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A 69-year-old man visited a local doctor for fever, pain in the left abdomen, and macroscopic hematuria. Computed tomography (CT) revealed hydronephrosis of the left kidney, and he was referred to our hospital. Detailed examinations suggested left-side pyonephrosis due to urothelial cancer, and left-side total nephroureterectomy was performed. Pathological diagnosis was sarcomatoid renal cell carcinoma. Sunitinib administration was started postoperatively for para-aortic lymph node metastasis, which disappeared. However, metastasis to the common iliac lymph node and liver appeared newly 11 months later. Nivolumab was started in combination with radiation thepapy for the lymph node metastases. The patient remains in a stable disease state as of 21 months after nivolumab administration.

Robotic-assisted surgery has been wide-spreading rapidly as a technique to develop laparoscopic surgery by innovative technological improvement such as high magnifided 3D-image and multi-degree freedom of forceps, leading to safety enhancement and better functional recovery. Robotic surgery in the urological field made it possible to highly fine operation in a narrow field, such as pelvic cavity or retroperitoneal space. Better outcomes were recognized especially in perioperative complications and postoperative QOL recovery than other procedures like open or laparoscopic. According to these results, radical prostatectomy, partial nephrectomy and radical cystectomy were approved for health insurance coverage in 2012, 2016 and 2018, respectively. Robotic-assistance has definitely brought a paradigm shift in urologic surgery. The application to more and more a variety of procedure and the improvement of treatment outcomes are expected in the future.

A 47-year-old woman who was diagnosed with right pyelonephritis by a local physician, but failed to respond to antimicrobial chemotherapy, was referred to our hospital. Here, the diagnosis of right pyonephrosis was confirmed byabdominal computed tomography(CT). Retrograde pyelography(RP) revealed a severe stricture at the ureteropelvic junction, and it was considered difficult to advance a guidewire through the stricture. Urine cytologywas pseudo-positive ; thus, the possibilityof a malignant tumor of the urinarytract could not be ruled out. Therefore, right nephroureterectomywas performed. The final, histopathological diagnosis was urothelial carcinoma, (G2, pT3). After surgery, the signs and symptoms of the infection were rapidlyameliorated ; however, swelling of the lymph-nodes between the aorta and vena cava was observed, which was considered to be metastasis. Therefore, 4 courses of gemcitabine ＋cisplatin therapywere administered, which resulted in complete resolution of the lymph-node swelling. The patient has remained free of recurrence for 2 years after surgery.

A 42-year-old female visited our hospital with the chief complaint of macrohematuria and left lateroabdominal pain. Computed tomography and retrograde pyelogram showed left hydronephroureter and obstructive uropathy which was 20 mm in diameter in the middle ureter. Urine cytology was negative. Ureter biopsy revealed amyloidosis. Our diagnosis was localized amyloidosis of the ureter, because amyloid was not found in other places in her whole body inspection. Partial ureterectomy was performed. Left renal function was preserved. The patient has been free of recurrence for 18 months after surgery.

Holmium laser enucleation of the prostate (HoLEP) has been established as a procedure for the treatment of patients with benign prostate hyperplasia, instead of transurethral resection of prostate (TURP). To determine the appropriate antimicrobial prophylaxis for the prevention of perioperative urinary tract infection following HoLEP we sent a questionnaire to 79 institutes belonging to the Japanese Urological Association. We surveyed 1) the performance of HoLEP, 2) number of HoLEP performed in 2009, 3) antimicrobial agents and the term of the administration for prophylaxis, 4) rate of perioperative infections, and 5) usage of other antimicrobial prophylaxis in HoLEP, as compared with in TUR-P. We received answers from 59 institutes (74. 9%). We examined 43 responses, which were obtained from executive members who performed more than eleven cases of HoLEP in 2009. Thirty-one of these institutes (72.1%) indicated parenteral antibiotics ; three of them adopted oral antibiotics, and nine of them added oral antibiotics following parenteral antibiotics. In 40 of them (93.0%), the rate of perioperative infections was reported to be fewer than 5%. Twenty-seven of them (62. 7%) adopted the same schedule for the prophylaxis in both HoLEP and TUR-P. Eleven of them indicated shorter antimicrobial usage in HoLEP than in TUR-P. Ten of the eleven institutes reported that the rate of perioperative infections in HoLEP had been lower than in TUR-P. Our questionnaire survey demonstrated that shorter antimicrobial prophylaxis might be possible in HoLEP than in TUR-P.

Objectives: For the management of patients with small renal tumor, laparoscopic partial nephrectomy (LPN) provides similar oncological control as radical nephrectomy (RN) and is superior to RN with respect to preserving renal function and preventing chronic kidney disease (CKD). The challenge of LPN is to resect a tumor in a bloodless field within a limited warm ischemia time (WIT) , followed by hemostatic renorrhaphy under restricted movement of laparoscopic forceps. Therefore, LPN still remains challenging to even experienced laparoscopic surgeon. DaVinci device improved the movability of forceps in LPN and provided three-dimensional visualization. We evaluated outcome and safety of our first series of robot-assisted laparoscopic partial nephrectomy (RALPN) for localized kidney tumor. There was no previous report of RALPN undertaken in our country., Patients and Methods: Since August 2010, our team carried out RALPN for a total of five cases of renal tumor. There were four males and one female with an age range of 41 to 65 years-old. Size of tumor ranged from 15 to 28 mm, located in exophytic region, and four cases in right side and one in left. RALPN was undertaken by single surgeon through transperitoneal approach in two cases and retroperitoneal in tree., Results: RALPN was completed in all patients without conversion to open or hand-assisted surgery. The median operative time and the estimated blood loss were 189 minutes, ranged from 150 to 264, and 29 ml, from 10 to 50, respectively. The median volume of removed tumor and the length of WIT were 7 g, ranged from 4 to 13 g, and 18 minutes, from 13 to 26 minutes, respectively. No complications or reoperations were associated during or post our RALPN cases. Pathological examination of removed tumor showed renal cell carcinoma with negative surgical margin in all cases., Conclusions: Introduction of daVinci device to LPN made this procedure, RALPN, a secured and promising one, which leading to shorten the WIT and to achieve satisfied renorrhaphy. Even for the complex and technically challenging renal tumors, robotic assistance is expected to provide patients the benefit of minimally invasive surgery with safety and satisfactory renal function.

Zoledronic acid is reported to significantly reduce skeletal morbidity and prolong time to bone lesion progression in patients with bone metastases from various malignant tumors including renal cell carcinoma. Due to renal uptake and elimination of zoledronic acid, however, it is difficult to control dose alignment in patients with kidney dysfunction. We reviewed significance of hemodialysis and monitoring of serum creatinine and calcium in patients with ESRD. (Cases) We experienced two cases of end-stage renal disease (ESRD) with bone metastases from advanced renal cell carcinoma. Zoledronic acid was given to both patients by 15 minutes intravenous infusion followed by hemodialysis 24 hours later. Systemic cytokine infusion and oral thalidomide were also given to both patients. Level of serum calcium reduced in one case two weeks later, and treated by calcium administration. No other adverse effects were noted for more than six months of combination therapy. Both cases maintained stable disease not only for bone metastases but also for the systemic condition without any organ failure. Even in patients under maintenance hemodialysis, zoledronic acid can be given with certain safety and efficacy by hemodialysis 24 hours after administration and intense monitoring of serum calcium level. We think this is the first report of zoledronic acid treatment to ESRD patients with bone metastases from malignant tumors.

We examined the effectiveness of supplemental administration of flavoxate hydrochloride in patients with benign prostatic hyperplasia (BPH) whose nocturia was not adequately relieved by an alpha1-adrenoceptor blocker. Fifty-two patients who had two or more nocturnal micturition after administration of tamsulosin hydrochloride or naftopidil for 4 weeks or more received 400-600 mg of flavoxate hydrochloride in addition to an alpha1-adrenoceptor blocker for another 8-12 weeks. With supplemental administration of flavoxate hydrochloride, significant improvement was observed in the number of nocturnal micturition, total International Prostate Sympton Score, quality of life score and BPH impact index. No significant change was observed in the voided volume, Qmax, voiding time and residual urine volume. Supplemental administration of flavoxate hydrochloride is therefore effective for the improvement of nocturia and QOL in BPH patients resistant to an alpha1-adrenoceptor blocker.

Stress urinary incontinence (SUI) is a major urologic health problem and the number of patients with SUI will rise dramatically as the population of elderly people continues to increase in Japan. This condition causes unnecessary and detrimental psychological distress, social isolation, and public expense for care. Surgery remains the cornerstone of treatment for female SUI and also in those who have failed to improve with conservative measures. Many surgical procedures, however, have been described with varying degree of success. The ideal surgical treatment for this disease should be effective in QOL improvement, minimal invasive and durable for the long-term. Based on a new understanding of the pathophysiology of SUI as well as the development of surgical techniques and devices, mid urethral sling operations such as TVT (tension-free vaginal tape) have become widely used and they provide significant short-term and long-term cure rates. However, perioperative complications, including serious problems like bowel, vascular and bladder injuries have been reported. Most complications are related to blind trocar passage in the retropubic space. The alternative procedure transobturator procedure was developed to minimize these complications, in which tape is introduced through the obturator foramen. This technique provides high short-term cure rates, similar to those achieved with TVT, but with fewer complications. A number of injectables have been used for the treatment of SUI, including collagen, coated-beeds and Teflon. Although injectable treatment is convenient and minimally invasive, efficacy and durability are lower than other surgical procedures. Modification by tissue-engineering techniques using autologous stem cells or precursors of mature cells showed regeneration and reconstitution of urinary sphincteric function. In the future this strategy may be an attractive therapy for SUI. The choice of operation should be tailored to suit each individual case based on the clinical and urodynamic findings, as well as the age and the expectations of treatment outcome.

We performed an investigative and clinical study of docetaxel, and evaluated its efficacy against hormone-refractory prostate carcinoma (HRPC). In an in vitro experiment, docetaxel suppressed the human prostate cell line proliferation not only in an androgen-dependent cell line, LNCaP, but also in androgen-independent cell line, PC-3, in a dose-dependent manner. In an in vivo experiment applying an SCID mouse xenograft model with PC-3, docetaxel administration suppressed the tumor growth more than 95%. In a clinical study, eight cases were enrolled to low-dose (20 mg/m2/wk) weekly regimen and an other eight to high-dose (60 mg/m2/wk) administration of docetaxel every three weeks. A prostate specific antigen (PSA) decline of more than 50% were observed in 4 (50%) in the low-dose group and 5 (63%) in the high-dose group. The median time to progression and overall survival were 8.5 and 13.2 months in the low-dose group and more than 5.5 and 8.5 months in the high-dose one, respectively. This regimen was well tolerated, and the incidence of adverse effect was relatively low and light. Grade 3 neutropenia or leukocytopenia without fever was seen in three patients (18.8%). Only one patient required administration of granulocyte-colony stimulating factor because of neutropenia. No other grade 3 or 4 toxicity was observed. In conclusion, docetaxel-based chemotherapy was well tolerated and an active treatment for HRPC cases.

Post transplant infection is one of the serious complications of the organ recipients. We detected the donor infections and allograft contaminations in a limited period of time by polymerase chain reaction (PCR) and rapid shaking culture (RSC). The pre-procurement blood from 86 possible renal donors as well as the preservation solution (PS) and renal pelvic urine (PU) from 158 grafts were examined in order to detect highly virulent organisms such as methicillin resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and fungi. The average age of donors was 48.8 years old. The average period between the admission and brain death was 4.9 days, and the average period between the brain death and cardiac arrest was 3.6 days. The inflammatory indices such as body temperature, white blood cell count and C-reactive protein increased to 37.9 +/- 1.1 degree C, 12,600 +/- 6300/microl, and 20.2 +/- 11.6 mg/dl, respectively. Following PCR and RSC, procurement operations of the three possible donors were cancelled because of systemic bacterial infections by MRSA or Bacteroides fragilis. Six out of 158 grafts were discarded due to the diagnoses of MRSA or Candida albicans in PS and/or PU. All the other 148 grafts were transplanted. Following transplant, no single infectious complication transmitted by the graft was noted. We conclude that PCR combined with RSC is very accurate and useful for detecting donor infections and allograft contaminations, which may cause severe complications in the recipients.

Objective: To determine the extent of drug-resistance among Enterococcus species we investigated in vitro experiments., Methods: Studies were carried out on pure cultured of enterococci isolated from 8,575 urine specimens between 1990 and 2002. We had determined test strains to three kinds of species, which posses the urinary pathogenesis. Both an EF-agars and an ADH decarboxylase test performed the identification and speciation of the strains of enterococci. In vitro drug-susceptibility tests of enterococci were performed against the following antibiotics: ampicillin (ABPC), cefpirome (CPR), cefozopran (CZOP), imipenem/cilastatin (IPM/CS), minocycline (MINO), levofloxacin (LVFX), vancomycin (VCM), sulfamethoxazone/trimethoprim (ST), by employing the method for dilution antimicrobial susceptibility tests for bacteria that grow aerobically recommended by Japan Society of Chemotherapy. These drug-susceptibilities were shown susceptible, intermittent and resistant in according to National Committee for Clinical Laboratory Standards (M100-S12)., Results: The most common species isolated was E. faecalis (84.4%), followed by E. faecium (9.9%) and E. avium (5.6%). In E. faecium and E. avium, the sensitivity to ABPC has tended to improve from 1999. This tendency inverse correlated to decreasing dosage of PCs. There was much difference of resistant rate to IPM/CS between each species, and no correlation to used dosage of CBPs. The rate of resistance to MINO did not change during this period. 60% of E. faecalis had sensitivity to LVFX and the rate did not change during this period. In E. faecium, whose resistant rate to LVFX was 90%, the sensitivity has been improved to over 25% from 2001. The improved tendency of E. faecium to LVFX has inverse proportion to decreasing dosage of NQs. With the exception of a little bit VRE (VCM resistant Enterococci), almost of them had sensitivity to VCM., Conclusion: The emergence of enterococci with alarming rates of resistance concomitantly to multi-drugs highlights the need for a more rational and restricted use of antimicrobials, in order to minimize the selection and spread of such strains. An early detection of these problem pathogens is also important for preventing any treatment failures.

Although the precise mechanisms are unclear, not only alloantigen-dependent but also antigen-independent factors are generally thought to influence the development of chronic allograft nephropathy (CAN). Among the non-immunological determinants, there are various factors related with donor, recipient and graft procurement. As donor factors, age and cause of death were demonstrated to be significantly independent in long-term graft survival of cadaveric kidney transplantation. Grafts from aged donors and from donors with athelosclerosis showed poor prognosis on graft survival. Regarding recipient factors, cardiovascular complications, as hypertension and hyperlipidemia, were responsible for graft as well as patient survival. In addition, CMV infection and drug nephrotoxicity were also shown to affect graft survival. For procurement factors, warm ischemia was determined to possess the strongest impact on long-term graft survival in our series of kidney transplant using grafts from non-heart beating donors (NHBDs). Delayed graft function, which correlated well with length of warm ischemia, also influenced long-term graft survival. These results proved that the supply of viable donor nephrons and the physiologic demands of the recipient are important determinants of long-term graft survival. So far there seems to be neither definitive nor specific treatment for CAN. It is basically essential to avoid graft damage before transplant and keep recipients from risk factors after transplant as much as possible. To improve long-term graft survival in cadaveric kidney transplantation, recipient selection is greatly important in terms of not only immunological compatibility but also body to nephron mass imbalance and ischemic time, which might cause fatal damage to grafts before engraftment.

Diagnosis of acute rejection (AR) is difficult during acute tubular necrosis (ATN), and a delay of rejection treatment could result in negative impacts on the renal transplant outcome. At our center, 68 cadaveric kidneys were transplanted during the past 7 years. The 1-, 3- and 5-year graft survival rates were 95.4%, 93.8% and 81.4%, respectively. After the transplants, 16 patients had immediate graft function (G-I), 51 patients experienced ATN for 12.0 +/- 9.3 days, and one patient had a non-functioning graft due to diffuse arteriolar thrombosis caused by DIC in the donor. During ATN, 41 patients had no rejection episodes (G-II) and 10 patients had ARs (G-III). Nine patients were treated with bolus steroid and one with steroid and OKT-3. Although scintigraphic and sonographic examinations were routinely employed, only the histopathological findings of needle biopsies were helpful for the diagnosis of AR during ATN. When the transplant outcome was compared, the serum creatinene level was highest in G-III and lowest in G-I (1.48 vs 1.06 mg/dl, p < 0.05). The posttransplant ATN period was also longer in G-III compared to G-II (23.9 vs 9.1 days, p < 0.005). The 5-year graft survival rate was 85.2% in G-I, 88.0% in G-II and 59.3% in G-III. We conclude that routine serial renal biopsies should be scheduled when ATN develops after the cadaveric renal transplant, since only the histopathological diagnosis is reliable during ATN.

A 31-year-old man came to our hospital complaining of severe voiding pain. He had inserted a fishing line made of nylon into his urethra at the age of eighteen, which was unable to be taken out and had been left there for 13 years. Preoperative ultrasonogram showed severe bilateral hydronephrosis and the serum BUN and creatinine level were as high as 45.2 mg/dl and 4.8 mg/dl, respectively. A huge bladder stone was demonstrated in X-ray film, the patient was admitted and vesicolithotomy was performed. The size of the stone was 10.5 x 7.5 x 7.5 cm and the weight was 360 grams. The fishing line was found inside the stone and the length was over 3 meters. The serum BUN and creatinine level after the operation were still high as 28.4 mg/dl and 4.1 mg/dl, respectively, and they did not improve even after six months following.

Vasopressin, a hormone secreted from the posterior lobe of the hypophysis, has endocrinological and antidiuretic effects; it contracts vessels and smooth muscles, especially intestinal smooth muscle. In the present study, we investigated the role of vasopressin (Pitressin: arginine-vasopressin) in elimination of intestinal gas on excretory urography reading. Sixty outpatients were randomly divided into six groups. In Group I, the routine procedure was employed, i.e. laxatives the previous night and NPO the morning of the examination. In Groups II to VI, different dose regimens were employed: 6 or 10 units of Pitressin was administered by subcutaneous injection 30 minutes prior to injection of a contrast medium, with or without NPO. Intestinal gas elimination was evaluated by X-ray films taken before and after injection of Pitressin. The efficacy was rated by four grades. There were no significant differences in the gas elimination or occurrence of side effects between any two groups. Younger patients seemed to respond quickly to Pitressin and good effects were obtained. These results indicate that the pretreatment for excretory urography with 6 units of Pitressin without NPO may be a safe and effective alternative method for elimination of intestinal gas, in particular for young patients.