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The patient was a 69-year-old man with localized cT1cN0M0 prostate cancer, who underwent robotassisted laparoscopic prostatectomy (RALP). The operation time was 188 minutes, blood loss was 300 ml, including urine, and no intraoperative complications were noted. The fourth day after RALP, he suddenly complained of nausea and vomiting, and there was right lateral abdominal tenderness. Emergency abdominal computed tomographic scan revealed small intestinal hernia in the right lower abdomen, and we performed emergency laparoscopic surjery. At re-operation, we found lacerations of the peritoneum and transversus abdominis fascia at the insertion site of the 12 mm assistant port, and prolapse of the small intestine. Our diagnosis was lateral port site hernia following RALP. There was no necrosis in the small intestine. The transversus abdominis fascia was Z-sutured through the abdominal cavity with an absorbable thread, and the oblique abdominis muscle was Z-sutured extracorporeally to complete the operation. The patient was discharged on the eleventh day with good progress after re-operation. The possibility of lateral port-site hernia after RALP should be kept in mind, and more reliable port-site closure should be considered.

Robot-assisted laparoscopic radical prostatectomy (RARP) is becoming the standard treatment procedure for localized prostate cancer. The main complications associated with RARP include urinary incontinence and sexual dysfunction. In addition, acute urinary retention (AUR) after urethral catheter removal is sometimes seen. Early catheter removal is a risk factor for AUR, and administration of alphablockers before catheter removal reduces the occurrence of AUR. However, the ideal management of AUR after RARP is not known. Here we report the clinical course and treatment after AUR. We performed 279 RARPs at our institution, and AUR developed in 11 cases. In all cases, urination status was improved after placement of a urinary catheter or intermittent catheterization. Later, urethral stricture was seen in 2 out of 11 cases. Ourstudy suggests that when AUR is observed afterRARP, catheterur ination should be initially performed. If urinary retention recurs, a urinary catheter should be placed with administration of alpha-blockers. The catheter is removed after about 3 days, and administration of analgesics is effective for reducing the pain on urination. If urination status is not improved, evaluation of the urethral stricture should be considered.

We report a case of well leg compartment syndrome (WLCS) in both legs after robot-assisted laparoscopic prostatectomy (RALP). A 65-year-old man underwent surgery for prostate cancer. He was placed in the lithotomy position and both his legs were protected with elastic stockings and intermittent pneumatic com- pression to prevent deep vein thrombosis during sur- gery. After surgery, he complained of pain in both calves. Movement and sensory disorder along with swelling were found in both legs. Computed tomogra- phy of the legs showed damage to the soleus and gas- trocnemius muscles of both legs. The creatinine phos- phokinase level had increased to 10,560 IU · l⁻¹. The patient was diagnosed with WLCS in both legs and underwent conservative treatment. Symptoms in both legs started to improve from the next day. The right leg swelling receded within 10 days, while the left leg swelling receded 67 days after surgery. WLCS in the legs after RALP is a rare but severe complication requiring early diagnosis and intervention. To prevent WLCS, it is important that we recognize this disease as a potential complication after RALP.

Although radical retropubic prostatectomy had long been the mainstay as the surgical treatment for patients with localized prostate cancer, robot-assisted radical prostatectomy (RARP) has recently been achieving increasing acceptance, resulting in the leading option for treating such patients in the United States, and it has been progressively expanding in other countries, including Japan. To date, however, there have been limited data concerning prospective studies or randomized trials showing the superiority of RARP over other surgical approaches. In this review, we attempted to summarize the current status of RARP based on available evidence as well as the experience at our institution, and to discuss the future prospect of this novel system as a major surgical technique for localized prostate cancer.

The Hem-o-lok clips (HOLC) is frequently used for hemostasis of the lateral pedicles in robot-assisted prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP). We report a rare post-operative complication, the migration of a HOLC into the bladder leading to calculus formation after RARP. A 54 year-old man underwent RARP with nerve- sparing procedure with HOLCs in the left neurovascular bundle. Three months later, he was referred to our hospital for pollakisuria and spontaneous hematuria. Abdominal ultrasonographic examination and computed tomography (CT) demonstrated a bladder stone that was 7 mm in diameter. On cystourethroscopy, he was noted to have a yellow-colored stone at 9 o'clock position of vesicourethral anastomosis. A cystolithotripsy for a bladder stone was performed until the surface of it was broken. A HOLC with a calculus was revealed and retrieved by stone forceps through the urethra. Since then, Intravesical migration of a HOLC has not been observed.

Robot-assisted radical prostatectomy (RARP) for the patients with localized prostate cancer is increasingly being adopted around the world. The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA) provides the advantages of simplification and precision of exposure and suturing because of allowing movements of the robotic arm in real time with increased degree of freedom and magnified 3-dimensional view. Therefore, RARP has been expected to provide superior therapeutic benefit to patients in terms of surgical outcome to open or laparoscopic radical prostatectomy. In this review, we provide our technical aspects and tips and tricks of RARP to improve surgical outcome and postoperative quality of life.

Objective: In recent years, robot-assisted laparoscopic prostatectomy has become widely used, and the perineal approach is utilized much less than before. However, radical perineal prostatectomy has some advantages with regard to operative complications. Here I evaluate 200 cases for which the perineal approach was used in the past 12 years., Materials and Methods: From 2000 to 2012, radical perineal prostatectomies were performed for 200 patients and their operative complications were evaluated. The mean age of the patients was 68.5 years, with a PSA of 9.4 ng/ml, and Gleason score of 6.9. Their clinical stages were T1 in 168 cases (84.0%), T2 in 26 (13.0%) and T3 in 6 (3.0%)., Results: Mean operative time was 85 minutes, and estimated blood loss was 220.0 ml. The median time for urethral catheter indwelling was 7 days, and the admission term was 14 days. Operations were performed safely in patients with a BMI of more than 30 kg/m2. Lymphadenectomies from the same incision were performed in 20 cases and there were no lymph node metastases. Rectal injuries occurred in 7 cases (3.5%) with 100 cases of Blet's approach so I changed to Young's approach. With Young's approach I have not experienced any rectal injuries. Wound infection occurred in 4 cases (2.0%), hematoma in 2 (1.0%), anastomotic stricture in 1 (0.5%), inguinal hernia in 1 (0.5%), and transient lower extremity neurapraxia in 1 (0.5%). Postperineal pain after operation was tolerated using a donut cushion, though some pain relievers were needed in 20 cases (10.0%). Fecal incontinence occurred in 4 cases (2.0%) but was temporary., Conclusions: With radical perineal prostatectomy it is easy to perform vesicourethral anastomosis, apical dissection and nerve sparing, and there are few complications such as inguinal hernia, anastomotic stricture and so on. In addition, there is less blood loss with this approach because the dorsal vein complex and pudendal arteries are out of sight. Therefore, radical perineal prostatectomy is suggested to be useful because of its safety, short operation time and low cost. Finally this procedure can be selected as the first choice for patients with past history of lower abdominal operation and obesity.

Background: Aeroperitoneum increases intra-occular pressure (IOP). We measured IOP during robotic-assisted laparoscopic radical prostectomy (RALP) that requires steeper Trenderenburg position., Methods: Fourteen patients with no ocular diseases were candidates. We measured their IOP during robotic operation from beginning to end., Results: Our date shows that IOP continues to increase over the time of steep Trenderenburg position., Conclusions: Long time RALP might be risky for IOP.

Minimally invasive surgeries such as laparoscopic surgery and robot-assisted surgery have become validated treatment modalities and hold a prominent position in clinical practice. Robot-assisted radical prostatectomy(RARP)is a relatively new procedure. Because this technique does not require the urologist to overcome a steep and long learning curve, a dramatic increase in the number of RARP surgeries was observed in recent years and RARP has rapidly gained acceptance in the Japanese urological community after its introduction in Japan in 2006. Robot-assisted surgery that combines optical magnification, three-dimensional vision, and instruments with 7 degrees of freedom allows surgeons to perform meticulous, precise, and accurate movements. In summary, for the previously mentioned reasons, RARP is considered to be an effective procedure for improving intraoperative blood loss, the transfusion and complication rates, as well as the recovery of urinary continence and potency rates. In this article, we briefly describe the evolution of this minimally invasive technique. In addition, we present the current state of RARP and a critical evaluation of the learning curves associated with performing RARP as well as published oncological, continence, and potency outcomes.

A 53-year-old man presented to our hospital with a few-month history of fatigue and anorexia. His aging male's symptoms (AMS) score was 57, and the free testosterone value was low (6.5 pg/ml). He was diagnosed with severe late-onset hypogonadism indicative of androgen replacement therapy (ART). His serum prostate specific antigen was 8.7 ng/ml, and pelvic magnetic resonance imaging showed a low intensity area in the peripheral zone of the prostate. A systematic 10-core prostate biopsy revealed one core of adenocarcinoma with a Gleason score of 3 + 3=6. Imaging examination revealed organ-confined prostate cancer that was cT2aN0M0. Given his desire for ART for the treatment of hypogonadism, the patient underwent open radical prostatectomy. Pathologic examination demonstrated prostate adenocarcinoma that was pT2aN0, and Gleason score of 3 + 3=6. After confirming that the prostate specific antigen value was under 0.01 ng/ml for three years after prostatectomy, the patient received 125 mg methyltestosterone monthly. His hypogonadism-related symptoms diminished and AMS score dropped to 48. During a three-year follow-up of ART, no biochemical recurrence was found.

Robot-assisted radical prostatectomy(RARP)has emerged in the last decade. It has greatly improved clinical management of localized prostate cancer. Its use has been justified by its satisfactory oncological and functional outcomes and its fewer perioperative complications. RARP has the advantages of both conventional open radical retropubic prostatectomy and laparoscopic radical prostatectomy. However, its increased cost and the lack of tactile sensation it induces still remain problems.

We have 3 options when perfoming prostatectomy for the treatment of localized prostate cancer. Those are retropubic radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted laparoscopic radical prostatectomy. We compared the characteristics and results of these techniques. Robot-assisted laparoscopic radical prostatectomy could be superior to the others in many ways. However, it would be very difficult to adopt it in Japan because it would pose economical difficulties. The administrative assistance in the insurance systems requireds much more than we have.

We report 2 cases of bladder stone formation after radical retropubic prostatectomy (RPP). Case 1 is a 68-year-old man who complained of macrohematuria at the time of 10 months after RRP. Case 2 is a 62- year-old man who complained of urethralgia at 9 months after RRP. In both cases, bladder stones were diagnosed after cystoscopic examination and then removed by transurethral lithotripsy. They had no history of urinary tract stone formation. The performance of RRP is considered one of the main causes of their bladder stone formation.

We evaluated the relationship between the type of suture and occurrence of anastomotic stricture after radical retropubic prostatectomy (RRP). From April 2005 to February 2008, 48 RRP were performed. In the former 24 cases, 2-0 absorbable braided sutures were used (group A), and in the latter 24 cases, 3-0 absorbable monofilament sutures were used (group B) in the vesicourethral anastomosis. In group B, operation time was longer, blood loss was less and tumor stage was lower. While five patients in group A developed an anastomotic stricture, but no one in group B developed a stricture. Univariate analysis of the two groups revealed that only the type of suture and age were significant parameters for the anastomotic stricture.

The patient, a 56-year-old man, had surgery for anal fistula at the age of 28. In August 2007, he underwent a radical retropubic prostatectomy (RRP) for prostate cancer. Rectal injury was not recognized during the operation. However, on the 8th postoperative day, fecaluria appeared, and rectourethral fistula was diagnosed. We attempted conservative therapy including diverting colostomy and continued drainage using a urethral catheter. Subsequently, the fistula closed spontaneously 3 months after RRP. Eight months after RRP, we performed a transanal repair of rectal mucosa based on the rectal wall advancement flap procedure. The postoperative course was uneventful, and the colostomy was closed in July 2008. By April 2009, he had normal voiding and full anal continence without fistula recurrence.

A cross-sectional study for certain symptoms of postoperative incontinence was done for patients who underwent laparoscopic radical prostatectomy (LRP) using our original self-administered questionnaire. A total of 104 patients, who underwent LRP from April 2002 to March 2005 in our institute and related hospitals, participated in our questionnaire study. Mean age and median observation period was 64.6 years old (range 51-74) and 18 months (range 3-36). The patients were classified into "D group" (disappearance of incontinence during 3 months after LRP) and "C group" (continuous incontinence more than 3 months). Then age, body mass index, preoperative PSA level, status of voiding, defecation and potency were compared. Patients with incontinence were divided according to observation period into "short period group" (S group; 3-11 months), "intermediate period group" (IM group; 12-23 months) and "long period group" (L group; more than 23 months). Incitant factors of incontinence, status of taking pads and QOL score were compared. There were no differences between the D and C groups at any measurements. About 40% of incontinence patients were pad-free, although most of these patients did not satisfy the status of voiding. The incitant factor in 90% of the S group was "cough or sneeze", but that in the L group was "without notice" (about 40%) and "too late to toilet (voiding)" (about 25%). After all, postoperative QOL score was still lower in the patients with incontinence regardless of its volume. Further study to revolutionary improve incontinence is required.

A 65-year-old man underwent a radical retropubic prostatectomy for prostate cancer, and 5 days later fecaluria and serous diarrhea appeared suddenly. Cystourethrography domonstrated the flow of contrast material into the rectum through the fistula, so we diagnosed a rectourethral fistula. We first attempted conservative management, but the fistula did not close spontaneously. So we performed the transanal repair of rectourethral fistula about 2 months after surgery. This repair was effective, and the patient was alive without fistula recurrence at about 2 years after the repair surgery. This approach is simple and does not require a new incision, but it is only useful for low rectourethral

Urethrorectal fistula is a relatively rare disease. The most frequent cause of acquired urethrorectal fistulas is known to be iatrogenic complications, such as rectal injuries during the prostate operations. Rectal injuries are usually noticed during the operation and the majority can be repaired in situ. We report a case of late-onset urethrorectal fistula that lacked obvious rectal injury during the operation. Ischemic change or heat denaturation of rectal wall may be the potential cause of the present urethrorectal fistula.

A 76-year-old man with clinical stage T1c adenocarcinoma of the prostate underwent radical retropubic prostatectomy. After a cystography on postoperative day 7 demonstrated minimal contrast extravasation, gentle catheter traction was performed. However, a cystography on postoperative day 21 showed a displacement of the catheter out of the bladder due to more significant anastomotic rupture. The catheter was preserved without catheter traction for two months. A cystography revealed complete healing of anastomosis without extravasation. This case suggests that catheter traction for anastomotic leakage should be performed carefully because of a potential risk of further anastomotic leakage.

We report two cases of femoral nerve palsy after radical prostatectomy due to compression ascribed to the use of a ring retractor. The first case is in a 69-year-old man who fell when getting out of bed on the first postoperative day. Physical examination revealed hypoesthesia around the patella and weakness of the quadriceps muscle. The second case is in a 66-year-old man who complained of numbness of the anteromedial aspects of the right thigh and inability to extend his right knee on the first postoperative day. Postoperative femoral nerve palsy is not a well-recognized complication in urology. The literature was reviewed and the management of postoperative femoral nerve palsy was discussed.

We retrospectively analyzed the morbidity and risk factors of bladder neck contraction (BNC) after retropubic prostatectomy. Of 99 consecutive patients who underwent radical retropubic prostatectomy between 1995 and 2001, 10 (10%) developed anastomotic stricture after surgery. BNC was diagnosed 7 months on average after the surgery. Nine patients were successfully treated by cold-knife incision, but 5 required additional incision against the recurrence of BNC. None of them revealed newly diagnosed stricture or incontinence. Thirteen potential risk factors including age, stage, PSA, neoadjuvant treatment, pathology, intraoperative blood loss, operation time, operator, nerve sparing, extravasation of urine, marginal status, the year of operation, and the method of ureterovesical anastomosis were evaluated using univariate and multivariate analysis. The BNC rate was increased in patients with longer (more than 4 hrs) operations and excessive bleeding (more than 1,000 ml) (p=0.0027, respectively). The year of operation (before 1998, p=0.0015), the method of ureterovesical anastomosis (p=0.0017), operator experience (less than 5 cases, p=0.0056), and neoadjuvant treatment (p=0.09) were also risk factors. In multivariate analysis, the year of operation (p=0.03) and operator experience(p=0.04) were strong predictors of BNC. The skill levels of surgeons and institutes are expected to decrease BNC.

Urinary incontinence impairs the quality of life for patients following radical prostatectomy. We retrospectively reviewed the records of 36 patients who underwent radical retropubic prostatectomy between 1987 and 2002, and achieved the time from operation until urinary continence. A modification in the technique of apical dissection was introduced in 1999 and applied in 12 cases of consecutive radical prostatectomy. The principles for this technique were based on sharp division of the dorsal vein complex, continuous suturing cut edges of lateral pelvic fascia, and anterior anastomotic sutures including lateral pelvic fascia as well as urethra and bladder neck. None of the patients undergoing the new technique used pads at 6 months. With introduction of this technique, the rate of continence at 12 months increased from 58.3 to 100.0%. Our results suggest that the surgical technique of apical dissection is an important factor associated with postprostatectomy in continence.

We report a case of intractable lymphedema of the left leg following radical prostatectomy. The 69-year-old male patient complained of difficulty walking, caused by severe lymphedema. Intraarterial autologous lymphocyte transfusion therapy was performed because of failure of conventional conservative therapy, and the leg edema resolved almost completely. However, the treatment did not improve the penoscrotal edema necessitating excision of the edema and skin graft in a separate procedure. The post-operative course was excellent and the patient's performance status improved to 1 from 3.

We herein present a report of metastatic liver tumor arising from prostate cancer following transurethral resection of the prostate (TUR) in two patients. The two patients were diagnosed as having moderately differentiated prostate adenocarcinoma, either stage C or B2, and underwent hormonal and/or radiation therapy. TUR was performed due to the patients' complaints of urinary outlet obstruction. Liver metastasis, without evidence of bone or pulmonary metastasis, was then noted 23 and 5 months later in the patients with stage C and B2 prostate cancer, respectively. It is possible that the process of TUR is related to the release of tumor cells from the prostate into the systemic circulation and involved in the development of liver metastasis.

A retrospective study was conducted on the duration of pyuria after transurethral resection of the prostate (TURP) and the factors affecting the duration in 273 patients, who were diagnosed as having benign prostatic hyperplasia (BPH) with postoperative resolution of pyuria among those who underwent TURP over the last ten years at our clinic. In the 273 patients, the mean (+/- SD) weight of the resected prostate was 13.2 +/- 10.2 g (range : 1-52 g), the mean operating time was 74.3 +/- 29.8 min (25-215 min), the duration of pyuria was 110.6 +/- 38.3 days (23-273 days), and the resected weight to operating time ratio was 0.172 +/- 0.093 g/min (0.018-0.500 g/min). There was a significant correlation between the duration of pyuria and the patient's age, resected weight, operating time, or resected weight/operating time ratio, resected weight being the most important factor. The surgeon, the postoperative antibiotics used, and the preoperative existence of pyuria did not have any significant effect on the duration of postoperative pyuria. Investigation after stratification by the resected weight in 10 g increments suggested that a shorter operating time was important to reduce the duration of postoperative pyuria, particularly in BPH patients with a resected weight of 20-29 g.

The hot water spray on perineum restored voiding function in a 77-year-old male patient with the poorly contractile bladder. He noticed the gradual decrease of bladder sensation and voiding stream, and needed clean intermittent catheterization to empty bladder even after TUR-P. Neurological examination revealed only weakened anal and bulbocavernosus reflex and impaired skin sensation of foot plate and perineum. Simple cystometry showed impaired perception of bladder filling and underactive bladder. Electromyography of the pelvic floor displayed decreased responses to bladder filling and voluntary sphincter contraction. Spine-X-ray examination and computed tomography of brain and spinal cord did not reveal any neurological lesions except for the silent small infarction of subcortex. Trial of drug therapy with Distigmine bromide, Cernilton and Prazosin did not restore voiding function. By accident, however, patient himself found spontaneous voiding could be induced by hot water spray on perineum and/or scrotum during bidet using. Since then, he has been continuing this stimulation daily for 4 years, with which almost complete voiding is possible without catheterization, though bladder sensation remains impaired. The pathophysiology and affecting factors on micturition reflex in this case were discussed.

We report on two cases of aspiration pneumonia which developed during the endotracheal intubation after bladder perforation during TUR. The first case was a 79 y.o. male, who underwent TUR-P and lithotripsy under spinal and epidural anesthesia. The second case was a 69 y.o. male, who had undergone TUR-Bt under nitrous oxide-oxygen-enflurane anesthesia. General anesthesia was selected to perform an laparotomy when the diagnosis was made. They vomited a considerable amount of gastric content just after giving the drugs for induction. The chest X-rays revealed signs of aspiration pneumonia. These X-ray findings improved in a week using antibiotic therapy. Although TUR is performed as scheduled, vomiting may occur in the case of unexpected bladder perforation, which can cause aspiration pneumonia. In such emergency, we should insert a nasal tube before induction, press the cricoid (crush induction), or intubate with the patient awake.

Thirty four patients undergoing transurethral resection of the prostate (TURP) under spinal anesthesia were assigned to a TUR syndrome (TURS) group (n = 7) or an asymptomatic (ASP) group (n = 27) depending on the clinical manifestations of the TUR syndrome. Blood loss and distribution of absorbed irrigating fluid (3% sorbitol-Uromatic S, 170 mOsm.kgH2O-1, Baxter) were computed together with serum osmolality, blood urea nitrogen and hematocrit. Postoperative serum sodium concentration and hematocrit were significantly lower in the TURS group than in the ASP group (124 +/- 8.7 vs. 133.9 +/- 5.9 mOsm.l-1 and 26. 8 +/- 4.2 vs. 35.0 +/- 4.6%, respectively). Postoperative serum osmotic pressure did not differ between the groups despite the difference in sodium concentration because 3% sorbitol could contribute to osmoles in the serum. The volume of irrigating fluid absorbed and its distribution into the intracellular space (delta ICF) did not differ between the groups. However, blood loss was significantly greater in the TURS group than in the ASP group (1457 +/- 434 ml vs. 173 +/- 450 ml, P < 0.01), and consequently extracellular fluid (ECF) volume was significantly reduced in the TURS group (-354 +/- 1201 ml vs. 802 +/- 1302 ml, P < 0.05). Thus, massive blood loss and reduced ECFs rather than dilutional hyponatremia, are thought to contribute to clinical manifestation of the TUR syndrome.

A 77-year-old man had been suffering from stress urinary incontinence for 2 years since he had received transurethral resection of prostate (TUR-P) for benign prostatic hypertrophy. A 60-min pad test yielded 3 g of urine. Prostatic urethra was widely open and the external sphincteric injury was suggested because of the short membraneous urethra on the urethrogram. Urethral pressure profile indicated his maximal urethral closing pressure (MUCP) of 24 cmH2O and functional urethral length of 1.6 cm and cystometry demonstrated an underactive bladder, indicating that his incontinence was caused by sphincteric injury. Autologous fat injection therapy was performed in the lithotomy position under spinal anesthesia. Fifteen ml of subcutaneous fat was obtained from his lower abdomen by liposuction through a 15G needle, and 10 ml was injected submucosally from the perineum at 6 o'clock area of the prostatic apex under the guidance of transrectal echography using a 15G needle. The patient became completely dry after the procedure. MUCP and FUL increased to 35 cmH2O and 1.9 cm, respectively, although longer follow up is necessary. The advantage of autologous fat injection to the prostate for post-TUR-P SUI patients is briefly discussed.

A 73-year-old man presented to our hospital complaining of dysuria and nocturia. The examination revealed prostatic cancer. Metastatic cancer was not revealed by the examination. He underwent total prostatectomy and iliac lymphadenectomy. Pathological examination of the surgical specimen revealed moderately differentiated adenocarcinoma of the prostate with right iliac lymph node metastasis. On the 33rd postoperative day, he suddenly developed chest pain, dyspnea, tachycardia, and tachypnea. Arterial PO2 was 62 mmHg, and chest X-ray showed right ventricular hypertrophy. Pulmonary perfusion scan revealed multiple cold areas throughout both lung fields. The diagnosis was pulmonary embolism and anti-coagulant therapy was immediately successful in resolving his symptoms. We suggest that pulmonary embolism should be considered as one of the postoperative complications of urological operations.

Urinary incontinence following total prostatectomy was evaluated in 10 patients by urodynamics and lateral urethrography. The pathological stage of the tumors in these patients was pT2 in 5 patients, pT3 in 3 patients and pT4 in 2 patients. Urinary incontinence was present in 8 patients, of whom 7 were stress incontinence and one was urge and stress incontinence. The severity of incontinence of these patients was mild in 5 patients, moderate in 3 and severe in 2. The incontinence was severer in the patients with the tumors of pT3 or pT4 than in the patients with the tumors of pT2. But the severity of incontinence was not related to the pathological grade or resected weight of the tumors. The bladder capacity and bladder compliance were 214.9 ml and 14.3 ml/cmH2O in average, respectively, and was not related to severity of incontinence. The statistical significant differences between continence or mild incontinence patients and moderate or severe incontinence patients were found for the mean functional profile length (2.04 versus 1.37 cm, respectively; p < 0.05) and maximum urethral closure pressure (42.3 versus 17.3 cmH2O, respectively; p < 0.05). But some patients with continence or mild incontinence demonstrated low values in either parameters. No statistical difference was found between continence and mild incontinence patients. On lateral urethrography, the posterior urethrovesical angle was not correlated with the severity of incontinence.

Pre-operative and operative complications in 2266 patients having undergone transurethral resection of prostate (TURP) for the past 20 years at Kitasato University Hospital were analyzed. They consisted of 2008 benign prostatic hyperplasia and 258 prostate cancer patients. Seven hundred and fifty four patients showed some of physical disorders prior to TUR:hypertension in 147 cases, diabetes mallitus in 87, ischemic heart disease in 46, chronic obstructive lung disease in 41 and others. Operative and postoperative complications of TURP were seen in 308 cases (13.6%). Perforation of the prostatic capsule was seen in 100 cases (4.4%) and bladder perforation into intraperitoneal cavity in 6 cases (0.3%). Transurethral fulgulation for postoperative hemorrhage was conducted on 79 cases (3.5%). Hyponatremia lower than 130 mEq/L was noted in 14 cases (0.6%). Severe urinary tract infection leading to bacteremia was observed in 9 cases (0.4%). Postoperative epididymitis was evident in 20 cases (0.8%). There was postoperative urinary incontinence in 19 cases, 3 of which was treated with Teflon-paste injection successfully. One patient had to undergo AMS-800 artificial sphincter implantation. The number of postoperative urethral stricture patients requiring urethral dilatation or internal urethrotomy was 12 (0.5%) and postoperative bladder neck contracture was seen in 20 cases (0.9%). One patient (0.04%) who developed DIC after profuse postoperative hemorrhage died on the 37th postoperative day. The efficiency of TURP depends not so much on the skill of cutting as on the speed and accuracy of orientation and haemostasis. The quick recognition of anatomical landmarks will assure effective and safe resection.

Multifactorial analysis on 395 patients revealed important factors which prolong the pyuria after transurethral prostatectomy. They were the age of the patient, anemia and leukocytosis before surgery. These are factors which relate with the defense mechanism of the patient. Local factors, such as the duration of indwelling urethral catheter, the size of the prostate or prostatic bed and preoperative infection, were not so important for prolonging the pyuria after transurethral prostatectomy. The time of the resection and weight of the prostate had an intimate relation each other, and the former was the more important factor. The use of antimicrobials probably controlled these local risk factors, thus making them unimportant in the prolongation of the pyuria after transurethral prostatectomy.

Bladder neck stricture is a late complication of transurethral prostatectomy (TUR-P). Two patients with bladder neck stricture after TUR-P were treated by the balloon dilatation method. The procedure was performed with topical anesthesia using 2% viscous lidocaine applied liberally within the urethra. The dilating balloon catheter was inserted over a 0.035 in. (0.09 cm) floppy-tip guidewire and the balloon was inflated by normal saline. The balloon was placed at the level of the prostatic urethra above the external sphincter. The balloon pressure was then increased to 3 atm and maintained for 10 minutes. All maneuvers were conducted under guidance of transrectal longitudinal linear scanning to ensure proper positioning of the catheter. The 18 Fr pelvic catheter was passed over the guidewire into the bladder and the next day the catheter was removed. After the procedure, clinical and uroflowmetric improvements were seen in both cases. They continue to do well. Balloon dilatation can be performed on an outpatient basis and by using only topical anesthesia. Therefore, balloon dilatation seems to be a useful method for treatment of bladder neck stricture after TUR-P. However, it is not clear how dilatation brings about long-term relief of obstructive symptoms.

Retrograde transurethral balloon dilatation of urethral stenosis was performed in five patients: four patients with benign prostatic hypertrophy and one with urethral stricture following open prostatectomy. Significant resolution of symptoms of dysuria was seen in four patients throughout the follow-up period of 12 to 18 months. A balloon diameter of 25 mm was considered to be necessary for prostatic hypertrophy. The unsatisfactory result in one patient with prostatic hypertrophy was believed to be caused by incomplete dilation due to a small balloon diameter. Mild transient hematuria was seen in all cases. Only one patient with postoperative urethral stricture complained of pain during balloon inflation, while other patients with prostatic hypertrophy did not complain of any apparent pain. We conclude that this technique is a safe and effective method of treatment for prostatic hypertrophy and other urethral strictures.