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膀胱損傷15例(男9例・女6例, 17～69歳)を対象に損傷原因, 損傷形式, 症状, 検査所見, 診断, 治療法などについて検討した.原因は外傷性損傷10例, 自然損傷5例で, 飲酒状態で受傷した症例が外傷性損傷で6例と高率に認められた.損傷形式は腹膜内損傷9例, 腹膜外損傷6例, 破裂部位は膀胱頂部9例, 前壁5例, 後壁1例であった.肉眼的血尿は9例, 腹痛は9例, 尿閉は4例でみられた.また, 腹膜内損傷10例中4例に, 血中のBUN, Cr上昇を認めた.初期診断で膀胱損傷が疑われたのは7例(46.7%)であった.診断法は膀胱造影6例, 膀胱鏡3例, CT2例, 超音波検査1例であった.合併損傷は外傷性の4例認め, 骨盤骨折が多かった.治療法は開腹による損傷部位の縫合閉鎖11例, 経尿道的留置カテーテル2例であった, Since bladder injury has no specific clinical symptoms, accurate diagnosis at first consultation is relatively difficult. To elucidate the clinical characters type of injury, clinical symptoms, laboratory findings, methods of therapy and diagnosis, we reviewed 15 patients with bladder injury over a 9-year-period 1990-1998 (10 were traumatic injuries and 5 spontaneous injuries). We found no specific clinical symptom of bladder injury. Bladder injury may occur anywhere in the bladder wall, but most commonly occurred at the dome of the bladder (60.0%). Gross hematuria was not seen in 40.0% of the cases. The accuracy of diagnosis at first consultation was relatively low (46.7%) and the tendency to make a misdiagnosis as acute abdomen on digestive organs was found. Of the traumatic injuries 60% were afflicted in the drunken state, so alcohol intoxication was considered as an important enviromental factor of bladder injury. Surgical repair of injury sites was employed in 11 cases (73.3%: 7 were intraperitoneal injuries, 4 were extraperitoneal injuries), 4 cases were managed with indwelling urethral catheter. With appropriate treatment, the prognosis is excellent.

富士市立中央病院泌尿器科における10年間の手術統計を報告した.1)手術総数は10年間で1862件であった.2)疾患別に年間手術件数を比較すると, 悪性腫瘍は1994年以降は年々増加傾向である.前立腺癌は患者の年齢層の問題もあり, 殆ど症例でmedical castrationを施行している.前立腺肥大症に対するTUR-Pは1992年以降, α1-blockerの使用により減少した.尿路結石に対する治療は殆どの症例を外来通院にてESWL単独で施行しているが, 治療中, 入院を要した患者は, 全体のわずか1.2%であった, A 10-year statistic survey was carried out on the operations performed at the Department of Urology, Fuji City General Hospital. The total number of operations was 1, 862 cases during 10 years. The number of operations for malignant tumors has increased since 1994 year after year. Transurethral resection of prostate for benign prostatic hyperplasia has decreased since 1992, with the advent of the alpha 1-blocker. The patients with urolithiasis are being cured by extracorporeal shock wave lithotripsy on an outpatient basis, at our hospital, except in special cases. It was suggested to be safe, so the complications needing admission appeared in only 1.2% of the cases.

症例は72歳男性で, 無症候性血尿を主訴に来院し, 三角部および前壁に膀胱腫瘍を認め経尿道的膀胱腫瘍切除(TUR-BT)を施行した.その後, 1年10ヵ月間に計4回の再発病変に対するTUR-BTを施行した.いずれも有茎性乳頭状腫瘍で, 病理学的にはすべてgrade1～2の表在性の移行上皮癌であり, 再発予防療法としてBCG膀胱内注入療法を初回と第3回術後に, therarubicinを第2回術後に施行した.今回, 膀胱鏡にて右尿管口より間歇的に膀胱内に突出する直径約1cmの乳頭状腫瘍と膀胱頂部粘膜の膨隆を認め, 尿細胞診ではclass Vであった.排泄性腎盂造影・MRI所見から右尿管下端腫瘍および尿膜管嚢胞内腫瘍の術前診断で, 右尿管下端および尿管口周囲の膀胱部分切除と臍尿膜管全摘出および膀胱頂部の膀胱部分切除を施行した.摘出標本の病理組織学的所見から尿膜管移行上皮癌および右尿管癌と診断された.術後経過は良好で, 追加療法は施行せず, 術後10ヵ月現在再発は認めていない, We report a case of transitional cell carcinoma of urachus in a 72-year-old man. At follow up cystoscopy for past history of bladder cancer, we found a papillary tumor in the right orifice that came out to the bladder cavity intermittently. Although there was no cancerous lesion on the surface of the bladder mucosa, a submucosal eminence at the dome of bladder was observed. Sagittal magnetic resonance imaging (MRI) revealed an extravesical tumor (2 cm) at the position of urachus. Under the diagnosis of right ureteral cancer and urachal cancer, we performed right distal ureterectomy, ureteral reimplantation and total resection of urachus. Pathological examination revealed transitional cell carcinoma in the urachus and right ureter. The urachal cavity was isolated completely from the bladder cavity. Tumor infiltrated to the muscularis of the bladder dome from the urachal cavity, but there was no cancerous lesion on the surface of the bladder mucosa. Therefore, our diagnosis was urachal transitional cell carcinoma and right ureteral carcinoma.

症例は45歳女性で肉眼的血尿を主訴とした.左背部痛も出現し増強したため救急外来を受診した.腹部超音波で左腎に径12cmの巨大腫瘍性病変を認め入院した.腹部CTで左腎の巨大腫瘍による強血尿及び貧血と判断し, 安静及び輸血による保存的治療を施行した.腹部CT, MRI, 血管造影等の所見より悪性腫瘍と診断し, 第8肋骨切除で経腹的根治的左腎摘出術を施行した.病理組織所見から色素嫌性腎癌と診断した.色素嫌性腎癌は1974年にラットにおける実験的な腎腫瘍発生モデルで通常の腎細胞癌とは異なる組織像を呈する腫瘍として報告された.わが国における臨床報告例は現在まで9例の報告例があるにすぎない, We report a case of chromophobe cell renal carcinoma. A 45-year-old woman with a chief complaint of macrohematuria and left backache was introduced to our hospital in October 1998. Abdominal computed tomographic scan (CT) revealed a solitary, solid mass (16 x 14 x 12 cm) at the upper pole of the left kidney. Angiography showed a hypervascular character but irregular neovasculizations were found. We performed a radical nephrectomy with a preoperative diagnosis of malignant renal tumor. The cut surface appearance of the tumor was homogeneous, grey-beige and solid. Light microscopic findings revealed voluminous cells with light, but not clear cytoplasm displaying a fine reticular pattern. Histochemical staining with Hale's colloidal iron stain demonstrated a distinctly positive cytoplasmic reaction. Since the ultrastructural study revealed numerous intracytoplasmic microvesicles, we finally reached the diagnosis of chromophobe cell renal carcinoma. We report our case here with reference to the relevant literature.

症例は22歳女で, 肉眼的血尿と右背部痛を主訴とした.画像所見から右腎の悪性腫瘍を強く疑い, 経腹式根治的右腎摘出術を施行した.腫瘍は腎下極にあり, 径5×5×5cmの黄白色・充実性で, 明らかな腎被膜外への進展はみられなかった.顕微鏡学的には, 好塩基性の胞体を有する核細胞質比の大きい上皮性腫瘍細胞の管状及び管状乳頭状の増生がみられ, 一部に芽腫成分を認めた.間葉系成分は少ないものの, ごく一部に分化した軟骨組織を認めた.これらの所見から成人型Wilms' tumorの上皮型と診断した.術後補助療法は患者の強い希望で施行せず経過観察となったが, 術後26ヵ月経過して再発は認めない.本例を加えた成人型Wilms' tumorの報告例16例について臨床的検討を行ったところ, 疼痛や腹部腫瘤, 血尿など何らかの臨床症状を呈した症例が多かった.また, 初診時に隣接臓器への浸潤もしくは血行性遠隔転移を認めた症例が半数近くを占めていた, We present a case report of adult Wilms' tumor and reviewed from 1981. A 22-year-old woman with chief complaints of gross hematuria and right backache was introduced to our hospital in March 1998. Abdominal computed tomography (CT) revealed a solitary irregular mass (5.0 cm) at the lower pole of right kidney with no contrast medium enhancement. Angiography showed a hypovascular character, but irregular vascularization was found in the tumor. We performed a radical nephrectomy with a preoperative diagnosis of malignant renal tumor. Finally, adult Wilms' tumor (epithelial type) was diagnosed by pathological examination. We retrospectively studied the clinical and radiological features in 16 reported cases of adult Wilms' tumor from 1981. The average age was distinctly younger than that of renal cell carcinoma. Nearly half of the cases were at an advanced clinical stage (direct invasion or metastasis to other organs) at first consultation. Radiologically, Wilms' tumor tends to be visualized as a low density mass in the precontrast CT scan (75.0%) and hypovascular tumor by selective angiography (84.6%). Although this is not a definitive character to distinguish adult Wilms' tumor from renal cell carcinoma, it may be useful information for differential diagnosis.

肝障害の発生率は33/123で, 64%の症例は9ヵ月以内に発症していた.独立項目のχ二乗検定によるとBMI, 肝障害の既往, GPTの高値の3項目が肝障害の発生に有意と判定された.SASによる多変量解析による検討では, 肝障害の既往とGPTの高値が肝障害を増加させ, 喫煙経験が肝障害を低下させる, The antiandrogenic drug, flutamide (Odyne), is widely used in the treatment of carcinoma of prostate. It is well known that flutamide has adverse effects of liver disorders. To ascertain the risk of liver disorders before administering this drug, past history and lifestyle preferences were resurveyed in 123 patients who had been treated with flutamide. The results obtained were assessed in relation to the occurrence of liver disorders by multivariate logistic regression analysis. The incidence of liver disorders was 26% (33/123), with 64% of the disorders occurring within 9 months. The chi-square test for dependent variables revealed that three variables, i.e., body mass index, past history of liver disorders and elevated glutamic-pyruvic transaminase levels were significantly related to the incidence of liver disorders (p > 0.05). Multivariate analysis indicated that a history of liver disorders and elevated alanine aminotransferase (ALT) levels were related to a higher incidence of liver disorders. Elevated ALT levels were associated with a higher incidence of liver disorders and smoking was related to a lower incidence of the liver disorders.

64歳女, 皮下腫瘍を契機に受診し, 術前に診断しえた腎脂肪性置換例, および71歳女, 繰り返す腎盂腎炎を契機に偶然診断された腎脂肪性置換例を報告した。診断にはCTが最も有用であり, MRIの普及は診断をさらに正確にすると考えられた, Two cases of replacement lipomatosis of the kidney are reported. One patient was a 64-year-old woman who presented with pain caused by a subcutaneous abscess in the back as the chief complaint. Replacement lipomatosis of the kidney associated with staghorn calculi was diagnosed by computerized tomography (CT) and magnetic resonance imaging (MRI), and nephrectomy was performed. The other patient was a 71-year-old woman whose chief complaint was repeated episodes of pyelonephritis. Staghorn calculi and severe renal dysfunction were diagnosed, and nephrectomy was performed. In both patients, pathological examination revealed marked hyperplasia of adipose tissue in the renal sinus which consisted of mature fat cells, and replacement lipomatosis of the kidney was diagnosed. CT is useful in the diagnosis of this disease, and MRI provides further confirmation.

A 37-year-old woman presented to our hospital with the chief complaints of stroke and sudden onset of pain in the left flank. An abdominal ultrasonogram showed a solid tumor and abdominal CT revealed a tumor 3 cm in diameter and a capsule with a heterogeneous interior at the left lower pole of the kidney. This tumor was accompanied by retroperitoneal hemorrhage. Selective left angiogram showed an avascular tumor with an artery entering the region surrounding the tumor itself. Based on the above mentioned findings, rupture of a renal angiomyolipoma was suspected. However, renal cancer could not be ruled out. Surgery was performed. At operation, a frozen section showed no malignancy, and partial nephrectomy was performed. The tumor measured 3.0 x 3.5 x 3.5 cm, and had a capsule that was 3 mm thick; its interior was filled with brown necrotic tissue mixed with red-brown coagulated blood. The histological diagnosis was a tubulo-papillary renal adenoma, but since the inside of the tumor had undergone extensive necrosis a well-differentiated adenocarcinoma could not be excluded. A renal adenoma manifesting clinical symptoms is rare, and this case of pain caused by retroperitoneal hemorrhage is the first to be reported in Japan. It is difficult to diagnose renal adenoma by preoperative imaging and intraoperative frozen section examination. Diagnosis is considered to be difficult in some cases even when examining permanent specimens. Therefore, the type of surgery used in affected patients should also be investigated in the future.

59歳男.発熱, 右背部痛を主訴とした.KUBで右尿管U1の部位に直径4×4mm右尿管結石が認められた.超音波検査で右腎はごく軽度に水腎症を呈していた.入院後敗血症ショックを呈し, 直ちに昇圧剤(Dopamine)の投与と抗生剤をIPM/CSに変更した.昇圧剤の増量を行ったが血圧は上昇せず, 血液検査では著明なleukocy tosisおよび敗血症に伴う凝固能の低下を認めた.敗血症性ショックの改善及びエンドトキシンの除去を目的にエンドトキシン吸着カラムを用いてエンドトキシン吸着療法を施行した.吸着開始後約1時間で次第に血圧の上昇を認め昇圧剤の減量が可能となった.再度吸着療法を施行し, 同日にショックから離脱した.自然排石が確認された.尚, 入院時血液及び尿培養からいずれも大腸菌が検出され, 敗血症の原因菌と同定した, Although septic shock has a high mortality rate of 43%, recently the endotoxin adsorption column was established and its efficacy is interesting. We report a very effective case of endotoxin adsorption the rapy for septic shock due to acute pyelonephritis. A 59-year-old man with chief complaints of pyrexia and right backache was referred to our hospital with a small right ureteral stone (4 mm) associated with a low degree of right hydronephrosis. Since it was diagnosed as right acute pyelonephritis, antibiotics were administered; and then septic shock occurred on the day of hospitalization. Endotoxin adsorption therapy was performed for two days and hemodynamic stability was achieved. The concentration of blood endotoxin was reduced remarkably and the efficacy of endotoxin adsorption therapy was suggested.

Since bladder injury has no specific clinical symptoms, accurate diagnosis at first consultation is relatively difficult. To elucidate the clinical characters type of injury, clinical symptoms, laboratory findings, methods of therapy and diagnosis, we reviewed 15 patients with bladder injury over a 9-year-period 1990-1998 (10 were traumatic injuries and 5 spontaneous injuries). We found no specific clinical symptom of bladder injury. Bladder injury may occur anywhere in the bladder wall, but most commonly occurred at the dome of the bladder (60.0%). Gross hematuria was not seen in 40.0% of the cases. The accuracy of diagnosis at first consultation was relatively low (46.7%) and the tendency to make a misdiagnosis as acute abdomen on digestive organs was found. Of the traumatic injuries 60% were afflicted in the drunken state, so alcohol intoxication was considered as an important enviromental factor of bladder injury. Surgical repair of injury sites was employed in 11 cases (73.3%: 7 were intraperitoneal injuries, 4 were extraperitoneal injuries), 4 cases were managed with indwelling urethral catheter. With appropriate treatment, the prognosis is excellent.

A 10-year statistic survey was carried out on the operations performed at the Department of Urology, Fuji City General Hospital. The total number of operations was 1, 862 cases during 10 years. The number of operations for malignant tumors has increased since 1994 year after year. Transurethral resection of prostate for benign prostatic hyperplasia has decreased since 1992, with the advent of the alpha 1-blocker. The patients with urolithiasis are being cured by extracorporeal shock wave lithotripsy on an outpatient basis, at our hospital, except in special cases. It was suggested to be safe, so the complications needing admission appeared in only 1.2% of the cases.

We report a case of chromophobe cell renal carcinoma. A 45-year-old woman with a chief complaint of macrohematuria and left backache was introduced to our hospital in October 1998. Abdominal computed tomographic scan (CT) revealed a solitary, solid mass (16 x 14 x 12 cm) at the upper pole of the left kidney. Angiography showed a hypervascular character but irregular neovasculizations were found. We performed a radical nephrectomy with a preoperative diagnosis of malignant renal tumor. The cut surface appearance of the tumor was homogeneous, grey-beige and solid. Light microscopic findings revealed voluminous cells with light, but not clear cytoplasm displaying a fine reticular pattern. Histochemical staining with Hale's colloidal iron stain demonstrated a distinctly positive cytoplasmic reaction. Since the ultrastructural study revealed numerous intracytoplasmic microvesicles, we finally reached the diagnosis of chromophobe cell renal carcinoma. We report our case here with reference to the relevant literature.

We report a case of transitional cell carcinoma of urachus in a 72-year-old man. At follow up cystoscopy for past history of bladder cancer, we found a papillary tumor in the right orifice that came out to the bladder cavity intermittently. Although there was no cancerous lesion on the surface of the bladder mucosa, a submucosal eminence at the dome of bladder was observed. Sagittal magnetic resonance imaging (MRI) revealed an extravesical tumor (2 cm) at the position of urachus. Under the diagnosis of right ureteral cancer and urachal cancer, we performed right distal ureterectomy, ureteral reimplantation and total resection of urachus. Pathological examination revealed transitional cell carcinoma in the urachus and right ureter. The urachal cavity was isolated completely from the bladder cavity. Tumor infiltrated to the muscularis of the bladder dome from the urachal cavity, but there was no cancerous lesion on the surface of the bladder mucosa. Therefore, our diagnosis was urachal transitional cell carcinoma and right ureteral carcinoma.

We present a case report of adult Wilms' tumor and reviewed from 1981. A 22-year-old woman with chief complaints of gross hematuria and right backache was introduced to our hospital in March 1998. Abdominal computed tomography (CT) revealed a solitary irregular mass (5.0 cm) at the lower pole of right kidney with no contrast medium enhancement. Angiography showed a hypovascular character, but irregular vascularization was found in the tumor. We performed a radical nephrectomy with a preoperative diagnosis of malignant renal tumor. Finally, adult Wilms' tumor (epithelial type) was diagnosed by pathological examination. We retrospectively studied the clinical and radiological features in 16 reported cases of adult Wilms' tumor from 1981. The average age was distinctly younger than that of renal cell carcinoma. Nearly half of the cases were at an advanced clinical stage (direct invasion or metastasis to other organs) at first consultation. Radiologically, Wilms' tumor tends to be visualized as a low density mass in the precontrast CT scan (75.0%) and hypovascular tumor by selective angiography (84.6%). Although this is not a definitive character to distinguish adult Wilms' tumor from renal cell carcinoma, it may be useful information for differential diagnosis.

Although septic shock has a high mortality rate of 43%, recently the endotoxin adsorption column was established and its efficacy is interesting. We report a very effective case of endotoxin adsorption the rapy for septic shock due to acute pyelonephritis. A 59-year-old man with chief complaints of pyrexia and right backache was referred to our hospital with a small right ureteral stone (4 mm) associated with a low degree of right hydronephrosis. Since it was diagnosed as right acute pyelonephritis, antibiotics were administered; and then septic shock occurred on the day of hospitalization. Endotoxin adsorption therapy was performed for two days and hemodynamic stability was achieved. The concentration of blood endotoxin was reduced remarkably and the efficacy of endotoxin adsorption therapy was suggested.

The antiandrogenic drug, flutamide (Odyne), is widely used in the treatment of carcinoma of prostate. It is well known that flutamide has adverse effects of liver disorders. To ascertain the risk of liver disorders before administering this drug, past history and lifestyle preferences were resurveyed in 123 patients who had been treated with flutamide. The results obtained were assessed in relation to the occurrence of liver disorders by multivariate logistic regression analysis. The incidence of liver disorders was 26% (33/123), with 64% of the disorders occurring within 9 months. The chi-square test for dependent variables revealed that three variables, i.e., body mass index, past history of liver disorders and elevated glutamic-pyruvic transaminase levels were significantly related to the incidence of liver disorders (p > 0.05). Multivariate analysis indicated that a history of liver disorders and elevated alanine aminotransferase (ALT) levels were related to a higher incidence of liver disorders. Elevated ALT levels were associated with a higher incidence of liver disorders and smoking was related to a lower incidence of the liver disorders.

Two cases of replacement lipomatosis of the kidney are reported. One patient was a 64-year-old woman who presented with pain caused by a subcutaneous abscess in the back as the chief complaint. Replacement lipomatosis of the kidney associated with staghorn calculi was diagnosed by computerized tomography (CT) and magnetic resonance imaging (MRI), and nephrectomy was performed. The other patient was a 71-year-old woman whose chief complaint was repeated episodes of pyelonephritis. Staghorn calculi and severe renal dysfunction were diagnosed, and nephrectomy was performed. In both patients, pathological examination revealed marked hyperplasia of adipose tissue in the renal sinus which consisted of mature fat cells, and replacement lipomatosis of the kidney was diagnosed. CT is useful in the diagnosis of this disease, and MRI provides further confirmation.

A 37-year-old woman presented to our hospital with the chief complaints of stroke and sudden onset of pain in the left flank. An abdominal ultrasonogram showed a solid tumor and abdominal CT revealed a tumor 3 cm in diameter and a capsule with a heterogeneous interior at the left lower pole of the kidney. This tumor was accompanied by retroperitoneal hemorrhage. Selective left angiogram showed an avascular tumor with an artery entering the region surrounding the tumor itself. Based on the above mentioned findings, rupture of a renal angiomyolipoma was suspected. However, renal cancer could not be ruled out. Surgery was performed. At operation, a frozen section showed no malignancy, and partial nephrectomy was performed. The tumor measured 3.0 x 3.5 x 3.5 cm, and had a capsule that was 3 mm thick; its interior was filled with brown necrotic tissue mixed with red-brown coagulated blood. The histological diagnosis was a tubulo-papillary renal adenoma, but since the inside of the tumor had undergone extensive necrosis a well-differentiated adenocarcinoma could not be excluded. A renal adenoma manifesting clinical symptoms is rare, and this case of pain caused by retroperitoneal hemorrhage is the first to be reported in Japan. It is difficult to diagnose renal adenoma by preoperative imaging and intraoperative frozen section examination. Diagnosis is considered to be difficult in some cases even when examining permanent specimens. Therefore, the type of surgery used in affected patients should also be investigated in the future.

Recently, we encountered 9 cases of urachal tumor and conducted clinical studies on its diagnosis and treatment. The chief complaint was gross hematuria in all cases. Computed tomographic scan was performed in 7 cases, and in all cases it revealed a tumor between the dome of the bladder and the Retzius' cavity. This finding strongly suggested a urachal tumor before pathological study. Magnetic imaging resonance (MIR) was performed in one of the 9 cases, and it indicated the extent of the tumor more clearly than computed tomography. Partial cystectomy + en bloc removal of the umbilicus and urachus was performed in 5 cases, radical cystectomy + en bloc removal of the umbilicus and urachus was performed in 2 cases, and radical cystectomy was performed in 2 cases. As postoperative therapy, radiotherapy was administered to 4 cases, and chemotherapy was administered to 4 cases. One case died from cancer after 4 years and 10 months, while the other 8 cases are being treated on an outpatient basis without any local recurrence. All 5 patients who underwent partial cystectomy are alive (mean survival time: 97 months). Thus we believe that cure can be achieved by partial cystectomy and adjuvant therapy. In addition, serum carcinoembryonic antigen is thought to be useful as an indicator of residual tumor or local recurrence.