PURPOSE:To elucidate the factors contributing to staghorn stone formation in patients.MATERIALS AND METHODS:The records of 82 patients (44 men and 38 women) with complete staghorn calculi were reviewed retrospectively for clinical presentation, metabolic disturbances and anatomical abnormalities.RESULTS:There were 79 unilateral and three bilateral cases. The patient performance of the activities of daily life was assessed with the modified Rankin scale (MRS) and it was found that 69 patients were functionally independent (84.1%, MRS 0-1) and 10 patients had a severe disability (12.2%, MRS 4-5). Seven patients had chronic indwelling catheters (8.5%). A positive urine culture was found in 24.4% of patients. Analysis of stone composition revealed magnesium ammonium phosphate and mixed calcium oxalate-phosphate were the most frequently identified types of stone (32.1% and 22.2%, respectively). Urinary pH was low in patients with uric acid stones (mean 5.4). Hyperuricemia, cystinuria and hypercalciuria were found in 14.6%, 2.4% and 37.8%, respectively. Hypercalciuria was found more frequently in calcium-stone cases. Eleven patients (13.4%) showed structural abnormalities of the kidney.CONCLUSIONS:Our data show that the patients with severe disability, urinary tract infection and hypercalciuria could be recognized more frequently in staghorn calculi compared with common urolithiasis. However, in Western countries, the frequency of both urinary tract infection and struvite stones is much higher than in our data. Other Japanese authors have also reported the low frequency of struvite stones in staghorn calculi, suggesting that various factors other than urinary tract infection possibly contribute to the formation of staghorn calculi in Japan.

Primary signet-ring cell carcinoma (SRCC) of the prostate is very rare and has a poor prognosis, even when treated with aggressive therapy. We report herein a case of a 72-year-old man with prostatic SRCC. The patient had a tumor that extended directly to the rectum. Maximal androgen blockade was started and 20 months later, the patient was alive without evidence of recurrence. The present case of prostatic SRCC responded well to medical therapy, however, tumors can recur after a long period of time. Therefore, adjuvant therapy is recommended.

A 58-year-old man presented with a stone within the dilated intravesical ureter, which was probably attributable to a previous ureteroscopy. Transurethral incision of the right intravesical ureter and lithotripsy were carried out without subsequent urinary tract impairment. Although some complications resulting from ureteroscopy, such as ureteral stricture, ureteral perforation and vesicoureteral reflux, have been reported, this complication is considered to be very rare.

We evaluated the availability of NMP22 for the diagnosis of urothelial cancer. Of 154 patients with gross hematuria or microscopic hematuria, 14 patients with bladder cancer and 4 patients with upper urothelial cancer were detected. Of 73 patients continued to be followed for urothelial cancers, 11 patients with bladder cancer were detected. NMP22 was not available when a large number of RBC was present in urine. Also, NMP22 was significantly higher in patients with urothelial cancers. Interpretation of the ROC curve indicated an optimal cutoff value of 9.2 u/ml. Using 9.2 u/ml as a cutoff, the sensitivity and specificity were, respectively 87.0% and 64.0% in patients with hematuria, and 81.8% and 78.7% in patients with a history of TCC. This indicated that when NMP22 was used for the diagnosis of urothelial cancers, 12.0 u/ml, the value recommended as a cutoff in Japan, might be too high to differentiate patients with urothelial cancers.

We herein report the clinical statistics on new outpatients over five years from 1994 at our hospital. The average number of new outpatients per year was 8,534.4 (8,366-8,658) and there was only a slight variation in the number over the last five years. The male to female ratio was 1.61:1. Twenty-one percent of the outpatients were referred to us by other sources. The representative operations on outpatients were circumcision, vasectomy, resection of condylomas and resection of caruncles. A statistical study was made on new outpatients according to the international classification of disease. There were 197.0 (2.3%) malignant urogenital tumors per year. There was a tendency for sexually transmitted diseases to increase over the last five years. In males, the major diseases were upper urinary tract stones (23-27%), benign prostatic hypertrophy (19-26%) and prostatitis (15-24%). In females, they were cystitis (57-59%), upper urinary tract stones (17-18%) and neurogenic bladder (3-4%). We conclude that our hospital plays a major role as a private urological hospital.

A total of 178 renal units in 173 patients with renal and upper ureteral calculi were treated by percutaneous nephrolithotripsy (PNL) between November 1984 and October 1995. PNL was performed as a monotherapy in 70 kidneys, while extracorporeal shock wave lithotripsy (ESWL) was combined in 108 kidneys. At the time discharged 110 (61.8%) kidneys were stone-free and the overall success rate, defined as no residual stone or fragments < 4 mm, was 96.1%. The stone-free rate was significantly lower (44.2%) for staghorn renal calculi. For 105 stone-free kidneys with > 6 months of follow-up, the cumulative stone recurrence rate was 4.2% at 1 year, 16.6% at 3 years, 29.2% at 5 years, 34.4% at 5 years and 55.4% at 10 years. None of the pretreatment parameters, such as stone size, number, location, composition, past history of urolithiasis and upper urinary tract obstruction, had a significant influence on stone recurrence.

We report the clinical statistics of new outpatients for five years since 1989 at our hospital. The average total number of new outpatients in a year was 8309.8 (8122-8691) and new outpatients tended to show little change. The male to female ratio was 1.57:1, and 24.3% of the outpatients were referred to us by others sources. The representative operations on outpatients were circumcision, vasectomy, resection of condyloma and resection of caruncle. A statistical study was made on new outpatients according to the international classification of disease. There were 140.6 (1.97%) malignant urogenital tumors per year. Sexually transmitted diseases showed a tendency to increase for the last five years. In males the major disease was upper urinary tract stone (21-24%), prostatistis (21-24%) and benign prostatic hypertrophy (17-20%) and in females they were cystitis (58-61%), upper urinary tract stone (15-17%) and pyelonephritis (3-4%). We conclude that our hospital plays a major role as a private urological hospital.

A clinical statistic survey was carried out on the patient admitted, diseases and operations experienced at our urological clinic during 1985-1989. The total number of inpatients was 8,750 (The male to female ratio was 2.8:1). The major diseases of the inpatients were urolithiasis (4,134 cases, 47.2%) and benign prostatic hypertrophy (1,529 cases, 17.5%). Among the operations extracorporeal shock-wave lithotripsy 2,589 cases (44.6%) and transurethral resection of prostate 1,295 cases (22.3%) were predominant.

Thirty-nine patients, 27 males and 12 females with renal and ureteral stones, were treated using the Modulith SL 20 between October 1990 and January 1991. Thirty-three of the 39 cases had a single session of extracorporeal shockwave lithotripsy (ESWL) and the other six cases had two sessions. The pulverization rate of ESWL by this device was 84.6%. According to the X-rays taken 21 days after ESWL, of the 37 cases, 14 (37.8%) were stone-free, 18 (48.7%) had residual sandy stones less than 4 mm in diameter, five (13.5%) had residual stone fragments larger than 4.1 mm in diameter, and two cases were not clear. Using the criterion of cases which can be expected to have spontaneous passage, in other words, residual stones less than 4 mm in diameter, lithotripsy with the Modulith SL 20 was regarded as "effective" in 32 of the 37 cases (86.5%). As side effects of this treatment, hematuria was observed for several days after ESWL in all patients, but not other serious complications were observed. Among the 37 cases in which the grade could be evaluated the evaluation for 24 (64.9%) was "useful" and that for 13 (35.1%) "useful to some extent". Therefore, ESWL was performed very successfully.

During the 4 year period from September 1, 1984 through August 31, 1988, a total of 1,866 patients with calculi of the urinary tract (125 patients had bilateral calculi) were subjected to extracorporeal shock wave lithotripsy (ESWL) with a DORNIER HM3 ESWL apparatus. Follow-up was performed factor 1,056 cases 3 or more months after complete elimination of the calculi, and data were obtained for 343 of them. Lithiasis was found to have recurred after ESWL in 30 cases, with a recurrence rate of 11.1%. Recurrence was seen in 16.9% of cases with multiple calculi and 6.5% of cases with a single calculus. The difference was statistically significant. Surgical removed of calculi or spontaneous discharge of calculi had been experienced in 50.0% of the recurrent cases and 27.8% of the non recurrent cases. The difference was also statistically significant. Stone size, stone location and urinary tract infection were unrelated to the recurrence.

Forty-two (44 renal units) were treated by combination of ESWL and percutaneous nephrostomy or PNL. Staghorn calculi were found in 33, renal stones in 6 and ureter stones in 5. Residual stone rate was 18.2% in staghorn calculi. No severe complications were seen.

Transurethral resection of prostate was done on 11 prostates weighing over 100g among 1664 cases seen during the last 9 years. The largest prostate weighed 180g and needed 140 minutes for resection. From 400 ml up to 1,600 ml, mean 890 ml of blood were transfused in these patients. No severe complication or death occurred. In conclusion, a prostate weighing less than 200 g can be operated by transurethral resection.

During the last 9 years, 1,892 patients underwent surgery of the prostate. Benign prostatic hypertrophy (BPH) accounted for 1,812 cases, and prostatic cancer 80 cases. In the case of BPH, transurethral resection was done in 1,645 cases, cryosurgery in 136 cases, and suprapubic prostatectomy in 31 cases. Latent cancer was detected in 54 (3.3%) of the BPH cases. The average patient age of the patients with latent cancer (73.6 +/- 6.9 years) was higher than that of those without latent cancer (69.5 +/- 7.7 years). This suggested a significant relationship between the age of the patient and the occurrence of latent cancer.

We report our 3-year experience with extracorporeal shock wave lithotripsy (ESWL) since we first used it for upper urinary tract stones on September 1st, 1984. A total of 1,225 patients (1,320 cases) underwent 1,647 sessions with ESWL; They consisted of 855 males (70%) and 370 females (30%). Treated stone locations were 593 renal stones, which contained 112 complete staghorn calculi, 504 ureteral stones, 110 renoureteral stones, and 1 bladder stone. ESWL monotherapy was performed on 90% of cases with renal and ureteral stones, and 46% of cases with complete staghorn calculi. In all the cases so far observed for more than 12 weeks after ESWL, 84.9% of the former showed complete discharge of the stones, and 0.7% showed no change. Only 48.9% of the later showed the complete discharge of the stones, 43.3% of which had residual stones, and 7.8% had fragments of the size of small beans. Complications, which were fever and pain, were noticed in 33.6% of the cases with renal and ureteral stones, and 64.3% of the cases with complete staghorn calculi. After ESWL, hematuria was noticed in almost cases, but the average volume of hemorrhage was 28 +/- 33 ml/day. The only contraindication of ESWL was severe obesity, and in the cases in which spontaneous stone discharge can be expected.

Thirty-five patients (37 renal units) were treated by PNL. Nine had complete staghorn calculi, 2 multiple reno-ureteral stones, 12 solitary renal stone, and 14 upper ureteral stone. The success rate was 94.6%. No severe complications were seen.

During the 11-year period from September 1984 through August 1995, extracorporeal shock wave lithotripsy (ESWL) was performed on 5,558 patients using a Dornier HM3 apparatus. A recurrence questionnaire was sent out to 2,379 of those who had had complete elimination of the calculi and for whom at least 3 years had passed since the ESWL. The last day of follow-up was defined as follows: the day of completion of the questionnaire in the recurrence-free group (n = 787), the day when recurrence of calculi was diagnosed in the recurrence group (n = 415) and the day of the last visit to the outpatient clinic in the miscellaneous group (n = 1,133). The cumulative recurrence rates were calculated by the Kaplan-Meier equation. The resultant data were analyzed for statistically significant differences by the log rank test and the generalized Wilcoxon test. Ap value of < or = 0.05 was considered to indicate significance. The recurrence rate was examined for differences in relation to the following risk factors: the patients' age and sex, the stone location, size and number, the presence or absence of past history of lithiasis, the composition of the stone (s), and the presence or absence of urinary tract complications. The cumulative recurrence rates for the total cases were 2.0% at one year, 13.1% at 3 years, 23.9% at 5 years, 30.7% at 7 years and 40.7% at 10 years. Significantly higher recurrence rates were found for patients under 60 years of age, those with multiple stones and those with a past history of disease.

ESWL has been used to treat distal ureteral stones in ten patients. All stones were broken up to sandy fragments. In six patients, all fragments were discharged completely within 3 days and in two patients within 20 days without any additional manipulation. The other two patients were lost to follow up regarding complete discharge.

1984年9月から本邦で開始されたESWL (Extracorporeal shock wave lithotripter) の治験は1985年3月に終了し, その後数多くの施設に導入されている. このうち, 1986年6月30日までにESWLを導入した全国11施設を対象にアンケート調査をおこなった. 治療人数は3,702名, 男女比は2.7:1で, 尿路結石症羅患の自然の男女比よりも男性に多い傾向がみられた. 又, 腎盂あるいは腎盂尿管移行部を対象としたものが71%で, 自然の結石分布よりも多かった. ESWLで治療した患者の約7%に内泌尿器科的併用療法がおこなわれた. 79%の症例で結石は完全消失しており, 5mm以上の残石があったのは4%であった. 合併症としては, 腎血腫, 消化管出血, 菌血症などがあり, 注意深い治療をおこなう必要があると考えられる. 2～3cmを越える大きな結石に対しては, 合併症を少なくし, 腎機能を保持し, かつ治療効果をあげる為に, 内泌尿器科学的治療 (Endourologic treatments) を併用することが必要であろう.この間の11施設の経験を総合すれば, 第4腰椎より上にある腎尿管結石に対して, ESWLは使用上適切な注意を払うならば安全で侵襲の少ない, 第一選択として選べる治療手段であるといえる.

This report describes the treatment of 64 cases of complete staghorn calculi using extracorporeal shock wave lithotripsy (ESWL). Thirty cases (46.8%) were successfully treated using ESWL monotherapy and the rest of the cases (53.2%) required ESWL combined with an auxiliary procedure. Forty-four of the cases (68.7%) had symptoms such as fever and pain after ESWL. These cases were treated with chemotherapeutic agents and an auxiliary procedure. X-ray examination showed that the result of ESWL treatment was satisfactory in 97.4% of the 34 cases followed up for more than 12 weeks after ESWL. Based on the results of this study, the following plan of treatment for complete staghorn calculi has been adopted in our hospital. ESWL monotherapy is performed in cases without a dilated collecting system or stricture. ESWL combined with an auxiliary procedure is performed in cases with a dilated collecting system, stricture, ileal conduit and solitary kidney.

A statistical study was performed on new outpatients, the total number of which was 7,786 (male: 4,953, female: 2,833) in 1985. The male to female ratio was 1.75:1. They had urogenital diseases definitely diagnosed (6,786), tentatively diagnosed (600), normal (260), and diseases other than urogenital (140), and 36.2% of them had been referred to us by other sources. On these outpatients 206 operations had been performed circumcision, resection of condyloma and vasectomy were representative. The peak of the age distribution was in the thirties for males and in the twenties for females. For the first time in Japan, we treated renal and upper ureteral stones using extracorporeal shock wave lithotripsy (ESWL) on September 1, 1984. The results of ESWL at out hospital have been satisfactory. A statistical study was made on new outpatients according to the international disease classification. There were 152 malignant (urogenital) tumors (2.1%). The major diseases of the new outpatients were cystitis (acute or chronic: 20.6%), upper urinary tract stones (19.4%), prostatitis (13.5%), benign prostatic hypertrophy (10.7%). In males the major diseases were prostatitis, upper urinary tract stones, benign prostatic hypertrophy, balanoposthitis, and phimosis, and in females they were cystitis, upper urinary tract stone, pyelonephritis, and renoptosis. We conclude that our hospital plays a major role as a private urological hospital.