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A 55-year-old female presented to the hospital with a complaint of gross hematuria. Transurethral resection of bladder tumor was performed. The specimens pathologically showed signet ring cells and no urothelial carcinoma components. Magnetic resonance imaging and computed tomographic (CT) scan revealed bladder tumor, cervical metastasis, bilateral ovarian metastasis, and multiple lymph node metastasis. She was diagnosed with a primary signet ring cell carcinoma of the urinary bladder with cT3bN2M1, and was treated with chemotherapy of gemcitabine and cisplatin combination (GC). After 2 cycles of GC, the value of CEA which was elevated to 106 ng/ml before treatment, became negative. CT scan showed that her disease had successfully responded to the chemotherapy, and remained efficacious till the end of 6 cycles. The patient subsequently received 1 cycle of gemcitabine and nedaplatin and 3 cycles of avelumab due to renal insufficiency. Yet, 14 months after diagnosis, cerebellar metastases appeared and the patient died of meningeal carcinomatosis.

A 71-year-old man was referred to our hospital for treatment of a 2 cm-sized right renal mass incidentally found by computed tomography (CT) and was diagnosed with right renal cell carcinoma cT1aN0M0. Contrast-enhanced CT revealed that the aorta was completely occluded below the inferior mesenteric artery origin, and Leriche syndrome was diagnosed. CT angiography showed several collateral arteries along the abdominal wall. A robot-assisted laparoscopic partial nephrectomy was performed to treat renal cell carcinoma. Preoperatively, we marked the collateral arteries using ultrasonography to avoid injury during trocar insertion. We did not observe any decrease in blood flow in the right leg during the operation. The pathological diagnosis was clear cell renal cell carcinoma. Leriche syndrome is a chronic occlusive disease involving the infrarenal aorta and the iliac arteries. Since lower limb blood flow is dependent on collateral circulation, it is important to avoid injuring the collateral arteries during surgery., 本論文の要旨は，第240回日本泌尿器科学会関西地方会にて発表した．

A 41-year-old female who suffered local recurrence of cervical cancer after receiving chemoradiotherapy underwent radical hysterectomy, radical vaginal resection, and pelvic and paraaortic lymph node dissection. After surgery, bilateral hydronephrosis due to right ureteral stenosis and left uretero-vaginal fistula occurred. We therefore placed a bilateral ureteral stent. Thereafter, we continued to replace the bilateral ureteral stent once every 3 months, but the replacement of the right ureteral stent became impossible three years after the initial placement. We thus performed bilateral upper urinary tract reconstruction using an ileal ureter with the aim of both eliminating the left ureteral vaginal fistula and resolving the right ureteral stricture.

A 79-year-old woman who presented with right hydronephrosis was referred to our hospital. Abdominal computed tomography (CT) showed a right ureteral tumor (cT3N0M0). Right nephroureterectomy and partial cystectomy were performed. Pathological examination revealed small cell carcinoma (mixed type ; INFb, pT3, ly1, v1, u-rt0, ur0, RM0). Cystoscopy showed intravesical recurrence of the tumor 3 months after the surgery. Transurethral resection was performed, and histopathological examination revealed small cell carcinoma (pT2). We recommended postoperative chemotherapy ; however, the patient and her family refused consent for chemotherapy. Liver and lymph node metastases developed, and the patient died 2 months after the transurethral resection.

A 72-year-old female with left renal cell carcinoma and lymphadenopathy had undergone hand-assisted laparoscopic left nephrectomy and dissection of the lymph node (papillary renal cell carcinoma, type 2, pT3a pN2 M1). She had been treated with adjuvant chemotherapy with sunitinib, temsirolimus and pazopanib. However, the patient was started on nivolumab due to disease progression. After receiving 5 cycles of nivolumab, she was admitted to our emergency room for chest discomfort and appetite loss. Since computed tomographic (CT) scan showed pericardial effusion, we performed pericardiocentesis. Cytological examination of the pericardial effusion demonstrated leukocytes and no malignant cells. CT scan two weeks after cardiocentesis showed no recurrent pericardial effusion. She became stable with nivolumab, but the administration of nivolumab was discontinued and she started receiving axitinib.

Most upper tract urothelial carcinomas (UTUC) are muscle invasive at the time of diagnosis. Current standard methods for the diagnosis of UTUC are invasive. Urine cytology is the only non-invasive test for detecting UTUC, but its sensitivity is low. A novel non-invasive assay for UTUC detection would improve patient outcome. This study aimed to investigate the mutation of cell-free DNA (cfDNA) in urine supernatant to develop a reliable diagnostic biomarker for UTUC patients. We studied urinary cfDNA from 153 individuals, including 56 patients with localized UTUC, and carried out droplet digital PCR assay for TERT promoter and FGFR3 hotspot mutations. We could detect mutations of TERT C228T in 22/56 (39.3%), TERT C250T in 4/56 (7.1%), and FGFR3 S249C in 9/56 (16.1%) patients. FGFR3 mutation was detected only in ≤pT1 tumors (positive predictive value: 100.0%). In combination with cytology results, the sensitivity was 78.6%, and the specificity was 96.0%. Although these data need to be validated in a larger-scale cohort, mutation analysis of TERT promoter and FGFR3 in urinary cfDNA has the potential to be a non-invasive diagnostic marker and reliable factor for tumor staging.

We report two cases of clear cell adenocarcinoma arising in the urethral diverticulum. Case 1 occurred in a 79-year-old woman presenting with complaints of frequent micturition. Magnetic resonance imaging (MRI) revealed a localized urethral diverticular tumor. Transurethral resection of the tumor was performed, and the final histopathological diagnosis was clear cell adenocarcinoma. Anterior pelvic exenteration was performed. She had no recurrence 15 months after surgery. Case 2 occurred in a 79-year-old woman presenting with urinary incontinence. As in Case 1, MRI and histopathological findings of transurethral resection of the tumor revealed clear cell adenocarcinoma in the urethral diverticulum. Anterior pelvic exenteration and ileal conduit formation were performed. She had no recurrence 16 months after surgery. Clear cell adenocarcinoma in the urethral diverticulum is very rare. We review 17 cases of clear cell adenocarcinoma arising in the urethral diverticulum in Japan.

Poorly differentiated ureteral cancer has a poor prognosis, and tumor recurrence is frequent even after nephroureterectomy. We performed neoadjuvant chemotherapy to prevent postoperative recurrence. A 74-year-old man was diagnosed with ureteral cancer (3 cm) by magnetic resonance imaging (MRI). The clinical stage was T4N1M0. Histological examination by transurethral biopsy revealed an urothelial carcinoma, G3, pT1. After a month, the tumor size increased from 3.0 cm to 4.0 cm. With two cycles of neoadjuvant chemotherapy consisting of methotrexate, vinblastine, epirubicin and cisplatin (MVEC) partial remission (regression rate : 87%) was achieved, Following MVEC, right retroperitoneoscopy-assisted nephroureterectomy, total cystectomy, and ileal conduit were performed. Pathological stage was pT0. After two years, postoperative recurrence has not appeared.

A 61-year-old woman was diagnosed with left renal cell carcinoma. Clinical stage was cT1bN0M0. She underwent retroperitoneoscopic radical nephrectomy. The pathological diagnosis was clear cell carcinoma, pT1b, G1＞G2, INFα, v(+). At 33 months postoperatively CT demonstrated an enhancing tumor just under the port site for evacuation route of the kidney. The tumor was removed by surgery. The pathological diagnosis was clear cell carcinoma. The patient had no recurrence or metastasis 21 months after the surgery.

A 58-year-old woman wasfound to have a tumor of the left kidney by ultrasonography and x-ray at a medical examination. Computed tomography showed a mass with calcification adjacent to the left kidney. The patient was successfully treated with open nephrectomy. Pathological examination revealed the malignant fibrous histiocytoma (MFH) arising from the renal capsule, striform-pleomorphic type, low grade malignancy. She wasfree of disease at fourteen monthspos toperatively. To our knowledge, thisisthe 26th case of MFH arising from the renal capsule in Japan.

A 62-year-old man was suffering from asymptomatic gross hematuria. Abdominal computed tomography demonstrated a horseshoe kidney and renal pelvic tumor in the left kidney. Open nephrectomy with division of the isthmus was performed. The pathological diagnosis was urothelial carcinoma, grade 2＞ grade 3, pT3. He is free of disease at 13 months after operation. To our knowledge, in Japan, this is the 33th case of renal pelvic tumor in a horseshoe kidney.

Systemic cisplatin-based chemotherapy regimens are the gold standard in advanced bladder cancer. Gemcitabine plus cisplatin (GC) therapy has often been used, although there is no significant evidence that it is better than methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) therapy in neoadjuvant chemotherapy. We retrospectively evaluated the relative efficacy of the two chemotherapeutic regimens in the management of muscle-invasive bladder cancer on patients who had had radical cystectomy for clinical stage T2-T4, N and, M0 bladder cancer. Fourteen patients (24.1%) and 44 (75.9%) patients were treated with GC and MVAC therapy, respectively. GC therapy was significantly more effective than MVAC therapy in pathological down-staging (to pT0) rate. On multivariate analysis, the choice of regimen (MVAC) was an independent predictor of the presence of residual cancer after a neoadjuvant chemotherapy. The clinical response to neoadjuvant GC therapy was superior to that to neoadjuvant MVAC therapy. Moreover, GC therapy was associated with less non-hematologic toxicity than MVAC therapy, especially with respect to the occurrence of nausea.

A 46-year-old man underwent total cystectomy and Indiana pouch urinary diversion for bladder cancer in 2001. Pathological examination revealed an urothelial carcinoma of the bladder (pT2N0M0). He was referred to our hospital for bilateral hydronephrosis in June 2009. Cytological examination of the urine was negative. Percutaneous nephrostomy was performed, and we suspected bilateral ureteral tumors from pyelo-ureterography. Percutaneous ureteroscopy revealed a papillary tumor in the right ureter. Since there appeared to be a papillary tumor in the left ureter, we decided to perform ureterectomy for bilateral ureteral tumors, and to keep the bilateral nephrostomy tube for urinary diversion. Pathological examination revealed urothelial carcinoma in bilateral ureters. There has been no sign of recurrence at 17 months after the operation.

A 45-year-old woman underwent abdominal simple hysterectomy and sacrocolpopexy with polypropylene mesh (GYNEMESH) for uterine prolapse at the department of Gynecology in October 2006. One month after the operation, she visited our department with a complaint of urinaryincontinence. Cystographyand magnetic resonance imaging revealed a vesicovaginal fistula. A foleycatheter was indwelt for the purpose of conservative treatment, but failed. Considering possible infection and inflammation remaining, we decided to perform abdominal repair of the vesicovaginal fistula about three months after the operation. Transabdominal repair of the vesicovaginal fistula was performed in February2007. During the operation, a fistula 3 mm in diameter was confirmed just adjacent to the distal edge of the polypropylene mesh which had been fixed between the bladder and the anterior wall of vagina. Eleven days after the operation, cystography revealed no evidence of the vesicovaginal fistula. There has been no sign of recurrence at three years after the operation.

A 64-year-old male was referred to our hospital with a prostate tumor accompanying a huge prostatic cyst. He had been followed up for 10 years by another urologist, and received several prostate biopsies, which failed to make a definite diagnosis. We carefully reviewed the biopsy slides and diagnosed the lesion as prostatic stromal tumor of uncertain malignant potential (STUMP). We performed radical prostatectomy. From the excised specimen, we confirmed the diagnosis of prostatic STUMP. Eight months later, there was no sign of metastasis or recurrence.

A 79-year-old man was admitted to our hospital with a chief complaint of pollakisuria. He was diagnosed as having bladder tumors and bladder stone by cystoscopy. Transurethral resection of bladder tumors (TURBT) and transurethral cystolithotripsy were performed and histology revealed non-muscleinvasive hepatoid adenocarcinoma that produced alpha-fetoprotein (AFP) and urothelial carcinoma. The serum AFP level was present at a high level of 39.08 ng/ml. After five months’ follow up, recurrent tumor were detected in the bladder. TURBT was performed and the pathologic finding showed non-muscleinvasive (not hepatoid) adenocarcinoma that produced AFP. After eight months’ follow up, a recurrent tumor was detected in the bladder again. TURBT was performed and the pathologic finding showed nonmuscle- invasive urothelial carcinoma. However, the serum AFP level remained above 35 ng/ml. After the 3rd TURBT, intravesical intillations were performed, which led to a normalization of the serum AFP level. Nineteen months after his final hospitalization, the patient has had no evidence of recurrence.

症例1(69歳男性)。13年前に膀胱癌(CIS)に対するBCG膀胱内注入療法が施行され, 約9ヵ月前より前立腺癌に対し内分泌療法が開始されたが, 顕微鏡的血尿が出現した。症例2(83歳女性)。肉眼的血尿を主訴とした。症例3(84歳男性)。無症候性肉眼的血尿を主訴とした。いずれの症例も膀胱鏡にて膀胱左壁または右壁に非乳頭状広基性腫瘍が認められ, TURBTが行われた。その結果, 3症例とも病理組織学的に膀胱小細胞癌であった。症例1はpT2N0M0にてirinotecan+carboplatinによる化学療法を3コース施行し, CRが得られたが, 化学療法終了16ヵ月後に前立腺癌の悪化のため死亡となった。症例2はpT2N0M0にて膀胱部分切除術を施行し, 術後6ヵ月経過で再発転移はみられていない。症例3はcT3bN0M1にてetoposide+carboplatinによる化学療法を4コース施行したところ, 腫瘍は縮小し, 現在は経過観察中である。, We report three cases of small cell carcinoma of the urinary bladder. Case 1: A 69-year-old man showed microscopic hematuria during follow up of prostate cancer of stage D2. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage of pT2N0M0. Complete remission was achieved by three courses of chemotherapy consisting of irinotecan and carboplatin. The patient was died by prostate cancer 16 months after the chemotherapy. Case 2: An 83-year-old woman presented with macroscopic hematuria. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage of pT2N0M0 and partial cystectomy was performed. The patient has been alive without any evidence of tumor recurrence at 6 months after surgery. Case 3: An 84-year-old man presented with macroscopic hematuria. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage ofcT3bN0M1 with multiple liver metastases. Complete remission was achieved by three courses of chemotherapy consisting of etoposide and carboplatin.

症例1(69歳男性)。左鼠径部腫脹を主訴とした。左鼠径ヘルニアの診断で経過観察されていたが, 左鼠径部から陰嚢にかけて弾性軟・表面平滑・圧痛のない腫瘤が触知された。MRIを施行したところ, 左陰嚢内に精巣を圧迫する脂肪分に富んだ多房性の腫瘍が認められた。症例2(63歳男性)。排尿困難を主訴とした。触診で左陰嚢内に小鶏卵大の腫瘤を指摘され, MRIにて左鼠径部から陰嚢内に到る脂肪分に富んだ腫瘍が認められた。両症例ともリンパ節転移ならびに遠隔転移は認めず, 左精索腫瘍の診断のもとに, 左精巣・精索を一塊として摘除した。病理組織学的所見では脂肪滴の大小不同とクロマチン濃染の異型核をもつlipoblastの増殖がみられ, 高分化型脂肪肉腫と診断された。症例1は残存腫瘍が存在し追加切除術を施行し, 症例2には追加治療は行わなかった。いずれも目下, 術後3～5年経過で再発は認められていない。, Liposarcomas are most commonly found in the extremities, in the retroperitoneum and, less often, in the head and neck area. The spermatic cord is a rare site of origin, accounting for about 3-7% of all liposarcomas. We report two cases of liposarcoma of spermatic cord. Case 1. A 69-year-old male presented with complaints of a painless left inguinal mass. MRI showed a huge fatty mass in the left inguinal region. The mass was removed with left testis and spermatic cord. Histopathological examination revealed a well-differentiated and dedifferentiated liposarcoma. The surgical margin was positive, so re-resection was performed. Complete excision was achieved after re-resection. Case 2. A 63-year-old male with the difficulty urinating had a left scrotal mass. Left radical orchiectomy was performed. Histopathological examination revealed a well-differentiated liposarcoma. These are the 84th and 85th cases of liposarcoma of the spermatic cord reported in Japan.

26歳男性。患者は左側腹部の腫瘤を主訴とした。受診時, 左側腹部に小児頭大の腫瘤が触知され, 腹部CTおよびMRIにて後腹膜の神経原性腫瘍が疑われた。後腹膜腫瘍摘出術を施行したところ, 病理組織学的に後腹膜発生の非機能性Paragangliomaと診断され, 術後9ヵ月が経過した現在, 再発・転移はみられず, 経過は良好である。, Paragangliomas are rare neuroendocrine tumors that arise from hyperplastic paraganglionic cells and occur in or near the ganglia of the autonomic nervous system. Paragangliomas are classed as either functional or nonfunctional based on production of catecholamines. We report a case of retroperitoneal nonfunctional paraganglioma, which was successfully resected. A 26-year-old man presented with complaints of a mass palpable in his left lateral region. Blood and urine studies, including catecholamines, were within normal limits. Computed tomography and magnetic resonance imaging showed a solid cystic mass in the left retroperitoneal space without any distant metastasis. On exploration, there was an encapsulated, vascular mass 10 cm in diameter. There was no pedicle and no connection of the tumor to the abdominal or retroperitoneal organs. Complete excision of the tumor was performed smoothly. The postoperative period was uneventful. Histological findings were of paraganglioma, and there was no surgical margin. The patient did not receive any further treatment. Nine months after surgery, there were no signs of tumor recurrence.

77歳男。主訴は膀胱移行上皮癌術後の腫瘍の再発であった。MRIでは膀胱頸部から後壁にかけて広範囲に腫瘍を認め, 前立腺への浸潤も疑われ, 経尿道的膀胱腫瘍切除術を施行した。組織診断はsarcomatoid carcinomaで, 膀胱全摘除術および右尿管皮膚瘻造設術を施行した。病理組織学的に腫瘍は明らかな上皮性の像を示す部分と異型性の強い肉腫様成分で構成され, 免疫組織学的検査では肉腫様成分で, 同一細胞がサイトケラチンとビメンチンを発現していた。術翌月に肺転移が出現し急速に増悪して1ヵ月後に死亡した。病理解剖では肉腫様成分のみで占められる両側胸膜播種性多発性転移と, 上皮性成分と肉腫様成分が混在する骨盤内局所再発を認めた。, A 77-year-old man was admitted to our hospital for a scheduled examination after transurethral resection of transitional cell carcinoma of urinary bladder. Tumor reccurence was found in the bladder by cystoscopic examination. Total cystectomy and unilateral cutaneous ureterostomy were performed. Histologically the tumor was composed of epithelial and sarcomatous elements. Therefore, we diagnosed this tumor as sarcomatoid carcinoma. The patient died of lung metastasis three months after operation. Autopsy findings showed lung metastasis and local reccurence which were composed of carcinomatous and sarcomatous elements. About 64 cases of sarcomatoid carcinoma of the urinary bladder have been reported in the Japanese literature and are reviewed briefly here.

58歳男。感冒症状で頸部リンパ節腫脹を指摘され, リンパ節摘除施行され, 組織診でN/C比大の異型細胞の増殖を認め, 低分化癌の転移を疑われた。腹部造影CTで右内腸骨動脈の内側に, 境界明瞭で内部に線状の石灰化を持つ5.0×4.0cmの腫瘍を認めた。造影では早期相で著しくenhanceされ, 後期相でwash outした。他臓器に異常所見はなく, 骨髄生検では正常骨髄であった。神経原性腫瘍を疑い, 後腹膜腫瘍摘除術を施行した。病理組織所見で, リンパ節の構造は保たれ, 濾胞は縮小し, 濾胞間組織にヒアリン化と毛細血管の増生を認めた。胚中心の萎縮がみられ, ヒアリン化物質の沈着と毛細血管の侵入を認めた。濾胞間組織にはリンパ球を認めたが, plasma cell typeにみられる細胞はなかった。Castleman's disease, hyaline vascular typeと診断した。右頸部リンパ節の低分化癌についてはリンパ節郭清術を行い, 他のリンパ節の組織診に悪性所見はなかった。術後4ヵ月経過し, 再発兆候はない。, Although Castleman's disease may occur in any lymph node of the body, it is the most commonly found in the thoracic cavity. Castleman's disease rarely occurs in the pelvic cavity and only 18 such cases have been reported. We report a case of pelvic Castleman's disease. A 57-year-old man was referred for evaluation of a pelvic tumor. The tumor was surgically resected and the histopathological diagnosis of the resected tissue was hyaline vascular type of Castleman's disease. No evidence of disease was detected five months post-operatively.

A 75-year-old man was admitted to our hospital with a complaint of fever and backpain. He was diagnosed with acute pyelonephritis, and was administered an antibiotic. However, since there was no improvement in the symptoms, he was admitted to our hospital. Computed tomography revealed a tumor which was in contact with a thoracic vertebra. Because he had had a total cystectomy for bladder cancer in the past, we suspected a spinal metastasis of urothelial carcinoma. However, after magnetic resonance imaging, we finally diagnosed it as pyogenic spondylodiscitis, and his condition improved after administration of antibiotics.

16歳男。左陰嚢内容腫大, 同部の疼痛が出現した。陰嚢内容は鵞卵大, 弾性硬で, 腹部CTでは左腎下極の高さで傍大動脈に径3cmのリンパ節腫大を複数認めた。精巣腫瘍の診断で左高位精巣摘除術を施行し, 腫瘍は傍精巣に存在していた。病理学的に腫瘍の精巣への浸潤は認めず, 高度の異型を示す紡錘形細胞が存在し, 紡錘形細胞の細胞質に明らかなstriationを確認した。傍精巣横紋肉腫の診断で, 後腹膜リンパ節転移の存在よりintergroup rhabdomyosarcoma study(IRS)のgroup IIと考えた。IRSのレジメンなどを参考に多剤併用化学療法を開始し, 3ヵ月後の腹部CTでは傍大動脈リンパ節の転移は縮小してPRと評価された。5ヵ月後に後腹膜リンパ節郭清術を施行し, 術中所見で傍大動脈領域に腫大したリンパ節を3個認め, 組織診断では残存腫瘍を認めるもののわずかであった。IRSレジメンに準じてVA療法を施行したが, 1年4ヵ月後に腹部に巨大な腫瘍を認めるようになった。トポテカン・シスプラチンなどによる化学療法を行うも無効であり, 死亡された。, We report a case of paratesticular rhabdomyosarcoma in a 16-year-old male. The patient with a mass in the right scrotum was at first diagnosed with testicular tumor. Right orchiectomy revealed paratesticular rhabdomyosarcoma. Para-aortic lymph node metastasis was pointed out by abdominal computed tomography. Although he received multidrug chemotherapy consisting of vincristine, adriamycin, cyclophosphamide, cisplatin, and actinomycin-D (IRS-III regimen 35 and IRS-IV regimen) without radiotherapy, he died twenty-one months after the operation.

78歳男。4年前に前立腺癌に対し前立腺全摘除術を施行し, その後放射線療法を行ったが, 4ヵ月前より肉眼的血尿を認め膀胱タンポナーデ状態に陥った。硬性膀胱鏡外筒による経尿道的圧迫止血および経尿道的電気凝固術(TUC)により一旦は止血したが, 2週間後膀胱出血による凝血塊のため尿閉をきたし入院した。尿道カテーテルを留置のうえ生理食塩水による膀胱内持続灌流を開始し, 2度にわたりTUCを行ったが肉眼的血尿の改善は見られなかった。水酸化アルミニウム・マグネシウム合剤(マーロックス)50～100mlによる膀胱内注入療法を計12日間施行した結果, 施行開始8日目には肉眼的血尿がほぼ消失し, 入院31日目に退院した。退院15日後に静脈性出血を再発したが, マーロックス注入療法を7日間施行し肉眼的血尿は消失した。その後12ヵ月経過して肉眼的血尿の再発は認めていない。, A 77-year-old man was admitted to our hospital due to macrohematuria and bladder tamponade. Bladder hemorrhage caused by radiation therapy had not improved after bladder lavage, intravesical drip infusion, medication of hemostatics, and transurethral coagulation. Bladder hemorrhage had completely disappeared 7 days after the intravesical instillation of 50-100 ml aluminium hydroxide gel and magnesium hydroxide for an hour per day. This method is easy and can be performed without complications. This method might be useful as first-line therapy in the case of severe bladder hemorrhage.

33歳男性。患者は血尿および失神を主訴に近医を受診, 救急入院となり, 膀胱鏡にて球部尿道に出血を伴うびらんを認め, 精査加療目的に著者らの施設へ紹介入院となった。静脈性腎盂造影・腹部CTおよび生検では異常所見は認められず, 陰茎MRIにて外因性による尿道損傷が疑われた。一方, 失神の原因検索を行うも明らかな異常所見は認めず, 入院後も尿道よりの出血を伴う失神発作を繰り返した。失神する場所が常に個室トイレであること, バルーンカテーテル留置中は尿道出血だけでなく失神発作も起こさないこと, 明らかな原因疾患がないことより, 自慰行為を含めた自傷行為が強く疑われた。確定診断には至らなかったが, 繰り返す出血に対し対症療法にて経過観察を行ったところ, 偶然ウエストポーチの中より血液の付着した塗り箸がみつかり, これによる自傷行為と判明した。精神科による検査の結果, ミュンヒハウゼン症候群の診断に至り, 患者は精神病院へ転院となった。, A 33-year-old man presented with urethral bleeding and syncope. Urethroscopy revealed erosive lesion with bleeding at bulbar urethra. Magnetic resonance imaging, biopsy, and blood examination were performed, but the cause of urethral bleeding was not identified. By accident, chopsticks with blood ware detected in his ward. It was revealed that urethral bleeding was caused by self-mutilation with chopsticks. He consulted a psychiatrist, and was diagnosed with 'munchausen's syndrome'.