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We report three patients with frequent febrile urinary tract infections (fUTI) who underwent transurethral injection therapy with Deflux for vesicoureteral reflux (VUR). The first case was in a 52-yearold woman who was initially diagnosed with right grade II and left grade I VUR at 18 years of age. She frequently experienced fUTI due to VUR. The second case was in a 29-year-old woman. At age 23, she was diagnosed with right grade III VUR when she developed fUTI. After that, she repeatedly developed fUTI. The third case was in a 40-year-old woman who had frequently experienced fUTI since 25 years of age and had gradually become antibiotics-resistant. She was diagnosed with right grade III VUR when she was referred to our hospital. No visible reflux was confirmed by postoperative voiding cystourethrography after the patients underwent transurethral injection using Deflux. One patient developed fUTI once after surgery, but there were no perioperative complications and no recurrences. Transurethral injection using Deflux for VUR might therefore be safe and effective for treating VUR in adult female patients.

Hyponatremia is one of the common electrolyte disorders associated with cisplatin (CDDP) administration. We report here two cases of hyponatremia associated with CDDP. Case 1 : A 75-year-old man with urothelial carcinoma of bladder (cT3N1M0) underwent neoadjuvant chemotherapy with CDDP and gemcitabine. He lost consciousness on the eighth day after the chemotherapy. Blood tests showed severe hyponatremia (Na 113 mEq/l), low plasma osmolality and high level of plasma vasopressin. Urine tests showed low osmolality. These findings were consistent with the syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH). His consciousness level was improved after saline infusion and fluid restriction. Case 2 : A 54-year-old man with penile cancer (cT3N2M0) underwent neoadjuvant chemotherapy with CDDP, paclitaxel and fluorouracil. He lost consciousness on the seventh day after the chemotherapy. Blood tests showed hyponatremia(Na 121 mEq/l) with renal dysfunction. We concluded that the hyponatremia is due to the renal salt wasting syndrome (RSWS) based on renal dysfunction and high urinary sodium excretion. His consciousness level was improved after saline infusion. Although it is difficult to distinguish between SIADH and RSWS, correct evaluation is necessary for appropriate management of hyponatremia after CDDP administration.

We examined the value of pre-biopsy magnetic resonance imaging (MRI) for detecting prostate cancer. We analyzed 267 men with prostate-specific antigen (PSA) levels of 3-10 ng/ml who underwent systematic prostate needle biopsy. From April 2009 to March 2011, a total of 98 male patients underwent 16-core prostatic biopsies without pre-biopsy magnetic resonance imaging (MRI) (nonenforcement group). From April 2011 to March 2013, 169 men underwent pre-biopsy MRI [T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI)] (enforcement group). When MRI findings indicated cancer in the latter group, in addition to the systematic 16-core biopsy one or two targeted biopsies were performed. Patients without suspicious MRI findings underwent only systematic 16-core biopsy. Cancer detection rates in the nonenforcement andenforcement groups were 42.9% (48/92) and46. 2% (78/169), respectively. The difference did not reach significance (p＝0.612). Although the cancer detection rates were 39.4% (41/104) in the MRI-negative group and56. 9% (37/65) in the MRI-positive group (p＝0.039), the sensitivity and specificity for cancer detection by MRI were relatively low : 47.4% and 69.2%, respectively. By receiveroperating curve analysis, the area under the curve for cancer detection by MRI was only 0.583. There were two study limitations. First, the patient sample size was small. Second, it is unclear whether an adequate sample of the suspicious lesion was obtained by biopsy. We thus demonstrated that it might be improper to base a diagnosis solely on pre-biopsy MRI (T2WI and DWI) findings in men with serum PSA levels of 3-10 ng/ml.

Introduction. Adrenal hemangioma is a rare disease, with only some 60 cases reported previously. Due to the difficulty of the preoperative diagnosis of adrenal hemangioma, almost all of the cases were diagnosed by a histopathological analysis of surgical specimens. Case Presentation. A 52-year-old man was referred to our department for further examination of his left retroperitoneal tumor. He had received hemodialysis due to chronic renal failure resulting from membranous nephropathy. Computed tomography revealed a mass around his left hilum. Magnetic resonance imaging (MRI) and positron-emission tomography (PET)-CT were unable to confirm or deny malignancy, and tumor markers, including CEA and CA19-9, showed slight elevation. His tumor grew from 38 mm to 54 mm in diameter in 7 months of follow-up. We therefore planned retroperitoneal tumor resection with left nephrectomy. Histopathologically, hyperplastic small vessels with hemorrhaging and denaturation were seen. The endothelial cells showed no variants or division of the nucleus. Based on this diagnosis, no further therapy was performed. He has had no recurrence in the eight months since the surgery. Conclusion. We herein report a rare case of adrenal hemangioma.

Our patient was a 31-year-old man who presented with right flank pain. Computed tomography revealed multiple tumors in the liver and lungs, with marked elevation of serum human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) levels. In addition, no testicular abnormalities were detected by palpation or ultrasonography. On the bases of these results, the patient was diagnosed with extragonadal germ cell tumor and was therefore started on chemotherapy with bleomycin, etoposide, and cisplatin (BEP). However, the result of a subsequent blood test showed marked pancytopenia at the initial stage of treatment. We speculated that the cause of anemia was not only bone marrow suppression but also intratumoral hemorrhage, collectively termed choriocarcinoma syndrome. After conservative treatment involving blood transfusion and administration of granulocyte colony-stimulating factor, he recovered. After several chemotherapy sessions, the levels of all tumor markers returned to normal. Finally, the patient underwent hepatectomy for residual tumors ; but, the resected specimen showed no viable cancer cells. Currently, the patient is free from disease since the last chemotherapy session, administered 5 months ago.

Introduction. Xanthogranulomatous pyelonephritis (XGP) is a type of chronic renal inflammation that usually occurs in immunocompromised middle-aged women with chronic urinary tract infection or ureteral obstruction induced by the formation of ureteral stones. XGP with an incomplete double ureter is extremely rare. Case Presentation. A 76-year-old woman was referred to our department to undergo further examination for a left renal tumor that was detected by ultrasonography. Dynamic contrast computed tomography (CT) revealed an enhanced tumor in the upper renal parenchyma. Laparoscopic radical nephrectomy was performed based on a preoperative diagnosis of renal cell carcinoma. Histological sections showed the aggregation of foam cells; thus, XGP was diagnosed. Conclusion. We herein report a rare case of XGP in the upper pole of the kidney, which might have been associated with an incomplete double ureter.

A 75-year-old man with advanced bladder cancer (cT4N1M0) received three courses of systemic chemotherapy with Methotrexate, Epirubicin and Nedaplatin (MEN). His metastatic lymph node completely disappeared. We performed total cystectomy. Three months after the surgery, he complained of neck pain and nausea. Brain magnetic resonance imaging (MRI) revealed a 3 cm tumor in his right cerebella and a 5 mm tumor in left parietal lobe. He underwent surgical resection of the right cerebellar tumor and a gamma knife therapy for the left parietal tumor. Pathological diagnosis was metastatic urothelial carcinoma. We performed three additional courses of chemotherapy of MEN. He has been well without local recurrence or distant metastasis for 18 months.

手術を行った褐色細胞腫38症例を対象に, 術中の血圧変動を予測する因子を検討するために尿中カテコールアミン代謝産物を測定した。副腎外発生例は6例で, 全例に高血圧を認めた。そのうち, 尿中カテコールアミンを測定した5例は全てノルアドレナリン分泌優位型(NAd型)であった。術前に高血圧を33例(87%)に認め, 発作性高血圧(発作型:12例・持続発作型:9例)が21例(64%), 持続型高血圧は12例であった。アドレナリン分泌優位型(Ad型)は発作性高血圧(発作型・持続発作型)19例中10例(52.7%), NAd型は持続型高血圧・正常型15例中9例(60%)であった。術中に血圧変動がみられたのは15例で, 発作型:73%, 持続発作型:75%, 持続型:40%, 正常型:0%であった。また, 24時間蓄尿中のバニリルマンデル酸(VMA)は血圧安定群14例に比べ, 有意に高値であった。24時間蓄尿中のカテコールアミン代謝産物の測定, 術前の高血圧分類, 尿中VMA分泌量は術中の血圧変動の予測因子と考えられた。, Pheochromocytoma is a rare tumor of chromaffin tissues most commonly arising from the adrenal medulla. We retrospectively reviewed the records of 38 patients with pheochromocytoma who underwent surgical treatment between 1977 and 2004 at our Yokohama City University Medical Center and Yokohama City University Hospital. Twenty two patients (57.9%) were females and 16 (42.1%) were males. The most frequent symptoms were headache (58%). One patient had bilateral adrenal tumors and pathological examination revealed malignant pheochromocytoma. Six patients had an extra-adrenal tumor and in 2 patients the tumor occurred in the urinary bladder. Twelve patients (31.6%) had sustained hypertension, 21 patients (55.3%) had paroxysmal hypertension and 5 patients (13.1%) remained normotensive. The 24-h urinary total metanephrines and vanillylmandelic acid (VMA) were the most sensitive biochemical tests for the diagnosis of pheochromocytoma. The sensitivity of urinary total metanephrines was 92.0% for all the patients and was 92.3% for the patients without paroxysmal hypertension. Fifteen patients had intraoperative hypertensive reactions in the surgical manipulation or hypotension after tumor resection. This group had more urinary excretion of VMA before surgery, compared with that with stable intraoperative blood pressure (p < 0.005).

Decrease in serum prostate specific antigen (PSA) concentration is inevitably associated with antiandrogen therapy for benign prostatic hyperplasia (BPH), and might mask the presence of prostate cancer or delay its diagnosis. To determine the appropriate timepoint for determination of correct PSA value, we sequentially measured serum PSA and testosterone levels after discontinuation of antiandrogen therapy for BPH. With informed consent, 12 patients (72.8 +/- 12.2* years old) with BPH were treated with allylestrenol 50 mg/day for 4 months. Serum testosterone and PSA concentrations were determined before and just after treatment, as well as every month after treatment up to 3 months. After treatment with allylestrenol for 4 months, mean serum testosterone and PSA levels were significantly decreased from 408 +/- 136* to 87.9 +/- 76.2* ng/dl, and from 2.81 +/- 0.87* to 2.04 +/- 0.82* ng/ml, respectively. The mean serum PSA level recovered to the pretreatment level within 2 months and mean serum testosterone concentration within one month after discontinuation of administration. In conclusion, during treatment of BPH with antiandrogen allylestrenol, a two-month washout is adequate for determination of correct PSA value (*: M +/- SD)., 前立腺肥大症をアンチアンドロゲン剤にて治療するとテストステロンの低下にともないPSAが低下する.これにより前立腺癌の診断が遅れることが危惧されている.しかしながら, アンチアンドロゲン剤の中断後4ヵ月で, 両者とも完全に前値に復することをすでに報告した.PSA4.0ng/ml以下の前立腺肥大症の症例においてアンチアンドロゲン剤中断後のテストステロンとPSAの変化を経時的に観察し, 治療前値に復するまでに要する期間につき検討した.症例は平均72.8±2.2歳前立腺肥大症(前立腺体積:36.7±7.9ml)患者でアンチアンドロゲン剤による治療およびテストステロン, PSAの経時的採血に文書同意を得た12症例である.アリルエストレノール50mg/dayを4ヵ月間投与した.これを中断後1ヵ月ごとに採血してテストステロンとPSAを経時的に観察した.アリルエストレノールの投与4ヵ月でテストステロンは低下し, これに伴いPSAも有意に低下した.治療の中断後1ヵ月でテストステロンは前値に復し, PSAは中断後2ヵ月でほぼ前値に復した.以上より, 前立腺肥大症のアリルエストレノールによる治療中に正確なPSA値を知るために必要なアリルエストレノールのwashout期間は, ほぼ2ヵ月であることが示唆された(著者抄録)

We report three patients with frequent febrile urinary tract infections (fUTI) who underwent transurethral injection therapy with Deflux for vesicoureteral reflux (VUR). The first case was in a 52-yearold woman who was initially diagnosed with right grade II and left grade I VUR at 18 years of age. She frequently experienced fUTI due to VUR. The second case was in a 29-year-old woman. At age 23, she was diagnosed with right grade III VUR when she developed fUTI. After that, she repeatedly developed fUTI. The third case was in a 40-year-old woman who had frequently experienced fUTI since 25 years of age and had gradually become antibiotics-resistant. She was diagnosed with right grade III VUR when she was referred to our hospital. No visible reflux was confirmed by postoperative voiding cystourethrography after the patients underwent transurethral injection using Deflux. One patient developed fUTI once after surgery, but there were no perioperative complications and no recurrences. Transurethral injection using Deflux for VUR might therefore be safe and effective for treating VUR in adult female patients.

A 58-year-old man visited our hospital with gross hematuria. Cystoscopy revealed a papillary tumor around the left ureteral orifice. Transurethral resection of bladder tumor (TUR-Bt) was performed and histopathological findings revealed a nested variant ofurothelial carcinoma. Computed tomography (CT) revealed no involvement ofother organs. Laparoscopic radical cystectomy and orthotopic neobladder substitution (Studer methods) were performed. The histopathological stage was pT3aN0M0. Adjuvant chemotherapy (gemcitabine＋cisplatin) was performed. The patient is currently free from disease at five months after the surgery.