosis of right nephroblastoma, 15 micrograms/kg/day of actinomycin D was given intravenously for 5 days from October 18, 1982. The regression rate of the tumor was 78 percent on CT scan after chemotherapy. On November 22, 1982, transperitoneal nephrectomy was performed through a right paramedian incision. The tumor was found to adhere tightly to the upper pole of the kidney. The surgical specimen was 76 g in weight. A section of the surgical specimen showed an extrarenal tumor located completely outside the kidney and separated from the renal cortex by a thickened renal capsule. Histological diagnosis was extrarenal nephroblastoma showing renal capsular invasion by epithelial tumor cells. No teratomatous components were encountered in the tumor.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of bilateral testicular seminomas with abdominal huge metastatic tumors is presented. The patient is a 23-year-old male. An abdominal huge mass was found incidentally by a physician. CT scan and ultrasonography revealed the presence of the tumor in the left retroperitoneal space and biopsy specimen of the abdominal tumor was diagnosed as seminoma. On March 7, 1985, he was referred to our clinic. Bilateral testicular tumors were detected on palpation and ultrasonography. Bilateral orchiectomy was performed. Histological diagnosis was pure seminoma. After four sessions of VAB-6 combined chemotherapy, the abdominal tumor, 14.1 x 12.3 cm in size, decreased to 5.7 x 4.4 cm ( a regression rate of 85.5%). Retroperitoneal lymph-node dissection was undertaken, but the abdominal tumor could not be resected completely. Histological examination of the resected tumor revealed complete necrosis of the tumor tissue. After the operation, one session of the chemotherapy and irradiation were added. A total of 109 cases of bilateral testicular germ cell tumors in Japan was reviewed.

Urological assessments were done on 132 patients with cerebral palsy, ranging from 5 to 59 years in age (mean 23.2). Concerning urological symptoms, urinary incontinence, decreased urinary stream and urinary tract infection were at 31.8, 14.4 and 16.7%, respectively. Patients with functionally impaired ambulation had a high incidence of urinary incontinence and decreased urinary stream. Decreased urinary stream was more prominent in an elderly patient group, and urinary incontinence was observed almost at the same rate in all age-classified groups. Urodynamic studies were performed in 30 patients with cerebral palsy who were referred to with urological symptoms. The patients were classified into two groups according to the presence or absence of spinal cord lesions. In a group of 15 patients with spinal cord lesions, electromyography of the external sphincter demonstrated detrusor-sphincter dyssynergia (DSD) in 9, of whom 6 complained of decreased urinary stream; while in the group without spinal cord lesions there was no DSD. These findings suggest that the cause of decreased urinary stream in cerebral palsied patients could be explained by DSD secondary to spinal cord lesions.