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Patients who contract severe renal infections often suffer from urosepsis. Therefore, early diagnosis and treatment are required. Sometimes, the treatment with antibiotics is not enough for control of the infections. Most of the patients also require surgical interventions including transurethral drainage and nephrectomy. Twenty-two patients with severe renal infections treated between April 2010 and October 2019 at our institute were evaluated retrospectively. Eleven patients had undergone nephrectomy. Open nephrectomy was performed on 10 patients. Laparoscopic nephrectomy was attempted in the other patient but was converted to open nephrectomy because severe adhesion was found around the tissues. Nephrectomy was performed by the retroperitoneal approach on 9 patients and by the transperitoneal approach on 2 patients. The reteroperitoneal approach was used on two patients who suffered postoperative colon perforation. Inflammatory involvement of renal pelvis, hilum and adjacent structures leads to dense fibrotic reaction and obliteration of tissue planes, which makes the nephrectomy procedure challenging. Therefore, it is important to choose the most appropriate nephrectomy procedure for each patient when they have contracted severe renal infections.

A 68-year-old man underwent radical nephrectomy for renal cell carcinoma of the right kidney 12 years ago. He was diagnosed as having a recurrent tumor of the contralateral kidney and a single metastatic pulmonary lesion by diagnostic imaging on the annual checkup. He visited us in order to receive nephron sparing surgery. Since the preoperative abdominal computed tomography showed tumor thrombus invading intothe intrarenal vein, ex vivo partial nephrectomy and auto-transplantation was performed. Although he received transit hemodialysis during the postoperative 10 days, his renal function, thereafter became stable without hemodialysis. Eighty-seven days later he underwent right lower lobectomy. At postoperative 6 months he has no local recurrence or distant metastasis and maintains well-preserved renal function.

A 5-year-old boy was diagnosed with febrile urinary tract infection (UTI) at the age of 2 months. Voiding cystourethrography (VCUG) showed grade IV reflux on the left side. Left ureterocystoneostomy was performed at 11 months because of recurrent febrile UTI under antibiotic prophylaxis. VCUG 1 year after surgery showed no reflux. The patient developed acute focal bacterial nephritis (AFBN) when he was 4 years and 2 months of age, and experienced 3 episodes of AFBNduring the following 9 months. The patient had normal urinary and bowel habits. Although VCUG showed no recurrence of reflux, AFBN developed in spite of antibiotic prophylaxis. Positioning the instillation of contrast (PIC) cystography under general anesthesia demonstrated the left occult reflux. Endoscopic injection with Deflux○R was performed simultaneously. PIC cystography is a useful examination in patients with persistent, repeated UTI episodes without any signs of reflux employing conventional diagnostic modalities.

59歳男性.患者は2年前の健康診断時の腹部超音波断層検査で, 左後腹膜腔に長径6cmの嚢胞性腫瘤を指摘されたが, 無症状のため経過観察されていた.しかし今回, 腫瘤の増大に伴い高血圧と尿中カテコラミンの軽度高値がみられたため, 精査加療を目的に著者らの施設へ紹介となった.所見では, 腹部CTおよびMRIで, 左副腎・横隔膜間に径7×3.5×3cmで, 高密度の内容液を含むダンベル型の嚢胞性腫瘤が認められた.内分泌活性を有する嚢胞性副腎腫瘍の疑いもあり開腹術にて摘除したものの, 病理組織診断では後腹膜腔では稀な気管支原性嚢胞であった, A 59-year-old hypertensive man was referred to our hospital with a retroperitoneal cystic tumor, measuring 6 cm in diameter that was detected by an ultrasound examination during routine check-up 2 years before coming to our department. During the 2-year follow-up, the cystic tumor gradually increased in size. The patient also became hypertensive with slightly elevated urine levels of noradrenaline and dopamine, while the plasma catecholamines and their metabolites in the urine were within the normal range. Computed tomographic scanning and magnetic resonance imaging revealed a dumbbell-shaped retroperitoneal cyst with dense fluid, measuring 7 x 3.5 x 3 cm in diameter, in the left supra-adrenal and sub-diaphragmatic regions. He underwent extirpation of the cystic tumor with suspicion of adrenal endocrine cystic tumor. The histopathological diagnosis was a bronchogenic cyst, which is an extremely rare developmental anomaly in the retroperitoneal space. We herein report this rare case of retroperitoneal bronchogenic cyst and present a brief review of the previously reported 30 Japanese cases.

Persistent mullerian duct syndrome describes a group of patients with a 46 XY karyotype and normal male external genitalia, but internal mullerian structures. A 7-month-old boy presented with a left inguinal hernia, a left undescended testis and a right impalpable testis. Inguinal herniorrhaphy was performed and laparoscopy was done for search of a right impalpable testis and internal genitalia simultaneously. Laparoscopic examination revealed the structure like a mullerian duct remnant along the left spermatic duct in rectovesical fossa and right intra-abdominal testis. The structure like a mullerian duct remnant was not removed to preserve the left spermatic duct. Left orchiopexy and right laparoscopic staged Fowler- Stephens orchiopexy were performed. Chromosomal analysis was 46 XY karyotype and we diagnosed this case as persistent mullerian duct syndrome.

69歳男.慢性肝炎の治療で近医に通院中であった.血中α-Fetoprotein(AFP)値が高値を示した為, 腹部超音波断層検査及びCTを施行した.右腎下極に腫瘍を指摘され, 精査加療目的で著者の病院に入院した.画像所見などから右腎細胞癌と診断して根治的右腎摘出術を施行した.病理組織学的所見からAFP産生腎細胞癌と診断した.術後AFP値は漸減し, 術後7週目には正常範囲まで下降した.術後38ヵ月後の現時点において, 画像上は局所再発, 転移を認めず, 肝原発腫瘍や慢性肝炎の増悪も認めていない.AFPの推移と再発・転移に関して外来で経過観察を行っている, Renal cell carcinoma (RCC) producing alpha-fetoprotein (AFP) is a rare condition with only 11 cases reported in Japan to our knowledge. A 69-year-old man was admitted to our hospital for further examination of an incidental right renal tumor. Laboratory tests showed markedly increased serum level of AFP whereas both HBs antigen and anti-HCV antibody were negative. Computed tomography and magnetic resonance imaging imagings showed a right renal tumor but no tumor in liver, testis or lymph node. We performed right radical nephrectomy. Serum level of AFP declined within the normal range 7 weeks after nephrectomy according to its half-life curve. The tumor specimen was composed mainly of granular cells. Immunohistochemical examination of the tumor cells proved the presence of AFP in the cytoplasm. The possibility of AFP as a tumor marker of renal cell carcinoma in this case was presented.

A 39-year-old man presented with left scrotal pain which lasted for 3 days. The laboratory test showed slightly elevated C-reactive protein and lactate dehydrogenase whereas α-fetoprotein and β-human chorionic gonadotropin were normal. Scrotal Doppler ultrasound test demonstrated an oval-shaped hypoechoic lesion and enhanced magnetic resonance imaging revealed an avascular lesion in the left testis with the rim enhancement. He underwent left high orchiectomy. The histopathological examination revealed segmental testicular infarction with partial necrosis

16歳女で, 腫瘍の長径は約7cmと大きかったが, 短径は約5cmで外下方に突出するように発育しており, 又, 良性腫瘍であること, 年齢などを考慮して無阻血核出術を選択した.手術にはマイクロ波組織凝固装置(Microtaze)を用い, 手術時間は2時間43分, 出血量は370gで, 術後経過良好であった, A case of renal angiomyolipoma, successfully treated with non-ischemic tumor enucleation, is reported. A 16-year-old Japanese female visited another hospital with a chief complaint of general fatigue. She was diagnosed with angiomyolipoma of the right kidney, 7 cm in the long axis, which developed exteriorly at the lower pole. A nephrectomy was recommended. The patient visited us for a second opinion. We judged that nephron-sparing surgery was applicable to this case. The patient underwent non-ischemic tumor enucleation using a microwave tissue coagulator via retroperitoneal approach. The patient was discharged from our hospital 9 days after the surgery. Since a preoperative diagnosis with renal angiomyolipoma can be obtained relatively easily, maximum efforts for nephron-sparing surgery should be made.