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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.

公立豊岡病院泌尿器科における1979年1月から1981年12月までの臨床統計を行った.1) 3年間の外来新患者総数は7, 354名で, 疾患別では感染症, 腫瘍, 先天異常が多かった.2)入院患者総数は637名で, 50%以上が60歳以上の老年層で占められていた.おもな疾患は, 腫瘍と尿路結石症であった.3)手術件数では, 前立腺肥大症に対する手術がもっとも多かった, The patients seen between January 1979 and December 1981 were reviewed. The outpatients according to our classification of the patients, presented the most frequently with infections, followed by urogenital tumors and anomalies. Urogenital tumors and urolithiasis were the predominant diseases of the inpatients. The representative operations were TUR-P and prostatectomy.

最近3年間に経験したKock回腸膀胱による尿路変更75例につき, その手術成績を, 手術手技の改良時期別に検討した.1)本法を施行した75例中, 評価可能な症例は71例であり, うち63例に満足できる最終成績を得た.2)主な術後晩期合併症は, ニップル不全9例と結合形成6例であった.3)ニップル不全の最終手術成績は, CUSA(キャビトロン超音波外科用吸引装置)による腸間膜処置, およびニップルのパウチ壁への固定という二つの改良により, 著しく改善された.4)尿路変更としてKock回腸膀胱は, 手術手技の改善により安全で確実な手術法となり, 廃絶した膀胱を有する患者あるいは膀胱全摘を余儀なくされる患者の生活の質を高める術式と考える, Internal urinary reservoir type urinary diversions have been getting popularity since Kock reported a continent ileal reservoir in 1982. From November 1984 through October 1987, we performed Kock pouch operation in 75 patients (male 64, female 11; from 24 to 82 years old, mean age 56 years old). The underlined diseases were mostly bladder cancer patients; bladder cancer 70, rectal cancer 2, prostatic sarcoma 1, vesical exstrophy 1 and neurogenic bladder 1 case. The end results for 71 evaluable cases, followed up more than 3 months, were excellent in 49 (69%), good 14 (20%), fair 6 (8.5%) and poor 2 (2.8%), with success rate 89%. The most common complication was the nipple malfunction; prolapse, including intermittent prolapse, in 7 patients, slippage or sliding in 1, and eversion in one patient. Stone formation occurred in 6 patients, mild acidosis in 2 and a entero-pouch fistula in a patient who was re-diverted from a ileal conduit. There were 2 deaths postoperatively. Late complications were prominently decreased due to several important modifications of the operative technique, such as usage of Cavitron Ultrasonic Surgical Aspirator (CUSA) for defatting the mesentery, and fixing the nipple to the pouch. In conclusion, Kock pouch can be a safe and sound operative modality for patients who need urinary bladder replacement.

Implantation surgery was performed twelve times in eleven patients with organic impotence, mainly due to radical cystectomy and prostatectomy against malignancy, between March, 1982 and April, 1987. A self-contained type prosthesis (AMS Hydroflex(TM] was used in 7 cases, reservoir type inflatable prosthesis (AMS 700TM) in 2, malleable semirigid type (ESKA-Jonas Silicon Silver(TM) Trimming Tip Version) in 2, and nonmalleable semirigid type (Fuji system Finney type) in 1 case. In the last case, the prosthesis was replaced by AMS Hydroflex 4.5 years later at patient's wish. Excellent results and good patients' acceptance were gained with inflatable-type prosthesis (AMS 700 and Hydroflex) in 7 out of 8 cases (88%), whereas concealment problems were produced by semirigid type prosthesis (Finney and Jonas). Experience with AMS Hydroflex penile implantation is reported for the first time in the Japanese literature. Intraoperatively, it was sometimes difficult to implant a pair of Hydroflex rods into both of the corpus cavernosum. Postoperative perineal pain was almost constantly seen and in one patient, penile edema continued for three weeks and subsided spontaneously in two months. In another patient, the length of the prosthesis (15 cm) was short, and exchange to the longer one (17 cm) was necessary. In this patient, the longer Hydroflex caused erosion of the glans to necessitate its removal on one side. From our experience, the diameter (11 mm) of the Hydroflex seems to be too big for the average Japanese patient. The operative procedures and results of each kind of the prostheses are briefly discussed.

尿路結石と尿路感染の関係を検討すべく尿路結石の手術症例について, 結石成分, 膿尿, 尿培養, 結石培養, 細菌のウレアーゼ活性などについて調べた.1)無菌性膿尿は感染結石では18%, 代謝結石では69%で, 細菌尿は感染結石で79%, 代謝結石で26%であった.2)結石内培養は感染結石で67%, 代謝結石で23%であった.尿培養の結石培養との菌種の一致率は感染結石49%, 代謝結石33%であった.このことは抗菌剤の使用時に特に留意すべきである.3)菌種は尿および結石培養とも感染結石ではウレアーゼ陽性菌のP. mirabilisが多く, 代謝結石ではウレアーゼ陰性のE. coliが多くみられた.4)感染結石では尿路感染の起炎菌は結石形成に直接的に働き, 代謝結石でそれは偶然付着し, 尿路感染を起しているものと思われる.代謝結石でのウレアーゼ陽性菌は代謝結石を感染結石に変化せしめる可能性が考えられる, We investigated 158 cases of urinary stones (infection stones 56, metabolic stones 102) with special reference to pyuria, bacteriuria, stone culture and urease activities of isolated bacteria. Abacterial pyuria was noted in 9 out of 49 (18%) infection stones and in 53 of 77 (69%) metabolic stones. Bacteriuria was noted in 79% of the infection stones and 26% of the metabolic stones. Sixty-seven percent of the infection stones were infected with mainly urea splitting bacteria such as Proteus mirabilis and Staphylococcus. Twenty-three percent of metabolic stones were also infected. Though E. coli, a non-urea splitting bacteria, was isolated most frequently from metabolic stones, urease positive Staphylococcus and Pseudomonas were also isolated. Bacteria within stones could be predicted on the basis of urine culture results of only 20 of 41 infection stones and 8 of 24 metabolic stones. These facts are useful for selection of some antibiotics in the treatment of urinary tract infections associated with urinary calculi. Urinary infections of urea splitting bacteria in infection stones are thought to be initial factors of stone formation and those of non-urea splitting bacteria are to be superimposed. However, urea splitting bacteria in metabolic stones may convert them into infection stones in future.

A statistic survey was carried out on the patients, diseases, and operations experienced at the urological ward of Kyoto University Hospital during the years of 1977 to 1982.

1984年3月から1985年4月までの間に超音波破砕により経皮的に治療した上部尿路結石70例(73腎単位)の成績を報告する.腎瘻を介して53例中49例に, 経尿道的尿管操作により12例中11例の結石除去に成功した.合併症としては血尿と発熱が主で, 3例に輸血を必要とした.経皮的超音波結石破砕法(PNL)は経尿道的尿管操作法(URS)とともに従来の手術法に代わる上部尿瘻結石治療法として有用であることが判明した.ESWL(体外衝撃波結石破砕法)の適応となる腎結石症例に対してはESWLとPNLの両治療法のあることを説明し, 患者にその選択をゆだねるべきであると思われる, From March, 1984 to April, 1985, 70 cases of upper urinary tract calculi (73 renal units) were treated by percutaneous nephrolithotripsy or transurethro-ureteral lithotripsy, mainly utilizing ultrasonic lithotrite. While in the early period of treatment, two stage procedure of creation of nephrostomy tract and percutaneous nephrolithotripsy was performed for renal and upper or middle part of the ureteral calculi, one stage procedure, nephrostomy tract formation followed by ultrasonic nephrolithotripsy is commonly used in recent cases. During this period, conventional stone surgery was seen in 6 cases of pyelolithotomy and 2 of ureterolithotomy, while 52 cases of stone surgery were performed during the earlier period (from January, 1983 to February, 1984). Renal and upper or middle part of ureteral calculi were successfully removed in 49 out of 58 cases (84.5%). Most of the patients required 1 or 2 trials of percutaneous nephrolithotripsy. Middle or lower part of ureteral calculi were removed in transurethro-ureteral approach in 11 of the 12 cases. Hematuria and fever were most common complications after treatment and 3 patients required blood transfusion after 3 or 4 sessions of nephrolithotripsy. Percutaneous nephrolithotripsy and transurethro-ureteral lithotripsy are now widely used for treatment of upper urinary tract calculi, replacing the conventional surgical treatment. Moreover, very recently, extracorporeal shock wave lithotripsy is available in Japan. To the patients with renal calculi indicative of this treatment, both percutaneous nephrolithotripsy and extracorporeal shock wave lithotripsy are introduced and either way of treatment can be chosen by the patient himself.

過去14年間に経験した38例の腎血管性高血圧症例を, 血行再建術を行なった1群, 腎摘出術を行なった2群, いろいろの理由で手術不能であった3群に分け, 術前の臨床像と治療成績を検討した.その結果, 血行再建術の適応となる要件は, 若年者で高血圧の期間が短いこと, 高血圧がレニン依存性で, 狭窄が昇圧に有意に働いていること, 総腎機能が保持され, 患側の腎機能が悪すぎないこと, 手術時に再建可能な病変であること, 全身性の動脈硬化症は好ましくないこと, Surgical riskがよいこと, 内科的治療に反応しない高血圧であること, などであることが明らかとなった.カプトリールやPercutaneous transluminal angioplastyなど非手術療法の普及もめざましいが, 一生薬を服用し腎機能も低下してゆくことを考えると, 上記の適応をみたす症例は, まず血行再建術が考慮されるべきであろう, Based on the retrospective analysis of 38 cases of renovascular hypertension treated by surgical intervention, the following indications are proposed for arterial reconstructive surgery: younger age of patient, short duration of hypertension, renin-mediated hypertension and extent and functional significance of the obstructing arterial lesion, favorable level of renal function in the affected side, and renal function threatened by advanced progressive vascular disease, surgically correctable lesion, and focal, unilateral renal arterial atherosclerosis without generalized atherosclerosis, good surgical risk, and hypertension not responding to medical treatment. Although the clinical use of the angiotensin I converting enzyme inhibitor and induction of percutaneous transluminal angioplasty can provide a new approach to non-surgical treatment for renovascular hypertension, the long-term use of antihypertensive drugs induces gradual decrease in renal function. Surgical treatment is best reserved for the patient on whom the available data meet the above criteria for vascular surgery.

1) 1984年11月より1985年8月までに, continent ileal reservoir (Kock回腸膀胱)による尿路変更術を行ったのは13例である.2)評価しえた10例中, 7例に非常に良好な結果, 2例に比較的良好な結果, 1例は不成功に終わった.3) 9例のパウチの容量は, 平均6ヵ月間の経過観察で300～500 mlとなり, 尿失禁もよくコントロールされ, 患者の満足度も高かった.4)術前腎機能障害のあった1例に軽度のアチドーシスをみたが, 少量の重曹投与により改善できた, We tried the new method of urinary diversion via a continent ileal reservoir, reported by Kock in 1982, and now being accepted with great enthusiasm and satisfaction not only by doctors, but also by patients in Europe and in the United States. With this method, continency with storage of urine under low pressure is well maintained so that no external appliances are necessary. Ileorenal reflux is also prevented with this nipple valve forming technique, minimizing impairment of renal function. We report for the first time in Japan 13 cases, in which this method of innovative urinary diversion was used, with special attention paid to its demanding surgical technique and early results with its complications. From November, 1984 to August, 1985, we performed urinary diversion via the Kock pouch in 13 cases: 10 males and 3 females, from 35 to 67 years old (mean age 49 years), 11 bladder cancer patients, and 2 rectal cancer patients. The 2 patients with rectal cancer died from cancer and 1 bladder cancer patient with psychosis died from mental crisis 4 months after the operation. Of the 10 cases followed up long enough, 7 cases were in excellent condition with complete continence, 2 cases were in good condition with minor leak due to intermittent prolapse of the nipple valve, and in one case with failure, due to the postoperative ileus and eversion of the nipple valve, which made it difficult to catheterize into the pouch. Excision of the pouch and conversion to the standard ileal conduit was performed by reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)

A recent six year statistic survey was carried out on the patients in the Urological Outpatients Clinic of Kyoto University Hospital.

Herein we report a 36-year-old man with hyperparathyroidism and a past history of internal irradiation to the thyroid. Twelve years previously at age 24 years he had received 8 mCi of radioactive iodine for Graves' disease. An additional dose of 4 mCi was required 3 years later. A right lower parathyroid adenoma (28 X 23 X 20 mm, 5.7 g) was found at neck exploration. Although the association of external ionizing radiation to the head and neck and the subsequent development of hyperfunctioning parathyroid glands has been described in recent years, there are only 4 cases in the literature of parathyroid surgery for hyperparathyroidism secondary to earlier treatment with radioactive iodine for Graves' disease. In a long-term follow-up of 180 patients treated with radioactive iodine for Graves' disease, neither hypercalcemia nor hypophosphatemia was found. Whether internal radiation therapy can be a causative factor in the development of hyperparathyroidism should be elucidated in future. However, it seems reasonable to suggest that patients whose hyperthyroidism has been treated with radioactive iodine should have their serum calcium levels examined at 5-year intervals.