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There have been few reports of multimodal treatment such as chemotherapy and surgical resection for testicular tumors over 40 years old. In this case, a 64-year-old man with nonseminoma, pT2N2M1aS1, stage IIIb, IGCCC good prognosis completed induction chemotherapy, followed by retroperitoneal lymph node dissection and resection of lung metastases. Chemotherapy (4 courses of etoposide and cisplatin therapy) was completed without serious adverse events other than grade 4 neutropenia. Resection of the residual tumor confirmed no viable tumor cells. There was no evidence of recurrence or elevation of tumor markers in the following 6 months. Similar cases could increase with the increase of testicular tumors in the elderly.

A 54-year-old female underwent open left adrenalectomy for a left adrenal tumor in 2013. The pathology showed metastatic poorly differentiated adenocarcinoma. Despite a close examination, the primary tumor could not be identified. During the follow-up, a computed tomographic scan showed a hyper vascular tumor in the left breast in2015. A left mastectomy was performed for diagnosis and treatment. The pathology showed invasive ductal carcinoma of the breast. Comparing the histopathology and immunohistochemistry of the breast tumor with the adrenal tumor, the adrenal tumor was finally confirmed as metastatic invasive ductal carcinoma. Adrenal gland metastasis from invasive ductal carcinoma is said to be extremely rare. To our knowledge, there have been no reports of cases in which metastatic invasive ductal carcinoma of the adrenal gland was found before the primary site. We report this case with some literature review., 本論文の要旨は第232回日本泌尿器科学会関西地方会において報告した．

The patient is a 72-year-old man who was referred to our hospital with an elevated prostate specific antigen (PSA) level. He was diagnosed with prostate cancer (cT2aN0M0) at the age of 62 years. He had undergone radical proton beam radiotherapy. The PSA level decreased to a nadir of 0.217 ng/ml after 5 years, gradually increasing thereafter to 1.595 ng/ml during the next 5 years. Although magnetic resonance imaging of the prostate showed an abnormal signal area in the prostate, repeated biopsies of the prostate revealed no malignant findings. Contrast-enhanced abdominal computed tomography (CT), bone scintigraphy and fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET)/CT did not detect any abnormalities in the prostate or metastatic lesions. ¹⁸F-prostate specific membrane antigen (PSMA)-PET/CT showed no accumulation in the prostate, but some accumulation in a left obturator lymph node. Open pelvic lymph node dissection was performed, and pathological examination confirmed lymph node metastasis from the prostate cancer. The PSA level decreased from 2.482 ng/ml preoperatively to 0.391 ng/ml at 3 months postoperatively. PSMA-PET/CT might be useful for early localization of recurrent lesions in biochemical recurrence after radical treatment for prostate cancer., 本論文の要旨は，第70回日本泌尿器科学会中部総会において発表した．

A 25-year-old woman, with chief complaints of palpitation and vomiting, was suspected of having acute myocarditis and was taken to our critical care center. She was diagnosed with Takotsubo syndrome based on the results of echocardiography, coronary angiography, and myocardial biopsy. The 24-hour urine test showed high levels of normetanephrine and noradrenaline. The abdominal computed tomographic scan showed a presacral tumor (26 mm) just below the aortic bifurcation, and ¹³¹I-meta-iodobenzylguanidine scintigraphy showed abnormal accumulation in the tumor. Finally, she was diagnosed with Takotsubo syndrome associated with presacral paraganglioma. The hemodynamics became stable with conservative treatment. Then she underwent elective laparoscopic surgery. The histopathological analysis revealed paraganglioma. The immunohistochemistry for succinate dehydrogenase was negative in the tumor cells. There has been no recurrence as of 15 months after surgery.

A 12-year-old girl was found to have decending colon diverticulum perforation and retroperitoneal abscess on computed tomography (CT) carried out to determine the cause of fever and stomachache. CT-guided drainage tube placement was performed. She was suspected of having MEN2B from her specific facial appearance, Marfan-like body shape and lingual mucosa neuroma. Cervical ultrasonography and serum tumor marker revealed medullary thyroid carcinoma and metastasis to cervical lymph node. Genetic examination revealed a mutation of RET gene codon 918. Therefore, she was diagnosed as having MEN2B. Laboratory data showed elevated urinary catecholamines. Metaiodobenzylguanidine (MIBG) adrenal scintigraphy showed bilateral adrenal uptake and a definitive diagnosis of bilateral adrenal pheochromocytomas was made. Discharge from the drainage tube persisted and it was difficult to continue conservative treatment. Therefore, laparoscopic bilateral adrenalectomy and transverse colon colostomy were performed. Subsequently, total thyroidectomy and cervical lymph node dissection were performed. At five years of follow up, bilateral lung metastases were observed, but the serum calcitonin level was normal and the patient is under observation., 本症例は第228回日本泌尿器科学会関西地方会（奈良）で報告した．

A 67-year-old man with non-muscle invasive bladder cancer (NMIBC) underwent transurethral resection (TUR) in January 2008. The pathological diagnosis was urothelial carcinoma (UC), grade 2, pT1. A second TUR was performed 2 months later, and no evidence of malignancy was found. After surgery, he was followed up via cystoscopy and urine cytology for 9 years, with no recurrence of the bladder tumor. In November 2017, he visited our orthopedic department complaining of pain in his left leg. Magnetic resonance imaging revealed an enlarged para-aortic lymph node (a suspected metastasis). Computed tomography (CT) revealed several enlarged lymph nodes but no recurrence in the bladder. A CT-guided biopsy was performed, and histopathological examination revealed a metastasis of the urothelial carcinoma. After definitive diagnosis, he received four cycles of gemcitabine-cisplatin chemotherapy. NMIBC with no local progression rarely causes distant metastases, but the possibility is always there.

A 22-year-old woman who was referred to our hospital presented with a complaint of urinary incontinence since childhood. Abdominal contrast-enhanced computed tomography revealed complete duplication of the left ureter. In addition, the upper half of the left kidney showed poor contrast, accompanied by signs of hydronephrosis. Magnetic resonance urography failed to show an opening between the upper half of the left kidney and the ectopic ureter. Cystoscopy revealed two normally positioned ureteral orifices. After intravenous injection of indigo carmine, however, the dye became evident in the vagina. Thus, she was diagnosed to have urinary incontinence due to complete duplication of the left ureter and an ectopic ureteral opening into the vagina. Transcatheter arterial embolization of the upper half of the kidney, the origin of the ectopic ureter, immediately relieved the patient of urinary incontinence. At the 6-month follow-up, the patient had experienced no recurrence or complications., 本論文の要旨は第242回日本泌尿器科学会関西地方会において発表した.

A 66-year-old man was referred to our hospital because of positive fecal occult blood test. Gastric and rectal cancers were diagnosed by upper and lower endoscopic biopsy, respectively. Enhanced computed tomography (CT) indicated a pulmonary tumor and a left adrenal mass with a diameter of 15 mm presenting heterogenous enhancement. The pulmonary tumor was diagnosed as adenocarcinoma by bronchoscopic biopsy. F18 fluoro-2-deoxy D-glucose (FDG) PET/CT showed abnormal FDG accumulation (maximum standardized uptake value=26. 1) in the left adrenal mass consistent with a metastatic adrenal tumor. Although radical surgical therapy was performed for the synchronous triple cancers of gastric, colon, and lung cancer, the patient refused adrenalectomy for the left adrenal tumor. One year after surgery, CT revealed an increase in the adrenal tumor diameter to 18 mm without development of new metastases. Laparoscopic adrenalectomy was performed for the left adrenal tumor which was strongly suspected of being a metastatic tumor. Pathological diagnosis was adrenal cortical adenoma. There has been no recurrence for 5 years after surgery for simultaneous triple cancer.

We report a case of perivascular epithelioid cell tumor (PEComa) of the uterus associated with tuberous sclerosis complex discovered as a result of intraabdominal bleeding. A 54-year-old woman visited the department of obstetrics and gynecology with chief complaints of genital bleeding and abdominal pain lasting three weeks. Abdominal computed tomography (CT) revealed intraabdominal bleeding from the uterine corpus. She had a history of bilateral renal angiomyolipoma, which was treated with partial bilateral nephrectomy at age 25. Moreover, pulmonary lymphangioleiomyomatosis was diagnosed at age 43. Both conditions were detected by the CT scan during this hospitalization. Immediately after the CT scans, the patient entered a state of hemorrhagic shock, and we performed an emergency simple total hysterectomy. Histopathological examination on the resected specimen yielded a diagnosis of uterine perivascular epithelial cell tumor (PEComa). After making a definitive diagnosis of tuberous sclerosis complex (TSC), systemic evaluation was performed. As a result, multiple skin and intracranial lesions characteristic of TSC were identified and we stated administration of everolimus.

A 53-year-old man visited a doctor due to left inguinal enlargement. He was diagnosed with left inguinal hernia with omentum as the content by a computed tomography (CT)scan. He underwent open inguinal hernia repair ; however, an inguinal tumor was diagnosed intraoperatively and was resected as much as possible. Although the tumor resection was macroscopically incomplete, he was followed up without any treatment because the tumor was histologically diagnosed as lipoma. Sixteen months after surgery, a 15 cm inguinal mass and a 7 cm left intrascrotal mass were detected by follow-up CT, and he was referred to our hospital. He underwent open surgery for wide excision of the tumor with a diagnosis of spermatic cord liposarcoma and left hydrocele of testis. The spermatic cord tumor was histologically diagnosed as well differentiated liposarcoma. He has been alive without recurrence for more than 10 months after surgery. It is sometimes difficult to distinguish a spermatic cord liposarcoma from inguinal hernia by imaging examinations.

A 62-year-old man had been treated for urethral stricture developed after his right kidney was harvested for donation to his sister 34 years ago. Transurethral biopsy was performed because of positive urinary cytology and squamous cell carcinoma was detected from the site of urethral stricture. The patient with the desire to preserve the penis was referred to our department. Magneticresonanc e imaging showed no evidence of invasion to subepithelial tissue. Re-biopsy from the site of urethral stricture revealed squamous cell carcinoma in situ. Under the diagnosis of urethral carcinoma cTisN0M0, urethrectomy of anterior urethra with perineal urethrostomy was performed. Histopathological diagnosis was squamous cell carcinoma of the urethra pTis and surgical margins were negative. The patient reported complete urinary continence, normal erections and ejaculation from his urethrostomy. He showed no evidence of recurrence at 28 months after surgery.

A 40-year-old man presented to our institution with a few-month history of increased urinary frequency, urgency and voiding difficulty. He had severe lower urinary tract symptoms with an International Prostate Symptom Score of 28 and quality of life score of 6. The mean urinary frequency and voided volume was 20 times per day and 150 ml, respectively. Abdominal ultrasonography and pelvic magnetic resonance imaging revealed the prostate measuring 15 cm3 with a 3 cm midline cyst which compressed the posterior of the bladder wall. A subsequent examination indicated that his lower urinary tract symptoms could be attributed to the cystic mass which mainly affected his storage symptoms. The patient underwent transurethral unroofing of the prostate cyst. Immediately after the surgery, his storage symptoms were improved greatly. The voiding volume was increased to 250 ml, and the frequency of urination was decreased to 8 times. No recurrent symptoms were found for seven months after the surgery.

Renal angiomyolipoma (AML) and aneurysm are common in tuberous sclerosis complex (TSC) and represent the main causes of morbidity in adults with TSC. Herein, we report a 22-year-old woman with TSC-associated AMLs and renal aneurysms. She was referred to our hospital for the treatment of multiple renal aneurysms larger than 5 mm in diameter. The previous hospital considered that transcatheter arterial embolization (TAE) of bilateral renal aneurysms would cause deterioration of renal function. To estimate the impact of TAE on renal function, we superimposed contrast enhanced computed tomography (CT) over single-photon emission CT (SPECT)-CT. This fusion image, referred to as functional kidney mapping image, revealed the location of renal arteries and aneurysms, and normal renal parenchyma simultaneously. Functional kidney mapping image was useful to distinguish the AML region from the normal renal parenchyma, and revealed that the planned embolization site was a non-functioning parenchyma. Therefore, TAE for her multiple renal aneurysms was successfully performed without deterioration of her renal function.

Microscopic subinguinal varicocelectomy has a recurrence of less than 1%, and varicocele recurrence is supposed to be an uncommon post-surgery adverse event. At present, no guidelines exist for the management of recurrent varicoceles after surgery. In this report, we present two cases of post-surgery recurrent varicocele of the testis. Case_1 : A 23-year-old male patient who had undergone microscopic subinguinal varicocelectomy for a grade 3 varicocele was referred to our hospital because of recurrent varicocele. Retrograde venography revealed the persistence of dilated spermatic veins. The former surgeon preserved the dilated vas deferens vein, and this was considered a possible cause of persistence of dilated spermatic veins. The vein considered as vas deferens vein was actually an internal spermatic vein. Case_2 : A 28-year-old male patient complained of recurrence of varicocele two months after the original operation for a grade 3 varicocele. Internal spermatic vessels were slightly visualized on retrograde venography. The possible cause of persistence in this case was insufficient ligation of the internal spermatic vessels. We performed embolization in both cases of recurrent varicocele. Both cases were successfully treated, and there has been no recurrence. Our findings suggest that percutaneous transcatheter embolization of the testicular vein may be effective in the management of postsurgical recurrent varicocele of the testis.

A 61-year-oldman presentedwith a chief complaint of abdominal pain. Enhancedcomputed tomography andmagnetic resonance imaging showeda left adrenal mass with a diameter of 7 cm with heterogeneous enchancement. He was referredto our hospital for further treatment. No endocrinological abnormality was detected. The tumor showed abnormal uptake on fludeoxyglucose positron emission tomography scan. Preoperative diagnosis was left adrenocortical carcinoma (cT2N0M0). Tumor excision was performedandpathological findings on the resectedspecimen revealedleiomyosarcoma of the left adrenal grand. The patient has been followed up for 16 months with no additional treatment. No evidence of local recurrence or metastasis was seen.

We report a case of recurrent renal cancer in the autografted kidney, treated with percutaneous cryoablation. A 59-year-old man who had bilateral renal tumors underwent radical left nephrectomy, ex vivo right partial nephrectomy and auto-transplantation at the right ileal fossa in our hospital 11 years ago. Histopathological examination showed clear cell renal cell carcinoma in bilateral kidneys (pT1bN0M0). He had been followed at another hospital without tumor recurrence for 11 years. In 2014, an enhanced CT scan revealed a renal tumor with a diameter of two centimeters in the autografted kidney, which was thought to be a recurrence of the initial renal cancer. He was referred to our hospital for further evaluation and treatment. He underwent percutaneous renal tumor biopsy, which confirmed renal cancer recurrence, followed by percutaneous cryoablation. Three months after cryoablation, an enhanced CT showed that the enhancement lesion in the autografted kidney had disappeared, and these findings were confirmed pathologically by absence of malignancy by a subsequent needle biopsy. The level of serum creatinine (sCr) was 1.16 md/dl immediately before cryoablation and 1.46 mg/dl at three months after cryoablation. Nine months after cryoablation, the patient had no reccurence and renal function was stable (sCr 1.43 mg/dl).

A 63-year-old male with a past history of left nephrectomy due to clear cell renal cell carcinoma at the age of 57 was admitted for further evaluation. Enhanced abdominal computed tomography revealed that there were several hypervascular tumors in the pancreas and a single hypervascular tumor in the gallbladder. Laparoscopic cholecystectomy was performed to obtainpathological diagnosis. Microscopically, the tumor in the gallbladder was filled with clear cells and was diagnosed as metastatic gallbladder cancer from the previous clear cell renal cell carcinoma. Metastatic renal cell carcinoma to the gallbladder is extremely rare, with reported frequencies of less than0. 6% in687 autopsies. We hereinreport a case inwhich cholecystectomy enabled a successful diagnosis and review the reported 22 cases in Japanese patients.

We report here a rare case of urethral fistula and scrotal abscess associated with colovesical fistula due to sigmoid colon cancer. An 84-year-old male was referred to our hospital complaining of macrohematuria, fecaluria, pneumaturia and micturitional pain. Computed tomography (CT) showed colovesical fistula. Other examinations, including colonoscopy and cystoscopy, did not reveal a clear cause for the colovesical fistula. Only an elevated serum level of the tumor marker CA19-9 suggested the possibility of sigmoid colon cancer. Eleven days after hospitalization, bilateral scrotal contents had swollen rapidly to the size of a goose egg. CT suggested urethral fistula with scrotal abscess formation. Drainage of scrotal abscess and colostomy were performed. Intraoperatively, the fistula of the bulbar urethra was revealed. Because increased serum CA19-9 suggested a diagnosis of sigmoid colon cancer, cystectomy and sigmoid colectomy with right nephrectomy were performed. Pathological examination revealed adenocarcinoma of sigmoid colon with bladder invasion. His condition was improved with rehabilitation 6 months after operation.

A 64-year-old man presented with right renal cell carcinoma with tumoral thrombosis in the inferior vena cava. Transthoracic echocardiography and contrast-enhanced computed tomography 2 days before the scheduled surgery revealed a tumoral thrombus floating in the right atrium. The tumoral thrombus measured 2 by 3 centimeters and the patient was asymptomatic. An emergency surgey was performed to remove the tumoral thrombus from the right atrium and a temporary inferior vena cava filter was placed. Right nephrectomy and thrombectomy were carried out 3 weeks later. Pathological diagnosis made from both surgical specimens was clear cell renal cell carcinoma, and the tumoral thrombus was considered to have separated from the tumor thrombus in inferior vena cava. No obvious recurrence has been observed for 6 months after the surgery.

A 46-year-old man was found to have a mass in the pelvic cavity on computed tomography (CT) carried out for an examination for lower abdominal pain. Abdominal magneticresonanc e imaging showed a mass which appeared to have hyposignals on both T1- and T2-weighted images. A positron emission tomography CT showed that the mass had a low maximum standardized uptake value (＝1.4). Biopsy of the mass showed tumoral cells demonstrating a‘patternless pattern’characterized by a haphazard, storiform arrangement of short spindle or ovoid cells. Immunohistochemistry disclosed CD34 positivity and desmin and alfa-smooth muscle actin (SMA) negativity which supported the diagnosis of solitary fibrous tumor. Tumorectomy was performed. Grossly, the tumor was a large encapsulated mass with well limited margins weighing 67.7 g. Histology revealed a mass with no necroticor hemorrhagicdegeneration. On immunohistochemistry, the tumor cells were strongly positive for CD34 and they were negative for desmin and alfa- SMA. At six months of follow up, the patient was well and he had no signs of recurrence.

We report a case of nonischemic priapism following brachytherapy. A 63-year-old man presented 22 days after brachytherapy for prostate cancer. He suffered painless sustained incomplete erection for a few days. The patient was diagnosed with nonischemic priapism by cavernosal blood gas analysis. Right internal pudendal arteriography showed blood pooling in the cavernosum caused by arteriovenous fistula. Selective arterial embolization with gelatin sponge particles was performed and detumescence achieved. To our knowledge, this is the first case of high flow priapism caused by brachytherapy for prostate cancer. In addition, we reviewed the mechanism of high flow priapism.

A 53-year-old man presented to our hospital with a few-month history of fatigue and anorexia. His aging male's symptoms (AMS) score was 57, and the free testosterone value was low (6.5 pg/ml). He was diagnosed with severe late-onset hypogonadism indicative of androgen replacement therapy (ART). His serum prostate specific antigen was 8.7 ng/ml, and pelvic magnetic resonance imaging showed a low intensity area in the peripheral zone of the prostate. A systematic 10-core prostate biopsy revealed one core of adenocarcinoma with a Gleason score of 3＋3=6. Imaging examination revealed organ-confined prostate cancer that was cT2aN0M0. Given his desire for ART for the treatment of hypogonadism, the patient underwent open radical prostatectomy. Pathologic examination demonstrated prostate adenocarcinoma that was pT2aN0, and Gleason score of 3＋3=6. After confirming that the prostate specific antigen value was under 0.01 ng/ml for three years after prostatectomy, the patient received 125 mg methyltestosterone monthly. His hypogonadism-related symptoms diminished and AMS score dropped to 48. During a three-year follow-up of ART, no biochemical recurrence was found.

A 56- year-old man underwent a laparoscopic low anterior resection for rectal cancer (cT3bN0M0). Postoperatively, he was fairly well and started oral intake on postoperative day (POD) 9. On POD 14, he had an uncomfortable feeling during urination and noticed pneumaturia, and urinalysis revealed hematopyuria. Abdominal computed tomography (CT) showed air collection in the left seminal vesicle and bladder, and colonoscopy demonstrated a fistula at the anastomotic site. Abdominal CT following the fistulography under colonoscopy demonstrated fistulous communication between the rectum and left seminal vesicle. Under the diagnosis of seminal vesicle-rectal fistula, the patient was successfully treated by filling the fistula with fibrin glue by colonoscopy. No obvious recurrence of the fistula has been observed for 6 months after the treatment.

A 32-year-old man was referred to our hospital for treatment of left renal cystic tumor, which was detected by computed tomographic (CT) scan 3 years ago. CT scan showed a multilocular cyst (5 cm in diameter) with a solid tumor in the left kidney which was enhanced with contrast. There was no evidence of extrarenal invasion or distant metastasis. We performed retroperitoneal laparoscopic radical nephrectomy. Pathological examinations revealed a cellular arrangement specific to carcinoid tumor and positive for CD56 (NCAM) and neuron-specific enolase. The cell proliferation rate was estimated to be under 2% with Ki67 staining. The pathological diagnosis was renal neuroendocrine tumor (carcinoid). At the 9-month follow up, he had no evidence of local recurrence or metastasis.

A 42-year-old female patient had been receiving medication for hypertension. Her symptoms worsened in 2007. A computed tomography image revealed a 2.5 cm round mass in the right adrenal gland. According to a careful examination, the patient was diagnosed with primary aldosteronism and subclinical Cushing's syndrome. There were no remarkable physical features related to Cushing's syndrome. The patient chose a medical therapy instead of surgery. In 2012, regardless of strict diet therapy, however, the patient gained 10 kg weight in a year. The diagnosis was the same as that determined in 2007, except for exceeding value of cortisol over the criterion for Cushing's syndrome. A laparoscopic right adrenalectomy was performed to attenuate Cushing's syndrome. The histopathological examination revealed an adrenocortical adenoma. The patient lost 4.5 kg of weight 2 months after the surgery.

A 66-year-old man presented with a retroperitoneal mass found in a routine medical examination. He had no complaints and no medical history. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a cystic mass in the retroperitoneal space, attached to the left crus of the diaphragm, 5.5 cm in size. Retroperitoneal cystic tumor was diagnosed, and transperitoneal tumor resection was performed. Pathological findings revealed a cyst wall lined with ciliated epithelium and cartilage, diagnosed as a retroperitoneal bronchogenic cyst. The patient was in good health at 12 months after the surgery with no evidence of recurrence.]

A 67-year-old man visited an urological clinic with a chief complaint of urination pain. Cystourethroscopy and magnetic resonance imaging (MRI) examination revealed a bladder tumor (cT3bN0M0). Marked leukocytosis and respiratory distress with pleural effusion appeared. Pulse steroid therapy improved the general condition partially. The patient was sent to our hospital for further examination. Serum granulocyte colony-stimulating factor (G-CSF) and interleukin-6 (IL-6) were high and the pathological findings of bladder tumor obtained by transurethral resection (TUR) revealed an urothelial carcinoma that produced G-CSF and IL-6. Neoadjuvant systemic chemotherapy was performed along with use of steroid and sivelestat, which ameliorated the respiratory distress. After three courses of systemic chemotherapy, serum G-CSF and IL-6 normalized and cystoprostatectomy was performed. The patient has been in good health at 20 months after the surgery with no evidence of recurrence.

A 70-year-old man visited a urological clinic with a chief complaint of pollakiuria, which was refractory to various medications. Pelvic magnetic resonance imaging (MRI) revealed a mass 6 cm in diameter immediately next to the left side of the bladder. The patient was referred to our hospital for further examination. Since he had a past history of neurofibroma of cauda equina, we suspected neurofibromatosis type 1. 18Fluorodeoxyglucose (FDG)-positron emission tomography (PET) demonstrated a high accumulation of FDG in the pelvic mass. Under a diagnosis of neurogenic tumor, surgery was performed. As an examination of frozen section during the surgery led us to suspect a sarcoma, the tumor was excised radically. The pathological examination demonstrated diffuse large B cell lymphoma.

We report a case of deep vein thrombosis and acute pulmonary thromboembolism that occurred during chemotherapy for urethral carcinoma. A 68-year-old woman suffered from dysuria for a period of 2 years. When the symptoms worsened, a urethral catheter was placed and she was referred to our hospital for further examinations. Imaging analysis revealed a urethral tumor with multiple metastases. Pathological diagnosis on a specimen obtained from transurethral resection of the urethral mucosa was urothelial carcinoma and combined chemotherapy with gemcitabine and cisplatin was administered. On day 6 of the second course, the patient collapsed and was found to be in cardiorespiratory arrest. Cardiopulmonary resuscitation was successful and she received percutaneous cardiopulmonary support. Computed tomography at that time revealed a pulmonary embolism and deep vein thrombosis in the right popliteal vein. After her condition improved, an inferior vena cava filter was inserted to avoid further thromboembolism. The patient decided to continue the chemotherapy despite this episode. After the fourth course of combined chemotherapy, the urethral tumor and metastatic tumors were downsized, and she could urinate as she did before.

Most stage I testicular germ cell tumors are curable by orchiectomy alone. However, some tumors recur and require subsequent treatment. The point for the management of stage I testicular germ cell tumors is how to reduce the recurrence rate by appropriate adjuvant treatment with less adverse events. The strategy for stage I seminoma and stage I nonseminoma is different. The adjuvant treatment options include radiotherapy and 1-2 courses of carboplatin for seminoma and retroperitoneal lymph node dissection (RPLND) and 1-2 courses of bleomycin, etoposide and cisplatin chemotherapy for nonseminoma. This review discusses recent literature on adjuvant treatment and updates the consensus for the management of stage I testicular germ cell tumor.

A 79-year-old man presented with a mass lesion under the left kidney that was revealed by abdominal ultrasonography. The retroperitoneal tumor was removed by transabdominal exploration. Histopathological diagnosis was a leiomyosarcoma. Seven years after the first operation, he presented with left flank pain. Computed tomography showed a mass lesion in the abdominal wall. Tumor resection was performed. The pathological diagnosis was recurrence of leiomyosarcoma. The patient remains free from disease recurrence 1 year after the second surgery.

A 49-year-old female was followed up at the gynecology clinic after conization for cervical cancer and underwent routine cervical smear, which revealed a cluster of adenocarcinoma cells. Positron emission tomography-computed tomography (PET-CT) showed increased FDG uptake around the proximal urethra. Urethroscopy showed a tumor arising from the urethral diverticulum, and it was revealed to be clear cell adenocarcinoma by cold-cup biopsy. Then, she was referred to our hospital for the treatment of the urethral cancer arising from the urethral diverticulum. MRI showed the urethral diverticulum at circumference of the urethra and a tumor projecting into its lumen. The patient underwent urethrectomy together with resection of the diverticulum tumor and cutaneous vesicostomy. Pathological examination demonstrated pT2, clear cell adenocarcinoma of the urethra. The patient had no local recurrence or metastasis 5 months after the surgery.

A 20-year-old woman referred to our hospital for further examination of primary amenorrhea with high levels of testosterone (998 ng/ml). Inspite of having normal female external genitalia, she had 5cm deep blind-ending vagina, absence of uterus and ovaries with the karyotype of 46, XY. Abdominal magnetic resonance imaging localized bilateral intra abdominal structures, which indicated bilateral testes. Thus, she was diagnosed with androgen insensitivity syndrome(AIS) based on both clinical and karyotypic evidence. She underwent laparoscopic bilateral gonadalectomythrough a single incision at the navel and histological examination showed intratubular germ cell neoplasia (ITGCN). Her postoperative course was uneventful with less pain and a small surgical wound was onlyat the navel. Laparoendoscopic single site surgery (LESS) can be considered a surgical procedure for gonadalectomyin AIS patients.

A 79-year-old man presented with a chief complaint of difficulty in urination. Digital rectal examination and transrectal ultrasonography showed an enlarged prostate. Holmium laser enucleation of the prostate (HoLEP) was performed. Histological findings revealed diffuse large B-cell lymphoma by immunohistochemical studies. Pelvic Lymph nodes were swollen on fluoro deoxygiucose-positron emission tomography examination. Therefore, the disease was classified into clinical stage II according to Ann Arbor’s criteria. The patient achieved complete response after 6 cycles of combination chemotherapy with rituximab, pirarubicin, cyclophosphamide, vincristine, and prednisolone (R-THP-COP). Now, 1 year 8 months after the chemotherapy, he remains free of the disease.

A 60-year-old woman presented at another hospital with a complaint of voiding difficulty. She had had left nephrectomy and bladder augmentation using the sigmoid colon for treatment of urinary tract tuberculosis38 yearsago. Left ovarian tumor wasfound by computed tomography and she wasreferred to our hospital. Another tumor which involved the uterus, bladder, and urethra was revealed by magnetic resonance imaging. An anterior pelvic exenteration was performed with preoperative diagnosis of left ovarian cancer with peritoneal dissemination. Histopathological examination revealed a clear cell adenocarcinoma of the left ovary and a sigmoid cancer arising in the augmented bladder. The sigmoid cancer arose from the anastomotic site between the bladder and sigmoid segment. This is the 34th case of neoplasms following augmentation enterocystoplasty reported in Japan.

A 76-year-old female presented with edema in the bilateral lower legs and computed tomography (CT) subsequently revealed a tumor under the right side of the kidney that extended to the inferior vena cava. Under suspicion of a right renal sarcoma or malignant teratoma, we performed a right nephrectomy and tumor thrombectomy. Histopathological features of the resected specimen were compatible with a leiomyosarcoma originating from either extrarenal blood vessels or muscle fibers of the renal pelvis. Immunohistological findings showed that the tumor cells were spindle-shaped, arranged in bundles, and stained positive for α-smooth muscle actin and desmin. The patient was free from recurrence 10 months after surgery. The prognosis of patients with a renal leiomyosarcoma with venous thrombus has been considered to be poor. Herein, we provide details of our case and conclude that radical tumor resection is necessary for a long-term cure.

A 67-year-old man presented with macroscopic hematuria. Transrectal prostatic needle biopsy was performed because of elevated prostate specific antigen (PSA) (3.85 ng/ml) and palpation of hard nodules at the prostate. Pathological diagnosis was leiomysarcoma. Computed tomography revealed several pulmonary metastases. Radical cysto-prostatectomy and construction of ileal conduct were performed. Adjuvant radiotherapy (50 Gy) was also performed. During follow-up, the size of the pulmonary metastases increased, and we decided to start systemic chemotherapy 7 months after surgery. The chemotherapy consisted of gemcitabine (900 mg/m2 on day1 and day 8), and docetaxel (100 mg/m2 on day 8). After eight courses, there was 20% reduction in the size of some pulmonary metastases. He remained alive 21 months after diagnosis.

A 67-year-old man had undergone a right ureteronephrectomy because of a right ureter tumor, but the pathological diagnosis was inflammatory tissue with plasma cells, lymphocytes, and fibrosis. About 3 years later, abdominal computed tomography (CT) revealed a solid tumor at the left renal hilus. We resected the tumor and the pathological diagnosis was the same as before. More than 2 years later, because of elevated pancreatic enzymes, immunoglobulin G (IgG) and IgG4, more detailed examinations ware done, and he was diagnosed with IgG4-related autoimmune pancreatitis. We believe that the retroperitoneal tumor was retroperitoneal fibrosis associated with IgG4-related sclerosing disease. Now, he is being treated with steroid therapy. IgG4-related sclerosing disease is a systemic disease whose concept is now being established. Much more work is needed to understand this disease.

A 64-year-old male was referred to our hospital with a prostate tumor accompanying a huge prostatic cyst. He had been followed up for 10 years by another urologist, and received several prostate biopsies, which failed to make a definite diagnosis. We carefully reviewed the biopsy slides and diagnosed the lesion as prostatic stromal tumor of uncertain malignant potential (STUMP). We performed radical prostatectomy. From the excised specimen, we confirmed the diagnosis of prostatic STUMP. Eight months later, there was no sign of metastasis or recurrence.

A 79-year-old woman presented with gross hematuria. She had undergone a right radical nephrectomy 2 years previously for G2 pT2 renal cell carcinoma, clear cell variant. Intravenous pyelography showed a filling defect in the left ureter. Systemic work-up demonstrated no evidence of other metastases. Partial uretectomy and end-to-end ureteroureterostomy were performed. Histology showed metastatic clear cell carcinoma consistent with the primary renal tumor. Six months after surgery, her serum creatinine was stable at 1.6 mg/dl and she was doing well without evidence of recurrent disease. Solitary metastasis of renal cell carcinoma to the contralateral renal pelvis or ureter is extremely rare, with only 7 cases having been reported. We herein describe the present case and review the relevant literature.

15歳女児。無症候性血尿を主訴とした。近医での超音波検査で膀胱腫瘍が疑われ前医を受診した。膀胱鏡で膀胱腫瘍が認められ, その翌日肉眼的血尿による膀胱タンポナーデとなり, 著明な全身倦怠感を認めて当科紹介となった。顔面蒼白, 末梢冷感があり, 出血性ショック状態と診断して緊急入院となった。骨盤CTで膀胱の左前壁から側壁にかけて径4cm大の造影効果のある腫瘍性病変を認めた。MAP 2単位の輸血施行後, 緊急でTUR-BTを施行して腫瘍を切除した。HE染色で線維芽細胞の増生と浮腫状の間質, 炎症性細胞浸潤からなる腫瘍を認めた。免疫染色ではanaplastic lymphoma kinaseで筋線維芽細胞の細胞質の濃染を認め, 陽性であった。以上より, 膀胱炎症性筋線維芽細胞性腫瘍と診断した。術後13ヵ月のMRIでは再発を認めず, 肉眼的血尿も認めなかった。, A 15-year-old girl presented to a clinic with an asymptomatic macrohematuria. Cystoscopy revealed a bladder tumor. The next day she was admitted to our hospital because of preshock status with macrohematuria. Abdominal computed tomography (CT) revealed a solid tumor in the left anterior to lateral wall. Urinary cytology was negative. She received a transfusion and transurethral resection of bladder tumor as an emergent operation. Histopathological examination revealed inflammatory myofibroblastic tumor. Anaplastic lymphoma kinase immunohistopathological studies revealed cytoplasmic staining of the myofibroblasts. To our knowledge, this is the 35th reported case of inflammatory myofibroblastic tumor of the bladder in Japan. She has been followed up for 13 months without any evidence of local recurrence.

42歳男性。患者は人間ドックにてPSA高値を指摘され, 精査加療目的で著者らの施設へ入院となった。画像上, 前立腺の背側から精嚢に突出する境界明瞭なsolid and cystic tumorが認められたが, その他の臓器に異常病変は認めなかった。経直腸エコーガイド下に前立腺生検を行い, 前立腺STUMPと診断され, 前立腺全摘術を施行した。現在, 術後10ヵ月経過でPSA値は感度以下で, 画像上も再発転移はみられていない。, Sarcomas and related proliferative lesions of specialized stroma of prostate are rare. Lesions have been classified into prostatic stromal tumor of uncertain malignant potential (STUMP) and prostatic stromal sarcoma (SS) based on the degree of stromal cellularity, presence of mitotic figures, necrosis, and stromal overgrowth. STUMPs are considered neoplastic, based on the observations that they may diffusely infiltrate the prostate gland and extend into adjacent tissues, and often recur. Although most cases of STUMP do not behave in an aggressive fashion, occasional cases have been documented to recur rapidly after resection and a minority have progressed to stromal sarcoma. Here we describe a case of STUMP. A 42-year-old male was seen at a hospital with the chief complaint of elevated levels of prostate specific antigen. Since digital examination revealed abnormal findings in the prostate, then he was referred to our hospital. We diagnosed STUMP by ultra-sound-guided needle biopsy of the prostate. Then we performed radical prostatectomy. Finally we made the pathological diagnosis of prostatic STUMP. Ten months later, there was no sign of metastasis or recurrence.

Once, prostate cancer becomes hormone-refractory, there are only a few effective therapies such as docetaxel-based chemotherapies. Several molecular targeted therapeutic drugs have been tested for prostate cancer such as endothelin-A receptor antagonist, endothelial growth factor receptor or platelet derived growth factor receptor inhibitor. Nuclear factor kappa B (NFkappaB) is a key molecule for the growth of prostate cancer. Therefore, NFkappaB can be a good target for the therapy. In fact, a couple of NFkappaB inhibitors have been clinically or pre-clinically tested. Among them, Bortezomib and thalidomide showed little clinical efficacy as a single therapeutic agent. However, these drugs exerted clinical benefits to some extent when used with other chemotherapeutic drugs. Dexamethasone is also an NFkappaB inhibitor. Its clinical efficacy is through suppressing the adrenal androgen level. Besides adrenal androgen blockade, dexamethasone suppresses the growth of prostate cancer via NFkappaB inactivation, and also via the inhibition of interleukin-6 production which is reportedly important for the growth of prostate cancer. One of the clinical benefits of dexamethasone treatment is the improvement in anemia.

Molecular-targeted therapy is to treat pathologic pathways specifically in tumor cell or tumor microenvironment. Specific molecular-targeted therapeutic agents for hormone-refractory prostate cancer (HRPC) include endothelin-A receptor antagonist, EGF receptor (EGFR) inhibitor, platelet derived growth factor receptor (PDGFR) inhibitor, nuclear factor of kappaB (NF-kappaB) inhibitor, cyclooxygenase-2 (COX2) inhibitor, and active form of Vitamin D. These agents have been investigated in clinical trials. So far, none of the above-mentioned agent has shown a sufficient clinical efficacy alone. However, docetaxel-based combinations with thalidomide or calcitriol have promising clinical activities. Further investigations are needed to optimize the molecular-targeted agents in the combinations with chemotherapeutic agents for the treatment of HRPC.

39歳男.全身倦怠感, 血痰を主訴とした.約半年後に近医を受診し, 左精巣腫瘍, 及び多発性肺転移の診断で左精巣高位摘除術を受けた.病理組織診断は絨毛癌であった.術後, 化学療法目的で来院した.頭皮・左頬部・前胸部には出血を伴う3cm大, 弾性硬, 黒色の皮膚腫瘤を認めた.胸部X線, 胸部CT, 頭部CT, 腹部CT, 上部消化管内視鏡検査では両肺の結節影, 左小脳半球の高濃度病変, 肝S7の低濃度域, 両腎の結節病変, 胃後壁の粘膜下腫瘤を認めた.BEP療法(ブレオマイシン・エトポシド・シスプラチン), EP療法(エトポシド・シスプラチン), TIP療法(パクリタキセル・イホスファミド・シスプラチン)などを行った.小脳転移に変化はなかったが, 肺転移は縮小傾向, 肝・腎・胃・皮膚転移は消失し, 腫瘍マーカーも正常化した.しかし, β-ヒト絨毛性性腺刺激ホルモンの再上昇がみられ, TIP療法, Nedaplatin+塩酸イリノテカン療法, γナイフ療法を行ったが, 脳転移巣の増大・出血による神経症状, 肺転移巣の増大を認め, 術後17ヵ月目に死亡した, A 39-year-old man whose chief complaints were general fatigue and bloody phlegm was diagnosed with testicular cancer and underwent left high orchiectomy at an affiliated hospital. The histopathologic diagnosis was chorio carcinoma. Several imaging examinations revealed the metastases in the lung, liver, brain, stomach, kidneys and skin. In spite of various chemotherapies, he died 17 months after the operation. Skin metastasis of testicular cancer is very rare and this is the twelfth case reported in the world, to our knowledge. The significance of skin metastasis in testicular cancer is discussed.

37歳男性.患者は健診で肝機能異常を指摘され, 近医のCTで右副腎腫瘍を疑われ紹介入院となった.所見では, 内分泌検査でアルドステロンの若干の高値を認め, CTでは右副腎に6.7×5.7cmの境界明瞭で内部に粗大な点状石灰化を含む分葉状腫瘤が認められた.また, MRIではT1強調で内部は均一な低信号で, 造影早期に隔壁様濃染を示し, 次第に濃染範囲は拡大し, T2強調では中～高信号で, 内部は隔壁様に低信号で境界されていた.内分泌非活性型右副腎腫瘍と診断し, 癒着・浸潤を懸念して開放手術による腫瘍摘出術を施行した.病理組織所見では, 腫瘍は副腎組織と融合し, 腫瘍本体内に副腎組織を認め, Schwann細胞および神経線維が主体で部分的に良く分化したganglion cellが混在しており, 副腎原発の神経節細胞腫と診断された.術後6ヵ月経過現在, 再発は認められていない, A patient with an incidentally diagnosed adrenal ganglioneuroma is reported. A 37-year-old man who underwent abdominal computed tomography (CT) in the course of evaluating liver dysfunction was found to have a right adrenal tumor. Laboratory data including results of endocrinologic tests were normal except for a slight elevation of plasma aldosterone. With a preoperative diagnosis of non-functioning right adrenal tumor, resection was performed. The tumor specimen was noncystic weighing 150 g and measuring 10 x 8 x 3 cm. The histopathologic diagnosis was ganglioneuroma originating from the adrenal gland. Adrenal ganglioneuroma is relatively rare, 147 cases including ours have been reported in Japan. Increasing numbers of these tumors are being found incidentally by ultrasonography or CT. Ganglioneuroma is a benign tumor, and disagreement exists concerning diagnosis and indications for surgery.

36歳男性.患者は発熱が続き近医でCRP高値を指摘されたがNSAID投与で軽快したため放置していた.しかし今回, 38℃以上の不明熱の持続で著者らの施設へ受診となった.所見では, 左下腹部に表面平滑, 弾性硬, 可動性ある腫瘤を触知し, CTでは小骨盤左壁腹側に66×42mmの境界明瞭, 辺縁平滑な腫瘤を認めた.また, 造影CTでは均一な軽度の造影効果を認め, MRIでは内部はT1強調像で筋肉と等信号, T2強調像で高信号を呈し, 腫瘤の周囲に1～2cmのリンパ節の多発を認めた.更にMRアンギオグラフィーでは栄養動脈は左内腸骨動脈であり, 動脈相から濃染する充実性腫瘤と考えられ, 骨盤内腫瘍摘除術を施行することとなった.その結果, 病理所見で摘除組織は腫大したリンパ節で, 内部に大小不規則なリンパ濾胞の過形成と, 濾胞間に形質細胞の著明な浸潤を認め, Castleman diseaseのplasma cell typeと診断した.術後1年経過現在, 再発は認められていない, Although Castleman disease may occur in any lymph node of the body, it is the most commonly found in the thoracic cavity. Castleman disease rarely occurs in the pelvic cavity and only 8 such cases have been reported previously in Japan. In this report, we describe a case of Castleman disease in the pelvic cavity. A 36-year-old man complained of fever. Both serum c-reactive protein (CRP) and serum interleukin-6 (IL-6) were elevated. Computed tomography and magnetic resonance imaging showed a solid mass with calcification in the pelvic cavity. The pelvic mass was surgically excised. The removed mass was solid and 75 x 45 x 30 mm in size. The histological diagnosis was the plasma cell type of Castleman disease. Fever subsided and both serum CRP and serum IL-6 were normalized after the operation. No evidence of disease was detected one year post operation.

65歳男.右側腹部痛, 発熱を主訴とした.腹部CTで右腎膿瘍を指摘され, 5ヵ月間経過観察後, 腎悪性腫瘍を疑われ紹介入院となった.画像診断より下大静脈腫瘍塞栓を伴った右腎細胞癌と診断し根治的右腎摘除術, 下大静脈腫瘍塞栓摘除術およびCTにて指摘されていた部位のリンパ節摘除術を施行した.摘除標本は1380g, 腎実質は殆ど認めず腫瘍により占拠され, 腎盂構造は腫瘍により形態をとどめていなかった.病理診断はTCC, G3, pT3, pN2であった.術後腎盂腫瘍診断のためM-VACを補助化学療法として行った.施行中に腎機能の低下による肺水腫および白血球低下により誘発されたと思われる肺炎によりDICとなり, 全身状態の悪化のため, 化学療法は1コースで終了した.術後4ヵ月目のSCC 3ng/ml, IAP 211μg/mlと改善を示した.その後4年8ヵ月経過した現在, 腹部および胸部に再発は認めていない, We report a case of right renal pelvic cancer with tumor thrombus in the inferior vena cava. A 65-year-old man with right flank abdominal pain and high fever was reffered to our hospital. Computed tomography showed right renal mass. Magnetic resonance imaging revealed tumor thrombus extending into the renal vein and the inferior vena cava. Preoperative diagnosis was renal cell carcinoma with vena caval thrombus. Radical nephrectomy with thrombectomy and lymphodenectomy was performed. Pathologic evaluation revealed transitional cell carcinoma with tumor thrombus into the vena cava. One course of M-VAC chemotherapy was added and he has been alive for 56 months without recurrence. A literature review of 15 cases of renal pelvic cancer with tumor thrombus in the vena cava in Japan revealed that 7 cases were diagnosed as renal cell carcinoma preoperatively.

54歳女.頻尿を主訴とした.腟前壁に腫瘤を触知し, 尿検査では血膿尿を認め, 尿細胞診はclass Vであった.骨盤部CTでは尿道周囲に不均一に造影される腫瘤を認め, 骨盤部MRIではT1強調画像上isointensity, T2強調画像上high intensityで尿道を取り囲むように存在する腫瘤を認めた.また, 腫瘤内に嚢胞状変化を認め, voiding cystographyにて嚢胞状病変と尿道との交通が明らかとなり, 尿道憩室と考えられた.尿道腺癌と診断し, 前方骨盤内臓器全摘出術, 骨盤内リンパ節郭清術および回腸導管造設術を施行した.病理組織診断は尿道原発のClear cell adenocarcinomaであった.尚, PSA及びPAPの免疫抗体染色を行ったが陰性であった.追加療法は特に施行せず, 術後4ヵ月目に傍大動脈および鼠径リンパ節転移が出現するも生存中である.女子尿道に発生するClear cell adenocarcinomaは, 調べ得た限りでは本邦で自験例を含め33例を数えるのみであり, 稀な疾患と考えられた, Clear cell adenocarcinoma of the female urethra is extremely rare. We herein describe the 33rd case of clear cell adenocarcinoma of the female urethra in Japan. A 54-year-old female who presented with pollakisuria was referred to our department. Transvaginal examination showed a walnut-sized firm mass on the anterior vaginal wall. Computed tomography, magnetic resonance imaging (MRI), cystourethroscopy and the histopathological findings of the biopsied specimen revealed adenocarcinoma of the urethra. Anterior pelvic exenteration and ileal conduit urinary diversion were performed and the final pathological diagnosis was clear cell adenocarcinoma of the urethra, pT3, pN2. No further adjuvant therapy was conducted. She remains alive 6 months after surgery in spite of paraaortic and inguinal lymph node metastases.

33歳男性.不妊を主訴とした精巣Leydig細胞腫の1例を経験した.不妊で他院に高度乏精子症と左精巣腫瘤を指摘され紹介受診した.左精巣上極に径2cmの表面不整, 弾性硬の腫瘤を触知し, 内分泌検査でテストステロン, FSHの低下を認めた.超音波検査, CTで左精巣内に境界明瞭な径2cmの腫瘤を認め, 左精巣腫瘍と診断し左高位精巣摘除術を施行した.精巣の正常部位の顕鏡では奇形死滅精子のみであった.病理所見では強拡大像は好酸性微細顆粒状の豊富な細胞質と核小体が目立つ, 大型で均一な核をもつ腫瘍細胞を認め, 精巣Leydig細胞腫と診断した.術後テストステロンは徐々に正常値に上昇し, LH, FSHは術直後より急激な上昇を認め, 精液所見も著しく改善し, 術後10ヵ月経過で再発・転移は認めていない, A 33-year-old male was referred to our hospital for male infertility with painless swelling of the left scrotal content. Left high orchiectomy was performed under the diagnosis of left testicular tumor. Histologically, this testicular mass was a Leydig cell tumor. We reviewed 55 cases of Leydig cell tumor of the testis previously reported in Japan, and reported the hormonal profile in our case before and after surgery.