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Postoperative femoral nerve palsy (FNP) is a rare complication associated with urologic surgery. Inappropriate use of retractors, use of lithotomy position, and prolonged surgery that lead to the femoral nerve compression have been reported as risk factors for FNP. Here, we report two cases of FNP after pelvic surgery. Case 1: A 47-year-old woman underwent ureterocystoneostomy for a giant ureterocele. On the first postoperative day, she developed muscle weakness and paresthesia in the left lower leg. An orthopedic surgeon diagnosed her with FNP associated with the surgery. Case 2: An 82-year-old woman underwent radical cystectomy for invasive bladder cancer. On the second postoperative day, she developed extension deficit in the left lower leg and was diagnosed with an iatrogenic FNP. Although this complication is infrequent, at onset, it leads to difficulty in walking and gait disturbance in the patient. As a result, it greatly reduces the patient's postoperative quality of life. Therefore, preventive measures should be taken to reduce the risk of this postsurgical nerve injury, such as appropriate placement of retractors and proper patient positioning during the operation.

Adrenocortical oncocytic tumors are rare. As the Weiss criteria overestimate the malignancy of oncocytic tumor due to histological hallmarks, the Lin-Weiss-Bisceglia system (LWB system) is required for an accurate diagnosis of the malignant potential of an oncocytic tumor. We report two cases diagnosed as an oncocytic tumor with uncertain malignant potential (borderline) and an oncocytic tumor (benign) based on the LWB system, both of which were diagnosed as malignant based on the Weiss criteria. Case 1 : A man in his 20s was referred to our hospital for treatment of a left adrenal tumor. A non-functional pheochromocytoma or adrenal cancer was suspected. He underwent surgical resection of the left adrenal tumor and left kidney. The specimen was positive for 3 of the 9 Weiss criteria, but met one minor criterion in the LWB system. He was diagnosed with an oncocytic tumor with uncertain malignant potential (borderline). Case 2 : A woman in her 40s was referred to our hospital for treatment of a left adrenal tumor. Under the possibility of adrenal cancer, she underwent surgical resection of the left adrenal tumor. The specimen was positive for 3 of the 9 Weiss criteria, but the specimen met no criteria in the LWB system. She was diagnosed with an oncocytic tumor (benign). There has been no recurrence of the oncocytic tumor as of 2 years of follow-up in the two patients.

A 17-year-old man received continuous ambulatory peritoneal dialysis (CAPD) catheter implantation and had started peritoneal dialysis. Perfusion failure of peritoneal dialysis catheter occurred one month after the catheter implantation. Transcatheter contrast examination revealed catheter obstruction about 4-5 cm from the catheter tip. We performed reduced port surgery to remove the obstruction. Laparoscopy revealed that the omentum was adhered to the abdominal wall and wrapped the catheter. We diagnosed the cause of catheter malfunction as omentum wrapping. We removed the omentum from the catheter, and repositioned the catheter into the Douglas fossa. Although CAPD worked successfully after the operation, perfusion failure recurred one month after the operation. The patient requested discontinuation of CAPD and change to hemodialysis. Therefore, we removed the CAPD catheter. The catheter was adhered to the omentum. Reduced port surgery for peritoneal dialysis catheter obstruction has the advantage of being minimally invasive and is a reliable procedure, but further studies are needed to reduce the recurrence rate of perfusion failure and to establish the procedure after perfusion failure.

A 32-year-old woman was referred to our hospital for consultation with a suspected left adrenal tumor detected by ultrasonography at a health check. Computed tomography and magnetic resonance imaging revealed a 3×1×4 cm multilocular cystic mass arising from the diaphragmatic crura, suggesting a retroperitoneal bronchogenic cyst. The patient underwent excision of the cyst and adjacent diaphragm using a retroperitoneoscopic approach. Retroperitoneal bronchogenic cysts are rare. We review the cases of 26 patients who underwent laparoscopic resection of a retroperitoneal bronchogenic cyst.

A 78-year-old man presented with swelling of para-aortic and left iliac lymph nodes (LNs). He had undergone left high orchiectomy 10 years ago. He was diagnosed with stage I seminoma, and was managed with active surveillance. Eight years later, the follow-up computed tomography (CT) revealed para-aortic LN swelling, but the patient refused further treatment. He complained of left lower extremity edema 10 years after orchiectomy. CT showed enlargement of both LNs, especially, diameter of left iliac lymph nodes was up to 9 cm. He was referred to our hospital. LDH was slightly increased to 261 IU/1, but α-fetoprotein, and total and free beta human chorionic gonadotropin were within normal limits. Results of pathological review of the testicular tumor was also seminoma. The treatment with etoposide and cisplatin (EP) was started under the diagnosis of late relapse of seminoma. However, CT after 1 course of EP showed no shrinkage of LN metastases. At this time, soluble interleukin-2 receptor (sIL-2R) was elevated up to 5, 090 U/ml (normal range: 613 U/ml). Needle biopsy from pelvic LN was performed on suspicion of metachronous malignant lymphoma. The pathological diagnosis was mantle cell lymphoma. The patient was transferred to the department of hematology, and treated successfully with rituximab and bendamustine. When LN swelling is seen after long-term active surveillance, there is a possibility of late relapse. However, metachronous malignant lymphoma also should be considered in an elderly patient.

A 78-year-old man was referred to Tsukuba University Hospital for right hydronephrosis. He had undergone ureteroscopy and ureteral stenting in another hospital, but no tumor was revealed in renal pelvis and ureter. The urinary cytology was negative. Computed tomography (CT) revealed remarkable thickening of right renal pelvis and ureter wall. CT also showed para-aortic, iliac, supraclavicular and mediastinal lymph node (LN) swelling. 18F-fluoro-2-deoxy-D-glucose positron emission tomography (PET) revealed high uptake at thickened right renal pelvis and ureter wall and enlarged LNs. The soluble interleukin-2 receptor was elevated to 1, 110 U/ml (normal range: 613 U/ml). Those findings suggested that the malignant lymphoma originated from the renal pelvis and ureter rather than urothelial cancer. Therefore we performed open biopsy of iliac LN and periureteral tissue. The pathological diagnosis was mucosa associated lymphoid tissue (MALT) lymphoma. The patient was trasferred to the department of hematology, and treated with rituximab and bendamustine. After 6 courses of chemotherapy, swelling of renal pelvis, ureter and LN was markedly reduced. The ureteral sent could be removed. MALT lymphoma of the upper urinary tract is extremely rare and pretreatment diagnosis is difficult. In 8 of 11 reported cases, the diagnosis was made by nephroureterectomy. In our cases, open biopsy could avoid nephroureterectomy.

A 70-year-old man was admitted with complaint of gross hematuria. Cystoscopy and computed tomography (CT) revealed a 2.5 cm nodular tumor in the urinary bladder. Pathological diagnosis after the transurethral resection of bladder tumor (TURBT) was invasive urothelial cancer with trophoblastic differentiation of pT1. The tumor was positively stained with human chorionic gonadotropin (HCG). The serum HCG level was 12.8 IU/l in the fourth week after TURBT, and it increased to 35.7 IU/l in the 20th week after TURBT. However, radiological examination at this point did not reveal tumor recurrence or metastases. Three months later, the patient coughed up bloody sputum. Lung metastases (up to 2.4 cm) were identified, and they were surgically removed. The pathological specimen consisted of syncytiotrophoblastic giant cells with hemorrhage and necrosis, but no urothelial cancer element. Because the lung and lymph node metastases developed soon after surgery, chemotherapy was planned. Because the patient had impaired renal function with a creatinine clearance of 33.7 ml/min, we selected combination chemotherapy with gemcitabine and oxaliplatin (GEMOX) rather than cisplatin -based chemotherapy. CT after two courses of GEMOX showed stable disease, but HCG levels markedly decreased from 1, 240 IU/l to 7.9 IU/l. This marker of response continued through six courses of GEMOX. Then, the chemotherapy was discontinued due to grade 2 neuropathy. He died of cancer 12 months after development of metastases. Autopsy revealed only tumor cells with trophoblastic differentiation, but no urothelial carcinoma in multiple metastatic sites.

A 68-year-old Japanese man was referred to Tsukuba University Hospital for bladder cancer treatment. He had undergone a transurethral resection of a bladder tumor (TURBT) at a local hospital, but the pathological specimen did not contain muscle layer. Abdominal computed tomography (CT) and magnetic resonance imaging revealed a 3 cm non-papillary bladder tumor with muscle invasion, but there was no apparent calcification. The patient underwent re-TURBT at our hospital for diagnosis and staging. A non-papillary pedunculated tumor was identified in the bladder dome, and it contained a small papillary part. The non-papillary part was stony hard and difficult to cut with electrocautery, whereas the small papillary part was easily cut. Histologically, the non-papillary part was composed of sarcomatous elements including osteosarcoma, chondrosarcoma, and spindle cell sarcoma. The papillary part was composed of high-grade urothelial carcinoma and spindle cell sarcoma. Muscularis propria was not present in the specimen. Since the staging study with CT was negative for metastases, we performed a total cystectomy with an ileal conduit under the clinical diagnosis of muscle-invasive sarcomatoid urothelial carcinoma. The pathological findings were identical to those of the re-TURBT specimens, and our diagnosis was pTxN0 sarcomatoid urothelial carcinoma. The patient received adjuvant chemotherapy with two courses of gemcitabine and cisplatin. There was neither recurrence nor metastases during the 20-month follow-up. Reports of sarcomatoid urothelial carcinoma of the bladder with an osteosarcoma element are rare, and only eight other cases hane been reported in the Japanese literature.

A 54-year-old woman presented withtransient back pain. She was diagnosed withleiomyosarcoma of the inferior vena cava (IVC) by computed tomography (CT) and was referred to our hospital. Contrastenhanced CT revealed a mass (38×42 mm) located in the retroperitoneal space along the course of the right ovarian vein. The mass compressed the IVC into a crescent shape. A tumor thrombus was also found in the IVC. 18 F-fluoro-2-deoxy-D-glucose positron emission tomography (PET) revealed high uptake at the caudal side of the tumor. These radiological findings strongly suggested the diagnosis of leiomyosarcoma arising from the right ovarian vein. She underwent tumor resection with right nephrectomy, IVC resection, and IVC patch reconstruction without any notable events after surgery. Histopathological diagnosis was leiomyosarcoma arising from the ovarian vein, not from the IVC. Two months after the surgery, CT revealed multiple pulmonary metastases and a single liver metastasis. The patient was referred to another hospital for further treatment. She was treated with chemotherapy and was alive with disease at 14 months after the surgery., 訂正版のpdfは、泌尿器科紀要vol.63 no.12 p.537(2017年12月発行)

A 68-year-old woman presented with a bladder tumor. She was asymptomatic, and the tumor was incidentally detected with radiological imaging performed during treatment of cervical cancer. Magnetic resonance imaging and computed tomography revealed a solitary submucosal tumor located in the anterior wall of the urinary bladder, with homogeneous contrast enhancement. Cystoscopy showed a submucosal tumor covered by normal mucosa. A paraganglioma was considered in the differential diagnosis, but symptoms suggesting hypercatecholaminemia were not apparent. Moreover, she did not have a family history or symptoms associated with neurofibromatosis-1 (NF-1). She underwent partial cystectomy with a preliminary diagnosis of submucosal bladder tumor. Histopathological diagnosis confirmed a schwannoma arising from the bladder wall. She was followed up without intravesical recurrence or metastases for 6 months. In the literature, only 12 cases of bladder schwannoma have been reported. There was no reported family history or symptoms associated with NF-1 in any of the cases. Although the number of cases is limited, literature review showed a favorable prognosis for bladder schwannoma with local tumor resection in patients without NF-1.

Deep vein thrombus (DVT) in a patient awaiting surgery is a considerable source of pulmonary embolisms (PEs) during the surgical period, but screening for DVTs has not been emphasized. This retrospective study was conducted to identify factors associated with a positive D-dimer result and DVT diagnosis in order to evaluate the usefulness of DVT screening for patients awaiting surgery. A total of 1, 061 patients (872 males, 189 females) underwent D-dimer testing prior to urological surgery at Tsukuba University Hospital between April 2013 and March 2016. Factors associated with a positive D-dimer result and DVT diagnosis were determined by a univariate analysis. Among the 75 patients with a positive Ddimer result, venousultras onography of the lower extremitieswasperformed in 69 patientsand DVT was diagnosed in 14 patients. The overall true-positive rate of D-dimer was 20. 3% (14/69), and it was significantly higher in the females (males11.3% vsfemales50% ; p＝0.0021). Age, body mass index and Ddimer value were not associated with the true-positive D-dimer result. Among the 1, 061 patients, DVT was significantly more likely to be diagnosed in elderly patients (median age 73.5 vs 67 yrs, p＝0.0087) and females(males0. 69% vsfemales4. 23% ; p＝0. 0010). Among the three patientswith an acute-phase thrombus, two postponed surgery and required anti-thrombus therapy, and the other patient underwent the implantation of an inferior vena cava filter in order to undergo surgery on schedule. No PE occurred during the surgical period. These results indicate that DVT screening for patients awaiting surgery is useful and should be considered as part of the prevention of PEs during the surgical period.

Histologically pure seminoma with elevated alpha-fetoprotein (AFP), so-called AFP-positive seminoma, is rare. It is recommended that patients with AFP-positive seminoma be managed as non-seminoma, but the clinical features and prognosis of this disease are not fully understood. In this study, we retrospectively analyzed 6 cases of metastatic AFP-positive seminoma at Tsukuba University Hospital (TUH). AFP was elevated before induction chemotherapy in 4 patients with an average of 1, 372 ng/ml. In the remaining 2 patients, AFP became elevated during or after induction chemotherapy. In all 4 patients examined, AFPL3% was abnormally increased. As induction chemotherapy, all patients received bleomycin, etoposide and cisplatin (BEP), which was then followed by etoposide, ifosfamide and cisplatin (VIP) in 3 patients. After or during induction chemotherapy, 3 patients suffered from disease progression accompanied by AFP elevation. All 3 were treated by salvage chemotherapy and surgery. Four patients underwent retroperitoneal lymph node dissection (RPLND) after induction chemotherapy ; the pathological findings were necrosis in 3 patients, and viable nonseminomatous cancer in 1 patient. Furthermore, RPLND was performed as salvage surgery in 3 patients ; the pathological findings were necrosis, viable nonseminomatous cancer and teratoma with malignant transformation, respectively. The 5-year progression-free survival rate of the 6 patients was 50%, which is somewhat inferior to that of poor-prognosis non-seminoma patients treated at TUH. One patient ultimately died of cancer, and the remaining 5 are in remission with a median follow-up of 58 months. The present study demonstrates that AFP-positive seminoma patients have a higher risk of relapse compared to non-seminoma patients.

A 37-year-old man presented at our hospital. Pathological examination of a right orchiectomy specimen, radiographic examination, and tumor marker profile resulted in a diagnosis of retroperitoneal nonseminomatous germ cell tumor (intermediate risk according to IGCC classification). Laboratory testing revealed mild elevation of low density lipoprotein cholesterol. Induction chemotherapy with bleomycin, etoposide and cisplatin (BEP) was started, but he complained of chest pain on day 10 of the second cycle of BEP. We immediately started cardiac monitoring. One hour later, he suffered cardiac arrest due to ventricular fibrillation. Fortunately, sinus rhythm was restored after defibrillation. A diagnosis of acute myocardial infarction (AMI) with total occlusion at the mid-portion of the left anterior descending coronary artery was established by coronary angiography. After percutaneous transluminal coronary angioplasty was successfully performed, he recovered uneventfully. The induction chemotherapy was re-started 19 days after AMI. To avoid endothelial damage by bleomycin, we elected to treat with etoposide, ifosfamide, and cisplatin (VIP). After two further courses of VIP, the patient underwent resection of retoperitoneal tumor and achieved complete remission. The patient has remained disease-free during 3 years follow up without recurrence of AMI.

We reported two cases of hyperthyroidism that developed during induction chemotherapy for advanced germ cell tumors with high serum human chorionic gonadotropin (hCG) levels. Case 1 : An 18-year-old man with mediastinal choriocarcinoma complained of tachycardia and tremor. His pretreatment serum hCG level was 1.37 million mIU/ml. The free thyroxine (fT4) level measured on day 2 of the first course of bleomycin, etoposide and cisplatin (BEP) was elevated to 7.8 ng/dl (＜1.7 ng/dl), whereasthe thyroidstimulating hormone (TSH) level was undetectable. We diagnosed the patient with hyperthyroidism and started oral propranolol and thiamazole. Subsequently, his tachycardia and tremor disappeared. On day 12 of the first course of BEP, his hCG level decreased to less than 50, 000 mIU/ml. Also, his fT4 level returned to the normal range. Case 2 : A 29-year-old man presented with a left scrotal mass. He was diagnosed with non-seminoma testicular cancer (embryonal carcinoma and choriocarcinoma) with multiple lung, liver and lymph node metastases. On the admission day, his serum hCG and fT4 levels were high ; 3.23 million mIU/ml and 2.2 ng/dl, respectively. The TSH level was low at 0.011 mIU/ml. On day 3 of the first course of BEP, his hCG and fT4 levels increased to 4.5 million mIU/ml and 3.0 ng/dl, respectively. He complained of tachycardia, tremor and hyperhydrosis. He was started on propranolol and potassium iodide. After the treatment, histachycardia, tremor and hyperhidrosisdis appeared. HisfT4 level normalized on day 17 of the first course of BEP. The TSH-like activity of hCG is considered to be responsible for paraneoplastic hyperthyroidism among germ cell cancer patients with high hCG levels. To our knowledge, thisisthe first report of such a case in Japan. However, thisphenomenon isnot rare among patients with extremely high hCG levels. Therefore, we should be careful of these patients.

Tumor lysis syndrome (TLS) is a major oncological emergency. TLS is common in patients with hematological malignancies, but it can occur across a spectrum of cancer types. Germ cell tumors (GCT) have rapid cancer cell turnover and often present with bulky metastasis. The international TLS expert consensus panel has recommended guidelines for a medical decision tree to assign low, intermediate and high risk to patients with cancer at risk for TLS. GCT is classified as intermediate risk for TLS, and the patients who have other TLS risks factors are classified to be at high risk for TLS. In this study, we retrospectively analyzed 67 patients with metastatic GCT who were treated with induction chemotherapy at Tsukuba University Hospital between 2000 and 2013. Thirty-one, 15 and 21 patients were classified with good-, intermediate- and poor-prognosis disease, respectively, according to the International Germ Cell Cancer Collaborative Group criteria. Twelve patients (18%) were classified to be at high risk for TLS, and two patients were treated with allopurinol or rasburicase as prophylaxes for TLS. They did not show progression to laboratory TLS (L-TLS). In the remaining 10 TLS high-risk patients, three (30%) patients developed L-TLS after chemotherapy and started receiving oral allopurinol. As a result, no patients developed clinical TLS (C-TLS). In this study, 30% of TLS-high risk patients developed L-TLS without prophylactic treatment. Therefore, it is important to conduct TLS-risk stratification and consider prophylaxis such as rasburicase for advanced GCT patients at induction chemotherapy.

A 64-year-oldman with flank pain was diagnosed with right renal angiomyolipoma (AML) with tumor thrombus invading the inferior vena cava (IVC). Computedtomography showed a 55 mm IVC tumor thrombus with fat density. The patient underwent radical nephrectomy and IVC thrombcetomy with uneventful postoperative recovery. Pathological diagnosis was AML without malignancy. No recurrence has been observed for 18 months after surgery. We reviewed 60 case reports of AML with venous involvement. Furthermore, we discussed differential diagnosis between AML and other renal tumors mimicking AML with caval involvement.

Testicular tumors are representative solidcancers that occur in young men, and the standard multi-drug combination chemotherapy has been established for metastatic tumors. However, they develop rarely in elderly men over 70 years old, and there are few reports about the information of combination chemotherapy for elderly testicular tumor patients. Here, we present a case in a 79-year-old who had right testicular tumors (seminoma, cT2N3M1a, IGCC classification : goodprognosis) safely treated with multi-drug combination chemotherapy. To reduce the risk of side effects, we selected 4 courses of etoposide and cisplatin (EP) to the patient. The patient suffered from febrile neutropenia (FN) and oral mucositis during the first cycle of EP. However, no further episodes of oral mucositis and FN were observed after introduction of oral health care by a dentist. The patient received 4 courses of EP without dose reduction or treatment postponement. There was no evidence of recurrence 6 months after chemotherapy. To our knowledge, the present case is the oldest patient with metastatic testicular treated with combination chemotherapy including cisplatin.

This paper will explore the relationship between the migration of Palaung Buddhists and the constructionof their own practices in Namhsan, northern Shan State, Myanmar. The Palaung are uplanders of this area, while the Shan are rulers of the valleys. Previous studies concluded that the Palaung simply imitated ShanBuddhist practices, citing how the Palaung would typically deliver teachings in the Shan language and usetexts written in the Shan script. However, conducting fieldwork in Namhsan, I found that the Palaung haverecently begun to translate Buddhist texts using the Palaung script and to deliver dharma teachings in thePalaung language. One factor of this phenomenon is that the social contacts between Burmese and Palaungpeople have become more intense, on account of the increasing of migration. As a result, influence fromBurmese Buddhism has become stronger. Yet elite monks try to make their own style of practice andcreate a “Palaung sect.” These developments demonstrate how the Palaung have exercised their owncultural agency and remade the ethnic connectedness in the articulation of Buddhist practices. Nonethelesswe must exercise caution in assessing the reality of the “Palaung sect.” Owing to the great differencesin language among the Palaung sub-groups, the Buddhist texts composed in Samloŋ language aredifficult to understand for other sub-groups. Therefore, there is great diversity in the Palaung texts of eachsub-group. This means that these sub-groups of Palaung still maintain a micro-regional community byremaking and reinforcing connectedness within the groups., 〈特集〉現代東南アジアにおける宗教の越境現象―タイ，ミャンマーを中心に―

A 54-year-old woman underwent resection of malignant melanoma of the left leg and inguinal lymph node metastases and subsequent radiation therapy (60 Gy) following three courses of dacarbazine, nimustine, vincristine and interferon-beta chemotherapy in January 2010. In September 2011, she was referred to our department with the chief complaint of asymptomatic gross hematuria. A non-papillary bladder tumor was detected on cystoscopy and fluorodeoxyglucose (FDG) positron emission fomography-computed tomography revealed increased uptake of FDG only in the area of the bladder tumor. Melanoma cells were also found on urinary cytology. Our diagnosis was metastatic malignant melanoma of the bladder. Complete transurethral resection of the bladder tumor was performed, and pathological examination confirmed metastatic malignant melanoma. Metastatic bladder tumors constitute less than 5% of all bladder tumors. There are metastases in other organs at the time of diagnosis in almost all cases. In Japan, metastatic malignant melanoma of the urinary bladder is rare in clinical practice, there having been about a dozen reported cases. Solitary metastasis as in our case is even rarer.

Ureteral endometriosis is a rare but important clinical problem that requires early detection and treatment. The urinary tract is affected in approximately 2% of women with endometriosis. Even though the bladder is the most frequent urinary tract organ affected in these patients, the ureter is also affected in 10-40% of the cases, thus requiring immediate clinical attention. The majority of endometrial lesions is typically located in the lower segment of the ureter and is often difficult to differentiate between endometriosis and malignancy. Ureteral endmetriosis should be considered for women with hydronephrosis. In this report we present one clinical case of mixed-type ureteral endometriosis. A 37-year-old woman was referred to our hospital due to left hydronephrosis. Contrast-enhanced CT scan confirmed left hydronephrosis and also showed a solid mass at the left lower ureter. Retrograde pyelography revealed stenosis of the left lower ureter and Renogram revealed severely impaired renal function. Laparoscopic nephroureterectomy was performed. Pathologically, mixed-type endometriosis of the left ureter was diagnosed.

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