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Severe urinary tract infection occasionally causes urosepsis and disseminated intravascular coagulation (DIC). We experienced six cases of DIC with severe urinary tract infection from July 2009 to January 2011. Patients comprised two men and four women, ranging in age from 67-84 years old. In all cases, urinary tract infection was caused by pyelonephritis. The results of analysis of bacterial culture from blood and urine revealed E. faecalis in 2 cases, E. coli in 1 case, P. mirabilis in 1 case and Candida tripicalis in 1 case. Percutaneous nephrostomy in 1 case and ureteral stent indwelling in 3 cases and ureteral stent exchange in 2 cases were used for the drainage of the origin of infection. Under the diagnosis of DIC, the administration of antibiotics and anti-DIC treatment with recombinant thrombomodulin (rTM) were performed. rTM isa new drug for the treatment of DIC. rTM binds to thrombin to inactivate coagulation, and the thrombinrTM complex activates protein C to form activated protein C. Therefore, rTM actsasa negative feedback regulator of blood coagulation. Treatment with rTM improved in 5 of the 6 patients.

A 67-year-old woman was admitted with aching pain in her left flank and nausea. Bilateral renal infarctions were noticed by CT scan and arteriography. Selective intra-arterial thrombolytic therapy was performed. Urokinase (UK) was administered through a balloon catheter embedded into the occlusive segment of the left renal artery selectively. UK (20,000 units/hour) was continuously infused after short-term high dose UK (360,000) infusion. In spite of recanalization of the occluded artery, CT scan and renoscintigraphy image did not suggest recovery of renal function. Conservative intra-arterial thrombolytic therapy is considered to be the most effective treatment for renal infarction.

99mTc-DMSA renal scintigraphy was utilized to investigate the influence of ESWL on renal function in comparison with that of PNL. In the beginning, the reproducibility of renal uptake rate by the scintigraphy was examined in eleven healthy volunteers under both non-diuretic and diuretic states. The renal uptake rate was shown to be sufficiently reproducible in the same person in the two different trials. However, the differences and the standard deviations were shown to be a few percentages, which were not statistically significant. Changes in the repeated renal uptake rate seem to indicate not only changes of renal function with the treatment but also some technical errors. Herein, to investigate changes in renal function of the therapeutic side, the uptake ratio rate (rate of uptake rate in the therapeutic side/uptake rate in the contral lateral side) was utilized instead of uptake rate. Renal scintigraphy was carried out in 48 patients with unilateral renal stones before and after ESWL or PNL monotherapy or the combined ESWL and PNL therapies. Within one week of treatment, the uptake ratio rate significantly decreased in patients with PNL or the combined ESWL and PNL, although DMSA uptake rate in the therapeutic side did not significantly changes. Neither renal uptake rate nor uptake ratio rate significantly changed after ESWL treatment. There was no significant difference in changes of uptake ratio rate between Siemens Lithostars Plus and the improved Dornier HM-3 lithotriptors. This study indicated that ESWL monotherapy did not affect the uptake ratio rate, although PNL monotherapy and the combined ESWL and PNL therapies may affect the uptake ratio rate to some extent.

Between August, 1987 and December, 1991, 84 patients with 87 staghorn calculi were treated mainly with extracorporeal shockwave lithotripsy (ESWL) using a Dornier HM-3 improved lithotriptor. Patients were 38 men (38 renal units, mean age 54.9 years) and 46 women (49 renal units, mean age 54.3 years). Staghorn calculi were divided into 2 types; 54 units of complete type (mean stone area 9.2 cm2) and 34 units of incomplete type (mean stone area 5.5 cm2). Patients with complete type were treated with 3.6 sessions and 7,779 shock waves on average and 31.6 days for hospitalization was required, while patients with incomplete type were treated with 2.4 sessions and 5,288 shock waves on average and 15.7 days for hospitalization was required. After treatment, the excellent rate was 47.2% for the complete type and 44.1% for the incomplete type. After the monotherapy of ESWL the excellent rate was 46.9% and after the combined therapy with percutaneous nephrolithotripsy (PNL) and/or percutaneous nephrostomy (PCN) it was 43.5%. We considered that the ESWL monotherapy for staghorn calculi was not feasible in patients with a large stone volume, with severe hydrocalices, with cystine stones and with so-called "complex staghorn calculi".

To determine the current status of urolithiasis in 1988, in comparison with that in 1985, we analyzed the 1937 patients of urolithiasis at 17 departments of urology in Mie Prefecture and 2 departments of urology in Wakayama Prefecture. The ratio of male to female patients was 2.6 to 1.0. Geographically, the number of urolithiasis patients was most frequently distributed in Matsusaka City. The frequency of urolithiasis in the urban area was almost the same as that in the rural area. Most of the stones (96.3%) were in the upper urinary tract. The frequency of lower urinary tract calculi tended to be high in southern Mie Prefecture. The ratio of the upper urinary tract calculi to the lower urinary tract calculi in the urban area was higher than in the rural area. The age distribution in males was in the forties, while that in females was in the fifties. The average age was 46.4 years old. The surgical treatment was performed in 671 patients (34.6%) and the extracorporeal shock wave lithotripsy (ESWL) was the most frequent mode of treatment (85.0%), followed by cysto-lithotripsy (4.2%) and percutaneous nephro-uretero-lithotripsy (2.4%). The most frequent component of the urinary tract calculi was calcium oxalate and/or calcium phosphate (81.7%). The stone patient increased in the number during the summer season (July, August and September). In conclusion, in 1988 when the ESWL treatment started in Mie Prefecture, the epidemiologic features of urolithiasis was characterized as follows: the number of patients increased and the broad application of the ESWL treatment resulted in the decreased number of patients with spontaneous discharge and the increased number of patients with recurrent stones and with bilateral or multiple complex stones.

The effect of intravesical combination chemotherapy on superficial bladder tumors was analyzed. Seventy-two patients were treated with intravesical instillation of the following anticancer drugs. MMC group: Mitomycin C (MMC) 10 mg and cytosine arabinoside (CA) 300 mg. ADM group: Adriamycin (ADM) 30 mg and CA 300 mg. PEP group: Peplomycin (PEP) 30 mg and CA 300 mg. MAC group: MMC 10 mg, ADM 30 mg and CA 300 mg. Antitumor effects in the MMC, ADM, PEP and MAC groups were evaluated in 16, 18, 17 and 21 patients and objective response (CR + PR) of tumor was observed in 87.5%, 50.0%, 35.3% and 28.6% of these patients. The papillary tumors, small tumors and low grade tumors responded better to these intravesical chemotherapies than the non-papillary tumors, the middle grade tumors and the high grade tumors. The recurrence rate in 72 patients was 6.9, 14.6 and 26.8% within 1, 2 and 3 years. No significant difference in the recurrence rate was observed between the MMC, ADM, PEP and MAC group, but the MMC group tended to have a lower recurrence rate than the other groups. The recurrence rate for the low grade tumors and the middle grade tumors was significantly lower than that for the high grade tumors and the small tumors. The major side effect of instillation therapy with these drugs was bladder irritation which appeared in 16.7% of all the patients (78 cases). In conclusion, intravesical chemotherapy is a useful approach for controlling superficial urinary bladder tumors, especially the combination of MMC and CA.

To determine the present status of urolithiasis in Mie Prefecture, we analyzed the 1,314 patients of urolithiasis at 17 Departments of Urology and 2 Departments of Medicine in 1985. The ratio of male patients to female patients was 2.6 to 1. The most frequent incidence of urolithiasis was observed in Iinan county. The incidence of urolithiasis in the urban area was the same as that in the country. Most of the stones (96.9%) were in the upper urinary tract. The incidence of lower urinary tract calculi tended to be high in southern Mie Prefecture. The ratio of upper urinary tract calculi to lower urinary tract calculi in the urban area was the same as that in the country. The peak incidence in males was in the forties, while that in females was in the fifties. The average age was 44.5 years old. Ureterolithotomy was the most frequent (37.5%) surgical therapy, percutaneous nephrolithotomy and shock wave lithotomy done in 8.0% and 6.3%, respectively. The most frequent component of the urinary tract calculi was calcium oxalate and/or calcium phosphate (84.0%). The incidence increased in summer (April through September).

Evoked response of bulbocavernosus reflex was taken in 8 normal control individuals and in 15 abnormal voiding patients (8 benign prostatic hyperplasia, 4 diabetic neuropathy, 3 supranuclear neurogenic bladder). the latency in control group showed 31.5 +/- 5.0 msec duration after penile stimulation and 65.4 +/- 11.0 msec duration after posterior urethral stimulation. The latency in diabetic neuropathy group was obviously prolonged but not that in the supranuclear neurogenic bladder group. This modern neurophysiological electrostimulation method provides simple and accurate information of bulbocavernosus reflex.

A 55-year-old man was admitted to our hospital because of pollakisuria and dysuria. Rectal examination revealed a normal prostate and did not show fluctuation or tenderness. Cystography and cystoscopic examination revealed a lesion projecting into the bladder cavity. An echogram showed an irregular internal echo at the left lobe of the prostate, but prostatic biopsy revealed benign prostatic hypertrophy. Transvesical removal of the prostatic cyst was performed. The cyst was about 3 cm in diameter and filled with yellow fluid (5.8 ml). The fluid contained no sperm and its acid phosphatase and zinc levels were high. The cystic wall was lined by cubo-collumnar cells and partly by flattened epithelium.

The urinary tract calculus patients seen at our Department between January, 1974 and December, 1983 were reviewed to determine the trend of urolithiasis. The urinary tract calculus patients accounted for 10.1% of all the outpatients. Recurrent calculus diseases were seen in 16.9% of male patients and in 12.1% of female patients. The frequency of recurrence was very high in the patients in their forties. Upper urinary tract calculi were seen most frequently in the patients in their forties. We could expect spontaneous passage of stone for at least 6 months in the case of a middle-sized stone (less than 6 X 10 mm). The percentage of calcium oxalate-containing stone was 73.2% in male patients and the percentage of phosphate-containing stones was 81.6% in female patients. Hypercalciuric patients were seen in 34.0% of the calculus inpatients. Urinary bacterial culture revealed positive in 33.0% of the calculus inpatients.

Twenty-six undescended testes in 22 patients between 1 and 31 years old were evaluated with ultrasonographic examination between October, 1981 and December, 1985. All 22 patients were operated on, and the accuracy of the ultrasonic diagnosis was evaluated in comparison to that of palpation diagnosis. Fourteen of 26 testes could be palpated preoperatively and these were all identified ultrasonographically and surgically. Twelve testes could not be palpated. On these 12 testes, surgical exploration revealed 9 testes in the inguinal region and absence of 3 testes. Ultrasound examination predicted its presence in 5 of 9 testes and its absence in all 3 testes. Both sonography and palpation failed to identify their presence in 4 tests. Thus, sensitivity of ultrasound examination was 82.6%, specificity 100% and accuracy 84.6% retrospectively. We conclude that ultrasound examination is useful in diagnosis of impalpable undescended testes in inguinal region.

Two cases of triple primary neoplasm and two cases of quadruple primary neoplasm including transitional cell carcinoma (TCC) of bladder are reported. The first case was a 70-year-old male who had bladder cancer, occult cancer of prostate (adenocarcinoma) and highly differentiated adenocarcinoma of pancreas. He died of cachexy. The second case was a 69-year-old male. This case was also triple primary neoplasm including bladder cancer, squamous cell carcinoma (SCC) of penis and SCC of larynx. The third case was a 78-year-old male who had bladder cancer, adenocarcinoma of prostate similar to that of the first case, adenocarcinoma of stomach, and SCC of lung. He died of obstructive jaundice and renal failure owing to massive metastases of gastric cancer. The fourth case was a 78-year-old male who had four primary neoplasms such as bladder cancer, branchiogenic epithelial carcinoma, SCC of buccal mucosa and adenocarcinoma of rectum.

Urinary amikacin concentration was determined in 9 patients with severely unilateral ureteral obstruction. Serum levels were within the normal range. The average concentration of amikacin in the urine from obstructed urinary tract was 118.9 mcg/ml 6 hours after 100 mg amikacin iv infusion. Urine concentration from the normal kidney was 155.9 mcg/ml at the first 2 hours after intravenous infusion, 98.8 at the second 2 hours 83.3 at the third 2 hours. Urinary amikacin excretion from severely obstructed urinary tract was about one third of the total excretion from a normal system. In summary, the urinary level in severely obstructed urinary tract after iv infusion of 100 mg amikacin may be enough prophylactically. But at the onset of infection in severely obstructed urinary tract, the administration of at least 200 mg amikacin intravenously is required.

A 63-year-old male was admitted with a complaint of right abdominal mass. A right renal tumor associated with direct invasion to liver and with lobulated cystic lesion and renal solitary cyst were diagnosed preoperatively by aortography and computed tomography. Transperitoneal radical nephrectomy and partial resection of liver metastasis were performed. Histological diagnosis was clear cell carcinoma with dilated tubuli. Tumor invasion to the inferolateral portion of the liver and to the renal solitary cyst wall were demonstrated by both gross and microscopic examinations. The coexistence of tumor and cyst in the same kidney is rare. Our case probably had both the type I and II or III tumors according to Gibson classification. Twenty months after radical nephrectomy, pulmonary metastases were detected by chest x-ray, tomography and bronchial arteriography. All metastatic lesions were replaced by fibrous change 7 months after the four bronchial arterial infusions (BAI) of ADM 30 mg and irradiation with a dose of 5,000 rads to each lesion. After 9 tumor-free months, recurrence of pulmonary metastases were pointed out by chest x-ray and tomography. They (four coin lesions) were treated with anticancer therapy, mainly irradiation and twice insufficient BAI. Three of them were occupied entirely by fibrous change and another solid one remained in the right pulmonary apex without enlargement for the past 4 months. Radical nephrectomy and partial resection of the liver for the primary renal cell carcinoma with direct invasion to liver, BAI and irradiation for the two pulmonary metastases have kept the patient alive for 4 years.

A case of a 73-year-old patient with preputial calculi is presented. The patient visited our hospital complaining of consciousness loss. It was impossible to place a catheter because of complete phimosis. Palpatory examination suggested the presence of stones in preputial cavity. Dorsal incision was made. After pus discharge nine small stones were extirpated. Ammonium hydrogen urate (96%) and calcium phosphate (4%) were found in these stones with infrared spectroscopic analysis. Bacteriodes ureolytcus and Peptostreptcoccus asaccharolyticus were isolated from urine specimen.

The diurnal variations in the plasma oxalate concentration and oxalate clearance were examined at the state of oxalate restriction and loading on 6 normal subjects and 11 calcium oxalate stone formers. The oxalate-restricted diet contained 44.5 mg of total oxalate, 32.2 mg of soluble oxalate, and for oxalate loading, spinach (100 g: total oxalate 429 mg, soluble oxalate 156 mg) was added to the oxalate-restricted diet at breakfast. Normal subjects showed a diurnal variation in plasma oxalate at oxalate restriction and loading. The plasma oxalate concentration showed the highest level under the fasting condition, gradually dropped and was then fixed at the lower level during the day. The oxalate clearance during the day was significantly higher (p less than 0.05) than that during the night in normal subjects taking the oxalate restricted diet, and after they were oxalate loaded, it increased significantly (p less than 0.05) for 6 hours, but returned to the level at oxalate restriction during the night. Meanwhile, there was no significant difference in oxalate clearance between day and night in calcium oxalate stone formers. As compared with the control group, there were no significant differences in the diurnal variation in the plasma oxalate concentration, oxalate clearance at oxalate restriction, or in the diurnal variation of the plasma oxalate concentration at oxalate loading. However, the oxalate clearance during the night after oxalate loading increased significantly (p less than 0.05) compared with the control group. Based on the pattern of urinary oxalate excretion during the night compared with the control group, the stone formers were divided into two groups. The first group showed significantly (p less than 0.01) higher oxalate clearance during the night both during oxalate restriction and loading. The oxalate clearance increased significantly up to 8 hours after oxalate loading (p less than 0.01) and during the night (p less than 0.05) compared with the level during oxalate restriction. The plasma oxalate concentration did not increase after loading. The second group showed a significantly (p less than 0.05) lower oxalate clearance during the day after oxalate loading. The oxalate clearance (p less than 0.05) was significantly increased for 4 hours after the loading compared to the during oxalate restriction. The plasma oxalate concentration increased at 6 hours after oxalate loading. There was no significant difference in oxalate clearance during the night. The diurnal variation in plasma oxalate level, a decrease during the day and an increase during the night, was shown in both normal subjects and stone formers.(ABSTRACT TRUNCATED AT 400 WORDS)

The diagnosis and management of 6 patients with spontaneous non-traumatic urinary extravasation are reported. It is important to distinguish extravasation of the fornical backflow type from that owing to frank rupture of the diseased renal pelvis. In Japan, 26 cases of spontaneous peripelvic extravasation and 29 cases of spontaneous pelvic rupture have been reported. Most of them were caused by calculous ureteral obstruction. Many of the cases of spontaneous peripelvic extravasation could be managed conservatively, and many of the cases of spontaneous pelvic rupture often required surgical treatment due to the patient's clinical condition, the persistence of obstruction or extravasation, or the presence of complication of extravasation such as urinoma or abscess. All of our 6 cases were managed conservatively and had no complications.