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当院のTransurethral resection of prostateに導入した医療者用, 患者用オールインワンパス(以後パス)の効果について検討した.泌尿器科におけるパス導入直前の連続27例, 導入直後の連続29例, 導入1年後の連続30例を対象とした.その結果, 術当日を含む尿道カテーテル留置期間は, パス導入後でも2～7日と幅があり3群間に有意差はなかったが, カテーテル抜去の基準は, 淡々血尿となった術後3～4日という認識が浸透し, 平均値が4日に近づいた.点滴抗生剤投与日数は2日と短縮し, 経口抗菌剤投与症例数は, パス導入前ではほぼ全例に施行していたが, 導入後減少し導入1年後では全く施行しなくなった.術後合併症の増加はなく, 入院期間は導入後に有意に短縮した.保険請求点数については, パス導入後多少減額していたが有意差を認めなかった.パス導入後のバリアンスにおいて, 導入直後に比べて導入1年後では, 術前検査忘れや追加検査は減少した.オールインワンパスは, 医療業務の効率化, 医療安全管理対策, インフォームドコンセントの充実化につながると考えられた, We evaluated the usefulness of our original all-in-one clinical pathway for transurethral resection of the prostate (TUR-P) on 86 consecutive patients. There were 27 consecutive patients treated before introduction of the clinical pathway (group 1). Twenty-nine consecutive patients were treated just after the introduction of the clinical pathway (group 2) and 30 consecutive patients were treated one year after the introduction of the clinical pathway (group 3). Our pathway includes all items such as vital sign charts and events charts. Although the hospitalization ranged from 5 days to 12 days after introduction of the clinical pathway, the average length of hospital stay was shortened by 2.6 days in group 3. Although the duration of the postoperative indwelling urethral catheter ranged from 2 days to 7 days in the groups 2 and 3, the average duration was approximately 4 days in group 3. Postoperative complications did not differ among the three groups. The medical insurance claims decreased with the introduction of the clinical pathway. Our all-in-one clinical pathway is considered to be a good tool for not only reduction of health care costs but also giving higher quality and better service to patients.

67歳女性.健診で左副腎の腫瘤を指摘され, 前医のCTで5.5cm大の副腎腫瘤を認め紹介入院となった.内分泌学的検査では明らかな異常は認めなかったが, CTで左副腎に5.5cm大で辺縁整, 円形の腫瘤を認め, 早期より辺縁を中心に不均一に造影効果があった.また, MRIではT1強調で低信号, T2強調で不均一な高信号を示したが, 確定診断が得られず, ミニマム創・内視鏡下経腰的左副腎摘除を施行した.摘出標本は表面平滑, 割面は赤褐色で中心部が白色の血腫様で, 病理組織所見では器質化と石灰沈着を一部に生じており, 亜急性から慢性期に相当の血腫で, 副腎髄質からの出血と考えられた.なお, 腫瘍細胞は認めず, 中心の白色部分は成熟脂肪細胞の集団であった, A 67-year-old woman underwent abdominal ultrasonography as part of a general health examination and was incidentally found to have a mass 5 cm in diameter in the left adrenal gland. She had no experience of abdominal trauma. Computerized tomography (CT) revealed a 5.5 x 5.0 cm mass in the left adrenal gland, which was heterogeneously enhanced by the contrast medium. Hormanal data for adrenal function were all within the normal range. For the suspected non-functioning adrenal tumor, the patient underwent adrenalectomy. Histopathological examination demonstrated only hematoma without tumor cells.

Indiana University分類でadvanced extentの5例を対象に, 導入化学療法としてVIP治療を行い, 効果の十分でない症例には早期に大量ICE療法を行う方針で治療した.VIPのみで寛解が得られた2例と大量ICE療法で寛解が得られた2例は, いずれも最低20ヵ月の経過観察を経て, 再発転移なしで生存している.重篤な合併症も認められなかった, Five patients with metastatic testicular cancer of advanced extent according to the Indiana University criteria were enrolled into this study. All tumors were non-pretreated non-seminomas. Initially all patients were treated with standard dose etoposide, ifosfamide and cisplatin (VIP) regimen. The response of two cycles of VIP was evaluated by tumor markers and diagnostic imagings. Two of the five patients showed a good response to VIP and subsequently achieved a pathological complete response (pCR) following surgical resection of residual masses after 3 or 5 courses of VIP. However, they suffered from severe myelosuppression and underwent peripheral blood stem cell transplantation (PBSCT) following the final course of VIP. The remaining three patients unlikely to be cured by VIP underwent chemotherapy consisting of high dose ICE:ifosfamide (6-10 g/m2 over 4days) carboplatin (1, 500 mg/m2 over 4 days), etoposide (1, 600-2, 400 mg/m2 over 4 days) combined with PBSCT. This regimen resulted in one partial response (PR) with marker-negative and two PR with marker-positive. Residual masses were removed in all three patients and viable tumor cells were found in two. Of the five patients enrolled, four patients (80%) remain disease-free with minimal follow-up of 20 months, and the remaining one died of cancer 10 months after PBSCT. No serious side effects or complications were encountered. This study shows that standard dose induction therapy of VIP followed by early salvage chemotherapy of high dose ICE with PBSCT is well tolerated and effective in the treatment of advanced poor-risk testicular cancer.

48歳女。患者は膀胱刺激症状を主訴とした。超音波および腹部CTでは右腎に腫瘤性病変を認め、膀胱鏡では右後三角部に小指大の血管増生と表面石灰化を伴った非乳頭状有茎性の単発性腫瘤を認めた。以上より、本症例は膀胱に単発性に転移した右腎癌と診断し、経尿道的膀胱腫瘍切除術を施行した。その結果、腫瘍基部は肉眼的に表在性であり、明らかな浸潤所見は認めなかった。病理診断的にはclear cell carcinomaで、他部位に明らかな転移は認めなかった。以後、術17日後、更に経腹的右腎摘除術を施行したが、病理組織学的所見で膀胱腫瘍と同様の小型円形核と淡明な胞体を有する腫瘍細胞が増生しており、clear cell carcinoma、G1、pT3a、v(+)、断端(-)と考えられた。術後、経過は良好で、目下、外来経過観察中である。, A 48-year-old woman was referred to our hospital with a bladder mass which was detected by a general practitioner. Ultrasonography showed a small bladder tumor and right renal mass. Cystoscopy revealed a solitary, non papillary tumor at the right side of the retro-trigone. Computed tomography revealed a large tumor at the right kidney. Transurethral resection of the bladder tumor was performed. The histopathological diagnosis was clear cell carcinoma. There was no other distant metastasis. Sequentially, radical nephrectomy was performed. Histopathologically, the right renal tumor showed clear cell carcinoma. This was considered to be a case of a solitary metastatic bladder tumor from renal cell carcinoma.

We experienced four cases of benign hemorrhagic renal cyst which were indistinguishable from cystic renal cell carcinoma on ultrasonography, computer tomographic scanning, magnetic resonance imaging and angiography. Nephrectomy was performed in one case and enucleation of the mass in the other three. Pathological diagnoses were hemorrhagic septate cyst in two cases, cyst with inflammation containing old blood clots in one, and organized hemorrhagic cyst with calcification in one. Conservative surgeries should be considered when the definite diagnosis for renal hemorrhagic cysts is not made.

A 71-year-old man who had undergone a total cystectomy and a transureterocutaneostomy more than a year earlier was admitted to our hospital on February, 1992 because of the chief complaints of anorexia and systemic bone pain due to multiple bone metastases of bladder cancer. At two weeks after the admission, he had a sudden attack of dyspnea. His chest reontgenogram revealed no significant abnormalities. He had repeated attacks and died of respiratory failure two days after the first attack. An autopsy disclosed diffuse microscopic pulmonary tumor emboli in the pulmonary arteries and arterioles of bilateral lungs, but there was no parenchymal metastasis. The metastatic lesions in the sinusoids of the liver were also occupied by numerous tumor emboli, suggesting that the tumor emboli in the lungs had derived from those in the sinusoids. Microembolization of the whole lung area must be considered as a cause of clinically unexplained dyspnea.

17歳から82歳までの45例の先行薬剤無効の複雑性尿路感染症症例に対し, IPM/CSを0.5 g×2/日, 5日間投与を行い, その薬剤効果を検討した.薬剤投与による起炎菌の消失率をみると, グラム陽性菌では79%に, 陰性菌では94%にみられた.総合臨床効果についてみると著効は8例, 有効は31例にみられ, 有効率87%であった.副作用は6例にみられたが, いずれも軽微であった, Clinical efficacy of sodium imipenem/cilastatin was studied on 45 patients with complicated urinary tract infections, on whom prior antimicrobial agents were ineffective. A 0.5g dose of IPM/CS was administered by drop infusion twice a day for 5 days. The clinical efficacy was evaluated according to the criteria of the Japanese UTI committee. Of a total of 65 strains, 29 strains of gram positive bacteria and 36 strains of gram negative bacteria, were detected as causative microbials. Bacteriologically, 23 strains of gram positive bacteria (79%) and 34 strains of gram negative bacteria (94%) were eradicated following the treatment. S. aureus, E. faecalis and Flavobacterium sp. were less sensitive to IPM/CS. Overall clinical effectiveness rate of IPM/CS in the present study was 87%. Adverse drug side effects were observed in six patients, namely they were eruption, headache and slight elevation of serum transaminase. These findings suggest that IPM/CS is an effective agent for the treatment of complicated UTI even when the prior medicine was ineffective.

A 63-year-old man was admitted to our hospital with complaints of right lower abdominal pain and stone excretions. The patient was diagnosed as having a pelvic kidney associated with staghorn calculus and extended pyelolithotomy was to be performed. However, during the operation, a papillary tumor was found in the renal pelvis occupied with staghorn calculus. As the pathological examination of its frozen section was low grade transitional cell carcinoma, nephro-ureterectomy was performed. Pelvic kidney associated with staghorn calculus or renal pelvic tumor with stones is not rare, but pelvic kidney associated with staghorn calculus and renal pelvic cancer is extremely rare.

The medical records of 8 consecutive patients with terminal urological cancers who were treated with implanted venous reservoirs between October 2001 and July 2004 were retrospectively reviewed. All 8 devices were placed safely in the 8 patients, and fluids and drugs were easily administered via the reservoirs. The devices were utilized for a mean of 40.6 days (range, 18 to 98) until the patients died of the cancer, and there were no complications which required removal of the devices such as catheter or reservoir infections, catheter occlusions and catheter thromboses. Seven patients were discharged or stayed at home on weekends and received home parental nutrition (HPN) through implanted venous reservoirs. Although HPN with the implanted venous reservoir is recently becoming common in digestive surgery or gynecological fields, it still remains uncommon in the urological field. Because this device would be useful and safe for patients with terminal urological cancers, we should consider the use of implanted venous reservoirs for patients who desire terminal home care.

A 48-year-old woman was referred to our hospital with a bladder mass which was detected by a general practitioner. Ultrasonography showed a small bladder tumor and right renal mass. Cystoscopy revealed a solitary, non papillary tumor at the right side of the retro-trigone. Computed tomography revealed a large tumor at the right kidney. Transurethral resection of the bladder tumor was performed. The histopathological diagnosis was clear cell carcinoma. There was no other distant metastasis. Sequentially, radical nephrectomy was performed. Histopathologically, the right renal tumor showed clear cell carcinoma. This was considered to be a case of a solitary metastatic bladder tumor from renal cell carcinoma.

We evaluated the usefulness of our original all-in-one clinical pathway for transurethral resection of the prostate (TUR-P) on 86 consecutive patients. There were 27 consecutive patients treated before introduction of the clinical pathway (group 1). Twenty-nine consecutive patients were treated just after the introduction of the clinical pathway (group 2) and 30 consecutive patients were treated one year after the introduction of the clinical pathway (group 3). Our pathway includes all items such as vital sign charts and events charts. Although the hospitalization ranged from 5 days to 12 days after introduction of the clinical pathway, the average length of hospital stay was shortened by 2.6 days in group 3. Although the duration of the postoperative indwelling urethral catheter ranged from 2 days to 7 days in the groups 2 and 3, the average duration was approximately 4 days in group 3. Postoperative complications did not differ among the three groups. The medical insurance claims decreased with the introduction of the clinical pathway. Our all-in-one clinical pathway is considered to be a good tool for not only reduction of health care costs but also giving higher quality and better service to patients.

A 67-year-old woman underwent abdominal ultrasonography as part of a general health examination and was incidentally found to have a mass 5 cm in diameter in the left adrenal gland. She had no experience of abdominal trauma. Computerized tomography (CT) revealed a 5.5 x 5.0 cm mass in the left adrenal gland, which was heterogeneously enhanced by the contrast medium. Hormanal data for adrenal function were all within the normal range. For the suspected non-functioning adrenal tumor, the patient underwent adrenalectomy. Histopathological examination demonstrated only hematoma without tumor cells.

Five patients with metastatic testicular cancer of advanced extent according to the Indiana University criteria were enrolled into this study. All tumors were non-pretreated non-seminomas. Initially all patients were treated with standard dose etoposide, ifosfamide and cisplatin (VIP) regimen. The response of two cycles of VIP was evaluated by tumor markers and diagnostic imagings. Two of the five patients showed a good response to VIP and subsequently achieved a pathological complete response (pCR) following surgical resection of residual masses after 3 or 5 courses of VIP. However, they suffered from severe myelosuppression and underwent peripheral blood stem cell transplantation (PBSCT) following the final course of VIP. The remaining three patients unlikely to be cured by VIP underwent chemotherapy consisting of high dose ICE:ifosfamide (6-10 g/m2 over 4days) carboplatin (1, 500 mg/m2 over 4 days), etoposide (1, 600-2, 400 mg/m2 over 4 days) combined with PBSCT. This regimen resulted in one partial response (PR) with marker-negative and two PR with marker-positive. Residual masses were removed in all three patients and viable tumor cells were found in two. Of the five patients enrolled, four patients (80%) remain disease-free with minimal follow-up of 20 months, and the remaining one died of cancer 10 months after PBSCT. No serious side effects or complications were encountered. This study shows that standard dose induction therapy of VIP followed by early salvage chemotherapy of high dose ICE with PBSCT is well tolerated and effective in the treatment of advanced poor-risk testicular cancer.

We report a case of squamous cell carcinoma of ureter. A 60-year-old female was referred to our hospital for the right hydronephrosis and the left atrophic kidney. She had been suffering from severe renal dysfunction and had hemodialysis a month earlier. Retrograde and antegrade right pyelography revealed complete obstruction of the right lower ureter about 2 cm in length. Transcutaneous retrograde left pyelography revealed vesicoureteral junction stenosis. After improvement of the renal function by transcutaneous right nephrostomy, the patient underwent right partial ureterectomy. Pathological examination revealed squamous cell carcinoma, grade 2, pT3 in the right ureter. Neither local recurrence nor distant metastasis has occurred for 19 months and the patient retains moderate renal function. We reviewed sixty-four cases of ureteral squamous cell carcinoma in the Japanese literature and discussed the renal parenchymal sparing surgery for the disease.

A 63-year-old man was admitted to our hospital with complaints of right lower abdominal pain and stone excretions. The patient was diagnosed as having a pelvic kidney associated with staghorn calculus and extended pyelolithotomy was to be performed. However, during the operation, a papillary tumor was found in the renal pelvis occupied with staghorn calculus. As the pathological examination of its frozen section was low grade transitional cell carcinoma, nephro-ureterectomy was performed. Pelvic kidney associated with staghorn calculus or renal pelvic tumor with stones is not rare, but pelvic kidney associated with staghorn calculus and renal pelvic cancer is extremely rare.

We experienced four cases of benign hemorrhagic renal cyst which were indistinguishable from cystic renal cell carcinoma on ultrasonography, computer tomographic scanning, magnetic resonance imaging and angiography. Nephrectomy was performed in one case and enucleation of the mass in the other three. Pathological diagnoses were hemorrhagic septate cyst in two cases, cyst with inflammation containing old blood clots in one, and organized hemorrhagic cyst with calcification in one. Conservative surgeries should be considered when the definite diagnosis for renal hemorrhagic cysts is not made.

A 71-year-old man who had undergone a total cystectomy and a transureterocutaneostomy more than a year earlier was admitted to our hospital on February, 1992 because of the chief complaints of anorexia and systemic bone pain due to multiple bone metastases of bladder cancer. At two weeks after the admission, he had a sudden attack of dyspnea. His chest reontgenogram revealed no significant abnormalities. He had repeated attacks and died of respiratory failure two days after the first attack. An autopsy disclosed diffuse microscopic pulmonary tumor emboli in the pulmonary arteries and arterioles of bilateral lungs, but there was no parenchymal metastasis. The metastatic lesions in the sinusoids of the liver were also occupied by numerous tumor emboli, suggesting that the tumor emboli in the lungs had derived from those in the sinusoids. Microembolization of the whole lung area must be considered as a cause of clinically unexplained dyspnea.

A 47-year-old architect and a 30-year-old designer of audio goods presented with thrombosis of left and right posterior scrotal vein, respectively. Both had scrotal masses associated with a feeling of heaviness. Physical, operative and microscopic findings were similar. The lesions were palpated as nontender, slender, elastic masses and located parallel to the urethra in the posterior aspect of the scrotum. At surgical exploration the lesions appeared to be thrombosis of posterior scrotal vein and were removed. Both patients have remained well one year in one and four months in the other after operation. Pathological diagnosis for both surgical specimens was organized thrombosis of vein with eosinophilic infiltration. Eosinophilic infiltration to lesions in the present cases and the occupation of patients suggested that some immunological disorders and localized venous stasis for long time during their sitting work might relate to the formation of thrombosis in the posterior scrotal vein. To our knowledge this is the first report of thrombosis of the posterior scrotal vein.

Clinical efficacy of sodium imipenem/cilastatin was studied on 45 patients with complicated urinary tract infections, on whom prior antimicrobial agents were ineffective. A 0.5g dose of IPM/CS was administered by drop infusion twice a day for 5 days. The clinical efficacy was evaluated according to the criteria of the Japanese UTI committee. Of a total of 65 strains, 29 strains of gram positive bacteria and 36 strains of gram negative bacteria, were detected as causative microbials. Bacteriologically, 23 strains of gram positive bacteria (79%) and 34 strains of gram negative bacteria (94%) were eradicated following the treatment. S. aureus, E. faecalis and Flavobacterium sp. were less sensitive to IPM/CS. Overall clinical effectiveness rate of IPM/CS in the present study was 87%. Adverse drug side effects were observed in six patients, namely they were eruption, headache and slight elevation of serum transaminase. These findings suggest that IPM/CS is an effective agent for the treatment of complicated UTI even when the prior medicine was ineffective.