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We report a case of acute scrotal hematoma associated with idiopathic thrombocytosis. A 75-year-old man visited our hospital for the treatment of a left scrotal mass that had been increasing in size; the mass had developed after the puncture of left testicular hydrocele. The patient was diagnosed with acute scrotal hematoma on the basis of ultrasonography findings. The patient underwent an emergency operation for the removal of the hematoma. On 2 days after the surgery we noticed an increase in the size of the hematoma. The patient had a 4-year clinical history of idiopathic thrombocytosis for which he had not received any treatment. Although the platelet count was slightly high at the time of the operation, complete hemostasis did not occur because of the existence of platelet dysfunction. The second hematoma was treated conservatively. To our knowledge, this is the first case report on the acute scrotal hematoma associated with idiopathic thrombocytosis.

Renal lymphangioma is a very rare benign tumor caused by failure in the development of the lymphatic communication system. Since December 1997, a 55-year-old man with chronic B-type virus hepatitis has been followed at our hospital. Neither kidney showed any sign of cysts at that time. In November 2000, ultrasound sonography showed a right renal simple cyst measuring 1.0 cm in diameter. Thereafter, the initial cyst increased to 5.5 cm and numerous right renal cysts, appearing similar to multilocular renal cysts, were detected in December 2004. Computed tomography demonstrated a right renal multilocular cystic tumor, 5.5 cm in diameter, which was enhanced by contrast medium. Radical nephrectomy was performed, and the pathological diagnosis was renal lymphangioma based on positive staining with D2-40 antibody, which is reactive to endothelial cells of the lymphatics.

Late recurrence of stage I testicular seminoma is rare. We herein report a case of retroperitoneal lymph node recurrence of testicular seminoma 6 years after high orchiectomy. A 39-year-old man had a left high orchiectomy for stage I testicular tumor in November 1997. Histopathological findings revealed seminoma (pT3). In 2003, follow up computed tomography showed retroperitoneal lymph nodes swelling. Serum tumor markers had been normal since 1997. Retroperitoneal lymph nodes were dissected in April 2004. Histopathological findings were recurrence of seminoma.

Watchful-waiting policy is an important treatment option for some patients with localized prostate cancer and it is widely recognized in Western countries in which the prostate cancer mortality rate is 510 fold higher than that in Japan. Most men with well and perhaps moderately differentiated prostate cancer who have a life expectancy of less than 10 years will die of other causes and it is not clear whether early primary hormone therapy improves survival and the quality of life compared to androgen suppression deferred until signs and symptoms of clinical progression. There is one major question as to whether patients who do not need radical treatment should undergo early primary hormone therapy in Japan in spite of high cost and treatment-related adverse effects of hormone therapy.

We report two cases of femoral nerve palsy after radical prostatectomy due to compression ascribed to the use of a ring retractor. The first case is in a 69-year-old man who fell when getting out of bed on the first postoperative day. Physical examination revealed hypoesthesia around the patella and weakness of the quadriceps muscle. The second case is in a 66-year-old man who complained of numbness of the anteromedial aspects of the right thigh and inability to extend his right knee on the first postoperative day. Postoperative femoral nerve palsy is not a well-recognized complication in urology. The literature was reviewed and the management of postoperative femoral nerve palsy was discussed.

'General Rule for Clinical and Pathological Studies on Prostate Cancer(The 1st edition)' was published at 1985 by Japanese Urological Association and The Japanese Society of Pathology. It was revised in 1992 and the 2nd edition was published. Current diagnostic tests including prostate specific antigen (PSA) and biopsy technique have changed diagnosis and treatment of prostate cancer greatly. The 3rd edition was published in 2001 based on these changes. Here, the feature of the 3rd edition is outlined.

A 79-year-old man presented in August 2002 with right flank pain, anorexia, and gross hematuria. Physical examination was significant for a palpable, nontender, firm, and fixed mass in the epigastric region. Computed tomography scan of abdomen revealed a 15 cm tumor occupying almost the whole right kidney with extension into the inferior vena cava. The para-aortic and retroperitoneal lymph nodes were significantly enlarged. Examinations including bone scintigram and chest X-ray revealed no metastases. The patient underwent a ultrasound sonography-guided biopsy of the renal tumor, which showed a small cell carcinoma pathologically, and immunohistochemically. The patient received palliative treatment, and died in February 2003. We reviewed 25 cases including our case, and analyzed the clinical outcome of small cell carcinoma of the kidney.

In recent years, early detection techniques including PSA have resulted in a dramatic increase in the number of patients with localized prostate cancer. The natural history of localized prostate cancer is unusually favorable as compared with many other common cancers. Because of this, the management is controversial. Radical prostatectomy (RP), various techniques of irradiation (RT), endocrine therapy (ET) and watchful waiting (WW) have been utilized, but well designed randomized clinical trials with end results are lacking. Currently, RP is generally accepted as the preferred treatment option for younger patients with lower PSA level. RT has been thought to be somewhat inferior in terms of long-term survival rate compared with RP. Aggressive treatments such as RP and RT are associated with side effects: RP has more urinary and sexual side effects, while RT has more bowel symptoms. For some patients of older age, with well-differentiated tumor and lower PSA level, WW is recommended. WW is devoid of treatment-related side effects, but patients have the risk of progression. Several clinical trials of treatment for localized prostate cancer are being conducted in Western countries. However, these studies will require at least 10 years to accumulate enough study endpoints to form any conclusion. Therefore, it is important for the treatment strategies that we should carry out interventions that are neither excessive nor insufficient for each patient, and take QOL into consideration.

Wilms' tumor is very rarely found in adults and there are no established treatment guidelines for such tumors in adults. A 56-year-old woman was referred to our hospital for further examination of macroscopic hematuria. Computed tomography scan revealed a large right renal mass with enlarged lymph nodes. Angiography showed a hypovascular tumor. She underwent right nephrectomy and resection of lymph node metastasis with a diagnosis of malignant renal tumor. Histopathological examination revealed nephroblastoma with lymph node metastasis. The disease was classified as stage III according to the National Wilms' Tumor Study classification. The patient received adjuvant chemotherapy consisting of ifosfamide, cisplatin, and etoposide. This protocol was selected because of the published poor results with the standard Wilms' tumor chemotherapeutic agents when used in adults. She remained without tumor recurrence as of six months after surgery. Development of better therapeutic approaches to adult Wilms' tumor is awaited.

A 61-year-old woman was diagnosed with a renal tumor of the left kidney by ultrasound sonography during a health check-up. Computerized tomography (CT) and colored Doppler ultrasound sonography demonstrated two hypervascular tumors as typical renal cell carcinomas. A radically nephrectomized specimen was step-sectioned. Four tumor nodules were detected macroscopically, and 47 small nodules were detected microscopically, showing the clear cell type and alveolar growth pattern. Then all nodules including the 47 small nodules were diagnosed renal cell carcinoma.

Since 1980, 73 patients with advanced testicular cancer have been treated with chemotherapy and 43 patients received post-chemotherapy (salvage) surgery. The median age of all patients was 31 years old, ranging from 17 to 63 years. The histology of the primary testicular tumor was pure seminoma in 23 patients and non-seminoma in 50 patients. According to the Japan Urological Association classification, 38 patients were classified as stage II and 35 patients as stage III. As first-line chamotherapy, 52 patients were treated with PVB regimen (cisplatin, vinblastin, bleomycin), 16 patients with PEB (cisplatin, etoposide, bleomycin) and 5 patients with VAB-6 (vinblastine, actinomycin-D, bleomycin, cisplatin, cyclophosphamide). Thirty (41%) of the 73 patients achieved a complete response (CR) with chemotherapy alone and 63 (86%) achieved no evidence of disease (NED) with salvage treatment. As second-line chemotherapy, 16 patients were treated with PE (cisplatin, etoposide), or VIP (etoposide, ifosfamide, cisplatin) or VeIP (vinblastine, ifosfamide, cisplatin). One of the 16 patients achieved CR and 11 (69%) patients achieved NED. As salvage surgery, retroperitoneal lymphnode dissection (RPLND) was performed in 22 patients, RPLND with thoracotomy in 7 cases and thoracotomy alone in 4 cases. Necrosis was found in surgical specimens of 24 (56%) patients, mature teratoma in 6 (14%) and residual cancer in 13 (30%). Ninety-six percent and 100% of the patients with necrosis and mature teratoma survived with NED, respectively, but only 54% of the patients with residual carcinoma survived despite further treatment. Residual cancer was still found in 8 of the 32 (25%) marker normalized cases. Residual cancer could not reliably be predicted or discriminated from necrosis or mature teratoma by the prognostic criteria. Therefore, salvage surgery remains essential in the treatment of advanced testicular cancer.

A 45-year-old man was referred to our department because of a right renal mass which was incidentally found at a health screening. Ultrasound sonography, computerized tomography and magnetic resonance imaging showed a hypovascular tumor 3 cm in diameter with the fluid at the upper pole of the right kidney, implicating that the tumor was renal cell carcinoma originating from a renal cyst wall, or with central necrosis. A radical nephrectomy was therefore performed. The tumor was dark-brown and contained brown fluid. The histopathological findings showed renal oncocytoma with cystic degeneration.

A 70-year-old man, who was diagnosed by computed tomographic scan as having bilateral synchronous adrenal myelolipomas 6 years ago during the follow-up of fatty liver, underwent tumor resection at our Department because of growth of bilateral tumors without any subjective symptoms. Histopathological examination revealed mature adipose tissue cells without atypism and areas of hematopoietic tissue, including the myelotic, lymphotic, erythrocytic, and megakaryocytic cells. The diagnosis of myelolipoma was confirmed. The in vivo doubling time of bilateral tumors was 16.1 months and 31.3 months, respectively.

A 68-year-old woman admitted to our hospital complaining of urinary incontinence and dysuria. On examination, the labia were found to be fused extensively, with a pinhole opening at the midline. Under spinal anesthesia, the adhesion was clearly separated with the Hegar's dilator. There remains no recurrence in this patient following therapy. The labial adhesion was considered to be an acquired disease caused by infection, trauma in the genitalia, or sexless life, according to hypoestrogenism.

The clinical significance of preoperative prostate specific antigen (PSA) and PSA density (PSAD) in distinguishing stage T1a and T1b prostate cancer from benign prostatic hyperplasia (BPH) was studied retrospectively in men who had undergone surgery for BPH. A total of 202 clinically BPH patients underwent transurethral resection of prostate (TURP) or retropubic prostatectomy, and histopathological findings were BPH in 179 patients, T1a cancer in 10 patients and T1b cancer in 13 patients. The T1a cancer group was similar to the BPH group in all parameters. The PSA and PSAD values in the T1b cancer group were significantly higher than those in the BPH group (P < 0.001). Prostate volume and amount of tissue resected in the T1b cancer group were significantly smaller than those in the BPH group (p < 0.001). The cut-off values of PSA and PSAD were examined with T1a and T1b cancer as a positive control and histologically proven BPH as a negative control. When 8.0 ng/ml was used as the PSA cut-off value, the sensitivity was 65% and specificity was 70%. When 0.25 ng/ml/ml was used as the PSAD cut-off value, the sensitivity and specificity were 65% and 75%, respectively. PSAD was useful for improving the specificity. Almost all the cases undetected by using both cut-off values were of T1a cancer. The receiver operating characteristics curve demonstrated that at any point, PSAD was a better detector for distinguishing T1a, T1b cancer from BPH, focusing especially in the range of PSA level between 6.0 and 10.0 ng/ml. These findings suggest that PSA and PSAD are useful parameters in distinguishing T1b cancer from BPH before surgery.

The proportion of patients with localized prostate cancer treated by radical prostatectomy is increasing rapidly in Japan. As for the qualifications of patient candidates for radical surgery, various clinical and pathological findings to predict tumor extent and disease-free outcome must be considered carefully. There has been increased interest in the application of neoadjuvant or adjuvant therapy for locally advanced tumor group in order to improve disease-free survival and overall survival. The new anatomical approach to radical prostatectomy with its nerve sparing option assures preservation of erection. This procedure achieves excellent cancer control for patients with a definite organ-confined tumor preoperatively. Finally, more time is needed to obtain information on the long-term outcome after radical prostatectomy.

Through the use of digital rectal examination, prostate-specific antigen and improved biopsy technique, it is possible to diagnose early stage prostate cancer. The management of this disease, however, has generated considerable controversy. The decision whether to treat actively or conservatively must be made on the basis of accurate staging and grading technique, a patient's life expectancy and performance status. This article will show the current staging and management of prostate cancer as practiced in Japan.

A 74-year-old man was admitted to our hospital. Diagnosis of invasive bladder cancer was made and a total cystectomy was performed on January, 30, 1980. Histological examination showed transitional cell carcinoma, grade 2, pT1 is N0M0. After 16 years, when he suffered left femur, he had right inguinal lymphnode swelling. On the biopsy of the inguinal mass, histology was transitional cell carcinoma. The urethral washing cytology was positive. Lung CT scan dem onstrated multiple lesions. He was diagnosed of the urethral recurrence, right inguinal lymphnode metastasis and lung metastasis of bladder cancer. This case is the 5th case of urethral recurrence of bladder cancer following cystectomy in our hospital.

Of the 69 patients with clinical stage C prostate cancer under 75 years old and with good performance status between 1986 and 1995, 29 underwent radical prostatectomy combined with endocrine therapy, 21 underwent radiation therapy combined with endocrine therapy and remaining 19 patients were treated by endocrine therapy alone. The median followup was 44 months (range 4 to 122). Radical prostatectomy resulted in progression-free rates of 79% and 61% at 5 and 10 years, respectively. Progression-free rates were lower in patients with lymph node metastasis or positive surgical margins. In patients with clinical stage T3a-c and well or moderately differentiated tumor, radical prostatectomy resulted in a progression-free rate of 100% at 5 years. However, in patients with clinical stage T4a or poorly differentiated tumor, radiation therapy resulted in a better progression-free rate than radical prostatectomy. These findings suggest that patients with clinical stage T3a-c and well or moderately differentiated tumor will benefit from radical prostatectomy combined with endocrine therapy and that radiation therapy well be effective for advanced diseases.

A 60-year-old man was admitted to our hospital with the chief complaints of dysuria and sense of abdominal fullness. On digital rectal examination, an enlarged prostate with a smooth surface and elasticity was palpated. The concentration of prostate specific antigen (PSA) was elevated to 78 ng/ml. Pelvic computed tomographic (CT) scan and magnetic resonance imaging (MRI) revealed a large prostate, 8 cm in diameter, with a cystic mass, and extra-iliac lymph node swelling. On needle biopsy of the prostate and cyst, the histology was poorly differentiated adenocarcinoma, and the aspirate comprised bloody fluid with a negative test for cytology. He was diagnosed with prostatic cancer of T4N3M0. This is the 19th case of prostatic cancer with cystic formation reported in Japan.

Recently, there has been an increasing interest in the application of preoperative endocrine therapy prior to radical prostatectomy. The main purpose of this treatment modality is to enhance surgical curability and increase survival. Endocrine therapy was performed before radical prostatectomy on 40 patients between 1986 and 1993; 15 had stage B2 and 25 had stage C disease. The median duration of preoperative endocrine therapy was 3.8 months. All patients subsequently underwent radical prostatectomy, pelvic lymphadenectomy and castration. There was on average a 25.5% (0-71.8%) decrease in maximal cross-sectional area of prostate gland as determined by transrectal ultrasonography. Treatment-related histological effects, divided into three grades were as follows; excellent in 17, moderate in 11 and poor or no regression in 12. Pathological downstaging of disease status from the diagnosis made at the initial clinical examination was seen in 13 of the 40 patients (33%). At a median follow-up of 50 months (19-118 months), 36 of the 40 patients are disease-free and two died of cancer 43 and 50 months postoperatively. These findings suggest that preoperative endocrine therapy plays an important role in the management of locally advanced prostatic cancer.

Nephron-sparing surgery was initially limited to the patients with localized renal cancer (RCC) present bilaterally or in a solitary kidney. Recently there is controversy in the indication for partial nephrectomy or enucleation to incidentally defined small RCC with normal opposite kidney. We examined the incidence of multicentricity in 43 kidneys removed for RCC with a diameter of less than 80 mm. The mean diameter of the predominant tumors was 45 mm (range 12 to 80 mm). The kidneys were serially sectioned at 5 mm intervals. Three of 43 kidneys (7%) had multiple RCC. The size of the concomitant tumors ranged from 2 to 15 mm. The multicentricity had no relation to pathological grade, stage, vascular invasion or infiltration pattern. In addition, the other 4 kidneys had 2 adenomas, 1 angiomyolipoma and 1 fibroma. Therefore we observed a 16% incidence of small renal nodules and a 7% multicentricity of RCC in the nephrectomized kidneys with normal opposite kidney.

A 52-year-old female with the chief complaint of miction pain was referred for the examination of a urethral nodule. Physical inspection revealed the meatus to be reddish and swollen. The painless nodule (1 x 1 x 2 cm) was situated between the urethra and vagina on transvaginal examination. Chest X-ray, drip infusion pyelography (DIP) and urethrocystography (UCG) showed no evidence of tuberculosis. Bladder mucosa was normal on cystoscopy. Mycobacterium tuberculosis was not detected from urine or sputum. The nodule was resected along with a portion of the urethra. Histopathological examination revealed tuberculous granuloma of the urethra.

It is a fact that there are few effective drugs available except for interferon for that treatment of renal cell carcinoma, and the efficacy rate of interferon is less than 10% even if multiple drug regimens are included. We have experienced a case of renal cell carcinoma in whom interferon therapy was successful in reducing the primary lesion and tumor thrombus extending into the inferior vena cava. A 57-year-old man was admitted to our department with a complaint of macroscopic hematuria. Computed tomography and magnetic resonance imaging revealed a right renal tumor and the tumor thrombus. Because of the past history of his myocardial infarction, a radical operation was considered risky. So we started interferon therapy. Four months after the start of interferon therapy, the primary lesion and the tumor thrombus markedly reduced in their size, and the clinical response was evaluated as partial response by response criteria for urological cancer treatment. Therefore, radical nephrectomy and tumor thrombectomy were performed with extracorporeal circulation. Histopathologically, necrosis and lymphocyte infiltration into the cancer cell focus were seen, and these immunologic reactions were considered at the affection of interferon. In some case, interferon therapy is a useful and safe in the treatment of the primary lesion of renal cell carcinoma, and further investigation must be studied.

Neoadjuvant therapy for prostatic cancer might be important to increase cure rates of the disease and preservability of the organs. There were 43 cases in a period of 1975-1990 in which total prostatectomy were performed after neoadjuvant therapy. According to the clinical stage, there were 14 cases in B, 23 in C, 4 in D1 and 2 in D2. The median duration of neoadjuvant therapy was 4 months. Clinical response of the prostate in 37 evaluable cases was as follows; 6 cases were PR (16%), 12 cases were MR (32%) and 19 cases were NC (52%). Histopathological effect was as follows; 5 cases were grade 0a (12%), 12 cases were grade 0b (28%), 16 cases were grade 1 (37%), 8 cases were grade 2 (19%) and 2 cases were grade 3 (5%). In 2 cases with histopathological effect of grade 3, lymph node metastases were thought to have obviously disappeared. Histopathological effect seemed related to clinical response. In cases given neoadjuvant therapy for less than 2 months, no adequate clinicopathological effect was obtained. Cases that could achieve downstaging were 8; 1 in grade 0a, 2 in grade 1, 3 in grade 2 and 2 in grade 3. These results suggest that neoadjuvant therapy plays an important role in advanced prostatic cancer.

The results of treatment by orchiectomy and radiotherapy for stage I testicular seminoma are excellent with cure rates exceeding 95% and relapse rates less than 5%. However, after the development of successful surveillance programs for stage I nonseminomatous testicular cancers, the role of radiotherapy has been questioned by some authors and they proposed a "surveillance policy" for these patients. The purpose of this study was to determine the percentage of patients cured by orchiectomy alone, percentage who ultimately required therapy for occult metastases, site of recurrence, and over-all cure rate and treatment morbidity. And these data were compared with those of adjuvant radiotherapy group retrospectively. Twenty seven patients were treated with adjuvant radiotherapy (RT group). Since 1986, 23 patients with stage I testicular seminoma entered the "surveillance only" protocol at our institution (S group) with a follow-up between 14 and 70 months (median 43 months). Informed consent for the policy of surveillance was obtained. Follow up consisted of physical examination, determination of serum tumor markers and chest X-ray bimonthly for 2 years, every 3 months for 1 year, every 6 months for 2 years and annually thereafter to 10 years. CT scans were performed every 4 months for 3 years, every 6 months for 2 years. Two patients in S group (8.7%) relapsed at 4 and 7 months after orchiectomy with nonbulky retroperitoneal disease (less than 5 cm in diameter), whereas only 1 (3.7%) irradiated patients did so after 4 months.

Three cases of renal cell carcinoma with tumor thrombus extending into the inferior vena cava are reported. Radical nephrectomy and thrombectomy were performed under extracorporeal circulation in all the cases. The level of tumor thrombus was preoperatively determined by computed tomography, magnetic resonance imaging or venacavography. The tumor thrombus extended into the right atrium in one, and above the hepatic vein in two cases. One patient whose thrombus reached the right atrium died of multiple metastasis of renal cell carcinoma 5 months after operation. Another patient with lung metastasis was given interferon-alpha and is alive 5 months after operation. The other patient is clinically free of disease and in good health 7 years after operation. We believe that extracorporeal circulation allows an opportunity to resect the tumor thrombus in a controlled situation, and makes the operation safer.

Ovarian carcinoma is a silent disease with few symptoms. Early detection of ovarian cancer is difficult. Transvaginal Doppler ultrasound with color flow imaging is a new technique in the evaluation of gynecological diseases. This method was used in the diagnosis of ovarian tumors in 39 women who were treated in the Department of Obstetrics and Gynecology, Nagoya University Hospital. Wave forms of the parenchymal tumor arteries or tumor surface arteries were compared by according to the pulsatility index (PI). 1/PI was 0.69 +/- 0.04 in benign tumor and 2.33 +/- 1.36 in malignant tumors (p less than 0.01). When the cutoff value of 1/PI was set at 0.8 (cutoff value of PI: 1.25), the accuracy of diagnosis was 84.6% (33/39). The accuracy of ultrasonographic pattern classification and CA125 were 74.4% (29/39) and 53.8% (21/39), respectively. In 18 tumors with low CA125 (less than 35 U/ml), 5 of 7 malignant tumors (71.4%) had high 1/PI (greater than 0.8), and benign tumor, low 1/PI (less than 0.8) or non-detectable wave forms. This procedure should prove to be useful in the diagnosis of ovarian cancer.

A case of spontaneous peripelvic extravasation associated with primary ureteral tumor is reported. A 56-year-old woman presented with left flank pain. Excretory urogram and abdominal computed tomographic (CT) scan demonstrated left hydronephrosis with extravasation of contrast materials around the renal pelvis. Retrograde pyelogram showed the filling defect in the left upper ureter. Under diagnosis of ureteral tumor, total nephroureterectomy was performed. Histological findings revealed transitional cell carcinoma. 80 cases of spontaneous peripelvic extravasation in Japan were reviewed and discussed briefly.

From January, 1986 to April, 1990, combination chemotherapy with ifosfamide (or cyclophosphamide), adriamycin, cis-platinum and peplomycin was performed in 15 patients with hormonally resistant metastatic adenocarcinoma. Three patients had partial response (PR) and 9 remained objectively stable (ST). The median response duration of PR + ST (12) was 5.7 months (range 2.8 to 18.0+). Three patients progressed while on this therapy. Of 8 patients with prior treatment of chemotherapy or chemo-hormonal therapy, 6 achieved an objective response (2 PR, 4 ST). Severe toxicities occurred in 2 patients. One died of lung fibrosis induced by peplomycin and the other received urinary diversion for persistent hemorrhagic cystitis. These results compare favorably with previous reports of chemotherapy treatment of metastatic prostatic cancer patients who failed on hormonal manipulation. However, careful treatment is needed for lung fibrosis and hemorrhagic cystitis.

We analyzed 237 patients who underwent total cystectomy with ileal conduit urinary diversion or cutaneous ureterostomy at the Center for Adult Diseases, Osaka. One-hundred and eighty-eight patients underwent ileal conduit diversion and 49 patients underwent cutaneous ureterostomy. No patient died within 30 days after the operation, but two patients who underwent ileal conduit diversion died of postoperative complications within 2 months. Early complications occurred in 94 patients (50%) in the ileal conduit group and in 18 patients (37%) in the ureterostomy group. Late complications occurred in 85 patients (45%) in the ileal conduit group and in 23 patients (47%) in the ureterostomy group. Frequent early complications in the ileal conduit group were wound infection (29%), and intestinal complications (13%) which included ileus and upper urinary tract complications (12%). The most frequent late complications were stomal complications (26%) which included peristomal dermatitis stomal stenosis, parastomal hernia, and stomal prolapse, and upper urinary tract complications which were noted in 27 patients (14%).

Radical surgery was administered to 63 patients with prostatic carcinoma, of whom 48 were put under total prostatectomy, 13 under cystoprostatectomy and 2 under pelvic exenteration. Adjuvant therapy was given in three forms: pretreatment to 31 patients, castration to 44 patients and pelvic lymphadenectomy to 39 patients. The 7 patients in stage A survived without carcinoma. Of the 25 patients in stage B, recurrence was seen in 7 patients but there were no deaths and the 5- and 10-year cumulative survival rates were both 86%. Of the 24 stage C patients, 8 developed recurrence, 4 died with the disease, and the 5 and 10 year cumulative survival rates were 82% and 55% respectively. There were 7 stage D patients, of whom 3 developed recurrence and 2 died, and these patients had a 5 year cumulative survival rate of 86%. The results demonstrated that total prostatectomy with suitable adjuvant therapy is useful for advanced carcinoma as well as clinically early stage carcinoma.

A 61-year-old man diagnosed with poorly differentiated adenocarcinoma of the prostate (T4 NxM0, stage C) underwent endocrine therapy. The reduction of the tumor was recognized but soon annular rectal stricture appeared. In spite of the subsequent chemotherapy, symptoms aggravated. Then total pelvic exenteration and colostomy were performed. Prostate was easily separated from the rectal wall and the tumor continuity was not proved. Immunohistochemical inspection indicated that the origin of the tumor cells of the rectum was the prostate. Histopathological examination of the rectum using the step section method showed no trace of cancer invasion but many cancer cells in the intramural lymphatic duct. We concluded that adenocarcinoma of the prostate metastasized to the rectum by way of lymphatic flow and caused the annular stricture of the rectum.

At the Center for Adult Diseases, Osaka, between 1961 and 1987, 28 cases (1.8%) of incidental prostatic adenocarcinoma were detected by transurethral or subcapsular prostatectomy for clinically benign prostatic hypertrophy (1388 cases) and cysto-prostatectomy for urinary bladder carcinoma (156). Nine (32%) and 19 (68%) cases were in stages A1 and A2, respectively. Of the 19 A2 cases, 9 were well, 9 were moderately and 1 was poorly differentiated adenocarcinoma. Five of the A2 and 1 of the A1 progressed into clinical carcinoma, but none of these patients died of the cancer. Four of these 5 A2 patients had received no treatment postoperatively and one received castration. The intervals from diagnosis to progression ranged from 11 to 78 months. The survival rates at 5 and 10 years with A1 were 75% and 75%, and those with A2 were 80% and 37%. We conclude that the patients in stage A2 should be treated because stage A2 tumors, especially those with no treatment, progress at a higher frequency than stage A1 tumors.

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.

Two hybridomas secreting two monoclonal antibodies IgG1 B1.4 and IgG2a B1.6 were obtained by immunizing BALB/c mice with human bladder cancer cell line EJ-1. In immunohistochemical staining of cryopreserved tissues, B1.4 reacted with 0 of 9 grade 1 TCC, 6 of 11 grade 2, all of 6 grade 3 and five metastatic specimens. The antigen recognized by B1.4 was not expressed by normal urothelial cells but were expressed by vascular endothelial cells and muscle of tunica media. The target antigen of B1.6 was expressed by normal urothelial cells and all grade of TCC. In this study, it was demonstrated that poorly differentiated bladder cancer and metastatic specimens of bladder cancer express a vascular carbohydrate antigen. Taking the escape mechanism of immune surveillance, into consideration, it is possible that the antigen recognized by B1.4 is an indicator of metastatic potential of bladder cancer.

We treated in total 795 patients with primary transitional cell carcinoma of the urinary bladder between April, 1964 and December, 1988. Eighteen patients of them had upper urothelial cancer during the follow-up period. Thirteen of the 18 patients had received transurethral resection for the initial bladder cancer, while 3 total cystectomy and 2 segmental resection. The over-all incidence of bladder cancer patients who subsequently developed upper urinary tract tumors was 2.3 per cent. The interval between initial treatment of the bladder cancer and treatment for the upper urinary tract tumor ranged from 2 to 74 months (median 20 months). The five-year survival rate after treatment for the upper urinary tract tumor was 31.7 per cent. We conclude that the following are high risk patients for development of upper urinary tract recurrences: 1) patients with bladder cancer near orifices, 2) patients with recurrent bladder cancer under bladder preserving treatment for a long time, 3) patients with G2 multifocal bladder cancer.

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.

We present a case of idiopathic retroperitoneal fibrosis that demonstrated a remarkable response to steroids. The patient, a 73-year-old man, complained of left flank pain and weight loss. Erythrocyte sedimentation rate was elevated and both CRP and antinuclear factor were positive. DIP showed left hydronephrosis, which proved to be due to the stenosis of the left ureter at the level of L5 by retrograde pyelography. Then abdominal computed tomography revealed a large retroperitoneal mass with the density of soft tissue in which the left ureter was involved. Based upon the above findings, we made the diagnosis of idiopathic retroperitoneal fibrosis. After confirming histological diagnosis by biopsy from the mass, we performed left ureterolysis. Since then, he has been treated with steroid administration. Now we can recognize a remarkable reduction of the mass in abdominal CT and improvement of the left renal function in DIP. We reviewed the association of autoimmune disease with idiopathic retroperitoneal fibrosis and recent therapies for this disease.

A case of secondary malignant lymphoma of the urinary bladder is presented. Clinical diagnosis was metastatic small cell carcinoma in urinary bladder. Pathological diagnosis after autopsy, however, revealed vesical involvement of malignant lymphoma. The primary focus was considered to be the lung, the biopsy specimen of which was initially diagnosed as small cell carcinoma, because clinical manifestation first occurred in the lung and the metastasis to subcutaneous tissue, bladder and other abdominal organs was found subsequently. In a study of secondary involvement of genitourinary organs as seen in the present case, we reviewed 303 patients who had died of malignant lymphoma at our institute between 1960 and 1985.

Thirteen evaluable patients with germinal testicular cancers failing to be cured with first-line therapy (refractory) were treated by salvage chemotherapy. Ten patients received salvage chemotherapy with VM-26 (50 mg/m2, twice a week X 6 weeks) and cisplatin (CDDP, 20 mg/m2 for 5 consecutive days every 3 weeks for 3-4 times) (P-VM), 3 patients were also treated by radiation therapy, and 3 patients received VP-16 (100 mg/m2) and CDDP (20 mg/m2) (P-VP), all given daily for 5 consecutive days every 3-4 weeks for 4-5 courses. Of 13 evaluable patients, 6 (46%) had complete response (CR) (three cases were also treated with radiation therapy), 4 (31%) achieved partial response (PR), and 3 (23%) had no response. Limited to 7 patients treated with only P-VM therapy, there were 3 (43%) CR and 4 (57%) PR. Nine patients (69%) remained alive and were continuously disease free 18 to 84 months (median 48 months). Hematologic toxicity was severe, but with no death related to sepsis. Salvage chemotherapy with VM-26 or VP-16 and cisplatin offers potentially curative treatment to patients with refractory testicular cancer. The addition of radiation therapy to salvage chemotherapy was also effective.

We have experienced 3 cases of retroperitoneal ganglioneuroma. One case was in a 5-year-old boy with the chief complaint of abdominal mass. The preoperative diagnosis was neuroblastoma due to excessive urinary excretion of vanillylmandelic acid. The other two cases were in adults, 40 and 28 years old, and were found incidentally. All three cases were doing well without any clinical signs of recurrence almost 10 years, 5 years, and 6 months, postoperatively. The literature is reviewed briefly concerning some cases in children under 5 years of age whose ganglioneuromas were sometimes confused with neuroblastoma because of excessive catecholamines.

Statistical observation on inpatients and operations at our department between January 1984 and December 1988 revealed the following results: 1) The total number of inpatients was 1962 (male: 1658, female: 304). The most frequent diseases were bladder cancer (30.0%), benign prostatic hypertrophy (19.2%), prostatic cancer (10.6%) and renal cancer (6.7%). 2) The total number of operations was 1699. The most frequent operations were transurethral resection (TUR) of bladder tumor (22.8%), TUR prostate (20.7%), TUR biopsy (6.5%) and total cystectomy (5.4%).

A case of exohepatic pedunculated hepatocellular carcinoma that was clinically diagnosed as nonfunctioning adrenal tumor is reported. A 66-year-old man was admitted to our hospital for further examination of unstable angina pectoris. Abdominal echogram and CT scan revealed a large tumor in the right retroperitoneal space. Selective right renal arteriography demonstrated that the tumor was fed by the capsular branch of right renal artery and the right adrenal artery. Adrenal function was normal. Preoperative diagnosis of right nonfunctioning adrenal tumor was made. On operation we found that the tumor was pedunculated from the liver and adhered massively to both right kidney and vena cava. The tumor and right kidney were removed. A histopathological examination demonstrated well differentiated hepatocellular carcinoma (Edmondson's grade II type).

Three cases of metastatic renal tumor are reported. The first case was of a 61-year-old man, who had a Miles' operation for rectal adenocarcinoma 30 months before, and suffered from high fever and right flank pain. Right nephrectomy was carried out and the kidney was found to contain an adenocarcinoma identical to the one previously removed from the rectum. He died 1 year after nephrectomy. The second case was of a 35-year-old man, who had undergone left pneumonectomy for a squamous cell carcinoma of the bronchus. One month later, he was readmitted with cloudiness of consciousness and high fever. Investigations revealed right kidney, adrenal gland and brain malignancies, and which were ectomized totally. On pathological examination all ectomized tissues were metastatic squamous cell carcinoma. He died 1 month after the second operation. The third case was of a 48-year-old man, who had undergone left pneumonectomy for a squamous cell carcinoma of the bronchus. One year after pneumonectomy, abdominal CT showed a left renal tumor. Right nephrectomy was performed and pathological examination revealed a metastatic squamous cell carcinoma. He is now alive 4 months after nephrectomy without any sign of recurrence. A total of 136 cases of metastatic renal tumors including 38 cases from the Japanese literature, are reviewed.

A characteristic lipogranuloma in the male genitalia is presented. Histopathological examination revealed a granuloma resembling sclerosing lipogranuloma with marked eosinophile infiltration. Only 11 cases with such a histopathological feature have been reported. Including this case all cases have similar localization, shape and clinical course. The genesis of these granulomas is discussed.

A case of giant vesical diverticulum is reported. A 31-year-old man was admitted with intermittent self-catheterization for 6 months duration due to urinary retention. A cystogram demonstrated a giant solitary diverticulum extended left-posteriorly, which compressed the bladder outlet and caused obstruction. On cystoscopy, the neck of the diverticulum was seen postero-lateral to left ureteral orifice. There was no vesical trabeculation, but slight obstruction of the bladder neck was suspected secondary to intermittent self-catheterization. A diverticulectomy was carried out by combined approach without ureterocystoneostomy. The patient had no difficulty in voiding after the operation.