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Laparoscopic adrenalectomy is widely accepted as a safe and minimally-invasive procedure. Although it is a standard procedure for the surgical treatment of adrenal tumors, its simultaneous use with bilateral adrenalectomy is relatively rare. A 21-year-old woman was referred to Hamamatsu University School of Medicine University Hospital complaining of a deepening voice, hirsutism and secondary amenorrhea. Abdominal computed tomography showed bilateral adrenal tumors, and hormonal examinations showed that the tumors secreted excessive testosterone, resulting in virilizing symptoms. Laparoscopic simultaneous bilateral adrenalectomy was carried out. Postoperatively, serum testosterone levels immediately recovered to within the normal range. Menstruation began the month after the operation, and the hirsutism gradually regressed. This is the third reported case of bilateral virilizing adrenal tumors, and the first to be successfully treated with laparoscopic simultaneous bilateral adrenalectomy., (© 2013 The Japanese Urological Association.)

Objectives: To review the medical records of patients with BK virus nephropathy (BKVN) following kidney transplantation in our institution., Methods: We screened patients for decoy cells using urine cytology, assessed serum creatinine levels, and conducted a graft biopsy, as well as assessed the presence of plasma BK virus DNA by quantitative real-time polymerase chain reaction. The treatment of BKVN was based on the decreased use of immunosuppressants., Results: Overall, six male patients were studied (mean age 40.8 years, range 18-58; mean donor age 45.2 years, range 15-67). A positive urine cytology screen led to the subsequent detection of plasma BK virus DNA in the five patients with urine cytology results positive for decoy cells. In the four patients in whom plasma BK virus DNA was detected, a maximum value of DNA of > or = 10 000 copies/mL was observed. Time elapsed from transplantation to BKVN diagnosis ranged from 3 to 62 months. Although the two cadaver grafts were lost, the loss was not due to any effects directly associated with BKVN. The other four grafts are still functioning with a mean creatinine level of 1.8 mg/dL. Most of the patients with BKVN were regarded as being in a state of heightened immunosuppression. BK virus transition to blood was prevented in one patient., Conclusions: Early diagnosis of BKV infection with reduction of immunosuppression may potentially counter BK viremia and retard progression of BKV nephropathy. Decoy cell screening by urine cytology as well as plasma BK virus DNA screening should be considered in addition to the required graft biopsy in kidney transplant recipients, particularly in those with impaired graft function.

The development of laparoscopic surgery has been accompanied by a rapid increase in the number of laparoscopic surgical procedures carried out in the field of urology. In 2002 laparoscopic nephrectomy was approved for coverage under Japanese national health insurance, and in 2003 there were over 1000 registered cases in which this procedure was carried out. This suggests that laparoscopic nephrectomy, a procedure formerly conducted at only a few institutions, is now spreading to hospitals across Japan. Laparoscopic surgery involves the use of specialized instruments within a restricted field of vision, and risky surgical techniques can potentially result in visceral or vascular damage. In order to promote the use of safe laparoscopic surgery procedures, the Japanese Urological Association and the Japanese Society of Endourology and Extracorporeal Shock Wave Lithotripsy (ESWL) have inaugurated a certification program for urologic laparoscopy. This program not only encourages development in this field of surgery and provides technical certification to ensure appropriate levels of expertise, but also reviews methods for the correct use of instruments such as trocars and hemostats. The purpose of this video is to present correct methods for the use of a variety of laparoscopic instruments, in order to increase the safety of this procedure. The video has been designed to be useful not only for practitioners who are just beginning laparoscopy, but also for those who already have extensive laparoscopic experience. The video discusses five laparoscopic instruments (trocar, electric surgical devices, ultrasonic surgery devices, clips and clip appliers and endo-staplers), and demonstrates their correct use. In addition, animal models are used to illustrate the potential complications that can be associated with some methods of use.

Objective: We retrospectively compared perioperative parameters, as well as the oncological and functional results, for laparoscopic radical prostatectomy (LRP) carried out via the posterior and anterior approaches in our hospital., Methods: We recorded pre-, peri-, and postoperative parameters and complications, and evaluated the oncological and functional results to compare the posterior approach (group 1, n = 25) with the anterior approach (group 2, n = 34)., Results: There were no significant differences regarding the preoperative characteristics of the two groups. The incidence of major complications, positive surgical margins, and continence at 3 and 6 months postoperatively showed no significant differences between the two groups. Although mean blood loss (including urine) was not significantly different, the mean prostatectomy time was significantly shorter in group 2 (174.21 +/- 57.97 min) than in group 1 (224.76 +/- 66.72 min) (P = 0.003 by Student's t-test). Also, the postoperative recovery period until discharge was 5.94 days in group 2, and was significantly shorter than in group 1 (7.48 days) (P = 0.02 by Student's t-test)., Conclusions: This retrospective comparative study shows that the anterior approach yields similar, if not better results than the posterior approach for LRP.

The BK polyomavirus (BKV) infects most of the human population, but clinically relevant infections are usually limited to individuals who are in an immunosuppressed state. The significance of BKV infection was investigated in a 50-year-old man who underwent cadaveric kidney transplantation and was treated with tacrolimus, mycophenolate mofetil and prednisolone. By staining renal biopsy specimens with a monoclonal antibody against BK large T antigen, we were able to observe the relationship between the appearance of the BKV antigen and the extent of immunosuppression in this patient. We also determined that BKV belonged to genotype I by analysis of viral DNA from the patient's urine.

Adrenalectomy was performed on a 37-year-old woman with right adrenal pheochromocytoma. Although the histological diagnosis was benign, telomerase repeat amplification protocol (TRAP) demonstrated positive telomerase activity. Thirty-five months after adrenalectomy, a recurrent tumor was found. Forty-seven months after adrenalectomy, bone metastases also appeared. Malignant pheochromocytoma was clinically diagnosed. Our experience suggests that telomerase-positive tumor cells are highly likely to repeat cell proliferation when they are left in the patient's body, and lead to recurrence. Therefore, telomerase-positive tumors should be clinically treated as malignant even if they have been histologically diagnosed as benign.

Laparoscopic surgery for urological conditions has now become popular worldwide. The case is reported of a 56-year-old woman who underwent simultaneous bilateral laparoscopic adrenalectomy for adrenocorticotropic hormone-independent macronodular adrenocortical hyperplasia (AIMAH), followed by autotransplantation of resected adrenal gland fragments. Simultaneous laparoscopic adrenalectomies seem feasible for a patient with AIMAH because of its minimally invasive nature. However, autotransplantation of adrenal fragments failed in this patient with AIMAH.

The details are reported of bladder dysfunction in a Japanese boy with adrenoleukodystrophy. He developed gait disturbance at the age of 15 years. Spastic paraparesis progressed from the legs to the hands and brain magnetic resonance imaging showed characteristic degenerative change. Detrusor hyperreflexia was found by a urodynamic study and detrusor-sphincter dyssynergia was also suspected.

Purpose: The score to predict the risk of post-extracorporeal shock wave lithotripsy (ESWL) pyelonephritis was evaluated. The score was based on the multivariate analysis of risk factors available pre-operatively. Stone size, pyuria, bacteriuria, previous pyelonephritis and other adjunctive procedures had been selected and scored., Methods: Three-hundred and forty-eight adult patients without active urinary infection undergoing ESWL therapy were studied. One of three regimens were selected by either doctor or patient: (i) no antimicrobial treatment; (ii) one dose of levofloxacin; or (iii) 1 week course of levofloxacin. Who and why selected it were described. Post-ESWL fever over 38 degrees C was defined as the unfavorable event., Results/conclusion: With increasing score, doctors recommend taking an antimicrobial. There were 11 bacteriuric patients and post-ESWL pyelonephritis developed in one of them. Bacteria within the stone and post-ESWL ureteral obstruction caused by the stone fragments were considered to be important in developing pyelonephritis. However, multiple factors were related with it. Although their decision was not based simply on the score, the score was confirmed to be useful in identifying the high-risk patients and, therefore, to implement cost-effective antimicrobial use.

We successfully performed a laparoscopy-assisted radical nephrectomy for renal cell carcinoma in 2 patients on long-term hemodialysis. Both tumors were incidentally discovered on screening by abdominal CT scanning. There were no complications during the operation or in the postoperative period, and both patients resumed normal activities by the fifth postoperative day. A laparoscopic-assisted radical nephrectomy may be useful for the treatment of renal cell carcinoma in hemodialysis patients.

We successfully performed a laparoscopic nephrectomy on 2 young girls in March 1994 and August 1994. The first patient was a 9-year-old girl with a hypoplastic kidney associated with an ectopic ureterocele, and the other was a 3-year-old girl with a nonfunctioning hydronephrotic kidney caused by stricture of the pyeloureteral junction. The operating times were 153 and 183 minutes, respectively. No complications occurred intraoperatively or postoperatively in either patient. The 9-year-old girl resumed normal daily activities by postoperative day 2, and the 3-year-old girl by postoperative day 3. Both girls were discharged on day 4.

Background: Although various strategies have been proposed, the treatment of staghorn calculi is still controversial. We report on the treatment of 27 staghorn calculi using fiberoptic transurethral nephrolithotripsy (f-TUL) combined with extracorporeal shock wave lithotripsy (ESWL)., Methods: Stones were initially disintegrated by f-TUL as an inpatient procedure. For stone fragmentation, we originally used an electrohydraulic lithotriptor (EHL) but changed to a pulsed-dye laser in 1993. After the stones were disintegrated as much as possible, a double-J ureteral stent was inserted and the patient was discharged. ESWL for the residual fragments was begun on an outpatient basis at 1 or 2 weeks after f-TUL and repeated until the residual fragments were smaller than 4 mm., Results: Since 1989, 27 staghorn calculi in 26 patients have been treated. Among them, 21 were successfully fragmented using this combined treatment regimen. From 3 to 26 ESWL sessions (mean, 8.4 sessions) were required to disintegrate the staghorn calculi. Auxiliary percutaneous endourological procedures were necessary in 2 cases due to ureteral obstruction. The other 4 patients are still receiving ESWL for residual fragments. Urinary tract injury occurred in 2 patients early in this series when an EHL was used, but was managed without any surgical procedures. A fever greater than 38 degrees C developed in 9 patients., Conclusion: Combining f-TUL with ESWL provides an alternative treatment option for staghorn calculi. The use of a small caliber fiberscope (2.6 mm in diameter) and a laser for fragmentation decreased the risk of complications.

Background: This study evaluated the long-term efficacy of transurethral microwave thermotherapy (TUMT) in the treatment of benign prostatic hyperplasia (BPH), and determined whether the indices obtained with transrectal ultrasonography (TRUS) can predict the clinical response to TUMT., Method: Between November 1991 and June 1992, 43 patients with symptomatic BPH were treated with TUMT using the Prostcare device. The therapy consisted of a 1-hour treatment under topical anesthesia. The findings of uroflowmetry and AUA symptom score before treatment were compared with those obtained at each visit after the therapy. As the indices, the transition zone (TZ) volume, transition zone ratio (TZ ratio = TZ volume/total prostate volume), total prostate volume, and presumed circle area ratio (PCAR) were calculated., Results: There was a significant correlation between pretreatment TZ ratio and residual urine volume (r = 0.472, P = 0.0022). The efficacy rates calculated by response criteria on the 3 point scale at 2 months, 12 months, and 30 months were 44.2%, 30.2%, and 25%, respectively. The significant prognostic factors that predicted the clinical effect 1 year after treatment were the TZ ratio and intraprostatic temperature. After controlling for the treatment temperature, the multivariate logistic regression model demonstrated that the TZ ratio was the significant predictor (P = 0.049) of 1 year efficacy of treatment., Conclusion: The present study showed that the efficacy rate of TUMT at 30 months was 25%, and that TRUS provides a simple parameter, the TZ ratio, which predicts the efficacy of TUMT.

A 30-year-old man presented at our hospital with microscopic hematuria. Ultrasonography and computed tomography scanning revealed a right adrenal mass measuring 20 x 20 mm. The tumor was asymptomatic, but there was obvious accumulation on the right side when scintigraphy was performed with radioactive iodine (131I)-labeled adosterol. Endocrinology studies showed elevation of the plasma cortisol and renin concentrations, while the plasma aldosterone level was low. Right laparoscopic adrenalectomy was done on July 4, 1994. Histologic examination showed an adrenocortical adenoma. Serum levels of adrenocortical hormones were measured before and after surgery, and the tissue content for the same hormones was determined in the resected tumor. The hormonal studies showed that the tumor produced 18-hydroxycorticosterone.

Background: The aim of the present study was to determine whether the indices of transrectal ultrasonography (TRUS) are related to the clinical response to tamsulosin, a long-acting selective alpha 1-blocker., Methods: Sixty patients with symptomatic benign prostatic hypertrophy (BPH) were treated with tamsulosin hydrochloride (0.2 mg/day) for 2 months. The findings on TRUS and uroflowmetry and the AUA symptom score before treatment were compared with those obtained at the end of the 2 month treatment period. For the indices of TRUS, transition zone (TZ) volume, transition zone ratio (TZ ratio = TZ volume/total prostate volume), total prostate volume, and prostate specific antigen density (PSAD) were calculated., Results: There was a significant correlation between the pretreatment TZ ratio and the residual urine volume (r = 0.421, P = 0.0005). Patients with a lower TZ ratio and/or PSAD responded well to the treatment. The correlation between the PSAD value and the percent change in peak urinary flow rate was statistically significant (r = -0.432, P = 0.0009)., Conclusion: TRUS provides simple parameters of PSAD that can be used to predict the response of patients to tamsulosin hydrochloride.

Background: The aim of the present study was to improve the accuracy of the prostate-specific antigen (PSA) density for detecting prostate cancer by using the transition zone (TZ) volume instead of the total prostate volume., Methods: From April 1994 to October 1995, we examined 164 consecutive patients (52-88 years old), with an elevated PSA and/or abnormal digital rectal examination. All patients underwent a transrectal ultrasound-guided biopsy. The PSA density for total prostate volume (PSAD) and for TZ volume (PSAT) were calculated from the transrectal ultrasound measurements., Results: Forty-four of the 162 patients (27.2%) had histological confirmation of prostate cancer on biopsy. The area under the receiver-operator characteristic curve was 0.667 for PSA, 0.663 for PSAD, and 0.826 for PSAT. These areas were not significantly different for PSA and PSAD. However, PSAT was significantly superior to PSAD in differentiating benign hyperplasia from prostate cancer (P < 0.01)., Conclusion: The TZ volume-adjusted PSA density (PSAT) is useful for selecting patients for prostate biopsy from those with suspected prostate cancer.

Background: The mechanism of renal stone genesis as well as the location of stone crystal formation in the kidney remains unclear. Possible sites of stone generation are either in the tubular lumen or tubular cell., Methods: We cultured Madin Darby canine kidney (MDCK), LLC-PK1 and Magen Krebs Niigata-28 (MKN-28) cells in DMEM + 10% FBS medium in a well without passage for 30 days., Results: MDCK cells produced microliths at the basolateral side but not on the lumen side of these cells. The other two cell lines did not form microliths., Conclusion: Our data show that microlith formation is a characteristic of MDCK cells and that biological mineralization of MDCK cells may serve as a human urolithiasis model in vitro. The findings support a significant role of the renal distal convoluted tubule and collecting ducts in the in vitro generation of urinary stones.