Search

An ectopic kidney is a common congenital anomaly of the urogenital system, but malignant tumor in an ectopic kidney has been rarely reported. We report a case of ureteral carcinoma arising from an ectopic kidney in an 83-year-old male. He visited a hospital complaining of gross hematuria. Computed tomography revealed right ectopic kidney, right ureteral tumor and bladder tumor around the right ureteral orifice. Transurethral resection of the bladder tumor was performed and histopathological diagnosis was urothelial carcinoma. He was referred to our clinic for surgery of the right ureteral tumor. We performed open right nephroureterectomy and partial cystectomy. The histopathological diagnosis was a high grade urothelial carcinoma of the right ureter, pT3N0. Four months postoperatively, there was no evidence of recurrence. We discuss the clinical and pathological features of the malignancy in an ectopic kidney.

A 67-year-old man presented at our hospital with severe edema on the left side of his neck, chest and brachial regions. He had a history of right radical nephrectomy due to renal cell carcinoma (RCC, clear cell subtype, stage II) 15 years earlier. Thereafter, metastases to the pancreatic tail and right lung, and left lung metastasis were removed at 8 years and 11 years, respectively, after the nephrectomy. Four years earlier, he had also undergone total gastrectomy for gastric carcinoma (poorly differentiated adenocarcinoma, stage IV) and subsequent maintenance chemotherapy for gastric carcinoma. Follow-up computed tomography (CT) disclosed bilateral lung metastases and a pancreatic head metastasis. Cytology of pleural effusion on admission suggested pleuritis carcinomatosa from RCC. Clinical diagnosis was bilateral lung and pancreatic head metastases, pleuritis carcinomatosa and left subclavian vein thrombosis due to RCC metastasis. Maintenance chemotherapy for gastric carcinoma was replaced by Sunitinib 50 mg for RCC but he died of progressive disease 20 days later. Immunohistochemical study of the tissue from autopsy revealed lung metastasis and pancreatic head metastasis from both RCC and gastric carcinoma as well as multiple visceral metastases, pleuritis carcinomatosa and left subclavian vein thrombosis due to gastric carcinoma. Cause of death was acute respiratory failure due to pulmonary tumor embolism and pulmonary edema. Immunohistochemical study from autopsy was able to reveal the exact diagnosis, and immunohistochemical studies may be helpful in diagnosing the exact origin of metastasis and selecting appropriate treatmentsin patientswith multiple cancers.

Six regional medical associations in Shiga prefecture agreed to cooperate in an investigation of medical care for male gonococcal and chlamydial urethritis. In June 2011, we sent a questionnaire to 372 medical offices in Shiga prefecture, and analyzed replies of respondents. Ten urologists and 175 non-urologists responded to the survey (response rate 49.7%). Among 185 physicians, 52 (10 urologists and 42 nonurologists) have treated male patients with gonococcal and chlamydial urethritis. More than 20% (42/175) of non-urological clinics are involved in the medical management. At initial diagnosis for sexually transmitted male urethritis, all urologists select the nucleic acid amplification method (100%), whereas many non-urologists do not (35%). For the treatment of chlamydial urethritis, non-urologists select levofloxacin (LVFX, 52.8%) rather than azithromycin (AZM, 22.0%), whereas urologists use AZM (78.0%) mostly but do not use LVFX (0%) (p＝0.023). For the treatment of gonococcal urethritis, non-urologists prefer oral new quinolones (53.1%) compared to urologists (25.0%) (p＝0. 74). For cure judgment of gonoccocal and chlamydial urethritis, many non-urologists rely on the improvement of subjective symptoms (50 and 47%), but urologists do not (10 and 0%) (p＝0.022 and 0.026, respectively). As for recognition of the clinical guideline for sexually transmitted disease, most urologists (90%) know it, but few non-urologists (13%) do (p ＜0.001). We found that non-urological clinics make a great contribution to the medical treatment for male gonococcal and chlamydial urethritis in Shiga prefecture. It is important to standardize the medical care for sexually transmitted male urethritis by familiarizing non-urological practitioners with the clinical guideline.

A 52-year-old man who had been treated with sorafenib for lung metastasis of renal cell carcinoma (RCC) presented to our hospital with iron-deficiency anemia. He had undergone right nephrectomy for RCC (clear cell carcinoma, pT1bN0M0) 11 years ago and lung metastasis developed 6 years after the surgery. Although upper gastrointestinal endoscopy and colonoscopy were performed on suspicion of gastrointestinal bleeding, no abnormality was detected. Capsule endoscopy and single balloon small bowel endoscopy disclosed a hemorrhagic submucosal tumor in the jejunum. Laparoscopic partial jejunectomy was performed, and pathological examination indicated metastatic RCC to the small intestine. After the operation, anemia improved but he died 8 months later because of intrabronchial bleeding from the metastatic lesion of the lung. Metastatic RCC of the small intestine is relatively rare, its diagnosis is difficult. Recently, new diagnostic tools such as capsule endoscopy and balloon-assisted endoscopy have been developed, and they are useful in diagnosing gastrointestinal bleeding (OGIB) which can not be detected by traditional enteroscopy. If patients with advanced RCC show gastrointestinal bleeding of uncertain etiology, we should perform aggressive examination of the digestive tract with these diagnostic tools.

Chemotherapy with docetaxcel (DTX) plus estramustine (EMP) for castration-resistant prostate cancer (CRPC) was started 30 months after the patient, a 65-year-old man, was diagnosed as having advanced prostate cancer cT3aN1M1 (OSS) with an initial PSA of 490 ng/ml. Prostate biopsy specimens revealed moderately differentiated adenocarcinoma, Gleason’s sum 4＋5. He was treated with DTX 30 mg/m2 on day 2 and oral EMP 560 mg/day days 1-3 weekly for 3 out of 4 weeks. PSA at start of DTX plus EMP was 81.7 ng/ml, and that after 59 months was 66.6 ng/ml. No objective change in computed tomography and bone scan were observed. He also had no cancer-related symptoms and activity of daily life was good. Chemotherapy was interrupted twice because of pleural effusion and dyspnea by DTX, at 3 and 4 months, respectively, long-term disease stabilization was obtained by this treatment. Other adverse events including interstitial pneumonia, cardiovascular disorders and myelosuppression were not observed. He was maintained on the same chemotherapy. DTX plus EMP chemotherapy is an effective treatment for CRPC patients. Continuing this therapy it is important to survey and control adverse events caused by DTX and EMP carefully.

Nocturnal urinary frequency is a predominant complaint among males presenting with benign prostatic hyperplasia (BPH), which markedly impacts quality of life (QOL) and often causes sleep disturbance. We studied the efficacy of naftopidil an alpha 1-adrenoreceptor antagonist used for treatment of BPH for improvement of nocturia and consequent sleep disturbance. Twenty-five patients diagnosed with BPH were administered daily oral doses of naftopidil (50 or 75 mg/day) for eight weeks. The symptoms were assessed quantitatively using the following criteria : International Prostate Symptoms Score (I-PSS), QOL index, frequency volume chart, and Pittsburgh Sleep Quality Index (PSQI). After treatment, the mean±SD of total I-PSS and nocturia decreased from 16.9±5.2 to 10.3±4.9 (p＜0.001) and 3.5±1.2 to 2.3±1.3 (p＜ 0.001), respectively. In addition, all categories of storage symptoms in I-PSS were also significantly improved. PSQI results were obtained in 21 of the 25 patients, and decreased from 6.4±4.2 to 5.3±3.5 (p＝0.026) (normal range : less than 5.5). This is the first report of a quantitative analysis of the effect of naftopidil on sleep quality in BPH patients. In conclusion, naftopidil appears to be an effective agent not only for nocturia and other urinary storage symptoms, but also for improving the quality of sleep.

We report a case of renal arteriovenous fistula (RAVF) following blunt renal trauma. An 84-year-old woman who presented with massive gross hematuria after striking her right flank region on the corner of a table was transferred to neighboring hospital on October 24, 2006. Plain computerized tomography (CT) revealed a small subcapsular hematoma on the right kidney, corresponding to a type I renal injury according to the classification of the Japanese Association for the Surgery of Trauma. However, subsequent enhanced CT demonstrated the migration of injected contrast material from the main trunk of the right renal artery to the inferior vena cava in the early phases. Because these findings suggested the occurrence of RAVF, the patient wasreferred to our hospital for further evaluation and therapy. Selective right renal arteriography enabled observation of trauma-induced RAVF in the upper pole of the affected kidney. Consecutively, transcatheter arterial embolization was performed with a metal coil, after which the shunt blood flow was successfully stopped. RAVF associated with blunt renal injury is extremely rare : only four cases have been previously reported in the literature.

68歳男。患者は浸潤性膀胱癌に対し根治的膀胱前立腺全摘除術, 回腸利用代用膀胱造設術が行われた。術後経過は良好であったが, 尿閉傾向がみられ, 腹部CTならびにMRIで膀胱頸部に腫瘤性病変が認められた。膀胱鏡を行ったところ, 新膀胱尿道吻合部には乳頭状腫瘍が確認され, 尿道にも多発性乳頭状腫瘍を同定された。また, 病理学的評価では浸潤性再発であった。以上, これらの所見より, 治療として尿道全摘除術および新膀胱頸部の部分切除術が施行された結果, 再発部位は尿道吻合部から遠位部尿道にかけてあり, リザーバーとしての機能を温存することを目的に再尿路変更に対し虫垂利用自己導尿型尿路変更術が選択された。だが, 術後21日目に小腸パウチ瘻の形成が認められ, 絶飲食により約1ヵ月で瘻孔は閉鎖されるも, その後は血行障害が生じ, 虫垂内腔が閉塞, 再建した虫垂ストーマからの導尿が困難となったためパウチストミーが併用された。患者はこの手術から約1年経過で局所再発となり再手術が行われたが, 術後3年4ヵ月で死亡となった。, A 68-year-old man underwent urinary re-diversion due to urethral recurrence 2 years after radical cystectomy with ileal neobladder reconstruction. Computed tomography, magnetic resonance imaging and cystoscopy revealed anastomotic recurrence between bladder and urethra with a tendency of urinary retention. Transurethral resection of bladder tumor was performed and pathological findings showed transitional cell carcinoma (TCC), papillary invasive G3, pT1 or more. Finally, we performed total urethrectomy and partial resection of bladder neck with self-catheterizable urinary rediversion using appendix. Pathological findings showed TCC, G3, pT1. Self-catheterizable urinary re-diversion using the appendix can be an option for urethral recurrence after ileal neobladder reconstruction.

前立腺小細胞癌3例について報告した。症例1(29歳男)。1998年1月に右側腹部痛で受診し、腹部CTで骨盤内腫瘍、両側水腎症を認めた。両側尿管ステント留置後腹部CTで小骨盤腔を占拠し径7cm大の腫瘍と両側骨盤リンパ節腫大も認めた。生検を行いNSE、NCAM染色で前立腺原発小細胞癌と確定した。治療開始から17ヵ月後癌死した。症例2(65歳男)。2004年4月に尿閉で受診し前立腺肥大症を疑われた。尿道カテーテル留置10日後乏尿と浮腫が現れ、両側水腎症及び急性腎不全と診断された。直腸診で石様硬の前立腺に触れ、経皮的腎瘻造設術を行い腎機能の改善後CDDP+VP-16を投与した。肺転移は消失したが16ヵ月後癌死した。症例3(73歳男)。2004年9月に前立腺生検で低分化腺癌と診断され、MAB療法開始後、10月に高度全身倦怠感が現れた。生化学検査で異常値を認め、腹部CT/MRIでは骨盤腔を占拠し膀胱直腸に湿潤する巨大な腫瘍と骨盤リンパ節転移を認め、15ヵ月目に癌死した。, Small cell carcinoma (SCC) originating from the prostate is rare. We report three cases of SCC of the prostate. Case 1: A 29-year-old man with large pelvic mass and pelvic lymph node metastases was diagnosed as having pure SCC of the prostate. Chemo-radiotherapy resulted in a great reduction of the tumor volume. However, the disease recurred immediately, and he died of disease 17 months after diagnosis. Case 2: A 65-year-old man presented with pure prostatic SCC with lung metastases. Although cystoprostatectomy combined with pre- and post-operative chemotherapy ended with no evidence of disease, he died after 16 months because of multiple metastases and local recurrence. Case 3: A 73-year-old man was diagnosed as having SCC and poorly differentiated adenocarcinoma of the prostate simultaneously. Chemo-endocrine therapy and pelvic irradiation were performed, achieving partial remission. However, he developed multiple distant metastases, and died of disease 15 months after diagnosis. We reviewed 82 cases previously reported in Japan. Patient's ages ranged from 24 to 86 years (mean 68.7 years). Many patients had lymph node or distant metastases (stage D, 73%). Thirty-seven (45%) were pure SCCs and 45 (55%) were associated with adenocarcinoma. The prognosis after the recognition of SCC is very poor, and the 1- and 2-year survival rates were 27% and 10%, respectively. Survival did not differ in patients with pure SCC or mixed glandular and small cell carcinoma. Higher elevation of pretreatment serum NSE value was associated with the poor prognosis.

An ectopic kidney is a common congenital anomaly of the urogenital system, but malignant tumor in an ectopic kidney has been rarely reported. We report a case of ureteral carcinoma arising from an ectopic kidney in an 83-year-old male. He visited a hospital complaining of gross hematuria. Computed tomography revealed right ectopic kidney, right ureteral tumor and bladder tumor around the right ureteral orifice. Transurethral resection of the bladder tumor was performed and histopathological diagnosis was urothelial carcinoma. He was referred to our clinic for surgery of the right ureteral tumor. We performed open right nephroureterectomy and partial cystectomy. The histopathological diagnosis was a high grade urothelial carcinoma of the right ureter, pT3N0. Four months postoperatively, there was no evidence of recurrence. We discuss the clinical and pathological features of the malignancy in an ectopic kidney.

2002年9月から2003年8月までに多施設で行われた開放・体腔鏡下泌尿器科手術1, 353症例を対象として同一プロトコールによる抗菌薬の予防投与を行い, 術式別の周術期感染症発生率と抗菌薬予防投与法の妥当性を検討した.手術部位感染(SSI)発生率は清潔手術0.7～3.5%, 準清潔手術6.0～10.0%, 消化管利用膀胱全摘除術23.3%であり, 遠隔部感染(RI)発生率は清潔手術5%以下, 準清潔手術7.6～16.7%, 消化管利用膀胱全摘除術35.2%であった.SSI起炎菌の85.3%はグラム陽性菌でMRSAが58.8%を占め, RI起因菌はグラム陽性菌が若干多い傾向にあったが, 尿路感染ではグラム陰性菌と陽性菌がほぼ同数であり, 尿路感染, ドレーン感染からは高率にMRSAが分離された.また, 周術期感染症の危険因子には性別, 年齢, BMI, TP, 糖尿病, 手術時間, 出血量, 肺疾患が挙げられ, 感染症発症群の術後体温, 白血球数, CRPは高い傾向にあり, 特にCRPは周術期感染症予知の鋭敏なマーカーであると考えられた, In order to assess the ability of our protocol for antibiotic prophylaxis to prevent perioperative infections in urologic surgery, 1, 353 operations of open and laparoscopic urologic surgery conducted in 21 hospitals between September 2002 and August 2003 were subjected to analyses. We classified surgical procedures into four categories by invasiveness and contamination levels: Category A; clean less invasive surgery, Category B; clean invasive or clean-contaminated surgery, Category C; surgery with urinary tract diversion using the intestine. Prophylactic antibiotics were administrated intravenously according to our protocol, such as Category A; first or second generation cephems or penicillins on the operative day only, Category B; first and second generation cephems or penicillins for 3 days, and Category C; first, second or third generation cephems or penicillins for 4 days. The wound conditions and general conditions were evaluated in terms of the surgical site infection (SSI) as well as remote infection (RI) up to postoperative day (POD) 30. The SSI rate highest (23.3%) for surgery with intestinal urinary diversion, followed by 10.0% for surgery for lower urinary tract, 8.9% for nephroureterctomy, and 6.0% for radical prostatectomy. The SSI rates in clean surgery including open and laparoscopic nephrectomy/adrenalectomy were 0.7 and 1.4%, respectively. In SSIs, gram-positive cocci such as methicillin-resistant Staphylococcus aureus (58.8%) or Enterobacter faecalis (26.5%) were the most common pathogen. Similarly, the RI rate was the highest (35.2%) for surgery using intestinal urinary diversion, followed by 16.7% for surgery for lower urinary tract, 11.4% for nephroureterctomy, and 7.6% for radical prostatectomy, while RI rates for clean surgery were less than 5%. RIs most frequently reported were urinary tract infections (2.6%) where Pseudomonas aeruginosa (20.3%) and Enterobacter faecalis (15.3%) were the major causative microorganisms. Parameters such as age, obesity, nutritional status (low proteinemia), diabetes mellitus, lung disease, duration of operation, and blood loss volume were recognized as risk factors for SSI or RI in several operative procedures. Postoperative body temperatures, peripheral white blood counts, C reactive protein (CRP) levels in POD 3 were much higher than those in POD 2 in cases suffering from perioperative infections, especially suggesting that CRP could be a predictable marker for perioperative infections.

77歳男.糖尿病・パーキンソン病の既往がある.4ヵ月ほど前から排尿困難を自覚し肉眼的血尿を認めるようになり来院, 腹部エコー所見で膀胱頸部より突出する腫瘤を認め精査加療目的で入院となった.入院時, 中等度嚥下困難・両下肢筋力低下・上肢振戦および前立腺の鶏卵大腫大を認め, 血液検査では軽度貧血とPSA値は1130ng/mlと高値を示し, 尿細胞診はclass IIで陰性であった.骨盤部造影CT・MRI所見で膀胱内に突出する前立腺に連続する腫瘤を認め, 骨シンチ検査では多発性の転移を認めた.膀胱鏡所見では膀胱頸部3時～7時方向にかけて腫瘤を認め, 生検の結果尿路上皮由来の移行上皮癌, G2と診断された.本症例は根治手術適応ではないが, 膀胱タンポナーデを繰り返すため膀胱前立腺全摘除術+尿管皮膚瘻造設術を施行した.摘出標本の病理組織学的所見から腺癌と導管癌の両方を含む前立腺癌と診断, 術後内分泌療法を施行したが奏効せず, 誤嚥性肺炎の併発により術後2ヵ月半で死亡した, A 77-year-old male with a complaint of dysuria and gross hematuria for 3 months visited our hospital. Abdominal ultrasonography, computed tomographic scan and magnetic resonance imaging revealed a prominent tumor from the bladder neck. Serum prostate specific antigen (PSA) level was high (1, 130 ng/ml) suggesting prostate cancer, but transitional cell carcinoma (TCC) was detected by transurethral biopsy. Bone scintigraphy revealed multiple bone metastasis. Since gross hematuria requiring bladder tamponade continued, simple cystoprostatectomy and cutaneous ureterostomy were performed. Pathological findings showed prostatic acinar carcinoma and prostatic duct carcinoma mimicking TCC, and PSA immunohistochemically weak positive. The final diagnosis was prostate cancer consisting of acinar and ductal component. Adjuvant hormonal therapy was performed, but was ineffective. The patient died 2.5 months after operation. We reviewed and discussed 66 cases of prostatic duct carcinoma, including our case, in the Japanese literature.

著者らは根治的前立腺摘除術後の尿失禁における前立腺尖部の処理ならび吻合法を改良したので, これを従来法と比較検討した.対象は, 前立腺癌に根治的恥骨後式前立腺摘除術を施行した36例で, うち24例(平均67.6歳)は従来法, 12例(平均64.8歳)は改良法を用いた.両群間で手術時間, 出血量に有意差は認めず, 尖部断端陽性率では差を認めなかった.術後尿失禁の消失率は出血量(1500cc未満と以上), 年齢(65歳未満と以上)では差は認めず, 従来法と改良法ではそれぞれ術後1ヵ月で8.3%, 41.7%, 3ヵ月で25.0%, 91.7%, 6ヵ月で29.2%, 100%, 12ヵ月で58.3%, 100%と改良法で有意に早期消失を認めた.術後合併症は従来法で創し開が4例, 膀胱尿道吻合部結石が1例あり, 改良法では術後血腫が1例, 一時的排尿障害が1例を認めたが, 吻合部狭窄は両群ともに認めなかった.以上, 本改良法は術後の尿失禁を軽減する有効な方法と考えられた, 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.

56歳女性.右膿腎症により近医で経皮的右腎瘻造設術後, 約3ヵ月後に発熱と右側腹部痛・腫脹で入院となった.腎瘻カレーテル抜去部から膿排出を認め, CT所見より腎周囲膿瘍を伴う右膿腎症と診断し, 膿培養ではProteus mirabilisが確認された.そのため, 感染コントロール後に右腎摘除術を施行したが, 術後出血が生じ, ドレーンチューブのクランプと輸血を行うもCTでガス産生を伴う後腹膜膿瘍を認め, ドレナージ術を施行し, 膿培養にてStaphylococcus epidermidis, Candida albicansが検出された.さらにドレーン排液が暗緑色を呈し, 上部消化管造影で十二指腸瘻(径約15mm)が確認され閉鎖術を行ったが, その4日後ショック状態となりCTで血腫の再形成を認め手術を行った.約6ヵ月後, 急性胆嚢炎が発症したものの, 胆嚢摘除術と十二指腸瘻孔閉鎖術を施行し, 術後は経過順調で30日目に退院となった, A 56-year-old woman was admitted to our hospital for treatment of right stone pyonephrosis with a perirenal abscess. After right nephrectomy for the pyonephrosis, the patient suffered from post-operative bleeding, which was stopped by closing off the drain tube with a clamp. However, a right retroperitoneal abscess with gas formation developed nine days after the operation, necessitating an operative procedure for drainage. Pus culture revealed Staphylococcus epidermidis and Candida albicans. Discharge from the drain tube became dark green days after the drainage procedure. Upper gastrointestinal series revealed a duodenal fistula, which could not be closed using a retroperitoneal approach, so the operative wound was left open. Because of the volume of discharge (800-1, 400 ml/day), somatostatin analogue, 100 micrograms, was injected subcutaneously twice a day. Discharge decreased by one-half within 2 weeks of the administration of somatostatin analogue. However, the duodenocutaneous fistula had not resolved over a period of 8 months. Since the patient developed acute cholecystitis, both cholecystectomy and closure of the duodenocutaneous fistula were performed transperitoneally. The duodenocutaneous fistula, which was closed with Endo GIA (35 mm), had protruded from a descending portion of the duodenum like the diverticulum. The postoperative course was uneventful. We speculated that the fistula occurred as a result of the inflammation with the abscess formation.

A 65-year-old man presented with gross hematuria in 2004. Computed tomography (CT) showed a left renal mass, and he underwent laparoscopic radical nephrectomy. Pathological diagnosis was clear cell carcinoma (pT2N0M0, G2＞G3). Four years later, a right adrenal tumor was disclosed by follow-up CT. Then laparoscopic adrenectomy was performed. Histology showed metastasis of the renal clear cell carcinoma. In 2009, he noticed gross hematuria, and cystoscopy revealed a 2cm solitary, non-papillary tumor at the anterior wall of the bladder. At the same time, small solitary liver metastasis (6 mm) was observed on abdominal CT. Transurethral resection of the bladder tumor and resection of liver tumor was performed, and pathological diagnosis was clear cell carcinoma both in vesical and hepatic masses. Nine months after the last surgery, he is living with no obvious tumor recurrence. To our knowledge this case is the 34th case of bladder metastasis from renal cell carcinoma in the Japanese literature. We reviewed literature and discuss the clinical features of bladder metastasis of renal cell carcinoma.

今回我々は, 2例の腎細胞癌患者に対して腹腔鏡下根治的腎摘除術 （LRN） を施行した. 症例1は72歳男性で, 右腎の直径2. 5cm の腎細胞癌と診断され, また盲腸の粘膜下腫蕩も存在した. 1999年9月28日, 経腹的到達法により LRN と腹腔鏡補助下回盲部切除を同時に施行した. 手術時聞は5時間08分, 出血量は320ml であったが, 回盲部切除に要した時聞を差し引いて LRN に要した時間のみを算定すると3時間19分であった. 術後は特に合併症はみられず, 術後7日目に退院を許可, 術後10日目に退院した. 症例2は81歳男性で, 右腎の直径3. 0cm の腎細胞癌と診断された. 77歳時に胃癌に対して胃全摘術, 79歳時にS状結腸癌にしてS状結腸切除術の既往があった. 再発の有無を検索する目的もあり, 1999年9月30日経腹的到達法により LRN を施行した. 術中癒着剥離操作時に横行結腸損傷を起こし, 小開腹 （5cm） 下に修復を行った. 手術時聞は6時間10分, 出血量は850ml であったが, 癒着剥離および結腸修復に要した時間を差し号引くと, 手術時聞は4時間34分であったと算定された本症例ではさらに2度の追加開腹手術を要した1度目は小静脈にかけたクリップの脱落による腹腔内出血のため, 2度目は腹壁創部の出血のためであったが, 以後の経過は良好で術後8日目に退院した. 今回の症例1では合併症はみられず, また回盲部切除を併施したため経口摂取開始が遅れ退院許可は7日目となったが, LRN だけを行っていたのて、あればより早期に退院可能であったと考えられた. しかし一方, 症例2では大きな合併症がみられた. その原因を追究し, 防止法を明らかにすることが, 本術式を安全で確立された術式として普及させることに重要であると考えられた. わずか2例の経験であるが, LRN は術後の QOL を改善し, 腎細胞癌の治療法として容認できる術式であると確信した.

We report a case of retroperitoneal schwannoma treated by laparoscopic surgery. A 32-year-old woman presented with a mass in the retroperitoneal space that was incidentally revealed by abdominal echography. Computed tomography and magnetic resonance imaging showed a mass 95 mm in diameter in the retroperitoneal cavity which had a cystic component. With a diagnosis of retroperitoneal tumor, laparoscopic resection was performed. Pathological diagnosis was retroperitoneal benign schwannoma consisting of Antoni A and B types. Our case is the largest retroperitoneal schwannoma tumor which was removed by laparoscopic surgery.

25歳女, 38歳女, 50歳女.右背部痛を初発症状とした胃癌(Borrmann IV型)の3症例を経験した.尿管結石や尿路系の腫瘍を認めないような尿管閉塞症状を呈した場合に, 消化器癌の検索も必要と考えられた, We experienced three cases of right hydronephrosis, which were later diagnosed to have been caused by gastric cancer (Borrmann type IV). The patients were 25-, 38-, and 50-year-old women who complained of right back pain. Ultrasound sonography revealed right hydronephrosis in all three cases. We conducted drip infusion pyelography, computed tomographic scan and retrograde pyelography, but there were no signs of urinary stones or tumors, except for the presence of right ureteral stenosis. Since the patients had upper abdominal discomfort, they underwent gastrofiberscopy, which revealed scirrhous gastric cancer. We suspected that the right ureteral stenosis was caused by metastasis of gastric cancer. After a double J catheter was indwelt at the right ureter, combination chemotherapy of methetrexate + 5-fluorouracil was conducted. The right hydronephrosis diminished and all three patients became catheter-free.

27歳男。患者は疼痛を伴わない不完全勃起の持続を主訴とした。作業中, 直径1cmの鉄筋で会陰部を打撲し, 当日の性交後から主訴が出現した。画像所見等により右陰茎海綿体に流入する動脈が会陰部打撲で破綻し, 海綿体洞との間に瘻孔ができたことで発症した動脈流入過剰型持続勃起症と診断された。更に右内陰部動脈造影検査により右内陰部動脈から分枝する陰茎深動脈の末端に破綻と陰茎海綿体洞への造影剤の溢流が認められた。治療として自己凝血塊を用いた超選択的動脈塞栓術が施行された結果, 塞栓術によって右内陰部動脈分枝からの造影剤の溢流は消失し, また勃起状態の改善も認められ, 3日後に退院となった。目下, 術後2年経過で, 再発ならびに勃起不全は認められていない。, Priapism is rare and usually unpredictable. High-flow priapism is caused by unregulated arterial inflow. Antecedent trauma is the most commonly described etiology. This condition does not require emergent treatment. The initial management of high-flow priapism should be observation, because treatment-related erectile dysfunction may appear. We report a case of high-flow priapism by perineal trauma in a 27-year-old man. His corpora were typically tumescent, but not completely rigid. He could not have sexual intercourse. Blood from the corpus cavernosum was normally oxygenated. Color duplex ultrasonography was performed in the lithotomy position, scanned at the perineum, showed pseudoaneurysmal appearance. Selective internal pudendal arteriography showed a right cavernous arterial extravasation. Superselective embolization of right internal pudendal arteries was performed with an autologous clot. After the procedure, detumescence was achieved as well as erectile function. We recommend superselective arterial embolization as the management of high flow priapism to patients who request treatment.

The adrenal glands lies deep in the abdomen, seemingly protected from blunt contusion. Wereport a case of a young female presenting left adrenal hemorrhage due to blunt abdominal contusioncaused by a collision during snowboarding, which was successfully treated with embolization.

A 67-year-old man presented at our hospital with severe edema on the left side of his neck, chest and brachial regions. He had a history of right radical nephrectomy due to renal cell carcinoma (RCC, clear cell subtype, stage II) 15 years earlier. Thereafter, metastases to the pancreatic tail and right lung, and left lung metastasis were removed at 8 years and 11 years, respectively, after the nephrectomy. Four years earlier, he had also undergone total gastrectomy for gastric carcinoma (poorly differentiated adenocarcinoma, stage IV) and subsequent maintenance chemotherapy for gastric carcinoma. Follow-up computed tomography (CT) disclosed bilateral lung metastases and a pancreatic head metastasis. Cytology of pleural effusion on admission suggested pleuritis carcinomatosa from RCC. Clinical diagnosis was bilateral lung and pancreatic head metastases, pleuritis carcinomatosa and left subclavian vein thrombosis due to RCC metastasis. Maintenance chemotherapy for gastric carcinoma was replaced by Sunitinib 50 mg for RCC but he died of progressive disease 20 days later. Immunohistochemical study of the tissue from autopsy revealed lung metastasis and pancreatic head metastasis from both RCC and gastric carcinoma as well as multiple visceral metastases, pleuritis carcinomatosa and left subclavian vein thrombosis due to gastric carcinoma. Cause of death was acute respiratory failure due to pulmonary tumor embolism and pulmonary edema. Immunohistochemical study from autopsy was able to reveal the exact diagnosis, and immunohistochemical studies may be helpful in diagnosing the exact origin of metastasis and selecting appropriate treatmentsin patientswith multiple cancers.

A 70-year-old man was given a diagnosis of sigmoidovesical fistula due to diverticulitis through the combination of examinations including cystoscopy, sigmoidoscopy, barium enema, urogram, computed tomography (CT), and magnetic resonance imaging (MRI). Among these, MRI was the most useful for the direct detection of the fistula in T1 weighted images and the confirmation of the lesion in T2 weighted images.

We report a case of transitional cell carcinoma in a patient with chronic renal failure receiving hemodialysis for 22 years. A 55-year-old man was admitted to our hospital. Under diagnosis of invasive bladder cancer and left renal pelvic tumor, removal of the whole urinary tract, e.g., bilateral nephroureterectomy and total cystourethrectomy was performed. Transitional cell carcinoma was found in bilateral renal pelvis, left ureter, bladder and prostate in the resected specimen. Thirteen months after the operation, multiple lung metastases and pathologic bone fracture of the 4th lumber vertebra were found. Chemotherapy (3 courses of modified CISCA, consisting of cisplatin, adriamycin and cyclophosphamide) was performed, but the died of systemic metastases of cancer and bleeding due to perforation of multiple gastric ulcers.

ヒト新鮮腎癌培養細胞及び腎癌株化細胞におけるMHCクラスI, MCHクラスII, ICAM-1, LFA-3, B7の発現を検討した.更に, この発現のIFN-α, cimetidineによる修飾についても検討した.IFN-αは腎癌細胞のMHCクラスI, ICAM-1, LFA-3の発現を, cimetidineはLFA-3の発現を増強することにより, リンパ球の腎癌に対する殺細胞効果を増強していることが示唆された, Recently the combined therapy with interferon-alpha (IFN-alpha) and cimetidine has been reported to be effective against advanced renal cell carcinoma (RCC). IFN-alpha and cimetidine have an antitumor effect partly due to enhancement of cytotoxic activity of lymphocytes against cancer cells. We examined the expression of major histocompatibility complex (MHC) antigens and adhesion molecules on 4 fresh RCC cells and 5 RCC cultured cell lines, which have an important role in recognition and killing of cytotoxic lymphocytes against cancer cells. The effect of treatment with IFN-alpha and/or cimetidine on the expression of MHC antigens and adhesion molecules on RCC cells was also investigated. MHC class I and leukocyte function-associated antigen-3 (LFA-3) were expressed on all RCC cells, but not MHC class II. Intercellular adhesion molecule-1 (ICAM-1) and B7 were expressed on 6 and 5 of 8 RCC cells, respectively. IFN-alpha significantly augmented the expression of MHC class I in 6 of 9 RCC cells, ICAM-1 in 1 and LFA-3 in 2 of 8 RCC cells. However, IFN-alpha did not affect the expression of MHC class II and B7. On the other hand, cimetidine enhanced the expression of LFA-3 in 2 of 8 RCC cells, but not MHC antigens, ICAM-1 or B7. The combination of IFN-alpha and cimetidine did not show a synergistic enhancing effect on the expression of MHC antigens, ICAM-1, LFA-3 or B7. These results suggest that IFN-alpha augments the sensitivity of RCC cells to lysis by cytotoxic lymphocytes partly due to the enhancement of expression of MHC class I, ICAM-1 and LFA-3 on RCC cells, and that cimetidine also augments the susceptibility of RCC cells to lymphocytes by the enhanced expression of LFA-3 on RCC cells.

自然排尿型尿路再建術を施行した23例の男子膀胱癌患者の手術成績を検討した.術式はhemi-Kock法8例, Hautmann法12例, Reddy法3例で, 平均経過観察期間は36ヵ月である.手術関連死はなかった.早期合併症は7例にみられ, パウチからの尿瘻4例, 創感染3例, 腎盂腎炎2例であった.昼間尿禁制は22例で得られたが, 夜間尿失禁は7例にみられ, Reddy法では3例全てにみられた.排尿困難は4例にみられ, うち1例は尿閉となった.晩期合併症としては, 尿道狭窄2例, 創ヘルニア 2例, パウチ内結石1例, 胆石症1例であった, Between 1988 and 1996, 23 male patients with bladder cancer underwent bladder substitution after cystectomy, using either the hemi-Kock, Hautmann, and Reddy procedures. The mean postoperative follow-up period was 36 months, with a range of 3 to 85 months. There were no perioperative deaths, and early postoperative complications occurred in 7 patients (30%); transient urine leak from the pouch in 4, wound infection in 3 and pyelonephritis in 2 patients. Twenty-two of the 23 patients (96%) were continent during the day, while 7 (30%) had nocturnal incontinence. All 3 patients with the Reddy procedure had nocturnal incontinence. Complete continence was preserved in 70% of the patients. Dysuria was seen in 4 patients, including retention in 1 patient. Late complications included urethral stricture in 3, wound hernia in 2, metabolic acidosis in 1, stone in the pouch in 1, and gallbladder stone in 1 patient. However, reoperation was necessary in 1 patient for internal urethrotomy and 1 patient for removal of a stone in the neobladder. Mild degree of hydronephrosis and unilateral reflux were seen in 3 patients each, and followed up conservatively. No urethral recurrence has occurred and only 1 patient died of cancer. The need for reoperation was very low and the high reservoir capacity resulted in continence from the beginning in most patients. We considered the neobladder useful as an alternative form of urinary diversion in selected cases.

82歳女.主訴は排尿困難と残尿感.膀胱底部から尿道周囲にかけて鶏卵大の腫瘤を認め, 生検で非ホジキンリンパ腫と診断された.他臓器に病変を認めなかった為, 尿道原発の悪性リンパ腫と診断し放射線療法を施行した.治療後, 腫瘍は著明に縮小したが肺転移が出現した.エトポシド単剤による化学療法を追加したが, 放射線治療後5ヵ月で腫瘍の急激な増加を認め癌死した, A patient with a primary malignant lymphoma surrounding the female urethra is reported. Despite the good response of the primary tumor to radiotherapy, the patient died shortly after diagnosis due to disseminated disease. We reviewed 16 cases of this rare entity reported previously.

62歳男.原発性副甲状腺機能亢進症及びCTにて偶然発見された腹部腫瘤の精査加療の為当科受診, 超音波断層法, CT, MRIにて4.0×2.5cmの内部不均一な腫瘍を肝と右腎の間に認めた.超音波カラードプラ法では明かな血流を認めず, 副腎機能は正常であった.原発性副甲状腺機能亢進症及び内分泌非活性型副腎腫瘍の診断にて, まず副甲状腺腫瘍摘除術を施行した.その3週間後腹腔鏡的右副腎摘除術を施行した所, 腫瘍は肝より発生しており, 開放的肝部分切除術を施行した.腫瘍は病理組織にて肝海綿状血管腫であった, A rare case of exophytic hepatic hemangioma preoperatively diagnosed as a non-functioning adrenal tumor is reported. A 62-year-old man was admitted for treatment of primary hyper-parathyroidism and an incidental adrenal tumor. A 4.0 x 2.5 cm heterogeneous tumor located between the liver and the right kidney was detected by abdominal ultrasonography, computed tomography and magnetic resonance imaging. Color doppler images revealed no apparent blood flow. Since the tumor seemed to have originated from the liver under laparoscopy, an open partial hepatectomy was performed. Histopathological examination revealed cavernous hemangioma of the liver. When diagnosing non-functioning right adrenal tumor, it may be necessary to carefully rule out an exophytic liver tumor.

1979年からの15年間に滋賀医科大学泌尿器科において膀胱全摘除術を行った105例の膀胱移行上皮癌症例を臨床的に検討した. 1)全例の5年生存率は68.9%であった. 2)異型度ではG2, G3例間の生存率に有意差を認めた. 3)深速度ではpT3例がpTa例に, pT4例がpTa, pT1, pT2例に比べ, それぞれ有意に不良な転帰を示した. 4)pN(+)例はpN0例に比べ有意に不良な転帰を示した, We assessed the treatment outcome of 105 patients with transitional cell carcinoma of the bladder treated by total cystectomy at our university hospital, between 1979 and 1993. The patients consisted of 84 men and 21 women (male to female ratio : 4:1), between 45 and 82 years old (mean, 65.5 years old). The overall cancer-specific survival rate at 3 and 5 years was 76.3% and 68.9%, respectively. The 5-year survival rate was 85.2% for grade 2 and 59.9% for grade 3 tumors with a significant difference in the survival curves between the two groups (p < 0.05). The 5-year survival rate according to pathological stage was 100% for pTa, 75.6% for pT1, 78.4% for pT2, 54.0% for pT3 and 39.8% for pT4. A significant difference was observed between pTa and pT3 (p < 0.05), and between pTa-2 and pT4 (p < 0.05). The 5-year survival rate was 72.3% for patients without lymph node involvement and 11.9% for those with lymph node involvement, the difference being significant (p < 0.01). Nineteen patients who received pre- and/or post-operative chemotherapy did not show a higher 5-year survival rate than those who did not.

1)U.urealyticumの感染性は弱く, 尿培養で, 菌接種後2日目に既に36匹中10匹は陰性であり, 更に2日目に陽性ラットも, その後の尿培養で, 時間の経過と共に菌は尿中より陰性化する傾向があった. 2)U.urealyticum感染により, ごく軽度の尿pHの上昇がみられるのみであった. 3)術後2日目の尿中にU.urealyticumがみられたラットでは, 69%に膀胱内に結石が形成され, 又, 術後6日目も尿中にU.urealyticumが陽性であったラットでは71%に結石がみられた, We examined the relationship between struvite stone formation and Ureaplasma urealyticum in male Wister rats by inoculating U. urealyticum and implanting a zinc disc into the bladder surgically. Cultures of U. urealyticum and pH measurements in urine obtained by forced urination were done on days 2 and 6 after operation. Half of the rats were killed 7 days after the operation and the remaining half 14 days after the operation. A total of 46 rats, consisting of 10 rats in the control group and 36 rats inoculated with U. urealyticum, were studied. U. urealyticum was weakly virulent, because it was not detected in the urine culture on day 2 in 10 of the 36 rats inoculated with the organism, and showed a tendency towards spontaneous elimination in the other rats. Urinary pH was elevated slightly by the presence of U. urealyticum. Struvite stones were formed in 52% of the rats by the inoculation on of U. urealyticum, and 69% and 71% of the positive rats in urine culture for U. urealyticum on day 2 and day 6 respectively. The stones tended to be larger the longer U. urealyticum was detected in urine. U. urealyticum may play a role in struvite stone formation, but not a major role.

80歳男では, 膀胱鏡検査で後壁に中心がある大きい腫瘍を認め, 生検で小細胞癌と診断された.動注化学療法を行ったが, 8ヵ月後に多発肝転移で死亡した.80歳男では, 膀胱鏡検査で左側壁に腫瘍を認め, 生検で小細胞癌と判明した.放射線療法及び膀胱部分切除を行った.術後6ヵ月に再発の証拠はなく元気である, Small cell carcinoma of the urinary bladder is a rare entity, and is considered to be of neurosecretary origin. Its prognosis is generally poor even with aggressive therapy. In Japan, 19 cases of small cell carcinoma of the urinary bladder have been reported including our cases. We herein report two cases of small cell carcinoma of the urinary bladder. One patient was an 80-year-old male. Cystoscopy revealed a large tumor centered on the posterior wall of the urinary bladder. The biopsy specimen of the tumor revealed small cell carcinoma. Intraarterial infusion chemotherapy was performed. He died of multiple liver metastasis 8 months after chemotherapy. The other patient was a 80-year-old male. Cystoscopy revealed a bladder tumor on the left lateral wall. The biopsy specimen of the tumor revealed small cell carcinoma. Irradiation and partial cystectomy were performed. He has been well without any evidence of recurrence 6 months after surgery. Our cases and a review of the literature indicate that a multidisciplinary treatment may improve prognosis of small cell carcinoma of the urinary bladder.

前立腺肥大症患者61例を対象に5α還元酵素阻害剤であるフィナステリド(MK906)の1mg/dayを48週間, そのうち33例には引き続き5mg/dayを24週間投与し, 前立腺体積, 尿流動態, 自覚症状などについて定期的に検討した.フィナステリドの投与により投与開始後16週で前立腺は著明に縮小し, 自覚症状も改善した.また最大尿流率も有意に増加し, 残尿も減少した.フィナステリド投与量を5mg/dayへ増加してもさらなる効果は認められず, 1mg/day投与時と同様な効果であった.副作用は4例に出現したが, 重篤なものは認められなかった, We evaluated the effect of long-term administration of finasteride (MK-906), a potent inhibitor of 5 alpha-reductase in patients with benign prostatic hyperplasia (BPH). The effect of an increase in dose was also assessed. Finasteride was administered to 61 patients with BPH at the dose of 1 mg/day for 48 weeks. Thirty three of these patients subsequently received finasteride at the dose of 5 mg/day for further 24 weeks in an open extension study. Urinary symptoms, urinary flow rate, residual urinary volume, prostatic volume and serum concentrations of dihydrotestosterone and prostate-specific antigen were examined periodically during the treatment. The size of the prostate and total urinary symptom scores decreased progressively during the first 16 weeks of treatment. The patients who received finasteride had a significant increase in the maximal urinary flow rate and a significant decrease in residual urinary volume. After 72 weeks of treatment, finasteride at an increased dose of 5 mg did not provide additional benefit to patients, although the effects of the drug at a dose of 1 mg were well maintained. Treatment with finasteride was well tolerated at both doses. In conclusion, the treatment of BPH with 1 mg of finasteride per day for 48 weeks results in a significant increase in maximal urinary flow rate, and a decrease in prostatic volume, symptoms of obstruction and residual urinary volume, with minimal toxicity.

A case of localized amyloidosis of the ureter is reported. The patient was a 49-year-old female whose chief complaint was macrohematuria. Roentogenographic examination showed left hydronephrosis due to stenosis of left middle ureter. Left nephrouretectomy with cuff was performed with a diagnosis of the left ureteral tumor, and pathological examination revealed localized amyloidosis of the left ureter. Localized amyloidosis of the ureter is a rare lesion, and this is the twenty-first case reported in the Japanese literature. Review of the literature revealed that it is difficult to differentiate this lesion from other ureteral tumors by roentgenographic examination, and it is important to perform preoperative or intraoperative biopsy of ureteral tumors if benign diseases cannot be ruled out.

1)Kock pouch(K群) 124例, Indiana pouch(I群) 51例, 虫垂臍ストーマMainz pouch(M群) 4例について検討した. 2)手術関連死はK, I群各2例であった.早期合併症は創感染15例, イレウス5例にみた. 3)晩期合併症は, K群(108例)で輸出脚不全18例, 輸入脚不全23例, ストーマ狭窄7例等, I群(47例)では, ストーマ狭窄3例, パウチ変形, 導尿困難各2例であった. 4)晩期合併症に対する修復再手術は, それぞれ22例, 5例に施行された. 5)結石形成は, K, I群でそれぞれ30例, 3例であった. 6)M群では晩期合併症は認めていない. 7)尿禁制はK, I, M群でそれぞれ90.2, 93.0, 100%で得られ, 水腎症はそれぞれ41.0, 9.5, 0%にみられた, A self-catheterizable continent urinary reservoir has become one of the major options for urinary diversion in patients with invasive bladder cancer or other pelvic malignancies. We performed the Kock pouch, the Indiana pouch and the appendiceal Mainz pouch in 124, 51 and 4 patients with the mean followup periods of 50, 33, and 10 months, respectively. In the Kock pouch, the efferent and afferent nipple valve malfunction was seen in 16.7 and 21.3 percent each, requiring repair surgery, such as fixation of the efferent nipple to the pouch wall, reconstruction of an isoperistaltic nipple valve in the former, and removal of the Dacron fabric collar or re-anastomosis of the ureter to the pouch using LeDuc technique in the latter. In the Indiana pouch, stomal stenosis, an hourglass-like pouch deformity, difficult catheterization occurred in 3, 2 and 2 patients, respectively. Among the 4 patients with the appendiceal Mainz pouch, there were no major late postoperative complications except for mild stenosis of the conduit, handled with bougienage. As a whole, surgical revisions, related to urinary diversion, was done in 20.3, 10.6, 0 percent in the Kock, Indiana, Mainz pouch patients, respectively. Stone formation, mostly multiple and recurrent, occurred in 27.8, 6.4, 0 percent in the Kock, Indiana, Mainz pouch, respectively. Most of the stones were removed endoscopically via a stoma or by percutaneous approach. Acidosis was seen in 3 patients in both the Kock and Indiana pouch, and 3 patients with the Kock pouch suffered from symptomatic choleithiasis. At the time of the latest observation, continence was achieved in 90.2, 93.0, and 100 percent, whereas excretory urograms showed normal collecting systems in 64.5, 90.4, and 100 percent in the Kock, Indiana, and Mainz pouch, respectively. In conclusion, the Kock pouch, performed by an original method using unabsorbable polyester fabric collars and metallic staples, has an intolerably high rate of late complications, and either the modified Indiana pouch with ileal patch or the appendiceal Mainz pouch using the umbilicus as a stoma is recommended for a self-catheterization continent urinary diversion.

A case of acquired diverticulum of the male anterior urethra is reported. A 67-year-old man with Pott paralysis caused by tuberculous spondylitis, visited our clinic due to recurrent urinary tract infection. He had used a condom penile sheath to collect urine. Voiding and retrograde cystourethrograms revealed anterior urethral diverticulum. Magnetic resonance imaging (MRI) clearly demonstrated diverticulum and corpus cavernosum penis, but corpus spongiosum penis was not defined. Urethroscopy showed diverticulum in the shape of partially dilated urethra with normal urethral mucosa. After diverticulectomy, self catheterization was endorsed. Histological study of removed diverticulum revealed squamous epithelium and fibrous connective tissue in the wall. The urethral diverticulum of this patient might have arisen from the elevated urethral pressure caused by the condom penile sheath.

A case of spontaneous rupture of the right kidney caused by a primary renal pelvic tumor is reported. A 57-year-old man complaining of right flank pain and gross hematuria was referred to our hospital in November 1992. In 1982, transurethral resection of the bladder tumor (TUR-Bt) and vesical instillation with mitomycin-C (MMC) had been performed at another hospital for recurrent bladder tumor. In 1988, the excretory urogram showed right hydronephrosis in the absence of a bladder tumor. In 1992, the excretory urogram revealed nonvisualization of the right kidney and obscurity of the right psoas muscle shadow. On the retrograde pyelogram, the upper calyx was irregular and the middle and lower calices were not clearly visualized. Selective renal arteriography demonstrated loss of continuity between the middle portion and lower poles. Right nephroureterectomy with bladder cuff was performed. The severely dilated pelvis contained a large amount of coagula and a papillary tumor. The thin renal parenchyme was lacerated at the lower pole. Histopathological findings revealed noninvasive transitional cell carcinoma. The present case represents the 6th spontaneous renal rupture caused by a renal pelvic tumor reported in Japan.

腎盂形成術を行った腎盂尿管移行部狭窄症23例25腎(男17例, 女6例, 平均15.9歳).術式はAnderson-Hynes法22腎, Y-V plasty, Hellstrom法, simple pelvi-ureterostomy各1腎であった.術後平均8.6年の排泄性腎盂尿管造影による判定で, 水腎症の程度が改善した初回成功例は21腎, 不変及び増悪の不成功は4腎であった.不成功の原因としては, 感染, 尿浸潤, 不適切な縫合による管腔内での肉芽形成を認めた, We retrospectively reviewed the records of 23 patients (25 kidneys) who underwent open pyeloplasty for ureteropelvic junction obstruction (UPJO) between 1980 and 2001, focusing on failures. The patients included 17 men and 6 women, ranging from 3 months to 69 years old (mean 15.9 years). The followup period was 6 months to 19 years (mean 8.6 years). Anderson-Hynes pyeloplasty, Y-V plasty, Hellstrom's operation and simple pelvi-ureterostomy were performed in 22, 1, 1 and 1 kidney, respectively. We successfully repaired 21 of 25 renal units (success rate 84.0%). Of the four patients (4 kidneys) with persistent UPJO occurring in this primary pyeloplasty series, repeat pyeloplasty was performed on 2 patients, nephrectomy on 1 patient and balloon dilatation on 1 patient. Infection and prolonged urinary drainage seem to result in fibrosis of periureteral tissues. Inadequate stitches may cause granuloma in the lumen of the anastomosis. The techniques and complications associated with open pyeloplasty are discussed.

前立腺癌組織におけるHNK-1抗原の発現を抗HNK-1抗体を用いてABC法での免疫組織化学的に検討した。HNK-1抗原は52例中49例に陽性で, その反応性は癌の組織分化度と相関した。高分化癌で陽性癌細胞の比率が最も高く, 低分化癌でもっとも低かった。進行癌での反応性は弱くなる傾向があったが, 各臨床病期間に統計学的に有意な反応性の違いはなかった。内分泌療法を受けた33例のstage D2症例について, HNK-1抗原が3分の2以上陽性のグループが3分の2未満のグループに比べて有意に良好な生存率と非進展率を示した, The anti-HNK-1 (Leu-7) monoclonal antibody (MAb) was revealed to be reactive with noncancerous and cancerous prostatic epithelial cells, although this antibody was originally found to be reactive against natural killer cells. However, the prognostic significance of HNK-1 antigen in prostatic cancer patients remains unknown. The expression of HNK-1 antigen on prostatic cancer was investigated immunohistochemically using the avidin-biotin-peroxidase complex (ABC) method with the anti-HNK-1 monoclonal antibody. Of the 52 patients with prostatic cancer, 49 patients (94%) showed reactivity to anti-HNK-1 MAb and the immunoreaction was associated with the histological differentiation of prostatic cancer. Well differentiated cancer showed the highest percentage of positively stained cancer cells and poorly differentiated cancer showed the lowest percentage. No statistically significant differences existed between groups classified by stage, although the more advanced cancers tended to have weaker reactions. The five-year survival rate and interval free of progression were then studied using the Kaplan-Meier method on 33 patients with stage D2 disease who had received endocrine therapy. The findings indicated that a high survival rate and a longer interval free of progression were associated with a higher fraction of positively stained cancer cells. In conclusion, the expression of HNK-1 antigen on prostatic cancer may be a useful prognostic factor in patients with prostatic cancer.

前立腺分泌細胞, 基底細胞, 間質細胞などの混合物を免疫原にし, BPH切片に対する蛍光抗体法でスクリーニングしてマウスモノクローナル抗体を作製した。前立腺分泌細胞に良く反応し, ホルマリン固定パラフィン切片にも適用可能である, PAP, PSAにそれぞれ特異的な抗体を産生する細胞を1クローンずつ樹立できた, Mouse monoclonal antibodies were prepared using a cell mixture containing prostatic secretory, basal cells and stromal cells as an immunogen, and by the immunofluorescence method with cryosections of prostate tissue. An immunohistochemical screening process was used in the expectation that it would help identify not only the antibodies reacting with the secretory cells predominant in the prostate but also those reacting with relatively rare cells in the prostate tissue. Two cell clones have been established which produce antibodies (IgG1) that react well with prostatic secretory cells: a clone producing antibodies specific to prostatic acid phosphatase (PAP) and one producing antibodies specific to prostate-specific antigen (PSA). These antibodies could recognize the native antigens in the seminal plasma, respectively. These findings indicate that antibodies recognizing only one substance can be prepared, even when a mixture of prostatic tissue including many proteases is used as an immunogen. Production of antibodies against prostate-specific antigens other than PAP and PSA by this method should provide a useful means for analyzing unknown antigens in the prostate.

1)非失禁性代用膀胱(Kock pouch, Indiana pouch)を造設した患者の術後の生活の質(QOL)を調査した。2)81例に106項目の質問用紙を郵送し, 自記式にて60例(74%)の症例より回答をえて分析対象とした。3)1回導尿量は約400mlで約4時間毎に導尿している。夜間導尿回数は1.2回である。4)肉体的健康状態や精神的健康状態はおおむね良好に保たれていた。5)ストーマを見られることを嫌うために, 家族と入浴することは少ないものの, 59%が公衆浴場にも行っていた。6)睡眠時には80%がストーマを気にしていなかった。7)社会生活に関するQOLでは, 交友関係, 運動や趣味においては20～30%の患者に悪影響があったが, 術前仕事をしていた患者の22%が術後仕事を止めていた。術後, 旅行を断念した者は少数であった。8)性生活に関しては, 術後勃起力の低下が著しく, 従って性生活はきわめて惨めであり, 勃起力を維持した術式の応用が望まれた。9)手術と関連した症状として, 皮膚の異常はあまり認められなかった。10)質問用紙中の簡単な説明のみの理解であったが, 再度尿路変更術をしなければならないとすれば, 同じ術式を選択すると答えたのは94%であった, To improve the quality of life (QOL) of patients requiring urinary diversion, various surgical techniques including those employing a continent urinary reservoir (CUR), such as Kock pouch or Indiana pouch, and those using the conventional ileal conduit have been advocated. In this study we asked patients who had undergone a CUR operation to complete a questionnaire, consisting of 106 questions relating to the QOL during the disease-free period. A total of 81 questionnaires were sent out, and 60 (74.1%) CUR patients responded. The average age was 61 and the male to female ratio was 49 to 11. The time elapsed from the operation was 42 months. Twenty-nine questions addressed the patients physical condition and on the whole it was kept in good quality. Because they were unwilling to show their stoma, they were reluctant to bathe together with family members. However, 59% of them went to a public bathhouse (common in Japan). Other physical abilities related to exercise were not significantly hampered by this operation. Eighty per-cent of them were not bothered by having a stoma. Twenty four questions were related to social life. The operation had a bad influence in 20-30% of them concerning their interaction with friends and hobbies. Twenty two percent of the patients who had a job prior to the operation stopped working. Only a few patients abandoned travelling. Concerning their sex life (7 questions), males suffered impotence at a very high rate, but only 26% of the patients lost interest in sex. Symptoms related to the operation (41 questions) were mild. Overall, 94% of the patients would choose the same operation again if it were required.(ABSTRACT TRUNCATED AT 250 WORDS)

92歳, 男.主訴は尿閉.X線検査で, 陰茎部に一致した多発性の石灰化像があった.腎不全は腎後性閉塞が原因ではないかと推測された.亀頭包皮炎による包皮口の閉鎖, それに引き続く尿閉及び包皮結石の診断にて, 緊急に包皮背面切開術, 結石除去が行われ, 尿道カテーテルが留置された.術後, 腎機能は速やかに回復し, スムーズな自尿が可能になった.この症例により, 高齢者の包茎に対する手術治療の必要性を再認識させられた, The patient was a 92-year-old male whose chief complaint was urinary retention. The X-ray film showed multiple overlapping calcification shadows in the penile region. Renal insufficiency was speculated to be due to post-renal obstruction. Under the diagnoses of closure of the preputial orifice by balanoposthitis followed by urinary retention and preputial calculi, an urgent dorsal incision of the prepuce was made. Then, stone removal and indwelling catheter placement were performed. Renal function recovered soon after the operation, and the patient could urinate freely without catheterization. This case reminds us of the significance of surgical treatment for phimosis in elderly patients.

尿路感染症によるurosepsisを併発し, エンドトキシンショック, DICへと進展した2症例に対しPMXを施行した.自験例では, 2症例とも昇圧剤の投与量を下げることができ, CRPの低下を比較的早期に認められた.しかしエンドトキシン血中濃度そのものの低下は認められなかった.PMXを使用することによりエンドトキシンショックに陥った症例では循環動態を安定させる効果が期待される, We report the effects of direct hemoperfusion using polymyxin B-immobilized fiber (PMX treatment) on two patients with endotoxin shock from urosepsis. In both cases, urosepsis caused by pyelonephritis from a ureteral stone progressed to endotoxin shock and disseminating intravascular coagulation (DIC). Single J catheter was indwelt in the ureter for the purpose of drainage before PMX treatment. Drainage of the origin of infection, using effective antibiotics and PMX treatment improved shock state and DIC earlier than we expected.

1) 1987年10月より1991年9月までにIndiana pouchによる尿路変更手術を39例に施行した.2)この間に, 結腸の完全なdetubularization, stapled plication, U-shaped ileal patch法などの手技の改良を行った.3)早期合併症は開放手術に共通する一般的なもので, continent urinary reservoir (CUR)に直接関連したものはなかった.4) 3ヵ月以上経過観察された37例の晩期合併症のおもなものは, pouch変形(2例), 導尿困難(2例), ストーマ狭窄(2例), アシドーシス(1例)などであった.5) 90%以上の症例で良好な尿のコンチネンスがえられ, 尿管への逆流を認めたものはなかった.6)本術式は, 術式が比較的簡単で重大な合併症も少ないことから, 今後もきわめて有用なCURであると考えられた, From October, 1987 through September, 1991, 39 patients underwent construction of Indiana pouch for cutaneous urinary diversion. There were 35 men and 4 women, and their ages ranged from 38 to 77 years (a mean age of 62 years). After the first 8 cases, Indiana pouch was constructed with several modifications which included complete detubularization of the cecum, construction of the pouch augmented with U-shaped ileal patch, and the use of stapled plication. There was no major early complication related to the pouch but one postoperative death of blood transfusion related graft versus host disease. End results were evaluated in 37 patients who were followed for 3 to 49 months. Late complications related to urinary reservoir occurred in 8 patients. The early two patients experienced pouch deformity due to incomplete detubularization of the colonic segment. Two patients had difficult catheterization due to a dilatation of the plicated ileum. One patient had metabolic acidosis requiring hospitalization. Patients perform self-catheterization 4-5 times during the day and 0-2 times at night for volumes ranging from 300 to 1, 000 cc. Of 37 patients 34 achieved acceptable urinary continence and one had significant leakage requiring cutaneous bag. The remaining two patients suffered mild nocturnal incontinence. Follow up examination with excretory urography showed no upper urinary tract obstruction except one with unilateral hydronephrosis due to ureteroanastomotic stricture. Reservoirgraphy showed no reflux into the upper urinary tract in all the follow up cases.(ABSTRACT TRUNCATED AT 250 WORDS)