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A 54-year-old man was introduced to our hospital for follow-up examinations after renal transplantation. At the initial visit, a 25 mm renal transplant stone was noted, which had enlarged to 32 mm at an examination 1 year later. We first attempted transurethral lithotripsy (TUL), but failed due to ureteral stricture. However, we could completely remove the stone in 2 sessions of percutaneous nephrolithotripsy (PNL). The incidence of urinary lithiasis after renal transplantation ranges from 0.17-1.8%, for which PNL and TUL are frequently used. Although considered to be accompanied with risks of bleeding, bowel injury, and renal dysfunction, PNL is effective for urinary lithiasis after renal transplantation. TUL is less invasive, but access may be difficult when the ureter has an unusual course or ureteral stricture exists, as in our patient.

A 67-year-old man with castration-resistant prostate cancer associated with multiple bone metastases had been treated with zoledronic acid and docetaxel. Although there was no evidence of damage around the right lower jaw bone, the patient complained of pain in May 2011, which worsened during the next 2 weeks and was followed by difficulty with breathing. Computed tomographic (CT) findings of the cervical area showed swelling of the cervical tissue with air and tightening of the trachea, suggesting cellulitis caused by gas gangrene. He was intubated and treated with antibiotics. On the 12th hospital day, CT scan revealed a pharyngeal abscess and we performed a drainage operation. On the 20th hospital day, bone of the intraoral lower jaw was exposed, revealing that the infection was caused by osteonecrosis. Additional CT findings showed the abscess extending to the mediastinum and multiple liver metastases. Although antibiotic therapy was continued, the patient died of liver failure on the 61st day.

A 61-year-old man came to our hospital with a complaint of lower abdominal pain. Computed tomography (CT) and magnetic resonance imaging (MRI) around his abdominal area showed large multiple cysts in the pelvis suggesting a malignant tumor. He showed high levels of serum carbohydrate antigen 19- 9 (CA19-9) and carcinoembryonic antigen (CEA). The complete diagnostic studies, including upper gastrointestinal endoscopy and colonoscopy examinations, failed to demonstrate the presence of alimentary primary tumors. With the diagnosis of cystic tumor in the pelvis, the operation was performed. The cysts adhered firmly to the surrounding organs including bladder and peritonium, which could not be resected completely. A histopathological diagnosis was papillary adenocarcinoma positive for prostate specific antigen (PSA). Because the level of serum PSA was 9.39 ng/ml, prostate biopsy was performed and ductal adenocarcinoma of prostate was revealed. After the operation, the levels of serum CA19-9 and CEA decreased to a normal level. Androgen deprivation therapy (ADT) was started, and the level of PSA was normalized one month later. Ductal adenocarcinoma forming cysts is rare. We reviewed 15 cases reported in the Japanese literature.

A 65-year-old man was referred to our hospital because of an elevated value of prostate specific antigen (PSA) (10.9 ng/ml). An eight-core prostate biopsy was negative. One year later, serum PSA increased to 55. 8 ng/ml and pelvic magnetic resonance imaging (MRI) showed a left external iliac lymph node enlargement. A ten-core prostate biopsy was negative. Six months later, the serum PSA increased to 88.1 ng/ml, but an seventeen-core prostate biopsy was negative again. A positron emission tomographycomputed tomography scan showed nothing other than increased uptake localized to the left enlarged external iliac lymph node. Pelvic lymphadenectomy was performed and histological examination, including immunohistological staining with PSA, confirmed lymph node metastasis from prostate cancer. Androgen deprivation therapy was started and 2 month later, serum PSA declined to below 1.0 ng/ml.

The patient was a 67-year-old man who was started on peritoneal dialysis for treatment of diabetic nephropathy in March 2010. He received an ABO-compatible living-donor kidney transplant from his wife in October 2010. The immunosuppressive regimen consisted of tacrolimus, mycophenolate mofetil, steroid and basiliximab. Before the operation, a bump on his forehead/temple region that was increasing in size for years was noted. The bump had a scaly surface and the top of the bump was sloughed on postoperative day 14. Histological examination suggested malignancy. On postoperative day 21, a skin biopsy was performed by dermatologists and squamous cell carcinoma was confirmed. On postoperative day 36, wide excision and transposition flap procedures were performed by the plastic surgeon. At 15 months after transplantation, the kidney graft was functioning well with a serum creatinine level of 0.84 mg/dl and there was no sign of recurrence of the squamous cell carcinoma.

A 43-year-old woman presented to our hospital with the chief complaints of gross hematuria and dysuria. Cystoscopy and magnetic resonance imaging showed a tumor on the dome of the bladder and large blood clots. Computed tomography demonstrated no findings of distant metastasis. Following transurethral resection of the tumor, the tumor was histologically diagnosed as myxofibrosarcoma with muscular invasion, and partial cystectomy was performed in September 2009. There has been no evidence of recurrence or metastasis for 24 months postoperatively. In addition, the Japanese literature on myxofibrosarcoma of the bladder was reviewed and discussed.

Topiramate is an antiepileptic medicine that has been used adjunctively in the treatment of refractory seizures in Japan since 2007. Topiramate has been shown to inhibit specific carbonic anhydrase activity in the kidney and may induce a distal type of renal tubular acidosis. Case 1 : A 22-year-old male was referred to our hospital after complaining of left flank pain. He developed a seizure disorder and had been using topiramate for 4 months. Drip infusion pyelography showed a left ureteral stone. Case 2 : A 7-year-old boy presented with gross hematuria. He developed West syndrome and had been using topiramate for 6 months. A computed tomographic scan showed a right kidney stone.

A 49-year-old woman with tuberous sclerosis visited our hospital complaining of left abdominal pain. She had been diagnosed with bilateral renal angiomyolipoma (AML) when she was 32 years old and had been on maintenance hemodialysis since the age of 44. Magnetic resonance imaging showed bilateral giant renal AML and hemorrhage in the AML of the left kidney. Transthoracolumbar left nephrectomy was performed in March 2008. The resected specimen weighed 3.2 kg. The histological diagnosis was consistent with AML. In addition, the Japanese literature on giant renal AML was reviewed and discussed.

A 65-year-old woman was referred to our hospital for further examination of recurrent urinary stone formation. She had undergone 49 sessions of extracorporeal shock-wave lithotripay (ESWL) and 3 sessions of transureteral lithotripsy (TUL) under the diagnosis of idiopathic recurrent urolithiasis at another hospital. An excretory urography showed bilateral hydronephrosis and a retrograde urography revealed bilateral lower ureteral stricture. Ammonium chloride loading test demonstrated incomplete distal renal tubular acidosis. Potassium citrate therapy had begun and bilateral nephrostomies were required in order to prevent recurrent urinary tract infection and new stone formation. Literature was reviewed and discussion was made on the ureteral stricture after ESWL and TUL, and on incomplete distal renal tubular acidosis.

A 54-year-old woman was referred to our hospital for the treatment of secondary hyperparathyroidism due to chronic renal failure. She was on hemodialysis for 7 years and suffered from giant tumor calcinosis of the major joints associated with severe hypercalcemia and hyperphosphatemia. The largest one of the left hip joint caused gait disturbance. Medical therapy was unsuccessful and she underwent subtotal parathyroidectomy. After the operation, although the levels of serum calcium and phosphate were not normalized, the level of parathyroid hormone was lowered to the normal range. The volume of the tumor calcinosis gradually reduced and she became able to walk for a short distance 10 months after the operation.

We report a case of squamous cell carcinoma of renal pelvis associated with giant hydronephrosis. A 71-year-old woman presented to our hospital with a complaint of abdominal fullness due to the right giant hydronephrosis. Although the diagnosis of her hydronephrosis was made about 20 years ago at another hospital, it had been left untreated. Computed tomography showed the right hydronephrosis of 20 x 20 x 25 cm in diameter and no evidence of tumor or calculus in the right urinary tract. For relief of her complaint, right nephrectomy was performed. The fluid content was bloody and 4,200 ml in volume. Histological examination revealed a flat type squamous cell carcinoma of the renal pelvis. This is the 30th case of renal pelvic malignant tumor associated with giant hydronephrosis reported in Japan. The literature was reviewed and the management of giant hydronephrosis was discussed.

We used a urethral stent for management of high-age and high-risk patients with benign prostatic hyperplasia (BPH) who needed surgical therapy. Nine patients were treated by this method. Chief complaints were urinary retention in 6 patients, dysuria with much residual urine in 2 and dysuria in 1. Blood loss and complications of the method were minimal. Postoperatively, 8 of the patients were able to void and on the average, residual urine of the patients was approximately 10 ml. Implantation of the urethral stent is a safe and non-invasive therapy for the patients who are unsuitable for invasive therapy.

Thirty two patients with cystinuria were enrolled in this long-term study and 16 patients were treated with tiopronin for 24 weeks. Tiopronin reduced daily urinary cystine excretion from 901.48 mg (before treatment) to 488.60 mg (on the average of 12th week and 24th week after tiopronin administration) successfully. Tiopronin therapy was tolerated well, but side effects were observed in 13 events in 6 patients. Thus tiopronin was expected to be effective in preventing cystine stone formation and tolerated well.

To our knowledge, no standard chemotherapy for patients with hormone-refractory prostate cancer (HRPC) has been established. Since most patients with HRPC are elderly and have bone metastasis, cytotoxic chemotherapy causes them to be at high risk for myelosuppression. Therefore, chemotherapeutic agents with low toxicity and good compliance should be elected. We conducted three regimens for HRPC on an outpatient basis. Eligibility criteria were defined as serial rising PSA values on 3 or more occasions at least 2 weeks apart or radiological new or extensive lesions under hormonal therapy. The first regimen is comprised of cyclophosphamide (CPM), 100 mg/day, UFT, 400 mg/day, and estramustine phosphate (EMP), 560 mg/day in two daily fractions. The second regimen is comprised of an oral administration of dexamethasone (DEX) (0.5-2 mg/day). The third regimen is comprised of DEX, 1 mg/day, cyclophosphamide, 100 mg/day and UFT, 400 mg/day in two daily fractions. Post-therapy prostate-specific antigen (PSA) level in serum, objective response on bone scan or measurable disease, and symptomatic response on bone pain were assessed. All regimens showed clinical efficacy with mild toxicity. Indications and limitations of these regimens are discussed. Further, the combination trials of taxane and EMP in patients with HRPC are reviewed.

A 63-year-old man was admitted to our hospital for a bladder tumor. Drip infusion pyelography, computerized tomography (CT) and magnetic resonance imaging suggested the presence of a large invasive tumor in the right wall of the bladder. Histopathological findings by transurethral resection of bladder tumor showed the presence of sarcomatous and carcinomatous elements. Immunohistochemical examination showed that the sarcomatous component did not stain for S-100 protein or for smooth muscle actin but it stained for epithelial markers. Under the diagnosis of sarcomatoid carcinoma, we performed a total cystectomy and ileal conduit without chemotherapy or radiation. A follow-up CT taken at four months postoperatively showed no evidence of recurrence.

A case of 48XXYY Klinefelter's syndrome diagnosed with foot ulcers, in a 43-year-old man, is reported. He presented to the Department of Dermatology in our hospital with the chief complaint of recurrent foot ulcers. He was referred to us because of atrophic external genitalia. The present condition and endocrinological examination suggested Klinefelter's syndrome. Chromosomal analysis revealed that his chromosomal type is 48XXYY. This is the 24th case of Klinefelter's syndrome with 48XXYY chromosome and is the 5th case associated with foot ulcers in Japan. Here we report this case together with a brief review of the previously reported cases.

In order to determine the modality of prophylactic intravesical instillation of pirarubicin (THP = tetrahydropyranyladriamycin) following transurethral resection (TUR) of superficial bladder cancer, a prospective randomized study was performed. A total of 79 patients were randomized into "2-hour instillation" (A), "5-min instillation" (B) and "control" (C) groups. Prophylactic efficacy and side effects were analyzed in each group. In groups A and B, 20 mg of THP was first dissolved in 10 ml of distilled water, adjusted to 40 ml with saline and was administered intravesically once a week for 10 weeks, starting from 1 week after TUR. The recurrence-free rate was calculated in 65 evaluable patients. The one-year recurrence-free rate was 70.2% in group A, 62.8% in group B and 52.1% in group C. The one-year recurrence-free rate was significantly higher in group A than in group C. Adverse effects were observed in 21.4% of the patients in group A and 40.7% in group B. There was no significant difference in the occurrence rate of side effects between these two groups. Taking the prophylactic efficacy and side effects into consideration, "2-hour instillation" seemed to be better than "5-min instillation".

Serum prostate specific antigen (PSA) is currently the best blood marker for prostate cancer. However, low specificity for detection of prostate cancer, especially in the gray zone of PSA, is a problem. We evaluated the clinical significance of PSA density (PSAD) in gray zone PSA cases with conversion of serum PSA to a Stanford reference value. In a series of histologically confirmed 63 benign prostatic hyperplasia (BPH) patients and 234 prostate cancer patients, 36 BPH patients and 25 prostate cancer patients had gray zone PSA levels. Serum PSA was measured with the Markit-F or Markit-M PA assay. All data were converted to Stanford reference values. We used transabdominal ultrasound to determine prostate volume. PSAD was determined as the serum PSA/prostate volume ratio. The mean PSA values for BPH and prostate cancer were 6.42 +/- 1.80 and 7.80 +/- 2.15 ng/ml (p = 0.0116), respectively, and prostate volume was 33.4 +/- 14.1 ml and 17.1 +/- 8.2 ml, respectively (p < 0.0001). The mean PSAD for prostate cancer was 0.572 +/- 0.363 while that for BPH was 0.218 +/- 0.085 (p = 0.0001). Cut-off values with sensitivity > 90% were 0.218 for PSAD and 30 ml for prostate volume. At these cut-off values, specificity reached 56% for each marker. In discriminating prostate cancer from BPH in the gray zone of PSA, PSAD demonstrated better performance than PSA.

Since solitary metastatic renal tumors are not commonly diagnosed before death, the conclusive treatment of the metastatic renal tumor has not been established. We report three cases of metastatic renal tumors and discuss the indication of surgical therapy for metastatic renal tumors. The first case was in a 64-year-old male who underwent esophagectomy for squamous cell carcinoma. Seven months after the operation, a right renal tumor was found. The second case was in a 63-year-old male who underwent right upper pneumonectomy for adenocarcinoma with a right renal tumor, which seemed to be a solitary metastasis. The third case was in a 69-year-old male who underwent right pneumonectomy for adenocarcinoma. One month after the initial operation, a left renal cystic tumor was found. Since, in all cases, the tumors seemed to be solitary metastatic renal tumors without any other metastatic lesions, nephrectomy was performed. Unfortunately, however, the nephrectomy did not improve prognosis and all three patients did within 10 months after the nephrectomy. Nephrectomy may not be recommended in cases of metastatic renal tumors even if no other metastatic lesions can be found by various image examinations.

Tuberous sclerosis is associated commonly with renal angiomyolipoma. On the other hand, the relation between tuberous sclerosis and renal cell carcinoma is not widely recognized. We report a case of renal cell carcinoma of the right kidney associated with tuberous sclerosis.

The clinical efficacy of fleroxacin (FLRX), a new fluoroquinolone, for acute uncomplicated cystitis (AUC) in women was assessed. Two regimens, 3-day and 7-day courses of FLRX, 200 mg once a day, were compared. Clinical and bacteriological efficacy were evaluated after the therapy, and recurrence rate was evaluated 1 week and 4 weeks after termination of the therapy. Of 136 registered subjects, 35 in the 3-day group and 47 in the 7-day group were evaluated. According to the criteria of Japanese UTI Committee (3rd edition), the rate of excellent results was significantly higher in the 7-day group (78.9%) than in the 3-day group (48.6%), but the overall clinical efficacy rate was similar being 100% and 97.9%, respectively. Although no recurrence was seen 1 week after the therapy in either group, recurrence was seen in 14.3% and 7.4% of the cases in the 3-day and 7-day groups, respectively, 4 weeks after the therapy. Adverse reactions were observed in 2 and 3 cases in the 3-day and 7-day groups, respectively. Both 3-day and 7-day regimens of FLRX treatment showed good efficacy. Although the 7-day treatment was superior to the 3-day treatment as to high rate of excellent results and low rate of recurrence, the 3-day treatment was concluded to be sufficient for AUC.

The inhibitory effect of two kinds of Kampou medicine, Chorei-to and Gorei-san, on calcium oxalate crystallization in human urine, was examined. Chorei-to or Gorei-san was administered to 15 healthy male volunteers for three consecutive days under normal dietary conditions and 24-hour urine samples were collected before and after the administration. Urinary parameters including calcium, phosphorus, uric acid, oxalate and citrate were measured on each sample obtained. The inhibitory effect on calcium oxalate crystallization was examined using part of the collected 24-hour urine. There was no significant difference in urinary parameters before and after Chorei-to administration. Gorei-san administration significantly increased magnesium excretion in urine. A significant inhibitory effect on calcium oxalate crystallization in human urine was recognized when Gorei-san was administered, whereas Chorei-to had no inhibitory effect on calcium oxalate crystallization in urine.

A prospective randomized study was conducted to evaluate the efficacy of prophylactic intravesical instillation of tetrahydropyranyladriamycin (THP) following complete transurethral resection (TUR) of superficial bladder cancer. A total of 80 patients were randomized into "THP" or "control" group. In the THP group, 20 mg of THP dissolved in 40 ml saline (or 5% dextrose) was administered intravesically once a week for 10 weeks, starting from about 7 days after TUR. In the control group, 40 ml saline was given with the same schedule. The patients were followed up by cystoscopy and urinary cytology every 3 months. The number of evaluable patients was 36 for the THP group and 37 for the control group. The non-recurrence rates in the THP group and control group were 79.4% versus 63.2% at 1 year and 69.8% versus 47.4% at 3 to 5 years, respectively. These figures were not statistically significant. However, THP instillation significantly reduced tumor recurrence rates for multiple tumors, and also tended to decrease recurrence rates for primary and pT1 tumors. Adverse effects were observed in 53.6% of the patients in the THP group, but they were tolerable. Our results suggest that intravesical THP instillation would not be effective for all patients with superficial bladder cancer. Further study is warranted in a selected group of patients.

A double-blind study was conducted to evaluate the efficacy, safety and usefulness of cimetropium bromide (DA3177) in the patients with pain caused by upper urinary calculus at a daily dose of 75 mg t.i.d. (Group D, 97 patients) in comparison with scopolamine butylbromide at a daily dose of 60 mg t.i.d. (Group B, 101 patients). According to patient's impression, the rate of "moderately improved" or better was significantly higher in Group D (68.7%) than in Group B (53.5%; Wilcoxon 2 sample test: p = 0.0044). For pain, the rate of "moderately improved" or better was 69.1% in Group D and 60.4% in Group B. In global improvement, the rate of "moderately improved" or better was significantly higher in Group D (70.1%) than in Group B (61.4%; Wilcoxon 2 sample test: p = 0.0469). The rate of "no problem in safety" showed no significant difference between Group D (91.5%) and Group B (93.3%). Adverse reactions occurred in 8.5% in Group D and 6.7% in Group B. The major adverse reactions were "dry mouth", "abdominal distension", "constipation" and "nausea". The rate of "useful" or better was 68.7% in Group D, and 60.4% in Group B. In conclusion, DA3177 was confirmed to be a useful drug for patient with pain caused by upper urinary calculus.

We previously reported that Takusya had the inhibitory effect on in vitro calcium oxalate crystallization and in vivo stone formation in an animal model and it could be a prophylactic agent against calcium oxalate stone formation. We studied the effect of Takusya on calcium oxalate crystallization in human urine. Takusya (500 mg/day and 1,000 mg/day) was administered to 16 healthy men for 3 days and then 24-hour urine samples were collected to measure the urinary excretion of calcium, phosphate, magnesium, uric acid, creatinine, citric acid and oxalic acid. The urine samples before the administration of Takusya was used as a control. The size and distribution of crystals, which were formed in the urine samples by adding calcium chloride and sodium oxalate, were measured using the Coulter counter technique. Urinary magnesium excretion was significantly reduced by 1,000 mg/day of Takusya compared with the control (p < 0.05). The growth of crystals was significantly inhibited by 500 mg/day of Takusya in the large crystal formers whose urine created crystals more than 3.5 microns before the administration of Takusya (p < 0.05). These findings suggested that Takusya inhibited the growth of crystals formed in human urine.

We report a case of renal cell carcinoma in acquired cystic disease of the kidney (ACDK) presenting with a spontaneous renal rupture. A 41-year-old man on chronic hemodialysis for 16 years was referred to our hospital with sudden left back pain. On arrival, the patient was in a state of hemorrhagic shock but his general condition improved by conservative therapy. Computed tomography demonstrated a left renal rupture as well as bilateral ACDK. Although there was no definite evidence of a renal tumor, a left radical nephrectomy was performed one week later. The resected kidney contained a yellowish-brown tumor of 5.5 x 5.0 x 4.5 cm in size. Pathological examination revealed renal cell carcinoma, cystic type, clear cell subtype, pT2pN0M0. He has been free of recurrence for 3 months.

We reviewed 45 cases of transitional cell carcinoma of the renal pelvis and ureter with reference to the coexistence or subsequent development of bladder cancer. Bladder cancer was associated with an upper urinary tract neoplasm in 26 of the 45 cases. The 5-year survival rate for coexistence of bladder cancer was 56% and that for subsequent bladder cancer was 65.6%. The 5-year survival rate for 19 cases unrelated with bladder cancer was 46.7%. Therefore, there was no significant difference among the three groups. As to degree of the malignancy of the renal pelvis and ureter, the 5-year survival rate was 73.7% for G1 and G2 and 26.2% for G3. As to the depth of invasion, of the renal pelvis and ureter the 5-year survival rate was 71.8% and 31.1% in the patients with stage of T1, T2 and T3, T4. The prognosis of cancer of the upper urinary tract depended on the degree of the malignancy, and the depth of invasion. Ninety two percent of subsequent bladder cancer was detected within 2 years after resection of the primary cancer.

We examined the inhibitory effect of the two Kampo medicines, takusha and kagosou on the formation of calcium oxalate renal stones induced by ethylene glycol (EG) and 1 alpha(OH)D3 (1 alpha-D3) in rats. Wistar strain rats were divided into 4 groups (A: normal control, B: stone, C: kagosou, D: takusya). There was no significant difference in urinary calcium excretion or oxalate excretion between the stone group and kampo medicine groups. The calcium content of the kidneys was significantly lower in the takusha group than in the other two groups (Stone group and kagosou group). Takusha was effective in preventing oxalate stone formation in rats. Kagosou, which had strong inhibitory effect on calcium oxalate crystal growth and aggregation in vitro as well as takusha, was not effective against in vivo calcium oxalate stone formation in rats. These findings suggest that takusha prevents the formation of calcium oxalate stone by inhibiting calcium oxalate crystal growth and aggregation.

A case of tranilast (Rizaben)-induced cystitis accompanied with possibly hypereosinophilic heart syndrome was described. A 75-year-old male, who had been taking tranilast for allergic dermatitis for two months, was admitted for severe bladder stimulating symptoms which was unresponsive to antibiotic therapies. Clinical examination revealed tenderness of the prostate, aseptic pyuria, eosinophilia, liver dysfunction and electrocardiographic disorders including atrial fibrillation, T-wave inversions and lowered ST segment without any cardiac symptoms. Cystitis symptoms, pyuria, eosinophilia and liver dysfunction improved within several days after discontinuance of tranilast, and ST-T changes on ECG gradually normalized within a few months. Tranilast-induced cystitis has been demonstrated as a type of eosinophilic cystitis. Since pathologic findings of eosinophilic cystitis and hypereosinophilic heart syndrome are markedly similar and all symptoms and signs disappeared after deprivation of tranilast, it appears likely that eosinophilic inflammation was induced to the heart, liver, bladder and prostate of the current patient by tranilast.

Between 1959 and Oct. 1990, 307 cases of primary hyperparathyroidism (PHPT) were operated on in our hospital. Among them, 23 cases (7.5%) were asymptomatic chemical type of PHPT, and the incidence of this type has been increasing these days. Various symptoms or signs including urolithiasis, bone disease, cardiovascular disease, gastrointestinal disease, diabetes mellitus and others were associated with PHPT. Especially, as a lethal factor, malignant tumors developed in 14 cases (4.6%); 9 cases of non-medullary thyroid cancer and tumors of other organs. In consideration of these associated disorders, the chemical type of PHPT should be operated prophylactically. In order to reduce operative complications, unilateral exploration is available for the cases of single normally localized adenoma; 85.7% of our 307 cases. Moreover, the positive rate of preoperative localized test by CT and ultrasonography for such adenomas is 78% in the recent 5 years. The predictive values of successful operation by unilateral exploration are 89% in the cases of normally localized single adenoma and 76% in all PHPT.

The effects of the compositional drugs of kanpou medicine on the growth and aggregation of calcium oxalate crystals were investigated in vitro. In the seeded crystal system, the inhibitory activities were calculated from the change of the number (Ia), total volume (Ig) and fractional volume (I) of crystals determined by a Coulter Multisizer. Among the tested drugs (Takusha, Akyou, Chorei, Bukuryou, Kasseki, Kinsensou, Kagosou), only Takusha and Kagosou had strong inhibitory activities on the growth and aggregation at the concentration of 5 micrograms/ml and 10 micrograms/ml (Ia greater than 80%, Ig, I greater than 90%). No significant correlation was observed between inhibitory activities and alcian blue precipitable polyanions (ABPP) of each drug. Thus some naturally existing substances composing the kanpou medicine may help prevent the stone formation in clinical use.

A case of synchronous ipsilateral renal cell carcinoma with renal pelvic and ureteral transitional cell carcinoma is reported. A 80-year-old man, who had had transurethral resection of bladder tumor three times, was admitted on August, 1989 for recurrence of bladder tumor. Excretory pyelography revealed a filling defect of left renal pelvis. Findings of retrograde pyelography and computed tomography were in accord with those of the excretory urograms. Under a diagnosis of the left renal pelvic and ureteral tumor associated with the bladder tumor, left nephroureterectomy with bladder cuff resection was performed. Pathological diagnosis was renal pelvic and ureteral transitional cell carcinoma with renal cell carcinoma, which existed incidentally in the same kidney. Double unrelated primary carcinoma in urinary tract, especially, double dissimilar primary carcinoma in the same kidney, is rare. To our knowledge, this case is the 20th double cancer in upper urinary tract reported in Japan.

A 69-year-old woman suffered from bilateral renal stones. Laboratory examinations showed primary hyperparathyroidism. Neck exploration including left hemithyroidectomy and partial thymectomy failed to reveal the abnormal parathyroid gland. Localization studies were done for an ectopic parathyroid adenoma. Repeated selective arteriography with digital subtraction technique revealed an ectopic parathyroid adenoma in the upper mediastinum. Computed tomography, ultrasonotomography and selective venous sampling also confirmed this finding. Subsequently, mediastinal exploration with partial sternotomy was performed and the ectopic parathyroid adenoma was removed. We discuss the preoperative localization studies for ectopic parathyroid adenoma.

A case of retroperitoneal Hodgkin's disease with dysuria is reported. A 56-year-old man visited our hospital with the complaints of dysuria and lower abdominal mass. On physical examination, an unmovable hard smooth mass of fist size was palpable in the lower abdomen and prostate was slightly swelling by rectal digital examination. Excretory urography demonstrated medial deviation of left lower ureter and bladder deformity. Retrograde urethrocystography showed deviation and compression of prostatic urethra. On CT, tumors were composed of several round masses, which surrounded the left common iliac artery on angiography. Surgical extirpation was carried out and histological examination revealed Hodgkin's disease. As postoperative treatment, chemotherapy with cyclophosphamide, adriamycin, vincristine and prednisolone was performed, and 30 months after the operation the patient was asymptomatic.

The enzymatic method for isolation and determination of urinary polyamines was modified to measure the polyamines in tissue. High recovery rates of polyamines in tissue by the enzymatic method were obtained, namely, 104.5 +/- 7.4% for diamine, 104.7 +/- 23.3% for spermidine and 104.8 +/- 7.5% for spermine. The results obtained by this method correlated well with those obtained by high performance liquid chromatography, and a close correlation was demonstrated for all fractions: diamine r = 0.8991, y = 0.9916x + 0.0499; spermidine r = 0.8936, y = 1.2073x + 0.1005; spermine r = 0.8921, y = 1.2200x-0.2194, (n = 13).

Polyamine concentrations of human cancerous and non-cancerous tissues from the kidney, ureter, bladder were measured by a new enzymatic method for isolation and determination of polyamines. In cancerous and non-cancerous tissue of the organs studied, the spermine level was highest followed by the spermidine and diamine levels. The concentrations of diamine, spermidine and spermine in cancerous tissues were significantly higher than those in non-cancerous tissues, but there was no significant difference in the spermidine/spermine ratio between the cancerous and non-cancerous tissues. These data suggest that polyamines are produced above the normal levels in pathological conditions such as renal cell carcinoma, ureteral cancer and bladder cancer.

A 41-year-old man was hospitalized, complaining of fecaluria and right lower abdominal pain. He was diagnosed to have vesicorectal fistula. Wedge resection of bladder and rectum, and partial resection of ileocecal legion were performed. Pathological diagnosis was Crohn's disease. Postoperative course was uneventful and no recurrence was observed. Including our case, 32 cases of enterovesical fistula due to Crohn's disease have been reported in the Japanese literature.

A case of testicular tumor (embryonal cell carcinoma with choriocarcinoma) in a 42-year-old man treated with renal autotransplantation is presented. After four courses of chemotherapy (carboplatin, vinblastine and bleomycin), we performed retroperitoneal lymph node dissection. At the operation, one of the swelling lymph nodes involved left renal artery completely, so we performed left renal autotransplantation and promoted more effective lymph node dissection. After the operation, renal function was impaired but returned completely in a short time. Autotransplantation provides excellent bench visualization of renal lesions and stable graft function. Therefore, this procedure should be taken into consideration when nephrectomy cannot be avoided.

A new enzymatic method for determining urinary polyamine concentration by fractionation of the urinary acetyl conjugate into free polyamines with acylpolyamine amido-hydrolase and quantification using two kinds of amine-oxidase of different substrate specificity was examined. High recovery rates of urinary polyamine by enzymatic hydrolyzation were obtained, namely, 95 +/- 4% for diamine, 95 +/- 1% for spermidine and 99 +/- 2% for spermine. Furthermore, excellent linearity was demonstrated with up to 150 mumole/l diamine, up to 75 mumole/l spermidine and up to 50 mumole/l spermine. Although urinary polyamine concentration varied diurnally even after correction of urinary creatinine, day-to-day variation disappeared. In 24-hour pooled urine and voluntary urine, diamine, spermidine and spermine correlated relatively well. Urinary leukocytes and erythrocytes exerted no influence on urinary polyamine.

In 6 patients (9 kidneys) irrigation with Solution G in the renal pelvis was performed for the dissolution of their infectious stones. Staghorn calculi larger than 30 mm in diameter were observed in all patients. In two kidneys all stones were dissolved and the rest were dissolved into small fragments that constituted no problem in those kidneys. Irrigation was done with no major side effects or complications. The dissolution of infectious stones with Solution G is another possible treatment that could be first chosen among percutaneous nephrolithotripsy, extracorporeal shock wave lithotripsy and other treatments.

Circulating immune complexes (CIC) were detected and quantitated in 49 patients with urological malignant diseases (9 cases of renal cell cancer, 3 cases of renal pelvic and ureter cancer, 21 cases of bladder cancer and 16 cases of prostatic cancer), 9 patients with urological benign diseases and in normal subjects by the polyethylene-glycol precipitation complement consumption test (PEG-CC test). The average CIC level was 2.7 +/- 3.0% in 18 normal subjects and the normal range was less than 10% of the CIC level. CIC level of patients with renal cell cancer was 14.3 +/- 20.1%, being elevated in 3 of the 9 patients, that of patients with renal pelvic and ureter cancer was 4.7 +/- 4.6%, being within the normal range in 3 cases, that of patients with bladder cancer was 4.7 +/- 4.4%, being elevated in 1 of 21 patients, and that of patients with prostatic cancer was 8.9 +/- 15.4%, being elevated in 3 of 16 patients. In urological malignant diseases such as renal cell cancer and prostatic cancer the CIC values were relatively high.

A case of prostatic rhabdomyosarcoma in a 5-year-old boy is reported. He was brought to our clinic on Apr. 1, 1982 with complaints of pollakisuria and urethral pain. X-ray examinations revealed a huge intrapelvic tumor, and it was histopathologically diagnosed as embryonal rhabdomyosarcoma with a specimen of transrectal needle biopsy. Since the tumor was too huge to resect completely, he was initially treated with combination chemotherapy regimen of vincristine, actinomycin D and cyclophosphamide (VAC therapy), and resulted in failure. Then another combination chemotherapy consisting of cis-diamminedichloroplatinum, vinblastine and bleomycin (PVB therapy) was tried, and the tumor showed reduction in size. On Oct. 15, 1982, total cystectomy with ileal conduit urinary diversion was performed. Histopathologically, degenerative change and partial necrosis of the tumor cell were recognized. After the operation, he was treated with radiation therapy and prophylactic VAC therapy. But six months later, multiple pulmonary metastases occurred and gradually increased in size and number. They did not respond to any other chemotherapy. He died on July 13, 1983. We discussed the chemotherapy for rhabdomyosarcoma, and emphasized that the PVB therapy should be tried on rhabdomyosarcoma as an initial chemotherapy.

Using the new enzymatic assay for isolation and determination of polyamine in blood presented in Report 4, the polyamines in the blood were isolated and determined in 84 patients with genitourinary cancer. In the early diagnosis, the positive rates of each fraction were not so high, but, relatively high positive rates were demonstrated, when any one of the polyamines were found positive: namely, 85.7% in renal cell cancer, 66.7% in renal pelvic and ureteral cancer, 44.0% in bladder cancers. These results seem to support the usefulness of the new method, and encourage further investigation of polyamines in the blood as tumor markers.

Recent reports have described that the accurate preoperative diagnosis of renal angiomyolipoma is possible with computerized tomography (CT). There are, however, some cases of angiomyolipoma which are indistinguishable from renal cell carcinoma on CT. Herein we report a case of renal angiomyolipoma which CT failed to reveal preoperatively. In a 71-year-old Japanese male, a left renal tumor was incidentally suspected on excretory urogram. Then CT demonstrated a homogeneous mass in the upper part of the left kidney, 6 cm in diameter, which showed a positive attenuation coefficient, slightly denser than renal parenchyma. Selective left renal arteriogram showed hypervascularity without aneurysmal formation or arteriovenous fistula. These radiologic findings strongly suggested renal cell carcinoma and radical left nephrectomy was performed. Histological examination confirmed angiomyolipoma composed mainly of smooth muscle with thick-walled vessels and immature fat cells. We reviewed the literature and discussed the computerized tomographic-pathologic correlation of angiomyolipoma.

Twenty-two cases of pheochromocytoma encountered at our department between 1965 and 1986 are reviewed. Eighteen of the patients were adults (26 to 62 years old) and 4 were children (9 to 13 years old). Thirteen were males and 9 were females. In a total of 23 operative procedures, 31 tumors were resected excluding lymph node metastasis. The preoperative accuracy of the diagnostic methods for locating the tumor was as follows. KUB and intravenous pyelography with tomography in 12 of 31 tumors (39%), aortography and/or selective arteriography in 21 of 27 (78%), selective venous sampling for catecholamine level in 4 of 4 (100%), computed tomography in 10 of 10 (100%), ultrasonography in 4 of 6 (67%), and iodine-131 metaiodobenzylguanidine scintigraphy in 4 of 6 (67%) tumors. The tumors resected were cases, as followings, a single unilateral adrenal tumor in 14 (right 6, left 8), bilateral adrenal tumors, bilateral adrenal plus extraadrenal tumors and unilateral adrenal plus extraadrenal in each, one case and extraadrenal tumor in six cases (single 5, multiple 1). Either lumbar or thoracolumbar surgery methods were adapted in 9 of 14 cases with single adrenal and one of 5 with single extraadrenal tumors, and in the remaining 13 cases transperitoneal methods were selected. One patient died on the 6th day after operation from gastrointestinal bleeding. Thus the surgical mortality rate in our series was 4.4%. Of the 3 patients with malignant pheochromocytoma, two (9 and 13 years old) are alive each 192 and 67 months after operation. The former is in a tumor-free condition, however in the latter multiple bone metastasis was detected 37 months after operation. The third patient (29 years old) died 62 months after operation from metastatic hemorrhagic tumors in the liver.

A 65-year-old man was admitted to our clinic with the chief complaint of gross hematuria and burning on urination. Cystoscopy revealed a papillary broad base tumor on right lateral and posterior wall. Barium enema showed a tumor of sigmoid colon. The other gastrointestinal and genitourinary tracts were examined but no tumor lesion could be found. Total cystectomy and partial resection of sigmoid colon were done, and the urinary tract was reconstructed using a Kock continent ileal reservoir. Histological findings revealed adenocarcinoma of its infiltration to the sigmoid colon.

A 9-year-old boy, who had been admitted to the Pediatric Department for the examination of IgA nephropathy, was transferred to our urological clinic on Aug. 6, 1985, because of parathyroid crisis. Before urological consultation, he had been complaining of bilateral knee and calcaneal pain, anorexia and abdominal pain, which had persisted for several days. Laboratory data indicated serum Ca of 17.6 mg/dl, iP of 2.3 mg/dl and iPTH of 0.77 ng/ml. Roentgenographic examination such as chest, extremities and neck computed tomography showed no abnormal findings. The final diagnosis was parathyroid crisis caused by primary hyperparathyroidism and neck exploration was carried out on August. 10. Left upper parathyroid gland, which was 1 cm in diameter, was surgically removed. The other three glands were normal in size. Histological examination of the resected parathyroid gland revealed chief cell adenoma. In the post-operative course, serum Ca level was soon reduced to the normal range and bone pain disappeared rapidly. During the follow up period of 2.5 years, the patient was clinically free of recurrence. Only 23 cases of primary hyperparathyroidism in children have been reported in the Japanese literature. The clinical characteristics of these specific cases are that primary hyperparathyroidism in children shows a low incidence of renal lesion, but the complicated bone disease is of higher incidence compared with the adult cases. Histopathologically, parathyroid adenoma was frequently observed (14/19), and the other 5 cases were parathyroid hyperplasia.

A new enzymatic method for isolation and determination of urinary polyamines was presented and basically studied in previous report 1 and 2 in comparison with existing techniques. Using the new method, urinary polyamines were isolated and determined in 56 patients with genitourinary cancer. Urinary polyamines were also determined in 63 controls consisting of 20 normal subjects, 25 patients with benign urological disease and 18 patients with BPH. The mean concentrations of Diamine, Spermidine, Spermine in 20 normal subjects were 16.6 +/- 5.8 mumoles/g Cr, 4.7 +/- 2.0 mumoles/g Cr and 0.99 +/- 0.51 mumoles/g Cr respectively. To emphasize the specificity to cancer, the level of positiveness was modified to a higher value than M+3SD. The positive values thus calculated were 40 mumoles/g Cr for Diamine, 15 mumoles/g Cr for Spermidine and 3 mumoles/g Cr for Spermine. The positive ratios of Diamine in patients with early cancer were 43% in renal cell cancer, 20% in pelvic and ureter cancer, 0% in bladder cancer and 20% in prostatic cancer. Those of Spermidine were 29% in renal cell cancer, 0% in pelvic and ureter cancer, 20% in bladder cancer and 40% in prostatic cancer. Those of Spermine were 29% in renal cell cancer, 20% in pelvic and ureter cancer, 20% in bladder cancer and 0% in prostatic cancer. In early diagnoses, Diamine indicated high positive ratios to renal cell cancer and Spermidine to prostatic cancer. Relatively high positive ratios were demonstrated, when any one of the isolated polyamines was found positive: namely, 57% in renal cell cancer, 20% in pelvic and ureter cancer, 30% in bladder cancer and 40% in prostatic cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

A 47-year-old man was admitted with chief complaints of macroscopic hematuria and bone pain. Hypercalcemia still remained after three small papillary tumors on the left retrotrigonal wall of the bladder were resected transurethrally. Some biochemical as well as X-ray examinations thereafter pointed out an association with primary hyperparathyroidism. An adenoma arising from right upper parathyroid gland was found and excised. Then his symptoms, both subjective and objective, were normalized. Six documented cases of primary hyperparathyroidism associated with urological malignancy including our own were found in the Japanese literature.

A simple enzymatic method for determining total polyamines in human blood was established. Polyamines in trichloroacetic acid extract from 1 ml of blood were isolated on an anion-exchange column and measured spectrophotometrically by the end point assay using polyamine oxidase and putrescine oxidase. The recovery was as high as 98.4% and within-run precision (coefficient of variance: 1.82%), and the values obtained by this method were in fair agreement with those obtained by high performance liquid chromatography and the enzymatic differential assay methods previously reported. The polyamine levels were not changed when the blood was stored at -20 degrees C. Blood polyamine levels were measured in 108 patients with genitourinary cancers, 29 patients with benign prostatic hypertrophy, 18 patients with benign urological diseases and 25 normal subjects. Although polyamines were not significantly elevated in the low stage of cancer, elevation was observed at a high stage of malignancy. These results indicate that the determination of total polyamines may be useful to determine biochemically the malignancy of cancers.