Mutations of the PKD1 gene among Japanese autosomal dominant polycystic kidney disease patients, including one heterozygous mutation identified in members of the same family

More than 80 mutations of the PKD1 gene have been reported, mostly in patients from Western Europe. New techniques are being used to detect an increasing number of mutations, even in the homologous region of the PKD1 gene. Polymerase chain reaction-single-strand conformation polymorphism (PCR-SSCP) or denaturing high-performance liquid chromatography (DHPLC) analyses were performed in the present study to screen mutations from exon 23 to exon 46 in the PKD1 gene and in the entire PKD2 gene. When an abnormal pattern was found in PCR-SSCP or DHPLC, the PCR products were directly sequenced. Four mutations were identified in the PKD1 gene: a missense mutation (C47413T causing T3509M in exon 35), a splicing mutation (del 20bp in 75 bp of intron 43), and two nonsense mutations (C48566A causing C3693X in exon 38, and C51237T causing Q4124X in exon 45). The nonsense mutation Q4124X existed in only two of three affected sib members in family K68. The pattern of the restriction enzyme digest and the haplotype analysis confirmed the presence of a heterozygous mutation in the family. Fifteen single nucleotide polymorphisms were identified in this study. Two of them (C50439A and C51659T) can be used as intragenic polymorphic markers.

[Prostate specific antigen: a role of PSA in the diagnosis of prostate cancer]

Early diagnosis of prostate cancer is best achieved using a combination of DRE and PSA as first-line tests to detect signs of prostate cancer. Because DRE and PSA do not always detect the same cancer, the tests are complementary. Among men with elevated PSA who are negative on DRE, the chance of cancer ranges from 12 to 32%. Most men with PSA elevations do not have cancer. This high false-positive rate among men without cancer has led to many approaches to decrease the incidence of false-positive test results, including PSA density, transition zone PSA density, PSA velocity, age-specific PSA reference ranges and percent free PSA.

Use of various combinations of free, complexed and total prostate-specific antigen levels as predictors of the pathologic stage of prostate cancer

BACKGROUND

The efficacy of various combinations of total, free and complexed prostate-specific antigen (PSA) levels were assessed to predict the pathologic stage of prostate cancer.

METHODS

Total PSA (tPSA), free PSA (fPSA) and complexed PSA (cPSA) levels were measured preoperatively in 52 patients with clinical localized prostate cancer who had undergone radical prostatectomy. Pathologic stages were classified as: organ-confined (n = 27); capsular penetration (n = 14); seminal vesicle involvement (n = 8); involvement of the surgical margins (n = 10); and lymph node involvement (n = 3).

RESULTS

The fPSA/tPSA and fPSA/cPSA ratios significantly differed between patients with organ-confined disease and non-organ-confined disease (P = 0.035, P = 0.033, respectively) and between those with favorable versus unfavorable pathology (P = 0.001, P = 0.014, respectively), but tPSA, cPSA, fPSA and the cPSA/tPSA ratio did not. Using a fPSA/tPSA cutoff level of 11%, the prediction of organ-confined disease would increase from 52 to 67% and the rate of predicting favorable pathology would increase from 42 to 62%. A fPSA/cPSA cutoff level of 12% would increase the rate of predicting organ-confined disease to 79% and the rate of predicting favorable pathology would increase to 69%. The positive predictive value of the fPSA/cPSA ratio was higher than that of the fPSA/tPSA ratio, although the receiver operating characteristic curve of the fPSA/cPSA ratio was not different from that of the fPSA/tPSA ratio.

CONCLUSION

Although there was no predictive difference found between fPSA/tPSA and fPSA/cPSA ratio, both ratios may help predict the pathologic stage of prostate cancer.

Prognostic value of three molecular forms of prostate-specific antigen ratios in patients with prostate adenocarcinoma

OBJECTIVES

To investigate whether different molecular forms of prostate-specific antigen (PSA) ratios could provide prognostic information about the stage and grade of prostate cancer.

METHODS

Serum specimens were examined from 53 patients who underwent radical prostatectomy for clinically localized prostate cancer and from 94 patients diagnosed as having no evidence of malignancy (total PSA between 4.1 and 20.0 ng/mL). The free/total PSA (fPSA/tPSA) ratio and complexed/total PSA (cPSA/tPSA) ratio in 18 patients with biochemical recurrence were compared with those of patients either without recurrence or with no evidence of malignancy.

RESULTS

The fPSA/tPSA and cPSA/tPSA ratios differed significantly (P <0.05) between patients with organ-confined and those with non-organ-confined disease, but the tPSA, cPSA, and fPSA levels did not (P >0.05). The median values of the fPSA/tPSA ratio in patients with recurrence (7.0%) were significantly lower than in the patients without recurrence (8.9%) or those without evidence of malignancy (15.2%) (P = 0.02 and P <0.01, respectively). The median values of the cPSA/tPSA ratio in patients with recurrence (97.4%) were significantly higher than in patients without recurrence (92.9%) or those without evidence of malignancy (86.7%) (P <0.01 and P <0.01, respectively). At the time of recurrence, 6 (33%) of 18 patients expressed higher fPSA/tPSA ratios (15% or greater) and lower cPSA/tPSA ratios (less than 95%). Five (83%) of these 6 patients appeared to have aggressive tumors according to pathologic stage.

CONCLUSIONS

The fPSA/tPSA and cPSA/tPSA ratios differed significantly among the three groups. Thus, a subset of tumors appears to be capable of producing high fPSA/tPSA and low cPSA/tPSA ratios at the time of recurrence, and some of these have an aggressive phenotype. Until this latter phenomenon can be adequately explained, use of these ratios for prognostic purposes should be approached cautiously.

[Comparisons of factors affecting voiding disorders between patients with benign prostate hyperplasia and volunteers]

PURPOSE

The prostate size and motivation to visit clinics were investigated in patients with prostate hyperplasia.

OBJECTS AND METHODS

One hundred ninety-five patients who had urinary symptoms and visited our outpatient clinic between September 1994 and October 1999 and 268 age-matched volunteers in Mitaka City who underwent a medical examination of the prostate in June 1997 were compared. International Prostate Symptom Score (IPSS), Quality Of Life Score (QOL score), residual urine volume, prostate volume and urinary flow rate were measured.

RESULTS

The prostate volume of the volunteers was 20-25 cm3 irrespective of the age. The prostate size of the outpatients was larger than that of the volunteers for every age group. IPSS and QOL score were significantly higher in the outpatients than in the volunteers. Diurnal urinary frequency and sense of residual urine contributed to the discrimination index of the two groups more significantly than the other scores. There was a significant correlation between prostate volume and residual urine volume. The score of weak urinary steam was inversely and significantly correlated with peak urinary flow rate.

CONCLUSIONS

There was no age-related enlargement of the prostate gland. The prostate gland was significantly larger in the patients than in the volunteers even in those in their fifties. Urinary frequency and sense of residual urine are important factors for men to seek and receive medical care.

[The significance of early detection for prostate cancer in mass screening]

PURPOSE

In Mitaka city, mass screening for prostate cancer was conducted for 3 years from 1995 to 1997. Clinical stages were compared between patients found by screening and those diagnosed at our clinic during the same time. The significance of serum-free prostate specific antigen (PSA) in mass screening for prostate cancer was examined.

MATERIAL AND METHODS

A prospective clinical trial was conducted on men aged 50 years or older. The primary examination consisted of taking the international prostate symptom score, quality of life score, PSA (Tandem-R) and digital rectal examination (DRE). If PSA was greater than 4.0 ng./ml and/or if DRE suggested cancer, transrectal ultrasound-guided sextant prostate biopsies were indicated.

RESULTS

Of the men screened, 23.2% (320/1375) had serum PSA greater than 4.0 ng./ml. and/or suspicious findings on DRE. Biopsy was performed in 199 of 320 (62.1%). Cancer was detected in 21 (1.5%, 21/1375). Prostate cancer was found in one case among 154 males (0.65%, 1/154) who were screened twice or more. The cancer stage found by screening was significantly earlier than that diagnosed at the outpatient clinic (Wilcoxon's rank-sum test: p = 0.0047). Receiver operating characteristics analysis showed that the optimal free PSA-to-PSA ratio was 12%. Positive predictive value increased from 18% to 50% when free PSA-to-PSA ratio was combined with PSA.

CONCLUSION

1. Cancer detection rate was 1.5% in the mass screening in Mitaka City. 2. Cancer stage found by screening was significantly earlier than that diagnosed at the outpatient clinic. 3. Free PSA determination might eliminate unnecessary biopsies in men with PSA above 4.0 ng./ml with minimal loss of cancer detection.

Comparisons of the various combinations of free, complexed, and total prostate-specific antigen for the detection of prostate cancer

OBJECTIVES

We compared the ability of three prostate-specific antigen (PSA) ratios - free-to- total PSA ratio (fPSA/tPSA), free-to-complexed PSA ratio (fPSA/cPSA), and complexed-to-total PSA ratio (cPSA/tPSA) - to distinguish prostate cancer from benign prostatic hyperplasia (BPH).

METHODS

We tested 258 consecutive patients who underwent transrectal ultrasound-guided prostate needle biopsy because of an abnormal digital rectal examination or a Tandem-R PSA of >4.1 ng/ml. Free PSA (fPSA) and total PSA (tPSA) were measured by Tandem-R assay. alpha(1)-Antichymotrypsin-complexed PSA (cPSA) was measured by Markit-M PSA-ACT assay.

RESULTS

Of the 258 patients, 204 had BPH, and 54 had prostate cancer. The specificity at 96% sensitivity for fPSA/tPSA, fPSA/cPSA, and cPSA/tPSA was 23, 25, and 33%, respectively. Of 162 patients with tPSA between 4.1 and 10.0 ng/ml, 132 had BPH and 30 had prostate cancer. The specificity at 96% sensitivity for f/tPSA, f/cPSA and c/tPSA was 32, 44, and 41%, respectively. There was no significant difference in the area under the receiver-operating characteristic curves among fPSA/tPSA, fPSA/cPSA, and cPSA/tPSA in the overall PSA range or in tPSA between 4.1 and 10.0 ng/ml.

CONCLUSION

fPSA/tPSA, fPSA/cPSA, and cPSA/tPSA did not differ in their ability to distinguish prostate cancer from BPH.

[A case of familial juvenile gouty nephropathy associated with a right renal tumor]

We present a case of familial juvenile gouty nephropathy which was associated with a right renal tumor that was found incidentally. The patient was a 27-year-old woman who initially presented with acute gouty arthritis at the age of twenty years. Her mother and her sister had been attacked with acute gouty arthritis in their early twenties. Progressive deterioration in the renal function was noted in the three family members who had experienced gouty attack. Her mother was maintained on hemodialysis. As image diagnoses could not rule out malignancy in her right renal tumor, in situ non-ischemic enucleation of the right renal tumor using a microwave tissue coagulator(Microtaze) and a renal biopsy were performed. The pathological diagnosis of the renal tumor was tubulopapillary adenoma, and the renal biopsy showed minimal change in the glomeruli and tubules. The post-operative course was uneventful. The serum creatinine and creatinine clearance before and three months after the operation were 2.4 mg/dl and 2.6 mg/dl, 36.7 ml/min and 32.5 ml/min, respectively. The renal biopsy findings that glomerular and tubular changes were minimal and there was no tissue precipitation of uric acid or sodium urate, and the fact that her renal function decreased progressively despite the treatment of hyperuricemia suggested strongly that renal function might have deteriorated due to unknown factors other than hyperuricemia.

[Urological procedures for progressive renal dysfunction due to polycystic kidney disease]

Urological procedures for progressive renal dysfunction due to polycystic kidney disease (PKD) such as percutaneous puncture of renal cysts are merely symptomatic treatments and have little effect on renal function. At present, the two most effective methods of preventing renal dysfunction are blood pressure management and dietetic therapy, which are more effective with early initiation. Moreover, as PKD is an autosomal dominant disease, there is a high risk that family members of the patient may have asymptomatic PKD. It is essential to identify and treat such potential patients at an early stage in order to prevent progressive renal dysfunction. In place of the traditional nephrectomy, we attempted transcutaneous renal arterial embolization (TRAE) for hemorrhage into renal cysts, hematuria and obstruction of intestine due to proliferation of cysts after the introduction of hemodialysis. When TRAE was carried out on one kidney, the cysts in the other kidney proliferated and even though the renal arteries were completely embolized, it required 5 to 6 weeks for the kidney to contract. Our conclusions are TRAE is effective with no adverse reactions for PKD. These results suggest that in the future TRAE may become the preferred treatment for PKD in place of nephrectomy.

Value of reverse transcription polymerase chain reaction assay in pathological stage T3N0 prostate cancer

BACKGROUND

We tested the ability of the nested reverse transcription polymerase chain reaction (RT-PCR) assay to detect signs of biochemical recurrence of prostate cancer in the lymph nodes and peripheral blood of patients with pT3N0 prostate cancer.

METHODS

Using lymph nodes and pre- and postoperative peripheral blood dissected from 30 patients with pT3N0 prostate cancer treated by radical prostatectomy, we used RT-PCR for prostate-specific membrane antigen (PSM) and serum prostate-specific antigen (PSA) to determine the presence of prostate cancer. Results of the nested RT-PCR assay were compared with pathological stages and biochemical recurrence.

RESULTS

Two of 13 patients with capsular penetration (15%), 6 of 10 patients with invasion of seminal vesicles (60%), and 3 of 7 patients with a positive surgical margin (43%) were RT-PCR-positive for PSM and/or PSA in the lymph nodes. Results of preoperative RT-PCRs of peripheral blood for PSM and for PSA significantly differed between positive and negative results of RT-PCR in lymph nodes (P < 0.001 and P < 0.001, respectively). Results of postoperative RT-PCRs of peripheral blood for PSM and for PSA also significantly different between positive and negative results of RT-PCR in lymph nodes (P = 0.011 and P = 0.001, respectively). Nine of 11 patients with positive nested RT-PCR for PSM and/or PSA in the lymph nodes (82%) experienced biochemical recurrence. Significant difference in Kaplan-Meier recurrence-free actuarial curves was noted between patients who nested positive and negative on RT-PCR in the lymph nodes, pre- and postoperative peripheral blood, biopsy and prostatectomy Gleason score, and preoperative PSA values. In multivariate analysis, biopsy and prostatectomy Gleason score (P = 0.026, P = 0.020, respectively), pre- and postoperative RT-PCR for PSM in peripheral blood (P = 0.030 and P = 0.040, respectively), and RT-PCR for PSM in lymph nodes (P = 0.035) were independent prognostic factors.

CONCLUSIONS

Nested RT-PCR assay of the lymph nodes or peripheral blood significantly predicted biochemical recurrence after surgery. It may help identify patients at risk for recurrence and progression of prostate cancer.

Complications of laparoscopic and retroperitoneoscopic adrenalectomies in 370 cases in Japan: a multi-institutional study

A total of 370 laparoscopic adrenalectomies, including 311 transperitoneal (TP) and 59 retroperitoneal (RP) approaches, were performed in nine urologic centers, where the laparoscopic adrenalectomy was first begun independently in Japan, and their affiliated hospitals between January 1992 and September 1996. The clinical diagnoses of those 370 adrenal diseases were primary aldosteronism in 155 patients, Cushing's syndrome in 61. preclinical Cushing's syndrome in 21. pheochromocytoma in 16, nonfunctioning adenoma in 87, complicated cyst in ten, myelolipoma in nine, adrenal cancer in four and other diagnoses in eight (table 1). There was no mortality in this series. Intraoperative complication rate was 33/370 (9%) in total: 26/311(8%) in the TP procedures and 7/59 (12%) in the RP procedures (table 11). Postoperative complication rate was 24/370 (6%) in total: 22/311 (7%) in the TP procedures and 2/59 (3%) in the RP ones (table 111). Conversion rates to open surgery in total, in the TP and in the RP procedures were 13/370 (3.5%), 10/311 (3.2%) and 3/59 (5.1 %). respectively (table IV). Although the RP procedure has a lower morbidity rate compared to the TP procedure, more skill is required to overcome the drawback of the narrow working space and fewer anatomical landmarks.

Comparative study of pulsed dye laser and pneumatic lithotripters for transurethral ureterolithotripsy

BACKGROUND

Clinical effectiveness and safety of the Swiss Lithoclast (Lithoclast) and the Candela MDL-2000 (MDL) in the treatment of lower ureteral stone were examined retrospectively.

METHODS

Eighty-six stones from 66 patients and 26 stones from 20 patients were treated by Lithoclast and MDL, respectively.

RESULTS

The stone-free rate on 3-month follow-up was 97% and 95% for the Lithoclast and MDL, respectively (no significant difference). The operation time was significantly shorter for the Lithoclast than for the MDL (90.2+/-50.2 vs 120.4+/-55.1 min; P<0.05). Postoperative analgesics were required significantly less frequently in Lithoclast (10/66 vs 11/20; P<0.01). Postoperative hospital stay was significantly shorter for Lithoclast (8.7+/-5.1 vs 12.1+/-4.2 days; P<0.01).

CONCLUSIONS

Swiss Lithoclast is an effective and less invasive modality for endoscopic treatment of lower ureteral stones.

Comparison of two investigative assays for the complexed prostate-specific antigen in total prostate-specific antigen between 4.1 and 10.0 ng/mL

OBJECTIVES

To determine the ability of complexed prostate-specific antigen (cPSA) levels to diagnose prostate cancer.

METHODS

Between September 1998 and March 1999, cPSA levels in 182 consecutive patients with an abnormal digital rectal examination (DRE) or a total PSA (tPSA; Tandem-R assay) level greater than 4.1 ng/mL were examined. Levels of cPSA were measured by the Markit-M PSA-ACT (alpha(1)-antichymotrypsin) assay (cPSA-MM) and Bayer Immuno 1 complexed PSA assay (cPSA-BI). Free PSA (fPSA) was measured by the Tandem-R free PSA assay.

RESULTS

Of the 140 patients with tPSA between 4.1 and 10.0 ng/mL, 116 were histologically confirmed as having benign tissue; the remaining 24 were diagnosed with prostate cancer. To ensure a 92% sensitivity of cancer detection, a cutoff value for the tPSA, cPSA-MM, and cPSA-BI assays of 4.8 ng/mL, 2.7 ng/mL, and 4.6 ng/mL, respectively, was determined. The percentage of negative biopsies prevented at these cutoff (ie, specificity) values was 14%, 23%, and 24%. No significant differences among these three assays were found. At 92% sensitivity, the cutoff value for the fPSA/tPSA, fPSA/cPSA-MM, and fPSA/cPSA-BI ratios was 18%, 27%, and 18%, respectively. The specificity was 35%, 49%, and 51%. No significant differences were found among these three fPSA ratios. Significant differences were noted between tPSA and the fPSA/cPSA-MM ratio and between tPSA and the fPSA/cPSA-BI ratio. No differences were seen among the other PSA parameters.

CONCLUSIONS

No difference in the ability of cPSA levels to distinguish prostate cancer and noncancer was observed between cPSA-MM and cPSA-BI or between their fPSA ratios. Only the fPSA/cPSA-MM and fPSA/cPSA-BI ratios provided significantly enhanced diagnostic performance compared with tPSA.

The significance of the free-to-complexed prostate-specific antigen (PSA) ratio in prostate cancer detection in patients with a PSA level of 4.1-10.0 ng/mL

OBJECTIVE

To compare the ratio of free prostate specific antigen (fPSA), total PSA (tPSA) and complexed PSA (cPSA, measured using a novel immunoassay) with other variables used to detect prostate cancer in patients with intermediate serum PSA levels of 4.1-10.0 ng/mL.

PATIENTS AND METHODS

From July 1997 to August 1998, 140 consecutive patients were assessed; all had intermediate serum PSA levels and/or abnormal findings on a digital rectal examination. All patients underwent transrectal ultrasonography (TRUS)-guided biopsy, and the prostate and transition zone volumes were determined by TRUS. Free and tPSA were measured using the Tandem-R assay (Hybritech Corp., San Diego, CA). PSA complexed with alpha1-antichymotrypsin (cPSA) was measured using an appropriate assay. The ability of cPSA, free-to-total PSA ratio (f/tPSA), free-to-complexed PSA ratio (f/cPSA), tPSA density of the whole prostate (PSAD), of the transition zone (tPSATZ), and cPSA density of the whole prostate (cPSAD) and of the transition zone (cPSATZ) to improve the power of PSA in detecting prostate cancer was evaluated using receiver operating characteristic (ROC) curves. Results Of the 140 patients, 126 had histologically confirmed benign disease and 14 had prostate cancer. The cPSA alone had better specificity for detecting prostate cancer than had tPSA alone but the difference was not significant. The area under the ROC curve for f/cPSA was larger than those for all other variables. With a 93% sensitivity for detecting prostate cancer, a f/cPSA threshold of 25% would result in fewer unnecessary biopsies (40% f/cPSA specificity) than with all other PSA variables. The difference in the resolution was significant between f/cPSA and tPSA, cPSA, tPSAD and tPSATZ, but not with f/tPSA, cPSAD or cPSATZ. In patients with a prostate volume of < 30 mL, the cPSATZ showed better specificity for prostate cancer than tPSA alone.

CONCLUSION

Measuring the level of cPSA and its derivatives may provide better differentiation of prostate cancer and benign disease than tPSA alone in patients with a tPSA level of 4.1-10.0 ng/mL.

Detection of micrometastatic prostate cancer cells in the lymph nodes by reverse transcriptase polymerase chain reaction is predictive of biochemical recurrence in pathological stage T2 prostate cancer

PURPOSE

We evaluated whether detecting prostate cancer cells by the nested reverse transcriptase-polymerase chain reaction (RT-PCR) in lymph nodes has predictive value for serum prostate specific antigen (PSA) recurrence in patients undergoing radical prostatectomy.

MATERIALS AND METHODS

We assessed the presence of prostate cancer cells by RT-PCR for prostate specific membrane antigen and PSA assay in lymph nodes dissected from 38 patients with localized prostate cancer treated with radical prostatectomy. The results of nested RT-PCR assay were compared with biochemical recurrence.

RESULTS

Nested RT-PCR was positive in the lymph nodes of 2 of 18 patients (11%) with stage pT2a and 5 of 20 (25%) with stage pT2b disease. All 7 patients had biochemical recurrence. We noted a significant difference in the Kaplan-Meier recurrence-free actuarial probability curve in those with positive and negative nested RT-PCR results for prostate specific membrane antigen, PSA and prostate specific membrane antigen-PSA in the lymph nodes (p = 3.02x10(-7), 2.23x10(-7) and 3.02x10(-7), respectively). Multivariate analysis of serum PSA, Gleason score and preoperative RT-PCR assay in peripheral blood showed that nested RT-PCR for prostate specific membrane antigen, PSA and prostate specific membrane antigen-PSA in the lymph nodes were independent predictors of recurrence (p = 0.0089, 0.0075 and 0.0089, respectively).

CONCLUSIONS

Nested RT-PCR of the lymph nodes may be a useful pretreatment prognostic test for patients undergoing radical prostatectomy. Further research is necessary using a much larger number of patients with a longer followup.

Subcellular localization of glucocorticoid receptor protein in the human kidney glomerulus

BACKGROUND

The detailed mechanisms of glucocorticoid action in idiopathic nephrotic syndrome and progressive glomerulonephritides have not been clearly elucidated. The pharmacological actions of glucocorticoids are mediated by their binding to an intracellular protein, the glucocorticoid receptor (GR). The determination of GR localization in normal glomerular cells is essential to elucidate the mechanisms of glucocorticoid action in various glomerular diseases.

METHODS

We carried out an immunoblot examination using antihuman GR-specific antibody and homogenates of isolated normal human glomeruli and mesangial cells in culture. Immunohistochemical examinations were also performed on normal human kidney specimens at light and electron microscopic levels. The nuclear translocation of GRs elicited by ligand binding was further investigated by confocal laser-scanning microscopic inspection of freshly isolated glomeruli and mesangial cells cultured with dexamethasone.

RESULTS

An immunoblot examination demonstrated the presence of a 94 kDa protein, a molecular weight consistent with that of GRs, in the homogenates of glomeruli and cultured mesangial cells. By light microscopic examination, GRs were strongly detected in the nucleus and moderately in the cytoplasm of all glomerular cells, parietal and visceral epithelial cells, endothelial cells, and mesangial cells. By electron microscopic examination, the nuclear GRs of all glomerular cells were found to be diffusely distributed in the euchromatin. Additionally, the immunofluorescence intensities of nuclear GRs in isolated glomeruli and mesangial cells in culture became more intense by the addition of dexamethasone.

CONCLUSIONS

Our findings suggest that all subsets of human glomerular cells definitely express the GR protein, which potentially undergoes translocation by glucocorticoids.

Preoperative nested reverse transcription-polymerase chain reaction for prostate specific membrane antigen predicts biochemical recurrence after radical prostatectomy

OBJECTIVE

To assess the utility of the nested reverse transcription-polymerase chain reaction (RT-PCR) method for measuring prostate specific membrane antigen (PSM) and prostate specific antigen (PSA) in predicting serum PSA recurrence after radical prostatectomy.

PATIENTS AND METHODS

Nested RT-PCRs for PSM and PSA were used in 40 patients who subsequently underwent radical prostatectomy. The accuracy of the RT-PCR assays in predicting PSA failure was compared with those for the preoperative serum PSA level, Gleason score and final pathological staging. The patients were monitored using a PSA assay (Tandem-R, Hybritech, San Diego, CA) at 3 weeks after radical prostatectomy and every 2 months thereafter. Biochemical recurrence was defined as a serum PSA level of >/=0.4 ng/mL.

RESULTS

Statistical analysis indicated that the nested RT-PCR assay for PSM was the most accurate preoperative predictor of potential surgical failure (PCR-PSM, P<0.001; PCR-PSA, P=0.018; serum PSA level, P=0.149; Gleason score P=0.388, by Fisher's exact probability test). Biochemical recurrence was evaluated in relation to these methods during a mean (range) follow-up of 16.7 (6-35) months. Of the 40 patients, eight (20%, one with organ-confined cancer and seven with extraprostatic extension of cancer) developed biochemical recurrence. The Kaplan-Meier recurrence-free actuarial probability curves differed significantly between patients with positive and those with negative results for the preoperative nested RT-PCR for PSM (P<0.01, generalized Wilcoxon's test). The nested RT-PCR for PSA, preoperative serum PSA value and Gleason score were not significant predictors of biochemical recurrence (P=0.16, 0.12 and 0.24, respectively).

CONCLUSIONS

The nested RT-PCR for PSM was the best preoperative predictor of biochemical recurrence among the factors examined.

[Comparison of Tandem-R PSA and Markit-M PA in the diagnosis of prostate cancer]

The Tandem-R PSA (TR) assay was compared with the Markit-M PA (MM) assay in the diagnosis of the prostate cancer. In patients with a serum prostate specific antigen (PSA) level higher than the cut-off values measured by either the TR assay or the MM assay (4.1 ng/ml and 3.7 ng/ml, respectively), or a suspicious digital rectal examination, sextant biopsy of the prostate was performed. Among 227 patients undergoing biopsy, 64 patients were diagnosed as having prostate cancer. There was a significant difference of serum PSA values between patients with and without prostate cancer in either assay. There was no significant difference between the assays with respect to diagnosing according to prostate cancer using receiver operating characteristic analysis. The correlation between TR and MM in 150 men with a serum Tandem-R PSA below 10 ng/ml was Y = 1.12X + 3.745 (R = 0.68, p < 0.001). The correlation coefficient for the relationship between TR and MM was only 0.68, indicating a poor correlation. Four of the 15 patients with MM values below 4.0 ng/ml calculated by transformation from MM to TR values had prostate cancer. This suggested that conversion of MM values to TR values in the low PSA range presents problems.

Prevalence and renal prognosis of diagnosed autosomal dominant polycystic kidney disease in Japan

The prevalence and renal prognosis of diagnosed autosomal dominant polycystic kidney disease (ADPKD) in Japan were estimated. Hospital-based nationwide surveys were conducted in 1995. The number of ADPKD patients who visited hospitals but were not on chronic dialysis was estimated to be 10,000 (95% confidence interval: 8, 200-11,900) and that of ADPKD patients on dialysis was 4,590, yielding a prevalence of ADPKD of 117 per million population at the end of 1994 (95% confidence interval: 102-132). The prevalence increased with age and reached a peak value of 261 per million population at the age group of 55-59 years. The rate of end-stage renal disease among living patients was calculated based on the assumption that the prevalence of ADPKD in the population under the age of 55 years was 261 per million population. The rate of end-stage renal disease increased with the progression of the patients' age, reaching 49% at the age of 65-69 years and declining thereafter.

CONCLUSION

The hospital-based prevalence of ADPKD is lower than the autopsy-based prevalence, suggesting that a fairly large number of these patients do not receive medical care in their lifetime. The probability of end-stage renal disease is at most 50% among ADPKD patients who visit a hospital.

Molecular staging of prostate cancer: comparison of nested reverse transcription polymerase chain reaction assay using prostate specific antigen versus prostate specific membrane antigen as primer

BACKGROUND

We examined the utility for prostate cancer staging of nested reverse transcription polymerase chain reaction (RT-PCR) using either prostate specific antigen (PSA) or prostate specific membrane antigen (PSM) as primer.

METHODS

LNCaP cells were used for the in vitro quantification of RT-PCR. RT-PCR was performed on the peripheral blood of 105 control subjects and 63 patients with prostate cancer (32 who eventually underwent radical prostatectomy and 31 with clinical stage D2 cancer).

RESULTS

The nested RT-PCR for the PSA and PSM primers was able to detect 1 LNCaP cell per 10(6) leukemia (K562) cells. None of the control subjects was found positive for the presence of prostate cancer cells by nested RT-PCR. In the 32-patient surgery group, the results of nested RT-PCR were significantly correlated with the pathologic stage of the cancer when using PSM primers (P=2.00 x 10(-3) by Kendall's correlation test) but not when using PSA primers (P=0.06). Extraprostatic extension was significantly more closely correlated with positive PSM nested RT-PCR results (P=0.012 by Fisher's exact probability test) than with positive results of PSA, nested RT-PCR, digital rectal examination, CT imaging, level of serum PSA or Gleason score. In the untreated stage D2 patients, the positive result rate of PSM nested RT-PCR was significantly higher than that of PSA nested RT-PCR (P=0.025 by McNemar test).

CONCLUSION

Nested RT-PCR using PSM primers appears to predict the prostate cancer stage more accurately than does nested RT-PCR using PSA primers or conventional clinical staging modalities.

Learning curve and conversion to open surgery in cases of laparoscopic adrenalectomy and nephrectomy

PURPOSE

We examine how the level of experience acquired by the laparoscopist affects the outcome of laparoscopic adrenalectomy and nephrectomy, and what is necessary to avoid complications in these surgeries.

MATERIALS AND METHODS

We retrospectively evaluated the experience levels of 8 urological laparoscopists between 1991 and 1995. In addition, other cases that were converted to open surgery were collected from the institutes with which the 8 laparoscopists were affiliated.

RESULTS

The rates of conversion to open surgery were 6.4% in 204 cases of adrenalectomy and 14.3% in 63 of nephrectomy. Conversion rates were related to blood loss volume but not operative time. The major causes of conversion were bleeding in 45% of cases and adhesion in 34%. There were no mortalities. Mean operative time decreased significantly, reaching that of open surgery as the number of procedures increased up to 20 adrenalectomies and 10 nephrectomies. The volume of blood lost remained low from the early experience. Blood transfusion rates were 4.4% for adrenalectomy and 11.1% for nephrectomy.

CONCLUSIONS

Operative time of these procedures decreased significantly with surgeon experience and reached that of open surgery. Cases in which adhesion is anticipated should be restricted to avoid conversion. These laparoscopic procedures are acceptable as a standard operative techniques for adrenal and renal diseases.

Expression of Fas in renal cell carcinoma

We have investigated whether the Fas-mediated cell death pathway is functional in renal cell carcinoma. The expression of Fas in surgical specimens and cell lines of renal cell carcinoma was examined. Fas expression was positive in six out of 18 tumors measured by flow cytometry and was prominent in advanced tumors. Three out of the six Fas-positive tumors had already metastasized at the time of surgery. A significant correlation was found between the tumor volume and the percentage of Fas-positive cells in a tumor (r = 0.70, P = 0.0007). Fas-positive tumors were larger than Fas-negative tumors [mean tumor volume (ml) +/- SD, Fas(+), 265.6 +/- 136.8; Fas(-), 65.8 +/- 80.9, P = 0.0012]. All human renal carcinoma cell lines tested (ACHN, Caki-1, SMKT-R-2, SMKT-R-3 and SMKT-R-4) expressed Fas abundantly, as Fas-positive cells accounted for > 50% in all cell lines by flow cytometry. Treatment with anti-Fas antibody caused apoptosis in Fas-positive renal cell carcinoma cell lines. However, the effectiveness of apoptosis induction in individual cell lines was not correlated with the level of Fas expressed. These data suggest that Fas targeting may be a therapeutic option for treatment of advanced renal cell carcinoma which is refractory to either chemotherapy or irradiation.

Significance of serum free prostate specific antigen in the screening of prostate cancer

PURPOSE

The significance of serum free prostate specific antigen (PSA) in the screening of prostate cancer was examined.

MATERIALS AND METHODS

A prospective clinical trial was conducted on 701 male volunteers 50 years old or older. Serum free PSA was determined and biopsies were performed if PSA was greater than 4 ng./ml. or if digital rectal examination was suspicious for cancer.

RESULTS

Of the men 187 (27%) had a PSA of greater than 4 ng./ml. (11%) and/or a suspicious digital rectal examination (19%). Of 116 biopsies performed in the 701 men cancer was detected in 13 (1.9%). PSA detected more tumors (12 of 13, 92%) than digital rectal examination (9, 69%). Receiver operating characteristic analysis showed that the optimal free PSA-to-PSA ratio (free PSA ratio) was 12%. The positive predictive value for cancer according to PSA with free PSA ratio (50%, 10 cancers in 20 biopsies) was significantly greater (p = 0.0473) than that according to PSA alone (24%, 12 cancers in 50 biopsies), which indicated that 30 of 50 biopsies were avoided with only 2 cancers missed when PSA and free PSA were used for biopsy indication.

CONCLUSIONS

Free PSA determination might eliminate unnecessary biopsies in men with a PSA of more than 4 ng./ml. with minimal missed cancers.

Significance of free prostate-specific antigen and gamma-seminoprotein in the screening of prostate cancer

BACKGROUND

Since free prostate-specific antigen (PSA) and gamma-seminoprotein (gamma-SM) recognize similar epitope(s) of PSA, the significance of serum-free PSA and gamma-SM in the early detection of prostate cancer was compared.

METHODS

A prospective clinical trial was conducted on 701 male volunteers, age 50 years or older. Free PSA (Tandem-R free PSA, Hybritech) and gamma-SM (gamma-SM, Chugai) levels were determined, and biopsies were performed if the PSA (Tandem-R, Hybritech) level was > 4 ng/ml, or if digital rectal examination (DRE) was suspicious.

RESULTS

One hundred and eighty-seven men (27%) had either a PSA level > 4 ng/ml or a suspicious DRE. Of 116 biopsies performed, cancer was detected in 13 (1.9%, 13/701). Receiver-operating characteristic analysis of free PSA to PSA ratio (free PSA ratio, %) and gamma-SM to PSA ratio (gamma-SM ratio), to differentiate normal biopsy findings from cancer, showed that the optimal values were 12% and 0.38, respectively. Positive predictive value for cancer was 24% (12 cancers/50 biopsies) for PSA alone, 42% (8/19) for the combination of PSA and DRE, 45.5% (10/22) for the combination of PSA and gamma-SM ratio, and 50% (10/20) for the combination of PSA and free PSA ratio. Regression analysis showed that gamma-SM highly correlated with free PSA, but that the analytical detection limit of gamma-SM was 1 ng/ml, significantly higher than that of free PSA.

CONCLUSIONS

Free PSA determination might effectively eliminate unnecessary biopsies in subjects with PSA > 4 ng/ml, and gamma-SM might provide a complementary index to free PSA, but its validity should be further studied in other settings, such as after radical prostatectomy or during endocrine treatment.

[Histochemical expression of proliferating cell nuclear antigen (PCNA) for pre and post chemotherapeutic bladder cancer]

We examined whether the staining of proliferating cell nuclear antigen (PCNA) could be useful as a marker of chemotherapeutic effectiveness in nine patients with invasive bladder cancer treated by bilateral internal iliac artery infusion of cisplatin (CDDP). Two types of monoclonal antibodies PC-10, 19A2 were used for immunohistochemical staining in formalin-fixed, paraffin-embedded tissue sections. There was no difference between positive rates of PC-10 and 19A2. The mean positive rates between pre-chemotherapeutic specimens (15.4 +/- 6.7%) and post-chemotherapeutic specimens (4.2 +/- 3.1%) showed statistically significant difference (p < 001). The immunohistochemical evaluation of PCNA has value for investigation of cell's turnover. Therefore, the changes of PCNA-positive rate could be a historical parameter for the evaluation of chemotherapeutic effects.

[Association of malignant neoplasms of other organs in patients with primary hyperparathyroidism]

There are several reports of an increased occurrence of nonparathyroid cancer in patients with primary hyperparathyroidism. Whether there is a cause and effect relationship has not been established. Especially, the coexistence of the parathyroid and thyroid tumors appears significantly high. Recently PRAD 1 was determined the one of the oncogenes of parathyroid adenoma. Interest in PRAD 1's role with respect to oncogenesis has been intensified by its incrimination in other, nonparathyroid, human tumors. If properly conducted surveillance programs do indicate a higher likelihood of cancer in patients with primary hyperparathyroidism, the current philosophy that the patient with mild and asymptomatic hyperparathyroidism does not need the surgery must be reevaluated.

[Evaluation of advanced bladder tumor]

Ninety-two cases of advanced bladder tumor treated at the University of Tokyo and branch hospital from January 1977 to December 1992 were analyzed. The advanced bladder tumor was defined as that of higher than pT2 (according to the General Rule for Clinical and Pathological Studies on Bladder Cancer) or that with distant metastases. The following variants were evaluated, the therapeutic methods, the histological type, grade, stage, type of infiltration. The evidence of lymphatic infiltration, vessel infiltration, and lymph node metastases were also reviewed. The survival rate was calculated using Kaplan-Meier's method. In the cases with lymph node metastases, the survival rate was significantly lower than in the cases without metastases (p < 0.01), while no other factors affected the survival rate.

Ethnic differences in allele frequencies of two microsatellite markers closely linked to the locus for polycystic kidney disease 1 (PKD1)

Two microsatellite markers, D16S283 and D16S284, closely linked to the locus of autosomal polycystic kidney disease (PKD1), were amplified in a Japanese population sample by the polymerase chain reaction to investigate differences in allele frequencies between Japanese and Caucasian populations. Ten D16S283 alleles and four D16S284 alleles were discerned among 53 Japanese. The observed heterozygosities of D16S283 and D16S284 in this study were 76.8 and 9.1%, and the polymorphism-informative contents were 0.75 and 0.09, respectively. Several allele frequencies of D16S283 exhibited significant differences. The Y9 allele (19 CA repeats, 91 bp) was the most frequent in both populations but its frequency in Caucasians was higher. The second most frequent allele was different: Y6 (22 CA repeats, 97 bp) in Japanese and Y10 (18 CA repeats, 89 bp) in Caucasians. Y8 (20 CA repeats, 93 bp) and Y11 (17 CA repeats, 87 bp) alleles also showed different frequencies. For D16S284, no differences in allele frequencies were observed between the two populations. As we observed differences in allele frequencies for D16S283, an association study with this polymorphism should carefully control for the ethnic origin of subjects.

[Treatment of advanced prostatic cancer--chronological change between 1975 and 1991]

A chronological analysis of the clinical features and treatments of advanced prostatic cancer, stages C and D, was performed in 154 cases treated from 1976 through 1991. These cases were divided into two chronological groups: 61 cases treated between 1976 and 1983, and 93 cases between 1984 and 1991. Concerning demographic features and diagnosis, the number of patients with lymph node metastasis was higher in the latter group. There was also increase in cases who were urologically asymptomatic and detected by checkup digital rectal examination or by the elevation of serum prostatic tumor markers. Histopathological differentiation was consistent between the two groups; more than 70% of cancers were moderately and poorly differentiated adenocarcinoma. As for the treatment, total prostatectomy was performed in eight cases in the latter against none in the earlier, but hormonal therapy remained the main treatment throughout the periods: 74.2% in the earlier and 70.7% in the latter. However the methods of the therapy have clearly changed; estrogens and castration were used less often in the latter period, while LH-RH analogues and antiandrogens replaced them although the therapy was equally effective in 82.3% of the cases in the earlier and in 90.4% in the later period and five-year survival rate and the progression-free survival rate at three years showed no significant difference between the two periods. These results showed 1) refined quality of diagnosis 2) a change in mode of hormonal therapy and 3) no detectable improvement of survival in these 16 years. Development of more effective therapies would be warranted for a better survival.

Mediation of renal cyst formation by hepatocyte growth factor

Hepatocyte growth factor (HGF) is a potent mitogen for renal tubular cells, and HGF and its receptor (c-met proto-oncogene product, Met) can induce lumen formation in epithelial cells. We measured the concentration of HGF in cyst fluids from patients with renal cystic diseases. The concentration of HGF was high in proximal cyst fluid (mean 2.45 vs 0.42 ng/mL in distal cysts). Cyclic AMP concentration was higher in distal than in proximal cysts (663 vs 6.0 pmol/L). mRNA of HGF and Met were co-expressed in cyst walls from cases with polycystic kidney disease. These findings suggest that HGF is a growth factor that may mediate human renal cyst genesis.

A case of familial central diabetes insipidus: the response of urinary prostaglandins to 1-deamino-8-D-arginine vasopressin

A case of familial central diabetes insipidus and dilatation of the urinary tract is reported. Administration of desmopressin for 1 year improved urinary tract dilatation with a concomitant reduction in urine volume. Urinary cyclic adenosine monophosphate and prostaglandin E2 excretion increased after treatment.

[Objective and subjective response in stage D2 prostate cancer patients with cancer pain]

Fourty-eight patients with stage D2 prostate cancer, initially treated with endocrine therapy at the University of Tokyo between 1981 and 1990, were followed up and analysed. For the assessment of a subjective response, pain score, narcotic score, and performance stages (PS) were used. Of the fourty-eight patients, twenty-one suffered from cancer pain due to bone metastases. These patients showed significantly (p < 0.01) more lesions of bone metastases and higher PS, compared with patients without cancer pain. The progression free survival of these patients was significantly (p < 0.01) lower than that of patients without cancer pain, although the actuarial survival was not significant. In twenty-one patients with cancer pain, the objective and subjective response rates to endocrine therapy were 75% and 86%, respectively. The duration of pain relief was 1.25-54 (median 19) months. Those rates to anti-cancer chemotherapy in refractory patients (8 patients) previously treated with endocrine therapy were both 25% and those to additional administration of flutamide (FUL) or diethylstilbestrol (DES) in refractory patients (6 patients) were 33% and 100%, respectively. Although the duration of pain relief was 0.78-8 (median 2) months, the additional administration of DES or FLU led to pain relief and improved quality of life (QOL) in all 6 patients. Endocrine therapy such as LH-RH agonist and non-steroidal pure anti-androgen, which has no severe side effects, would be of great usefulness in stage D2 prostatic cancer patients with pain on the basis of efficacy and safety.(ABSTRACT TRUNCATED AT 250 WORDS)

[Two-color flow cytometric analysis of lymphocytic subsets in renal cell carcinoma]

The subsets of tumor infiltrating lymphocytes (TILs) in 17 patients with renal cell carcinoma were studied by two-color flow cytometry and immunohistochemistry. In grade 1 tumors, CD4-positive cells were significantly increased compared to grade 2 and 3 tumors (35 +/- 7% vs 25 +/- 10%) (p < 0.05). In 10 of 14 patients, CD8-positive cells were predominant over CD4-positive cells, resulting in less than one in CD4/CD8-ratio. Regarding CD4 cells in all 17 cases, the helper T-cells (CD4-positive and CD45RA-negative) were statistically predominant over the inducer T-cells (CD4-positive and CD45RA-positive) (p < 0.01). When CD8 cells were investigated in 16 out of the 17 cases, the cytotoxic T-cells (CD8-positive and CD11b-negative) were found also significantly predominant over the suppressor T-cells (CD8-positive and CD11b-positive) (p < 0.01). Immunohistochemically, the infiltrating pattern of TILs in the 17 patients was classified into cluster (N = 4), separate (N = 6), and mixed types (N = 7). The tumor in the cluster and mixed type had a tendency to be dominant in low grade tumors, and had the prominent CD8-positive cells (more than 90% were cytotoxic T-cells) over CD4-positive cells. However, no statistical significance was noted in this finding. The advanced tumor tended to show the single type of TIL infiltration. These results suggest that cytotoxic T-cells consisted of most of TILs in cluster and mixed types play an immunoreactive role against renal cell carcinoma.

[A clinical study on renal pelvic and ureteral tumor associated with bladder tumor]

Of 65 cases of renal pelvic and/or ureteral tumor treated at Department of Urology, The University of Tokyo, during the period from January 1975 through December 1991, 26 had bladder tumors as well. These cases were divided into three groups; 1) bladder tumor preceding upper urinary tract tumor, 2) bladder tumor found simultaneously with upper urinary tract tumor, and 3) bladder tumor following upper urinary tract tumor. In group 1 (nine cases), the last bladder tumor preceded renal pelvic and/or ureteral tumors by 3 to 42 months (mean 14.6 months), and in seven cases, bladder tumor recurred 3 to 29 months (mean 9.0 months) after nephroureterectomy. The interval between the diagnosis of preceding bladder tumor and upper urinary tract tumor was highly correlated with the latent period of postoperative recurrence of bladder tumor (r = 0.948). Highly malignant pathological grade of bladder tumor featured seven cases of group 2, with the survival rate being significantly (p < 0.01) lower than that of other groups. In the group 3 consisting of ten cases, bladder tumors subsequently developed 6 to 37 months (mean 15.0 months). The latent period of bladder tumor was significantly (p < 0.01) longer than that in group 1. These results indicated that the bladder tumors associated with renal pelvic and/or ureteral tumors have distinct characteristics depending on the sequence of association.

[Clinical observations of advanced renal cell carcinomas--the chronological change between 1975 and 1991]

An analysis has been undertaken to determine chronological changes that have occurred in the clinical features and treatments of advanced renal cell carcinomas. To accomplish this, 96 renal cell carcinoma cases, handled by the authors' department and at the branch hospital, were divided into two groups: 48 patients treated between 1975 and 1983 (group 1) and 48 patients treated between 1984 and 1991 (group 2). Between the two groups, no differences were seen in the sex ratio, the mean age, and the ratio of those who were found to be advanced cases at the time of diagnosis and those whose cancers had advanced after undergoing a nephrectomy. Concerning treatment, interferon (IFN) and UFT were more frequently used in treating group 2 than group 1, and chemotherapy, radiotherapy, and endocrine therapy less frequently used. No differences were seen in the prognosis between the two groups; however, in those who had advanced after nephrectomy, group 2 cases survived for a significantly longer period than did group 1 cases. Patients who survived for 5 years or longer accounted for two cases in group 1 and 5 cases in group 2 and combination therapies involving surgery, IFN, UFT, or similar medications were used for their treatments. These results suggest that adjuvant therapies, such as surgery, IFN, and UFT, have possibly contributed to prolonging survival, especially for cases that advanced after nephrectomy.

Laparoscopic adrenalectomy: the initial 3 cases

Laparoscopic adrenalectomy was performed on 3 patients with primary aldosteronism. Traction with 2 steel skewers placed subcutaneously over the costal arch was combined with conventional intraperitoneal carbon dioxide gas insufflation. This combination provided a good operative field at 8 mm. Hg insufflation pressure. The laparoscopic approach to the adrenal gland requires neither a large skin and muscle incision nor resection of rib(s), and offers lower morbidity and rapid convalescence. Laparoscopic adrenalectomy is a new minimally invasive operation for the treatment of adrenal adenoma.

[Transurethral resection of papillary tumor in the lower end of the ureter: report of two cases]

Two cases of papillary ureteral end tumors, treated by transurethral resection are presented. Case 1: A 71-year-old female visited us for asymptomatic macroscopic hematuria. Cystoscopy revealed a papillary pedunculated tumor in the bladder protruding from the right ureteral orifice. Under a diagnosis of superficial tumor at the right ureteral end, transurethral resection was performed using a rigid ureteral resectoscope. Pathological examination revealed transitional cell carcinoma, grade 2 without muscular invasion. There is no evidence of recurrence after 25 months of follow up postoperatively. Case 2: On a routine cystoscopy after transurethral resection of bladder tumor in a 68-year-old male, papillary pedunculated tumors protruding from the right ureteral orifice were found. Under a diagnosis of superficial tumor at the right lower ureter, transurethral resection was performed using cold cup forceps and loop electrocoagulation. The tumor was transitional cell carcinoma, grade 1 without invasion. No evidence of recurrence was detected 15 months postoperatively. Transurethral resection of the ureteral tumor at the lower end appeared to be useful for the selected cases. The indications, complications and follow up for this procedure were discussed.

[A survey of postoperative steroid replacement in 40 patients with Cushing's syndrome]

Adrenalectomy for Cushing's syndrome due to adrenocortical adenoma was performed on 40 patients at Tokyo University Hospital between 1960 and 1990. There were 32 women and 8 men aged 2 to 59 (mean 35.7) years. Three different operative approaches to the adrenal gland were employed: lumbar approach in 24 cases, dorsal in 8, and transabdominal in 8 of whom 7 patients were operated before 1970 without definite preoperative localization of the lesions. Postoperative administration of cortisone and hydrocortisone as a steroid replacement has been reduced in duration and dosage in recent 10 years. Average treatment period was 3 years and 1 month in the 1970's, and 9.5 months in the 1980's, respectively. The mean daily dosage of steroid hormone was 517.5 mg (mean) on the operative day and 43.1 mg after three weeks in the 1970's, while 187.5 mg and 18.4 mg in the recent five years, respectively. Nonetheless, even in the recent 6 patients, metabolic alkalosis and hypopotassemia because of steroid excess were observed in a few days after the surgery. These observations indicate that period and dosage of steroid replacement have been reduced in these years and could be further shortened by means of rapid tapering in the early postoperative phase.

[A survey on urinary incontinence in the institutionalized elderly]

A survey on urinary incontinence in 161 (41 male, 120 female) institutionalized elderly was independently performed by urologists and attending nurses. Urinary incontinence was found in 107 cases (66%), with 76 cases (47%) suffering from severe leakage (more than 5 times a day and needs diaper). The prevalences of incontinence and severe leakage were 63% and 52% at geriatric hospitals, 59% and 29% at intermediate care centers and 78% and 63% at nursing homes, respectively. The risk factors for incontinence were consciousness disturbance, urinary urgency, impaired mobility and dementia, and those for severe leakage were apathy, loss of urinary sensation, dementia and impaired mobility. The type of incontinence was considered functional one in 81% of cases. The agreement of the incontinence type evaluated by urologists and that by nurses was found in 90% of incontinent cases. Incontinence was estimated "incurable" in 54% of cases by attending nurses. These observations indicate a high prevalence of severe and "incurable" incontinence in the institutionalized elderly, urgently warranting an effective remedy for the increasing aged society.

[A case report of laparoscopic adrenalectomy]

Laparoscopic left adrenalectomy was performed on a 47 years old male patient with primary aldosteronism. Subcutaneous steel traction method was utilized in addition to intraperitoneal CO2 insufflation method. The combined use of steel traction method reduced CO2 insufflation pressure below 12 mmHg and might reduce possibility of CO2-related complications. A left adrenal gland was approached by a resection of phrenic colic ligament and a traction of a transverse and descending colon. Laparoscopic adrenalectomy has distinct advantages over open adrenalectomy in terms of avoidance of skin and muscle incision and rib resection, and early convalescence. This less invasive method might prevail in near future.

Percutaneous reduction of cyst volume of polycystic kidney disease: effects on renal function

Percutaneous reduction of cyst volume was performed in 10 patients with autosomal dominant polycystic kidney disease and its effects on renal function were studied. Although creatinine clearance, urinary excretion of beta 2-microglobulin and N-acetyl-beta-D-glucosaminidase, and renal uptake of 99mtechnetium-dimercaptosuccinic acid did not change significantly, a transient increase in urinary protein and a decrease in inulin clearance were observed. Complications, such as hematuria, fever and decreases in hematocrit, were slight and transient in most patients. This procedure holds little promise for altering the course of polycystic kidney disease.