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A 52-year-old man was referred to our hospital for evaluation of painless right scrotal swelling persisting for 3 months. Palpation detected swelling and induration centered on the head of the upper epididymis, and ultrasonography revealed a blood-filled nodular mass at the same site continuing to the spermatic cord. No abnormalities were observed in the bilateral testes. Blood tests were negative for tumor markers such as α fetoprotein and human chorionic gonadotropin-β. Right radical inguinal orchiectomy was performed, and the pathological diagnosis was dedifferentiated liposarcoma of the spermatic cord. Although the spermatic cord stump was negative, the peri-spermatic cord stump, which had an exfoliated surface, was positive. No residual tumor was found on magnetic resonance imaging, but the tumor was suspected to remain. Thus, after approximately 1month, the tissue around the spermatic cord was resected. Eight months after the initial operation, no recurrence was observed. Here, we report a case of dedifferentiated liposarcoma of the spermatic cord, which is relatively rare, and review the related literature.

We report a case of primary central nervous system lymphoma (PCNSL) in an 81-year-old man who had undergone radical cystectomy with an ileal conduit urostomy due to a diagnosis of muscle-invasive bladder cancer. The postoperative diagnosis was invasive urothelial carcinoma (pT2bN1M0, stage IV). Gemcitabine-cisplatin therapy was provided as adjuvant chemotherapy, and there was no recurrence during follow-up. Four years after surgery, he visited the emergency department because of weakness of the lower extremities and stuttering. He was found to have a parietal lobe mass on magnetic resonance imaging (MRI) and hospitalized with suspicion of brain metastasis. Despite examination by a neurosurgeon, it was not possible to make a clinical diagnosis, and the patient gradually deteriorated and died 21 days later. The pathology results were diagnostic of PCNSL.

We report a case of dialysis kidney with multiple renal carcinomas in three locations. A 74-year-old man who had a 20-year history of dialysis, was admitted to our hospital complaining of sudden right lateral area pain. Computed tomography (CT) scan revealed hemorrhage from the right dialyzed renal subcapsule. He underwent immediate transcatheter arterial embolization (TAE), but after 6 days the CT scan showed new active bleeding. A second TAE was performed, but, the CT scan several days later showed hemorrhage from the same site. So we decided to perform a right radical nephrectomy. Pathological results revealed three different renal carcinomas at sites different from the bleeding site. The presence of triple carcinomas in the same organ of the kidney is quite rare. Because of the high incidence of renal carcinoma associated with polycystic kidney disease in long-term hemodialysis patients and the possibility of multiple carcinomas as in this case, radical nephrectomy is recommended even in the case of spontaneous rupture.

A 74-year-old woman with gross hematuria for 3 months was referred to our hospital. Contrast-enhanced computed tomographic scan showed a mass on the upper-right renal calyx, and retrograde pyelography showed stenoses from the renal pelvis to the renal calyx infundibulum. We performed an endoscopic biopsy, which led to a diagnosis of urothelial cancer. Therefore, she underwent total right nephroureterectomy, and pathological examination revealed a clear cell variant of invasive urothelial carcinoma. Irradiation was performed mainly on the renal arteriovenous stump 2 months postoperatively; subsequently, three courses of combination chemotherapy comprising gemcitabine plus cisplatin (GC) were administered. Port-site recurrence and pelvic recurrence were observed 22 months after the operation, and GC therapy and pembrolizumab were administered. However she died 36 months after the operation. The clear cell variant of invasive urothelial carcinoma of the upper urethra is rarely reported. Moreover, since this was a very rare case, we have included a literature review in our report.

A 75-year-old woman visited our hospital with left lumber pain and fever. Symptoms, and computed tomography imaging revealed left pyelonephritis. Then she was admitted to our hospital for treatment. She improved with tazobactam and piperacillin PIPC infusion immediately and was discharged from the hospital. After that she visited our hospital twice with the same symptoms and was given hospital treatment. A second retrograde pyelography (RP) was performed urgently, and the diagnosis was left ureteral sciatic hernia. Then we placed a left ureteral stent. Three months later, we confirmed that the hydronephrosis was improved and removed the stent. Six months after stent removal, recurrence has not been observed.

A 65-year-old man received docetaxel for prostate cancer. Eight months later, we observed abdominal free air and pneumatosis cystoides intestinalis by computed tomography. Pneumatosis cystoides intestinalis can be caused by various etiologies. However, in the present case, multiple factors could have contributed and we could not specify the exact cause. We reduced the dose of steroid hormone, stopped docetaxel, and followed the patient conservatively with oral antibiotics. The pneumatosis cystoides intestinalis and free air resolved promptly.

Choroidal and central nervous system metastases from prostate cancer are extremely rare. We report a case of choroidal and brain metastases from castration-resistant prostate cancer (CRPC). A 75-year-old male patient with metastatic CRPC presented with a 1-week history of a decrease in visual acuity in his left eye. An ophthalmoscopic examination revealed a choroidal tumor, 4 disc diameters across with serious retinal detachment. He was diagnosed with metastatic choroidal tumor from examination and patient's background. The external beam radiation therapy of total 30 Gy was successful and his visual acuity was improved. Three courses of chemotherapy with docetaxel (55 mg/m2) were performed, but finally he was found to have multiple brain metastases 4 months later. His headache disappeared after palliative whole brain radiotherapy, but he died 3 months after diagnosis of brain metastases. Although choroidal and brain metastases from prostate cancer are very rare, it is important for urologists to listen to the patient's complaints and consider the possibility of these rare metastases in patients with advanced cancer.

A 62-year-old man presented to our hospital with the chief complaint of continuous penile pain and swelling for 4 months. Computed tomography and magnetic resonance imaging showed an invasive bladder tumor with penile, bone, and lymph node metastases. Needle biopsies of the bladder and penile lesions were obtained, and histological evaluation of these specimens revealed urothelial carcinoma, findings which are consistent with invasive bladder cancer with penile metastasis. After several therapeutic options were discussed with the patient, he decided toundergogeneral chemotherapy. However, the patient died about 16 days after admission without treatment because of his poor general condition.

An 8-month-old girl with Diamond Blackfan syndrome and idiopathic neutropenia needed steroid therapy for anemia, but the left multicystic dysplastic kidney was often infected. We performed laparoscopic nephrectomy for infection control without any complications. Neutrocytes increased and the infection decreased after nephrectomy even with steroid therapy. Finally, she underwent bone marrow transplantation, as the anemia was not responding to steroid therapy.

A 75-year-old male undergoing hemodialysis because of diabetic nephropathy was referred to our hospital complaining of high fever and swelling of the left kidney. Our initial clinical diagnosis was severe pyelonephritis. He was initially treated with intravenous antibiotics and his clinical symptoms subsequently improved but only temporarily. The high fever soon recurred, accompanied by progressive thrombocytopenia. His general condition deteriorated despite conservative treatment. He then underwent nephrectomy of the left kidney. However, the thrombocytopenia persisted and his general condition did not improve. The pathological diagnosis was malignant lymphoma (non-Hodgkin's lymphoma, diffuse large B-cell type). He received chemotherapy, but his status rapidly deteriorated and he died 1.5 months after the operation. Primary renal malignant lymphoma is very rare, because the kidney lacks lymphatic tissue.

The patient was a 75 year-old male. Noticing areas of hardening in the lower abdomen, and consequently feelings of systemic fatigue and difficulty in walking, the patient visited a clinic and was diagnosed with kidney failure prior to the visit to our clinic. Computed tomography and magnetic resonance imaging showed thickness of the rectus abdominis muscle and the bladder wall, and bilateral hydronephrosis was also identified. As no explicit tumor was identified in the bladder, the patient underwent biopsies of the abdominal wall and bladder membrane mucous, and was diagnosed with a plasmacytoid urothelial carcinoma primarily developed in the bladder. The patient displayed a poor general state of health and died five months after the diagnosis. It is known that plasmacytoid urothelial carcinomas progress rapidly and the prognosis is poorer than for the micropapillary variant. It is important to obtain a tissue specimen in the early stage of this disease because there are cases in which no explicit tumor can be identified. Furthermore, the value of carbohydrate antigen (CA) 19-9 of the patient was much higher than would be expected as normal at the first visit. It kept rising during the follow-up and was useful as a marker to indicate the progress of the disease.

A case of vesico-appendiceal fistula caused by appendiceal cancer is reported. A 37-year-old male was admitted with the chief complaint of suspended dust in the urine. Under cystoscopy, a tumor (1 cm diameter) was found in the right posterior wall of the bladder. Transurethral resection of the bladder tumor was performed. The pathological outcome was intestinal metaplasia without malignancy. Preoperative abdominal computed tomography suggested vesico-appendiceal fistula, retrospectively. Therefore, appendectomy with partial cystectomy was attempted. However, the appendix was adhered to the sigmoid mesocolon, therefore, appendectomy, partial cystectomy, and sigmoid colectomy were performed. We diagnosed the tumor as mucinous adenocarcinoma. The patient has been receiving adjuvant chemotherapy with tegafur-gimeracil-oteracil potassium for 17 months, because he refused right hemicolectomy. There was no evidence of recurrence after 58 months of follow-up. Vesico-appendiceal fistula caused by appendiceal cancer is very rare. Our case is the 21st case reported in Japan.

We report a case of percutaneous bacillus Calmette-Guérin (BCG) perfusion therapy for carcinoma in situ (CIS) of upper urinary tract after radical cystectomy with ileal neobladder. A 42-year-old man underwent radical cystectomy and ileal neobladder diversion due to the recurrence of CIS in prostatic urethra after transurethral resection of bladder tumor 3 times and 2 courses of intravesical BCG therapy. Final pathological findings showed the presence of CIS in the right distal ureteral margin. After the radical cystectomy, our diagnosis was CIS in the right residual ureter, because of positive urine cytology and negative radiographic findings in the upper urinary tract. We performed the percutaneous BCG perfusion therapy for CIS of the right upper urinary tract after the construction of the percutaneous nephrostomy by intentionally inducing hydronephrosis. No recurrence was found after 3 years of BCG perfusion therapy.

The patient was a 78-year-old female. At the age of 76, the patient had undergone computed tomographic scanning for left lower abdominal pain. A retroperitoneal mass was detected on the right side of the abdomen. The patient had been subject to right nephrectomy due to renal calculus at the age of 33. With Doppler echocardiography and magnetic resonance imaging (MRI), based on the nephrectomy the patient was diagnosed with a renal arteriovenous fistula developed in the right renal bed. Following the wishes of the patient a follow-up examination was conducted. Because of poor heart condition and renal dysfunction, percutaneous arterial embolization was performed. After the embolization, the heart condition and renal dysfunction indicators improved and the blood flow in the arteriovenous fistula disappeared. Cases of renal arteriovenous fistulae after nephrectomy are rare, with only 90 reported worldwide, and percutaneous arterial embolization has been used as the first choice of treatment in recent years.

We report a case of a pediatric Wilms' tumor presenting after a right renal injury. A 6-year-old girl presented to a nearby hospital with right back pain after a fall. An abdominal computed tomography (CT) scan revealed a right renal injury with active hemorrhaging. She was then referred to our hospital. There another CT scan and a magnetic resonance imaging (MRI) scan revealed the disappearance of the active hemorrhaging but also the presence of a large renal tumor. We performed a right nephrectomy. The renal tumor was diagnosed as a nephroblastoma. Considering dissemination by trauma, chemotherapy and radiation therapy were performed.

A 70-year-old male presented with intermittent macroscopic hematuria. There was no history of previous trauma or pelvic operation. At first, we were unable to clarify the origin of the hematuria, but 3D computed tomography revealed an arteriovenous malformation (AVM) consisting of multiple feeding vessels arising from the bilateral, especially right, internal iliac artery. Treatment with transcatheter arterial embolization (TAE) with a combination of lipiodol and N-butyl-2-cyanoacrylate twice was effective. He needs to be followed up carefully for recurrence of AVM.

A 66-year-old man with a history of sporadic von Recklinghausen' s disease was treated for pseudosarcomatous myofibroblastic proliferation in the bladder. The patient had a history of repetitive recurrence of bladder carcinoma requiring transurethral resection (TUR) 4 times and 1 course of intravesical BCG instillation. Three months after the fourth TUR, an intravesical solid mass 4 cm in diameter was detected. Suspicion of recurrent bladder carcinoma led to a fifth TUR procedure. Pathological findings showed submucosal growth of myofibroblasts with myxoidal stroma and we made a diagnosis of Pseudosarcomatous myofibroblastic proliferation. The patient was well with no evidence of recurrence after 1 year.

Progress has been made in the diagnosis and treatment of urolithiasis over the last 10 years, after the first version of the Guidelines on Urolithiasis was published in December 2002. Considering such a situation, the revised version is due for publication soon. At this symposium, 3 persons who were engaged in the revision of the guidelines presented its digest. The revised version is characterized by the adoption of a "Frequently asked questions style", aiming to facilitate its usage as a reference book or dictionary readers can refer to when a question is raised in practice. It may be possible to further promote the medical treatment of urolithiasis by effectively using this in combination with the relatively textbook-like first version.

In Japan, the number of patients with urolithiasis has continued to increase at a faster rate, with a lifetime morbidity in 2005 of 15.1% for males and 6.8% for females, possibly due to : 1) westernization of dietary habits and lifestyle, 2) improvement of diagnostic technologies (CT and ultrasound examination), and 3) aging of the population. Additionally, this disease has a higher recurrence rate ; for example, approximately 50% for calcium-containing calculi. The guidelines on urolithiasis consist primarily of the guidelines for treatment and recurrence prevention, and the items concerning recurrence prevention were added in the 2007 updated Guidelines on Urolithiasis by the European Association of Urology (EAU) and the American Urological Association (AUA) (EAU/AUA guidelines). These facts reflect the importance of recurrence prevention. On the other hand, the Japanese guidelines on urolithiasis are now being revised and will adopt the form of "clinical questions". This paper provides an overview of the examination methods for recurrence, lifestyle guidance, and drug therapies based on the current guidelines for diagnosis and treatment of urolithiasis as well as the points for clinical questions to be included in the revised guidelines for a deeper understanding and, consequently, return to routine clinical practice.

A 64-year-old man underwent chemotherapy after radical cystectomy for bladder cancer (UC, G3, pT3aN1M0). Three years later, computed tomography showed a left adrenal mass, and we performed left adrenalectomy. Histological findings showed that the adrenal mass was a metastasis of the bladder cancer. Over 6 years after salvage chemotherapy, the patient had no evidence of metastasis to other parts of the body. In the case of a solitary metastasis of bladder cancer, surgical resection should be positively considered.

We herein present a case of a 65-year-old woman who developed severe septic shock following flexible transurethral lithotripsy (f-TUL) showing favourable response after treatment with doripenem and recombinant thrombomodulin (rTM). The patient underwent f-TUL for nephrolithiasis of the left kidney. Preoperative urine culture indicated the presence of a mucoid strain of E. coli that was susceptible to cefazolin ; therefore, the antibiotic cefazolin was administered as a preventive measure. The operation was completed without any specific intraoperative complications. On the day following the operation, blood pressure decreased and clouding of consciousness was observed. Hematological examination showed high levels of procalcitonin, a decrease in platelet count, and high levels of fibrin degradation products (FDP), indicative of severe septic shock and disseminated intravascular coagulation (DIC). The patient was immediately shifted to the intensive care unit (ICU), and multidisciplinary treatment consisting of doripenem (3 g/day) and rTM (380 U/kg) was administered. The medical treatment was successful ; the patient recovered from DIC at an early stage and was able to leave the hospital within 10 days after the operation. The risk of complications is expected to increase with the spread of f-TUL, and prompt action must be taken.

We retrospectively evaluated primary non-muscle-invasive bladder cancer diagnosed between 1999 and 2008 at 2 facilities (Kawasaki Municipal Hospital and Yokohama Minami Kyosai Hospital). Size (< 1 cm) solitary bladder cancer statistically evaluated the characteristics. Out of 463 bladder cancers, 52 were minimum-size solitary pTa bladder cancers less than 1 cm in diameter. The average follow-up period was 50.9 months. The recurrence rate of the minimum-size bladder cancer was significantly lower than that of bladder cancers of other sizes (1 to 3 cm or ≥ 3 cm). The 3-year non-recurrence rate was 80.7,71.0,and 62.9% in each group (< 1, 1 to 3, ≥ 3 cm). High-grade minimum size bladder cancer (pTa) showed a significantly higher recurrence rate than the low-grade cases (P = 0.0101). Intravesical chemotherapy with anti-cancer drugs significantly reduced the intravesical recurrence rate in the low-grade minimum-size bladder cancer group (P = 0.0418). There was no statistically significant difference in either the average recurrence number or the rate of multiple recurrences between the minimum-size tumor group and the 1 to 3 cm tumor group. Minimum size bladder cancer had a lower recurrence rate than tumors of other sizes; however, there were no differences in other characteristics between the groups. Therefore, sufficient treatment, in accordance with the guidelines, should be administered for minimum size tumors as well as tumors of other sizes.

The patient was a 22-year-old woman with a history of tuberous sclerosis who complained of abdominal distention. Computed tomography showed bilateral renal masses with minimal fat tissue that were unlike classical angiomyolipoma (AML), as well as enlargement of the paraaortic lymph nodes, pleural effusion, and ascites, similar to other advanced malignant neoplasms such as renal cell carcinoma and renal sarcoma. We performed a left nephrectomy to relieve the symptoms. A pathological examination revealed that the tumor was composed of polygonal epithelioid cells positive for both αSMA and HMB-45, as well as spindle-shaped cells, while immunoreactivity proved the tumor to be an eAML, a subtype of AML with malignant potential. Although the patient was scheduled for postoperative adjuvant chemotherapy, her condition worsened and she died on postoperative day 24 before receiving chemotherapy. We discuss this case with reference to previous reports.

We retrospectively studied 463 patients with primary non-muscle-invasive bladder cancer diagnosed between 1999 and 2008 at two facilities (Kawasaki Municipal Ida Hospital and Yokohama Minami Kyosai Hospital). In this study, disease progression was defined as invasion to the muscle or further (upstage) and presence of metastasis (metastasis). We detected progression in 22 cases, including 18 upstages and 4 metastasis. Univariate analysis showed that factors associated with progression were T category (pT1 p< 0.0001), grade (high grade p< 0.0001, G3 p< 0.0001) and number of tumors (multiple p=0.0213). Multivariate analysis showed that the only equivocal factor associated with progression was T category (T1). Use of a second tansurethral resection for high-grade pT1 cases was unrelated to progression. Among the patients with progression, many had a more advanced T category at the time of radical treatment, and the results of treatment were poor. The factors associated with progression of bladder cancer should be investigated in more detail, so that early radical treatment can be initiated in eligible patients.

A 75-year-old man consulted a physician because of gross hematuria and right flank pain. Since a bladder tumor and right hydronephrosis were found, the patient was referred to our hospital. The clinical diagnosis was cT3bN0M0 and radical cystectomy was done. The pathological diagnosis was micropapillary variant of urothelial carcinoma, pT3bN0M0. The local recurrence appeared in the interior of the pelvis by computed tomography after the operation. A complete response was obtained by radiotherapy.

Docetaxel-based chemotherapy has been shown to be effective and well tolerated by Japanese patients with metastatic hormone-refractory prostate cancer (HRPC). This study was undertaken to assess the feasibility of docetaxel in combination with UFT (a combination of tegafur and uracil) in Japanese patients with HRPC. Ten patients aged 60-86 years with HRPC, who were pre-treated with hormonal therapy and expected to have more than 3 month survival and without major organ dysfunction, were included in this study. Treatment consisted of docetaxel 70 mg/m2 every 3 weeks plus UFT 260 mg/m2 /day. The primary end point was prostate-specific antigen (PSA) response, and the secondary end points included progression-free survival and toxicity. Nine patients were evaluable for efficacy and toxicity. The PSA response rate was 50% (1 CR and 4 PR). The most common non-hematological adverse events (of any grade) possibly related to treatment were neutropenia and anorexia. Grade 3/4 neutropenia and anorexia occurred in 50 and 20% of patients, respectively. The combination of docetaxel and UFT was feasible and active in Japanese patients with HRPC, with a manageable adverse-event profile similar to that observed in lung cancer chemotherapy.

Urinary stones have an estimated lifetime morbidity of 15.1% in males and 6.1% in females ; in other words, one out of seven males and one out of fifteen females are affected with this disease at least once in their life. Previously, we reported a simple and easy method using microplates to measure the metastable limit (ML), which indicate the upper limit of supersaturation dissolution. In this study, we examined the usability of this microplate method. We confirmed that ML is correlated with the urinary calcium concentration in healthy subjects, single stone formers (SF), and recurrent stone formers (RSF). There was no significant difference between healthy subjects and RSF in urinary magnesium concentration, and ML was found to be correlated with urinary the concentration of oxalate and citrate acid in healthy subjects only. These results suggest that ML is a simple and easy way to measure the urinary calcium level and that ML could be a useful test item in outpatient settings as a convenient indicator for preventing recurrence of urinary stones in the future.

We reexamined the conditions of tissue disorders resulting from temporary ischemia of the organs as well as changes in tissue function and the effects on the preservation of renal function over time by using rat models in order to clinically utilize erythropoietin, which has inhibitory effects on ischemia-reperfusion disorders. In 8- to 9-week-old Wister male rats, after the right kidney had been resected under general anesthesia, the left renal artery was clamped to inhibit the blood flow for 45 minutes. At 30 minutes before inhibiting the blood flow and after releasing the inhibited blood flow, 100 U/kg of recombinant human erythropoietin (rhEPO) was administered via the inferior vena cava and the abdominal cavity, and then the tissues and blood samples were extracted at 6 hours and 24 hours after the release. The renal tissue specimens were evaluated for apoptosis and renal function using hematoxylin eosin staining and TUNEL staining. Changes in the emergence of active oxygen were investigated by using blood samples. The degree of renal dysfunction was evaluated by measuring neutrophil gelatinase-associated lipocalin (NGAL) in the spot urine samples. The changes in the serum creatinine level, showed that the renal function was preserved with a significant difference in the rhEPO administration group. The liver deviation enzymes clearly decreased in the rhEPO administration group. Active oxygen did not change before and after the ischemia-reperfusion nor was it changed by rhEPO administration. Apoptosis was inhibited by rhEPO administration. No direct effects of rhEPO administration on the emergence of active oxygen were observed. The administration of rhEPO, was suggested to help preserve the renal function in marginal donors with a longer agonal stageby effectively.

We evaluated the usefulness of a new shock-wave lithotripsy machine with a dual focus system (large focus : 9x50 mm, standard focus : 6x28 mm), "Modulith SLX-F2" on 361 patients. In the first period, 210 patients, were treated with the large focus, and in the second period, 151 patients were treated with the standard focus. Complications, efficacy and subsequent auxiliary procedures were compared between the first and second periods. The efficacy was evaluated with efficiency quotient (EQ). Administered total energy was displayed with stortz medical lithotripsy index (SMLI). After treatment, we performed ultrasonography to evaluate renal hematoma in all cases. Average size of renal stones and ureteral stones was 14.25 and 11.0 mm, respectivery, in the first period, and 13.80 and 8.97 mm, respectivery, in the second period. EQ of renal and ureteral stones was 0.565 and 0.626, respectivery, in the first stage, and 0.553 and 0.798, respectivery, in the second period. The total EQ was 0.646. This value was good and particularly the result obtained on ureteral stones in the second period was thought to be excellent compared with other reports. In this series, 6 renal hematomas were confirmed. A statistically significant risk factor was SMLI, but the severity of hematoma was not correlated with SMLI. In hematoma patients, 2 patients had no notable risk factor, but they were thin or were small. Dual focus has a potential to improve ESWL results on ureteral stones. Excessive SMLI may be a risk factor of renal hematoma in thin or small patients.

We investigated the patients with ammonium acid urate (AAU) calculi in relation to dietary history, habit and lifestyle. From April, 2002 to March, 2009, AAU calculi were found in 9 patients (0.66) out of 1,365 cases of stones. Three cases were pure, and 6 were mixed stones. We examined the risk factor of this stone generation, "continuation of malnutrition and dehydration" were seen in 5, "continuing urinary tract infection" was seen in 4 and "continuation of super-saturation of uric acid in urine" was seen in 3 cases. All the patients with "continuation of malnutrition and dehydration" were women, and 4 patients had a history of severe body weight loss. 2 patients were dieting consciously, and the other 2 were eating a poorly balanced diet unconsciously. One patient had no notable past history, but malnutrition was detected in blood examination. It is suggested that AAU calculi is generated even by dieting at a usual level. Compared with the report in the United States, obesity and inflammatory bowel disease were not major risk factors, and "continuation of malnutrition and dehydration" is the major factor in Japan.

A 63-year-old man with a retroperitoneal tumor found incidentally was referred to our hospital. Computed tomography showed a tumor ventrally adjacent to urinary bladder and prostate. Pathological examination of retroperitoneal tumor specimens obtained by percutaneous needle biopsy revealed hypercellularity of spindle cells positive for CD 34. Under the suspicion of solitary fibrous tumor (SFT) or stromal tumors of uncertain malignant potential (STUMP), we performed en bloc resection of tumor, urinary bladder and prostate because tumor was firmly fixed to urinary bladder and prostate. The final diagnosis of retroperitoneal tumor was SFT because pathological findings of the surgical specimen were the same as those of the biopsy specimens.

The low specificity of the prostate specific antigen (PSA) test is considered to be a problem when PSA measurement alone is performed to detect cancer. Therefore, we examined a method to decrease the number of unnecessary biopsies while maintaining the power of the test by using PSA, PSA free/total ratio (PSAf/t), and digital rectal examination (DRE). The subjects were 232 patients with PSA levels of 4.0 ng/ml or less who underwent biopsy for prostate cancer. An endorectal ultrasound perineal biopsy was conducted, and the average biopsy core number was 21. Cancer was detected in 37 of the 232 subjects. Receiver operating characteristic curves of PSA and PSAf/t were subsequently determined. Although the area under the curve (AUC) was 0.56 for PSA alone, the AUC increased to 0.75 when the factor of positive data in DRE was taken into account. Although the AUC was 0.62 for PSAf/t alone, when the factor of positive data in DRE was added as for PSA, the AUC increased to 0.79. In addition, as a result of examining the combination of PSA, PSAf/t and DRE, the condition of the biopsy for prostate cancer in the cases with PSA of 4.0 ng/ml was determined as follows: PSA should be 3.1 ng/ml or more and PSAf/t 27% or less, or the result of DRE should be positive. Based on these criteria, the sensitivity, specificity and detection rate of cancer increased to 0.919, 0.436 and 23.2%, respectively. We consider that this approach will be useful.

We evaluated the efficacy of magnetic resonance imaging (MRI) as the preoperative study in the management of the nonpalpable testis. From 1997 to 2005, a total of 41 MRI was performed for the patients with nonpalpable testis and 42 testes were evaluated. The MRI showed 19 testes from 18 patients in the inguinal region. Eighteen testes were found in the inguinal region and one was intraabdominal during groin exploration. Six testes were pointed out to be intra-abdominal by MRI. Five testes were identified in the abdomen and one was disclosed to be vanishing testis. Seventeen testes could not be detected by MRI and they underwent laparoscopic or groin exploration. Four abdominal testes were identified. Thirteen patients had a diagnosis of vanishing testis. The sensitivity and the specificity of our MRI studies in predicting the presence of nonpalpable testis were 85.7% and 92.9%, respectively. Enlarged lymph node could be misdiagnosed as abdominal testis. Inguinal undescended testes can be diagnosed accurately with MRI. MRI is informative regarding the testis location and useful for limiting the area of surgical exploration.

A 65-year-old female was admitted to our hospital complaining of left upper abdominal pain. Although the symptom improved with observation, serum creatinine rose to 2.0 mg/dl. Slight atrophy of the left kidney was seen on abdominal plain computed tomography. In order to examine the possibility of renal infarction from thrombosis with angiography, we consulted the department of cardiovascular medicine. Even though we did not detect thrombosis with left renal angiography or intravascular ultrasound, there was a dissection finding localized at the left renal artery. Based on this finding, we made a diagnosis of spontaneous renal artery dissection and performed stent placement. Spontaneous renal artery dissection is extremely rare and the frequency of occurrence is reported to be less than 0.05%. Recently, however the frequency of detection has risen with the development of clinical imaging. We must keep in mind that the condition has the possibility of leading to renal blood circulation disorders.

If bone metastasis of renal cell carcinoma is neglected, pain, paralysis, and pathologic fracture develope; consequently, the patient's quality of life is significantly lowered. We investigated the local effect of the radiation therapy to the patients with metastasis. The investigation targeted 22 cases (27 parts) of renal cell carcinoma with bone metastasis that were treated with radiation therapy in our hospital during the last 6 years. We analyzed cell type, presence or absence of organ metastasis, irradiated site, therapeutic dose, treatment period, and combination therapy. The object was classified into 2 groups by metastatic site: the group with metastasis in the vertebra, and the group of metastasis in the pelvis or long bones. We examined re-calcification rate, length of time to recalcification emergence, pain relief and duration of effect as therapeutic effects. The irradiated site was vertebra in 14, pelvis in 7, and long bone in 6 patients. The therapeutic dose was 15 to 50 Gy, and the average was 35.7 Gy. No difference was found in the re-calcification rate and length of time to recalcification according to the metastatic site. The pain relief effect was significant in the pelvis and long bone group compared to the vertebra group. The effect lasted longer when the radiation dose was 35 Gy or more, compared with a lower dose. The radiation therapy for renal cell carcinoma with bone metastasis was effective to relieve pain and improve the patients' quality of life. The results showed that early detection and recognition of bone metastasis provide local control.

A man in his 70's visited the Department of Internal Medicine due to lumbago that had first appeared two months previously. Abdominal computed tomography showed a low-density area in the liver and swelling of lymph nodes surrounding the abdominal aorta. Four months later, he was hospitalized on an emergency basis in a urology ward in order to control bladder tamponade. Cystoscopy revealed massive blood clots and a papillary tumor at the left wall of the urinary bladder. He underwent transurethral resection of a bladder tumor, and the pathological diagnosis was a collision tumor between urothelial carcinoma (G2, pTa) and malignant lymphoma (B cell type). He underwent a liver biopsy soon thereafter, and the pathological diagnosis was malignant lymphoma (as for the one found in the urinary bladder). Bladder tamponade was repeated, which was relieved after one course of chemotherapy for malignant lymphoma. He underwent six courses of chemotherapy (THP-CO), and he was well without recurrence of either malignant lymphoma or urothelial carcinoma with 3 years' follow-up. To our knowledge, this is the 14th reported case of a collision tumor in the urinary tract.

We retrospectively analyzed 163 patients who had been cryopreservating their sperm one year or more. They consisted of 72, 76 and 15 patients with a germ cell tumor, hematologic cancer and other diseases, respectively. Forty-eight patients (29.4%) were still cryoperservating their sperm, and the average period of cryoperservation was 4.7 +/- 3.0 years (1-13.1 years). Only 6 patients (3.7%) had used their cryopreserved sperm and the average preserved period was 6.0 years (1.3-12 years). In 115 of the 163 cases, the cryopreserved sperm was abandoned, and the main reason was the recovery of spermatogenesis. Of the cases that underwent semen analysis after treatment, 20.9% of the patients with testicular cancer and 57.9% of the patients with hematologic cancer, have not recovered spermatogenesis. Because chemotherapy to the testicular tumor and leukemia risk injuring testiclar function, cryopreservation of the sperm before treatment should be recommended. Because the preservation period tends to be prolonged, development of a system for long-time preservation is awaited.

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).

A chromosomal survey using the G-banding technique was performed on 87 subfertile male whose semen analysis demonstrated severe oligospermia and azoospermia at Yokohama City University Hospital between January 1990 and October 2002. Fourteen of these subjects demonstrated major chromosomal anomalies (16.1%). Semen analysis in these cases demonstrated azoospermia, except in one case of autosomal abnormality. Twelve patients showed sex chromosomal abnormalities including 8 Klinefelter syndrome (47XXY) and 2 XX males (46XX) and two patients had autosomal abnormalities. The follicle-stimulating hormone (FSH) value in these patients, except for the two cases of autosomal abnormality and one case of 46XYq-, was much higher than normal. Histological examination was performed in 7 cases. In these cases, intratesticular spermatozoa were seen in only two cases (Klinefelter syndrome case and ring chromosome 21 case). Chromosome studies are important in the evaluation of subfertile patients with azoospermia and severe oligospermia. Because the abnormal genotype could be transferred to the next generation, the importance of chromosome studies before ICSI should be emphasized.

We report two cases of adult tethered cord syndrome alleviated by untethering surgery. Case 1 was a 35 year-old female who complained of incontinence while exercising. Radiograph revealed spinal disraphism below the L5 level. In addition, magnetic resonance imaging (MRI) showed low placed conus medullaris at the levels of S2 and sacral intradural lipoma. Further urodynamic studies demonstrated normal sphincteric function and autonomous bladder. Diagnosis resulted in the decision to perform an untethering operation. The patient had increased bladder compliance after surgery for untethering and has continued to be continent 16 months post-operatively. Case 2 was a 27-year old female who complained of apprehension to void and straining during urination. Radiograph demonstrated spinal disraphism below the S2 level and MRI revealed low placed conus medullaris at the level of S5 and sacral intradural lipoma. Urodynamic examination verified normal sphincteric function and autonomous bladder. After complete diagnosis, an untethering operation was performed. Post-operatively, bladder compliance and urinary sensation normalized. Furthermore, the patient spontaneously delivered a baby 3 years after having the untethering operation.

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).

To investigate how urinary frequency and incontinence affect the patient's subjective quality of life (QOL) and whether an improvement in objective findings by medical treatment affects his/her subjective QOL, a voiding diary using the King's Health Questionnaire (KHQ) and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was delivered to patients with urinary frequency and/or incontinence before and after treatment with propiverine hydrochloride for 8 weeks. Sixty-eight patients completed the diary and the questionnaires. Objective symptoms decreased significantly with respect to the mean frequency of urination and to the mean incidence of urinary incontinence. The KHQ and ICIQ-SF scores improved significantly with respect to all domains except personal relationships in the KHQ. In the KHQ, furthermore, a significant correlation was found between decreased incidence of urinary incontinence and improvement in role limitations and between decreased incidence of urinary incontinence and improvement in emotional problems. In the ICIQ-SF, a significant correlation was found between decreased incidence of urinary frequency and subjective improvement in quantity of leakage, between decreased incidence of urinary frequency and improvement in subjective QOL scores, between decreased incidence of urinary frequency and improvement in the total ICIQ-SF score, and between decreased incidence of urinary incontinence and improvement in subjective QOL scores. Thirty-two episodes of adverse reactions were observed. None of them were serious. These results suggest that an improvement in objective symptoms with propiverine hydrochloride favorably improves subjective QOL of the patient, and provide further evidence about the safety and efficacy of propiverine hydrochloride.

We report a multicenter trial with transrectal high-intensity focused ultrasound (HIFU) in the treatment of localized prostate cancer. A total of 72 consecutive patients with stage T1c-2NOM0 prostate cancer were treated using the Sonablate 500TM HIFU device (Focus Surgery, Indianapolis, USA). Biochemical recurrence was defined according to the criteria recommended by the American Society for Therapeutic Radiology and Oncology Consensus Panel. The median age and prostate specific antigen (PSA) level were 72 years and 8.10 ng/ml, respectively. The median follow-up period for all patients was 14.0 months. Biochemical disease-free survival rates in all patients at 1 and 2 years were 78% and 76%, respectively. Biochemical disease-free survival rates in patients with stage T1c, T2a and T2b groups at 2 years were 89, 67% and 40% (p = 0.0817). Biochemical disease-free survival rates in patients with Gleason scores of 2-4, 5-7 and 8-10 at 2 years were 88, 72% and 80% (p = 0.6539). Biochemical disease-free survival rates in patients with serum PSA of less than 10 ng/ml and 10-20 ng/ml were 75% and 78% (p = 0.6152). No viable tumor cells were noted in 68% of patients by postoperative prostate needle biopsy. Prostatic volume was decreased from 24.2 ml to 14.0 ml at 6 months after HIFU (p < 0.01). No statistically significant differences were noted in International Prostate Symptom Score, maximum urinary flow rate and quality of life analysis with Functional Assessment of Cancer Therapy. HIFU therapy appears to be minimally invasive, efficacious and safe for patients with localized prostate cancer with pretreatment PSA levels less than 20 ng/ml.

Economical elements including surgical fee and hosipital stay become larger in the selection of surgical methods for the treatment of urinary stones. Then, urologists need to explain to patients the treatment cost to obtain informed consent. By comparing the data from participants' answer to Debate 1 at the 82th annual meeting of the Japanese Urological Association (April 2002, Tokyo) and questionnaire responses from the members of the annual meeting of central division of Japanese Urological Association (November 2002, Nagoya), we surveyed the trends of surgical methods on the treatments of staghorn caliculi and lower ureter stones. Furthermore, we clarified the cost of these methods. Based on the status of world countries, we demonstrate the ideal selection including economical aspects on the selection of endourological method.

The incidence of upper urinary stones has been increasing since World War II in Japan. One of the causes is the change in dietary habit to a more westernized diet. The consumption of animal protein, fats and oils also correlates with the incidence of upper urinary stones. The results of numerous treatments for preventing formation of calcium stones are not sufficient, and the improvement of daily life habits and dietary advice have been proposed to be important. An increased intake of fluid is of great value for patients with stone diseases, irrespective of the stone composition. We discuss whether or not non-alcoholic and alcoholic beverages, are appropriate for prevention of stone diseases from the viewpoint of the contents of the beverages.

We report two cases of urolithiasis related to anorexia nervosa and laxative abuse. Case 1: A 21-year-old woman was referred to our hospital because of left flank pain. A left ureteral stone, 10 x 6 mm in size, was successfully fragmented by extracorporeal shock-wave lithotripsy (ESWL), but she experienced repetitive formation of bilateral urinary stones and double J stent encrustation which required 13 sessions of ESWL, one session of transurethral ureterolithotripsy and one session of cystolithotripsy over a period of 5 years. All stones were comprised of pure ammonium acid urate. It was later revealed that she was diagnosed with anorexia nervosa at 15 years old and had suffered from laxative abuse (bisacodyl, 300-500 mg/day) ever since. Case 2: A 18-year-old woman was referred to our hospital because of left lower abdominal pain. A left renal stone, 15 x 10 mm in size, was successfully fragmented by ESWL, but she had double J stent encrustation which was managed by cystolithotripsy. All stones were comprised of pure ammonium acid urate. She was later diagnosed with anorexia nervosa and it turned out that she had suffered from an eating disorder and laxative abuse (bisacodyl, 200 mg/day) since the age of 15 years. Both patients had marked decrease in urine volume, hyponatremia and hypokalemia. Anorexia nervosa and laxative abuse should be suspected whenever a woman has an ammonium acid urate stone in sterile urine because the treatment of these disorders is crucial to the prevention of repetitive formation of urinary stones.

Prostate cancer is the most common urogenital cancer, and is increasing rapidly. We performed an epidemiological study on prostate cancer in Gunma Prefecture, Japan. Registration of prostate cancer patients diagnosed at clinics and hospitals in and around Gunma Prefecture was started at Gunma University in 1985. The epidemiological characteristics of prostate cancer patients in Gunma Prefecture were analyzed by these data. The incidence and crude incidence rates have increased five-fold, from 114 and 12.0 in 1985 to 539 and 53.9 in 2000, respectively. The age-adjusted incidence rate (adjusted to the world population) was increased three-fold, from 8.3 in 1985 to 24.2 in 2000. The age-specific incidence rate showed an increase with age. The cancers in clinical stages A and D decreased, while those in stages B and C increased. No change in distribution was observed in pathological differentiation. Prostate cancer has increased rapidly during these 16 years in Gunma Prefecture. It is important to perform PSA testing aggressively in males age 50 or older, and detect prostate cancer in an early stage.

We report a case of schwannoma in psoas muscle, difficult to make a preoperative differential diagnosis from multilocular renal cyst in a 44-year-old woman. She complained of epigastric discomfort, and abdominal computerized tomography revealed a left multi-cystic renal tumor. Drip infusion pyelography showed the tumor displacing the left kidney superiorly, and pushing the left ureter medially. Magnetic resonance imaging demonstrated that the tumor structure was multilocular. At the operation, the tumor was observed in psoas muscle and was revealed as schwannoma in microscopic findings.

A case of retroperitoneal liposarcoma with reactive pleural effusion is reported. A 58-year-old male who complained of weight gain and edema had visited another clinic in May, 2002. Computed tomography revealed a retroperitoneal tumor, 11 x 9 x 9.5 cm in size, surrounding his right kidney and bilateral pleural effusion. Complete resection of the tumor and right kidney was performed with a transperitoneal approach. Though the tumor was limited within Gerota's fascia, we noted two liters of abdominal ascites. Surgical specimen was histologically diagnosed as well differentiated liposarcoma. The post operative course was uneventful. The pleural effusion disappeared, and serum total protein level was normalized. He has remained free of disease for one year.

The ultrasound estimated bladder weight (UEBW) of 15 patients (13 male, 2 female; mean age 64.7 years) who underwent pressure flow study (PFS) were evaluated using the nomogram. In the nomogram, thickness of bladder wall (T) and bladder weight (BW) were plotted on the horizontal axis and on the vertical axis, respectively. BW points calculated from various values of T by the formula were plotted on the volume-fixed bladder capacity curve. BW of each case was estimated by the nomogram from echo-measured T at maximum bladder filling and injected volume (V) into the bladder. Bladder outlet obstruction (BOO): was evaluated from obtained results, and compared with the results of PFS. The features of the distribution on Schafer's nomogram were also investigated. It was possible to estimate BW immediately after ultrasonic examination. BW was under 35 g in one patient, and over 35 g in 14 patients. Obstruction grade on the Schafer's nomogram ranged from III to VI. BOO could be evaluated quantitatively with little invasion even in patients who could not undergo PFS for urinary retention and urge incontinence. In conclusion, the bladder weight calculation nomogram immediately showed the BOO information of the patient with neither invasive technique, complicated calculation, electronic calculator nor expansive computer. This nomogram may make a breakthrough for utilizing UEBW.