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A 58-year-old man with a chief complaint of exertional dyspnea was admitted to our hospital. One year earlier, he had visited another hospital for the evaluation of gross hematuria, and had undergone right nephro-ureterectomy with a diagnosis of right renal pelvic cancer. Blood chemistry revealed an elevated level of carcinoembryogenic antigen (CEA) (134.5 ng/ml). Computed tomographic scans showed multiple metastases to the liver and sternum. No primary lesion was detected, and immuno-histochemical findings of the specimen were CEA-positive. Thus, we diagnosed this case as CEA-producing renal pelvic cancer. Chemotherapy was ineffective. The patient committed suicide 10 months after admission., 58歳男。肉眼的血尿の増悪を自覚し、近医で右腎盂癌、膀胱癌と診断され、膀胱腫瘍切除、右腎尿管全摘除術を受けた。その後、膀胱内再発に対して2度腫瘍切除術を受けた。肝転移等も認められたが、受診を自己中断していた。労作時呼吸困難を主訴に救急外来を受診し、僧帽弁閉鎖不全症と診断され入院した。その際のCTで、胸骨転移、多発性肝転移、多発性腰椎転移、大動静脈間および傍大動脈リンパ節転移が認められた。CEAの異常高値を認め、当初他臓器癌との重複癌を疑い、上部、下部消化管、甲状腺に対して検査を行ったが異常を認めなかった。そこで、CEA産生尿路上皮癌を疑ってCEA染色を行った結果、腫瘍部分に一致して陽性を示した。CEA産生腎盂尿路上皮癌の術後多臓器転移と診断し、MEC化学療法を開始した。MEC化学療法は無効であったが、GT化学療法に変更したところ一時的に反応を示した。疼痛はコントロールされ、発熱、著明な食欲不振等は認めていなかったが、入院10ヵ月目に自殺した。

症例1は49歳女性で, 腹部超音波検査にて膀胱後壁に接する嚢胞様腫瘤を指摘され, 紹介来院した.排尿後の静脈性腎盂造影の立位像で膀胱下方に造影剤の貯留を認め, 逆行性膀胱尿管造影で尿道周囲に5×5×7.5cmの造影剤の貯留を認めた.MRIでは尿道全周を取り囲むように腫瘤が存在していた.以上の所見から尿道憩室と診断し, 経腟的尿道憩室摘除術および憩室口閉鎖術を施行した.病理組織学的所見では壁は炎症性肉芽組織が大半を占め内面は一部移行上皮で被われていた.症例2は36歳女性で, 第2子の妊娠5ヵ月頃より会陰部痛を認め, 産婦人科にて腟前壁の腫瘤を指摘され, 出産後に紹介来診した.腹部超音波検査で尿道を全周性に取り巻く多房性嚢胞を認め, 排尿時膀胱尿道造影で尿道周囲に3×3×4cmの造影剤貯留が認められた.CT・MRI所見で尿道全周を取り囲んだ憩室が認められ, 症例1と同様の手術を施行した.病理組織学的所見は炎症性肉芽組織を認めるのみであった, We report two cases of female urethral diverticula. A 49-year-old woman (case 1) complained of perineal pain when she voided urine. A 36-year-old woman (case 2) complained of perineal pain. In both cases, intravenous pyerography and urethrography revealed diverticula around their urethra, and we diagnosed them with urethral diverticula which surrounded their urethra by magnetic resonance imaging. We treated them by transvaginal diverticulectomy. Case 2 was successfully treated, but the diverticulum recurred after one year in case 1. There are over 200 reported cases of female diverticula in the Japanese literature, but a urethral diverticulum surrounding the urethra is rare.

急性単純性膀胱炎の女性56名を無作為に2群にわけ, レボフロキサシンの単回投与と3日間投与の臨床効果を比較した.200mg単回投与32例と, 200mg分2・3日間投与24例の間で, 有効性, 安全性, 再発防止効果に有意差を認めなかった.ただし単回投与では有意差を認めないものの, 再発がやや多かった, To investigate the safety, efficacy and recurrence-inhibiting effect of a single dose of levofloxacin (LVFX) for the treatment of acute uncomplicated cystitis in women, 56 females with acute uncomplicated cystitis between 17 and 73 years old were studied, based on the urinary tract infection (UTI) drug efficacy evaluation. The patients were divided into two groups; in Group A a single 200 mg dose of LVFX was administered, while in Group B, 100 mg of LVFX was administered twice a day for three days. The patients were re-examined three days later. The presence or absence of recurrence was surveyed by a questionnaire 3 months after the treatment. The efficacy rate on the third day after the administration in Group A and Group B was 96.9% (32 cases) and 95.8% (24 cases), respectively, and the recurrence rate within three months after administration 17.4% (4 in 23 cases) and 5.6% (1 in 18 cases), respectively. As for adverse drug reaction, abdominal pain was seen in one case, without a clear cause-effect relationship. Although the number of cases studied was small, no significant difference was seen between the single dose group and 3-day dose group in the safety, efficacy and recurrence-inhibiting effect of the new quinolone antibacterial treatment for acute uncomplicated cystitis in women, confirming the usefulness of the single dose treatment.

膀胱癌8例に動注併用M-VAC化学療法を施行し, CDDP動注時に内腸骨静脈内及び末梢静脈内Pt濃度を測定した. 1)内腸骨静脈内総Pt濃度は, 15.13±10.13(μg/ml), Free Pt濃度は, 8.08±7.98(μg/ml).この時末梢静脈Pt濃度は総4.11±1.72, Free Pt2.00±1.59(μg/ml). 2)動注時の局所静脈内薬剤濃度は, 末梢静脈薬剤濃度の約4倍. 3)動注時も末梢血薬剤濃度は静脈投与時と同等に認められ, このため, 動注併用M-VAC化学療法時も副作用は静脈投与時と同等に発現する, We evaluated the usefulness of internal iliac artery infusion of cisplatin (CDDP) in the M-VAC therapy for bladder cancer. CDDP (average 72 mg) was administered into the internal iliac artery with an infusion time of 15 minutes in 8 cases of bladder cancers. After the end of CDDP intra-arterial injection, we measured the total and free platinum (Pt) levels in the internal iliac venous blood and systemic venous blood. Both total and free platinum levels in the internal iliac venous blood were about 4 times higher than those in the systemic vein. No significant difference was found in total or free platinum level in the systemic blood between the intra-arterial and intra-venous infusion methods. Intra-arterial CDDP therapy is effective in the treatment of the local tumor and systemic micrometastasis.

48歳男。患者は右腎腫瘤を主訴とした。KUBでネフログラムの長軸が下方で交叉している馬蹄鉄腎に特徴的な所見が認められた。腹部エコーでは右腎下極に約4cm大のSOLを認め, ドップラーエコーでは血流豊富であり, 内部に隔壁がみられた。更にMDCTでは右腎動脈は4本認め, どれも大動脈から直接分岐していた。だが, 峡部への流入動脈ははっきりせず, 右腎静脈は2本であった。以上より, 本症例は馬蹄鉄腎に合併した右腎細胞癌と診断され, 経腹的に峡部離断術, 右半腎摘除術が施行された。その際, 峡部離断にはLigaSureを用い, ほぼ無血的に処理でき, 複数の腎血管の処理が行われた。病理組織学的所見ではclear cell carcinoma, pT3a, INFα, v-, G1>G2であり, 術後約7ヵ月現在, 再発および転移は認められていない。, We report a case of renal cell carcinoma in a horseshoe kidney in a 48-year-old man. A medical checkup revealed a renal tumor in the right kidney. Computed tomographic scan (CT) showed a renal tumor measuring about 4 cm in diameter on the right side of a horseshoe kidney. Right heminephrectomy was performed for renal cell carcinoma. Pathologic examination revealed renal cell carcinoma, clear cell subtype, G1>G2, INF alpha, pT3a, V (-). In addition to our case, we review 66 cases of renal cell carcinoma occurring in a horseshoe kidney which have been reported in Japanese publications; our case is the 67th.

64歳男。患者は胃潰瘍の加療中に超音波で骨盤内腫瘍が指摘され, 著者らの泌尿器科へ転科となった。骨盤部CTでは右骨盤内直腸右側に境界明瞭, 内部均一な充実性腫瘤が認められ, 淡い造影効果を示していた。しかし, 早期濃染は認められなかった。後腹膜神経原性腫瘍を疑い, 右骨盤腔内の腫瘍に対して経直腸内生検を施行したところ, 病理診断ではneurofiblomaであり, 腫瘍摘出術が施行された。その結果, 周囲への浸潤はなく, 本症例は神経線維症I型に合併したlow grade後腹膜悪性神経鞘腫瘍と診断された。術後は左閉鎖神経領域の軽度の知覚異常を認めるものの, 歩行障害などは認められていない。, A 64-year-old man who was diagnosed with type I neurofibromatosis was referred to our hospital with a pelvic mass incidentally found by ultrasonography. When examined by CT and MRI, the mass in the pelvis was 5 x 3 x 2 cm. In addition, another mass was found close to the obturator nerve at the S1-2 level. Transrectal biopsy was carried out, and a diagnosis of neurofibroma suspicious for low grade malignancy was made. We performed surgical resection of both of the tumors. The resected tumor was pathologically diagnosed as retroperitoneal malignant peripheral nerve sheath tumor (MPNST). We report our case and review the literature of MPNST detected in type I neurofibromatosis.

WBC, Hbのnadirの値やnadirまでの期間に差はなく, 腎機能, 食欲不振の期間においても差は認めなかった.血小板のnadirの平均値は全身投与の方が低かったが, nadirになるまでの期間は動注投与の方が早かった.動注特有の副作用として, 局所の皮膚障害や, 神経障害が認められた, We retrospectively studied the toxic effects in 14 patients with urothelial cancer who had undergone intra-arterial M-VAC chemotherapy (Group A) and 13 patients who had received intravenous M-VAC chemotherapy (Group V) between February 1991 and August 1995. No statistically significant differences were found in the white blood cell count nadir, liver function, renal function or appetite between the groups. While the platelet count nadir for intra-arterial infusion (14.0 x 10(4)/mm3) was larger than for intravenous infusion (9.0 x 10(4)), the median days to nadir for this count was shorter in the intra-arterial group (9.1 days) than in the intravenous group (13.5). In addition, the difference between the beginning hemoglobin level and the nadir level was larger in the intra-arterial infusion group (2.55 g/dl) than in the intravenous infusion group (1.95 g/dl). Additionally peculiar side effects were noted in the intra-arterial infusion group which included local erythema and nerve paralysis. Side effects should be managed for intra-arterial M-VAC as well as for intravenous infusion.

関西医科大学附属病院泌尿器科における1975年1月～1994年12月の入院・手術統計では, 尿路結石症例は, 体外衝撃波療法の出現が大きく影響している.悪性腫瘍は, 尿路上皮癌・腎癌の著しい増加が認められた.開放手術と内視鏡手術の対比上で件数の逆転がみられ, 各術式の変遷もみられた, The patients, diseases and operations experienced between 1975 and 1994 in our department were statistically analyzed. The numbers of in-patients and operations have been increasing since 1977. During these 20 years, endoscopic surgery has replaced many open surgical procedures. The introduction of extracorporeal shock wave lithotripsy has dramatically changed the therapeutic modality for urolithiasis, and decreased of the necessity of open surgery.

前立腺肥大症60例に対しPorges社製尿道スパイラルステントの留置を試みた。1) 57例に留置可能で40例は3ヵ月以上の継続留置が可能であった。2)留置3ヵ月目の自覚症状スコアの改善度は, 尿閉群81.2%, 排尿困難群70.4%で, 特に閉塞症状の改善が良好であった。自覚症状において, 尿閉群41人中29人(70.7%), 排尿困難群13人中6人(46.2%)に有効性を認めた。3)他覚所見は, 尿閉群41人中22人(53.7%), 排尿困難群13人中4人(30.8%)に有効性を認めた。4)合併症は, 尿失禁, 排尿痛などが多く, 4症例に移動を認めた。5)神経因性膀胱合併の4例を除く評価可能50例のうち28例(56.0%)が, 尿道ステント有効と考えられた, The Porges Urospiral, a urethral spiral stent made of stainless steel wire, is designed for patients with benign prostatic hypertrophy. To evaluate the safety and efficacy of the stent, a prospective uncontrolled study was performed on 60 patients who complained of urinary retention (48 patients) or severe dysuria (12 patients) due to prostatic hypertrophy. Four patients had neurogenic disorders resulting in bladder dysfunction. The average age of the patients was 77.4 years old, ranging from 61 to 91 years old. In 48 patients, the stent was used instead of transurethral resection of the prostate (TUR-P) because of the patients poor general conditions, while in 12 patients the stent was transiently used until TUR-P. Subjective symptoms, according to an original scoring system, and objective signs, uroflowmetry measurements and residual urine volume, before and 3 months after stent insertion were compared. The stent was indwelt for more than 3 months in 40 of the 57 patients in whom the stent could be inserted. Out of 37 evaluable patients, subjective symptoms improved in all the patients and objective symptoms improved in 26 patients (70.3%). Complications included urinary incontinence, urination pain, urethral pain, gross hematuria or migration of the stent. Although these complications disappeared in a few days after the insertion of the stent in a majority of the patients, the stent was removed in 17 patients due to complications within 3 months after insertion. The overall clinical efficacy of this stent was 56% in 50 evaluable patients who had no neurogenic disorders.(ABSTRACT TRUNCATED AT 250 WORDS)

91例の泌尿器腹腔鏡下手術において, 9例で腹腔鏡操作に関連した合併症を経験した。そのうち重篤なものは4例であった。頻度の高い合併症は気腹操作と外套管穿刺に関連したもので, 他に術中術後出血があった, Laparoscopic surgery is often associated with complications which never occur in open conventional surgery. We investigated operative and postoperative complications in urological laparoscopic surgery. From February 1990 to November 1992, 91 laparoscopic operations were performed, including 62 varicocelectomies, 5 pelvic lymphadenectomies, 6 adrenalectomies, 5 simple nephrectomies, 2 radical nephrectomies, 1 staged Fowler-Stephens operation and 10 laparoscopies for cryptorchidism or other disorders. The patients ranged from 3 months to 77 years old. Nine (9.9%) of the 91 patients had complications associated with laparoscopic procedures and 4 (4.4%) of them had major complications. Pneumoextraperitoneum occurred in 3 patients. Two patients, who suffered from preperitoneal insufflation or pneumothorax associated with pneumomediastinum, failed to undergo laparoscopy. A small amount of scrotal emphysema developed in one patient, which subsided within 12 hours. Another patient, who underwent radical nephrectomy and para-aortic lymphadenectomy for left renal cell carcinoma, complained of symptoms due to persistent pneumoperitoneum and subcutaneous emphysema, which subsided 2 weeks after the operation. Respiratory acidosis caused by carbon dioxide absorption, which was difficult to be controlled, occurred in the other two patients; one was an adult male with reduced respiratory function and the other was a 1-year-and-8-month-old child. Bleeding during or after the procedure was another serious complication. Vena caval laceration occurred during right simple nephrectomy for pyonephrosis with renal calculi and was managed with laparotomy. Two patients, one after simple nephrectomy and the other after right adrenalectomy, suffered from postoperative bleeding about 300 ml through the penrose drain, which subsided following a bed rest.(ABSTRACT TRUNCATED AT 250 WORDS)

36歳男, 腎盂尿管移行部狭窄による左無機能腎に対し, 腹腔鏡下腎摘出術を行った.CO2気腹下に5本の外套管を刺入して腎を剥離し, 腹腔内に挿入した袋を用いて遊離した腎を細切し, 穿刺創を延長することなく体外に摘出した.手術時間は585分であった.術後に約310 mlの後出血あるも自然に止血, 術後3日目に歩行, 9日目に退院した, Laparoscopic procedures are promising techniques which allow less invasive surgery not only for intra-abdominal organs but also for retroperitoneal organs. Laparoscopic nephrectomy was first described by Clayman et al. We removed the left kidney of a 36-year-old male patient using laparoscopic procedures according to Clayman's technique. The kidney had developed hydronephrosis due to congenital ureteropelvic junction stenosis. In the peritoneal cavity the freed kidney was pushed into a Lapsac, minced using scissors and forceps, and removed without elongation of the wound. During the operation, pneumoperitoneum with CO2 gas induced increases in PaCO2, central venous pressure, pulmonary artery wedge pressure and cardiac output, all of which the patient tolerated well. The patient was discharged from the hospital on the 9th postoperative day. Laparoscopic nephrectomy is a useful alternative to the conventional open surgery in selected cases, when surgical techniques and instruments are improved appropriately.

1歳5ヵ月, 2歳の精巣卵黄嚢腫瘍の2例.過去10年間の報告例56例を検討した結果, stage 1では全例再発なく, 精巣摘除および経過観察でよいと思われた.stage 2, stage 3では化学療法により完治した症例もあり, 化学療法を優先させるべきと思われた, Two cases of yolk sac tumor of the testis are presented. The patients were 17 months and 24 months old. The children were inflicted with painless swelling of their left scrotal content. alpha-Fetoprotein levels were elevated at presentation but decreased within normal limits after orchiectomy. Chest X-rays and CT scans were negative. The cases were diagnosed as stage I. Fifty six cases of testicular yolk sac tumor in children have been reported in Japan since 1981. There were no recurrent stage I cases. One patient with stage II and 3 patients with stage III died despite chemotherapy, while three children with stage II or stage III disease survived more than 36 months after a positive response to chemotherapy. We conclude that prepubertal stage I yolk sac tumor is treated best initially by orchiectomy alone. Aggressive chemotherapy has a major role in salvage of stage II or stage III patients.