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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)

Two cases of endometriosis causing ureteral stenosis are reported. Case 1. A 46-year-old woman was hospitalized with the complaint of right flank pain. Intravenous pyelography showed right hydronephrosis and retrograde pyelography revealed ureteral stenosis at the distal third ureter. Exploration revealed an abnormal periureteral mass, which was excised together with the distal part of the ureter. A right ureteroneocystostomy was performed with the Boari technique. Case 2. A 39-year-old woman was hospitalized with the complaint of pain in the left lower quadrant. A left retrograde pyelography showed stenosis of the ureter at 4 cm proximal of the bladder. An exploratory laparotomy revealed blue berry spots on the left side of the uterus and dense fibrous tissue around the ureter, which was successfully dissected out. The pathological diagnosis of both cases was extrinsic ureteral endometriosis. Ureteral endometriosis has rarely been described and the literatures on 30 cases reported in Japan were reviewed.

画像診断, 腹部造影CT共に左鼠径部と陰嚢内に内部不均一な腫瘤が認められた.左精巣腫瘍, 特に高年齢から悪性リンパ腫が疑われたが, 3年前に肺結核を患っていることより結核性の精巣上体炎や精巣結核も除外必要にて, 左高位精巣摘除術を施行した.病理組織学的所見は, 精細管等の固有構造は保たれているものの軟部組織に大小の成熟脂肪細胞と膠原線維を含む線維化が認められ, 分化型脂肪肉腫の硬化型(sclerosing type)と診断された.分化型の脂肪肉腫にて術後補助療法は施行せず, 術後12日目に退院となった.術後8ヵ月現在局所再発などは認めていない, We report a rare case of liposarcoma of the spermatic cord in the left scrotum and inguinal region. The patient was a 75 year old male, who visited our hospital with the complaint of painless left scrotal swelling and inguinal mass which had been noticed for 3 to 4 years. Ultrasonography and computed tomography (CT) showed a heterogenous mass in the left inguinal region and intrascrotum. We suspected a left testicular tumor and removed it by high inguinal orchiectomy. Histological examination revealed a well-differentiated liposarcoma of sclerosing type. Tumor local recurrence was not recognized at 8 months after operation. This is the 43rd case of liposarcoma of the spermatic cord in the Japanese literature.

1) GURが導入されて以来, 浸潤膀胱癌全摘に伴う尿路変更で全体の45%にCURが選択されている.2) Kock pouch 100例の成績からみると, 術後比較的早期にみられる輸出脚合併症は手術手技の改良で克服できたものの, より長期の観察でカラーに起因した輸入脚合併症と結石形成が増加している.3) Indiana pouch 30例の成績からみると, ileal patch法の方がHeineke-Mikulicz法よりも安定した成績を挙げており, CURの第一選択と考えられる.4)ハンモック法による回腸尿管吻, Continent urinary reservoirs (CUR) have become one of the major options of urinary diversion for invasive bladder cancer patients who require cystectomy and cutaneous urinary diversion. We have experienced 100 cases of Kock pouch and 30 cases of indiana pouch during the past 5 years which comprise 45% of all cases. Standard ileal conduit and ureterocutaneostomy were performed in 34% and 20%, respectively, and orthotopic urinary reservoir by hemi-Kock pouch was done in only one case during the same years. There were 3 perioperative deaths, 2 had Kock pouch and one Indiana pouch. Early postoperative complications were not substantial. However, significantly high rates of late postoperative complications were seen in Kock pouch, i.e., both efferent (18%) and afferent (13%) nipple valves and stone formation (18%). Uretero-ileal anastomosis by hammock method done in 10 cases resulted in success in 8 cases, abolishing the afferent nipple. Indiana pouch, in which no nipple valves or foreign materials like staples or collars are necessary, has been adopted as a first choice for the past 3 years. Of 29 evaluable cases, Heineke-Mikulicz method was used in 7 cases, and ileal patch method in 22 cases. An hourglass-like deformity was seen in 2 cases in the former method. Severely difficult catheterization, parastomal abscess, and acidosis occurred in one. Overall, 24 cases (83%) have come up with satisfactory results with minimal overflow incontinence in the early postoperative course. Although much longer followup is necessary, CUR's by Kock or Indiana pouch are more acceptable by bladder cancer patients requiring cystectomy.

Urinary incontinence caused by functional or anatomical incompetence of the urethral sphincter is one of the most challenging problems in urological surgery. Posterior urethral lengthening accomplished by tubularization of the trigonum, which was proposed by H. H. Young, J. E. Dees and G. W. Leadbetter, has been shown to improve the outcome in epispadia patients with incontinence. We report our experiences of Young-Dees-Leadbetter's operation in three patients. Case 1 was a 55-year-old woman who had undergone removal of the external genitalia to treat genital Paget's disease, resulting in total incontinence. About one half of the urethra had been removed, resulting in a shortened urethral length of 2.5 cm. Case 2 was a 6-year-old boy with penile epispadia, who had leadage of about a third of the total urine volume. Case 3, an 18 year-old female patient, suffered from total urinary incontinence which had resulted from a defect in the entire urethra and bladder neck following a motor vehicle accident. Posterior urethral lengthening together with ureteral reimplantation was performed on these three patients according to Leadbetter's or Dees' method. Subtotal continence was achieved in cases 1 and 3, and incontinence was completely cured in case 2. Based on our results with these three cases, we feel that Young-Dees-Leadbetter's operation is a useful method for treating sphincteric incontinence, particularly in female patients with an anatomical urethral defect.

A case of renal pseudoaneurysm which occurred as a complication of percutaneous nephrolithotomy (PNL) for right renal staghorn calculi is presented. A 59-year-old man, who previously had left nephrectomy due to renal staghorn calculi and right pyelolithotomy due to renal calculi, was admitted to our hospital for treatment of recurrent right renal staghorn calculi on March 29, 1990. Laboratory data on admission revealed no significant abnormality except for a mild elevation on blood glucose (116 mg/dl). Pseudomonas aeruginosa (10(6) CFU/ml) was cultured from urine. Preoperative plain abdominal film showed right partial staghorn calculi extending to the lower calyx and pelvis. Three sessions of PNL were performed. Two nephrostomy tubes were placed in the upper and middle calyces at the first session. Although all calculi were removed completely, massive renal bleeding with bladder tamponade occurred several times postoperatively and blood transfusion was necessary. Renal angiography was performed, and it was demonstrated renal pseudoaneurysm at the upper nephrostomy tract. At the same time the pseudoaneurysm was treated by superselective embolization with an absorbable gelatin sponge. We reviewed the related literature on complications of PNL. Etiology and treatment of a renal vascular injury associated with PNL are also discussed.

A case of large protruding cystitis glandularis is reported. A 36-year-old man was admitted to our hospital due to acute cholecystitis, and large protruding masses were incidentally found in the urinary bladder by abdominal ultrasonography. The histological study revealed that they consisted of a large number of Brunn's nests with or without cysts which were often accompanied with columnar epithelial metaplasia, and of glandular structures closely resembling the colonic crypts. The mucin-histochemical study demonstrated glandular lesions in the bladder secreted colonic type mucin, and endocrine cells positive with Grimelius' staining. A review of literature disclosed 19 clinical cases of cystitis glandularis, since 1970, in Japan, but such a large protruding lesion as this case is rare. We first performed detailed histological and mucin-histochemical studies for this clinical case.

PHPTは1980年以降急増した.臨床型は結石型33例, 骨型, 混合型12例, 化学型7例であった.病理組織像では49例が単一腺腫, 3例が過形成であった.腺腫例は全例術後の高Ca血症は軽快したが, 過形成は2例が軽快しなかった.画像診断の普及した1980年以降は腺腫の36/39例は局在診断が可能で, 正診率はCT 29例が最高であった.手術適応は化学型にも有り得, 腺腫の局在が診断された症例は小切開, 腺腫摘除の縮小手術も考慮される, Fifty-two cases of primary hyperparathyroidism were experienced at Kyoto University Hospital and affiliated hospitals between 1965 and 1990. Thirty-three of them (63%) were of the stone type, twelve (23%) of the bone or mixed type, seven (13%) of the chemical type. Histopathological findings showed adenoma in 49 cases and hyperplasia in 3 cases. Serum calcium levels decreased postoperatively in all cases of adenoma but unchanged in 2 of 3 cases of hyperplasia. For parathyroid adenoma, the accuracy of localization was more than 90% by the combination of computed tomography, magnetic resonance imaging, ultrasonography, subtraction scintigraphy with 201TI and 123I, venous sampling for parathyroid hormone and/or angiography. Simple removal of parathyroid adenoma may be recommended in a case of primary hyperparathyroidism due to a single adenoma which was revealed by preoperative image diagnosis.

The patient is a 54-year-old male presenting with a chief complaint of a right intrascrotal mass. Ultrasonographic image of the right testis demonstrated a marginally located cyst, 5 mm in diameter, with hydrocele fluid. Partial orchiectomy and hydrocelectomy with Bergmann's method were performed without any morbidity. Histopathological diagnosis was tunica albuginea cyst. To date, this case is the sixth reported case in Japan.

器質性インポテンス患者34名に対しAMSハイドロフレックスをインプラントして12週後, 1)満足度:非常に満足, 性交可能16例, 性交可能で満足13例, 性交可能でやや不満2例, 改善なし1例, 不明2例, 2)有用度:極めて有用20例, 有用11例, やや有用1例, 好ましくない1例, 判定不能1例, 3)副作用:海綿体膿瘍で抜去の1例, 平均19.2ヵ月中感染糜爛で抜去2例となった, The AMS Hydroflex penile prosthesis was implanted in 34 organic impotence patients between June 20, 1986 and Aug. 6, 1990. Patients ages ranged between 26 and 71 with an average of 50.5. The causes of impotences were; 17 cases of post-radical pelvic surgery, 7 cases of injury, 6 cases of diabetes and 4 of others. First evaluation was made after 12 weeks of implantation in terms of patient satisfaction with sexual intercourse and post operative complication. Sixteen patients (47.1%) were highly satisfied with intercourse, 13 (38.2%) satisfied with intercourse, 2 (5.9%) slightly dissatisfied even with successful intercourse, 1 (2.9%) with no improvement and 2 (5.9%) could not follow. Utility of the prosthesis, e.g. effectiveness and safety was; high utility in 20 (58.8%), good utility in 11 (32.4%), slight utility in 1 (2.9%), no favorable in 1 (2.9%) and no judgement in 1 (2.9%). The overall effectiveness and safety of the Hydroflex was demonstrated based on the above findings. Long term evaluation was made from the initial implantation of the device up to the termination of the trial with average of 19.2 months and was mentioned altogether.

We report a case of adrenal myelolipoma with multiple calcification and hypertension. A 69-year-old woman visited our hospital with a complaint of right flank pain. Computed tomography demonstrated a right adrenal tumor which was a spherical mass with fat density and multiple calcification. Adrenal scintigraphy of I-131 adosterol demonstrated predominant accumulation of the right adrenal gland. Selective venous sampling disclosed a high aldosterone level (303.7 ng/dl) from the affected side. Right adrenalectomy was performed. Pathological diagnosis revealed adrenal myelolipoma with calcification. After the operation the patient became normotensive. The characteristics of the 12 cases of myelolipoma with calcification we found in the Japanese literature are also briefly reviewed.

A case of a parathyroid cyst associated with an adenoma in a different gland is reported. A 55-year-old female was explored with preoperative diagnosis of primary hyperparathyroidism after endoscopic removal of a right ureteral stone. The operation revealed a cyst, 20 x 10 mm in size at the left lower gland, and a solid tumor, 32 x 12 x 7 mm in size and 1, 300 mg in weight in the left upper gland. Histological examination disclosed a parathyroid cyst and an oxyphilic and chief cell adenoma, respectively. Postoperative course was uneventful including normalized serum Ca level. To our knowledge, 59 cases of parathyroid cysts have been reported in the Japanese literature, of which 31 were in the hyperparathyroid status. The most common causes were cystic degeneration of the adenomas. A parathyroid cyst with a concomitant adenoma in a different gland like our case is very rare. This is the first reported case in Japan and the sixth reported case in the world literature.

1)術後1年以上長期観察されたKock回腸膀胱42症例につき, 晩期合併症としての輸入脚機能不全の有無を検討した.2) 42例中11例(26%)に輸入脚の合併症が認められた.10例で輸入脚合併症に起因する上部尿路の拡張があり, 7例に上部尿路感染がみられた.3)輸入脚合併症のあった11例中5例はDacron collarのpouch内脱出であり, 輸入脚の狭窄と間欠的閉塞がそれぞれ3例ずつ認められた.4) collarの脱出した5例中4例で外科的にこれを摘出した.狭窄例でも1例でcollar摘出が行われ, 閉塞例では1例で内視鏡的治療が行われた.5)輸入脚の合併症の大きな原因としてnipple valve形成に使用されたDacron collarが考えられ, これに腸管の蠕動運動が深く関与していることが推測された, Construction of a continent ileal urinary reservoir (Kock pouch) is associated with a high incidence of late complication because of malfunction of the nipple valve, the efferent limb in particular. We have so far experienced several types of afferent nipple malfunction. We herein report on the unexpected complications of the afferent nipple valve in patients with a post operative observation of 1 year or more. From 1984 through 1989, urinary diversion via a Kock pouch was performed on 47 patients at Kyoto University Hospital and Public Toyooka Hospital. The study group comprises 42 patients with a mean observation of 40 months (range 14 to 60 months). The late complications of the afferent nipple valve were observed in 11 of the 42 (26%) patients. These included erosion of Dacron fabric used as a collar (5 patients), afferent nipple stenosis (3 patients) and afferent nipple obstruction by mucous plug or fungus ball (3 patients). Removal of Dacron collar was performed in 4 of the 5 patients with collar erosion and in 1 of the 3 patients with nipple stenosis. Nipple obstruction was relieved by endoscopic manipulation or diuresis. All of the 11 patients had no problems with their efferent nipples. Our results suggest that the use of nonabsorbable material as a collar and peristaltic direction of the afferent limb are mainly involved in the complications of the afferent nipple. A more reliable and simpler procedure for antireflux anastomosis should be considered.

An 18-month-old boy was admitted in April, 1988 because of a penile mass which had been first noted at the age of one month. From nine months after birth, transient bleeding from the mass accompanied by pain had been occasionally noted. At the age of 14 months, the mass seemed to grow markedly. On physical examination, there was an irregularly shaped mass on the right side of the prepuce. It was palpated subcutaneously, soft in consistency and was 10 mm in diameter. It had a light-purple color. Upon surgery, the mass was found not to have originated from the cavernous body of the penis, so that it could be excised without difficulty. Histopathological diagnosis was cavernous hemangioma. Electron microscopic examination revealed findings suggestive of newly formed blood vessels such as abnormal cuboidal shape of endothelial cells and a high nucleocytoplasmic ratio. Immunohistochemical examination of factor VIII-related antigen was in homogeneously positive in vascular endothelial cells. To our knowledge, this is the twenty-eighth case reported in Japan.

A Clinical statistic survey was carried out on the patients, diseases, and the treatments undertaken at the Ward of Department of Urology, Kyoto University Hospital during the years of 1985 to 1988.

左陰嚢無痛性腫脹を主訴とした3歳男児で, 触診上, 腫瘤は精巣, 精巣上体, 及び精索から識別され, 透光性があった.腫瘤の一部は暗紫赤色であった.腫瘤全摘を行った.病変は多嚢胞性(2～15mm)で, 陰嚢皮膚に癒着していたが, 精巣から容易に剥離し得た.病理学的には大部分はリンパ管腫, 一部は血管腫であった.2年間再発をみていない, A 3-year-old boy was referred because of a painless mass in the left scrotum. On palpation, the mass was discriminated from the testis, epididymis and spermatic cord and showed transillumination. A part of the mass was dark purple in color. Total surgical excision of the mass was performed. The lesion was multicystic (2-15 mm), adherent to the scrotal skin, and easily dissectable from the testicle. Pathological examination revealed lymphangioma as a major component and hemangioma as a minor part. He has been free of recurrent disease for 2 years. This is the 7th case of hemo-lymphangioma of the scrotum in the Japanese literature.

53歳男.8cmの虫垂の遠位側3cmに強い炎症性狭窄が術中に判明した症例で, 盲腸部をGIA自動縫合器を用いて管状化することにより, 虫垂道尿管路の延長(4cmの延長で径9cm)を図った.得られた遊離虫垂をMitrofanoff法でパウチ吻合を行い, 盲腸即断端を臍窩と吻合した.術後経過は順調で, 軽度ストーマ狭窄はあるもののブジーのみで軽快し, 良好な結果が得られた, The Mainz pouch with appendix-umbilical stoma is a very stable method for continent, self-catheterizable urinary reservoir in the presence of a healthy appendix. If the appendix is too short or an unexpected stenosis is seen at its distal portion, the elongation of the conduit using a part of the cecum and the implantation of the conduit to the pouch by the Mitrofanoff method can be a good alternative procedure. We herein report our experience in a 53-year-old male with high grade, invasive bladder tumor, who underwent cystourethrectomy and appendix Mainz pouch operation using the above technique.

症例は肉眼的血尿を主訴とする46歳女で, 膀胱鏡検査で後三角部に黄褐色非乳頭状広基性腫瘍を認め, 腫瘍生検で膀胱アミロイドーシスと診断された.腫瘍部の経尿道的切除術を施行し, 術後4ヵ月まで再発は認められていない, A case of primary localized amyloidosis of the urinary bladder is reported. The patient was a 46-year-old female who suffered from macrohematuria and consulted our department. A yellowish non-papillary tumor at the retrotrigone of the bladder was observed on cystoscopy. Histological diagnosis was amyloidosis of the bladder. Since there was no evidence of disease in other organs, this patient was diagnosed with primary localized amyloidosis of the bladder and transurethral resection was performed. The clinical course was uneventful and she has been well without recurrence for 6 months postoperatively. This case was cured by transurethral resection, but close follow-up of the patients is necessary because of the recurrence.

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.

We report a case of prostatic malacoplakia clinically diagnosed as prostatic cancer. A 65-year-old man was seen with increased urinary frequency, and urinalysis disclosed moderate pyuria. After the administration of antibiotics for several days, the urine was sterile and the symptoms disappeared, but findings of digital examination of the prostate were compatible with prostatic cancer. Transperineal needle biopsy of the prostate was reported as poorly differentiated adenocarcinoma on the piece from the left lobe. Following further evaluation, the patient underwent radical prostatectomy under the preoperative diagnosis of stage B1 prostatic cancer. However, histological diagnosis of the surgical specimen was malacoplakia of the prostate.

We report a case of retroperitoneal myxoid leiomyoma in a 36-year-old woman complaining of urinary retention. An ultrasonogram revealed a mass in the pelvic space, while CT and MRI demonstrated a retroperitoneal tumor. Open resection of the tumor was performed. The resected tumor weighed 600 g and measured 16 x 11 x 9 cm. Histological examination disclosed a tumor mainly composed of smooth muscle with myxomatous change and only rare mitoses. The pathologic diagnosis was retroperitoneal myxoid leiomyoma. Twenty-seven cases of this type of lesion previously reported in the Japanese literature were reviewed.

A nationwide survey of urolithiasis in Japan conducted in 2005 disclosed its steady increase in incidence and the life-long risk was estimated to be 15% in men and 6% in women. The recurrence rate has also increased, to70 -80% in the extracorporeal shock wave lithotripsy (ESWL) era from around 50% previously. Although urolithiasis is very common and highly recurrent, the impact and concern of stone disease are not necessarily as high as expected either medically or socially, because of its benign nature and easy accessibility to treatments by ESWL and/or endourological procedures. Dramatic progress is taking place both experimentally and clinically in this field, such as development of a simple method of measuring metastable limits using a microplate, clarifying altered oxalate metabolism due to insulin resistance and close relationship between stone disease and metabolic syndrome, elucidating the exact role of osteopontin in an experimental model at a molecular level, prophylaxis of stone disease by angiotensin II type I receptor blocker, and addition of a new modality of fiberscopic transurethral lithotripsy (f-TUL) to the conventional endourological treatments. We hope that "change and future perspective" in the field of urolithiasis will be discussed and clarified in this symposium.

We report a case of long-term complete response of multiple lung metastases of renal cell carcinoma (RCC) by the combination therapy with interferon alpha (IFN alpha) and UFT. A 38 year-old man having left RCC with lung metastases underwent radical left nephrectomy and extended lymph node dissection, the pathological stage being pT2N2. Although metastatic lung tumors increased in size and number against intravenously admitted interferon gamma (IFN gamma) therapy after the surgery, they completely disappeared following the subsequent combination therapy with intramuscularly admitted interferon alpha (IFN alpha) and oral intake of UFT in about 2 years. The patient has been disease-free for 5 years after cessation of the treatment. Combination therapy with IFN alpha and UFT might be more effective on metastases of RCC than single use of IFN alpha or IFN gamma.

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.

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.

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.