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A 60-year-old man visited our hospital to treat a large cystic mass in the pelvis which had been found by abdominal ultrasonography in December 201X. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a multilocular cyst with a maximum diameter of about 10 cm. CT-guided drainage and sclerotherapy with minocycline reduced the size of tumor by 40%, but symptoms such as difficulty of defecation and urinary frequency appeared a year and a half later due to re-enlargement of the cysts. Laparoscopic resection of the multilocular cysts was performed, and all cysts were removed almost completely using transrectal ultrasonography. The multilocular cyst was positive for NKX3.1 by immunohistochemical staining, and was diagnosed as a giant multilocular prostatic cystadenoma. After surgery, the symptoms such as difficulty of defecation and urinary frequency were relieved promptly. One year after the surgery, the patient was free from recurrence of the disease., 本論文の要旨は第246回日本泌尿器科学会関西地方会にて発表した．

Case 1. A male in his 60s underwent a right transperitoneal laparoscopic partial nephrectomy procedure for a right renal tumor. Rupture of a renal cyst located close to the tumor occurred intraoperatively. The histopathological diagnosis was clear cell renal cell carcinoma (CCRCC), pT1aN0M0, G2, v0, with negative resection margins. At 84 months after surgery, computed tomography (CT) revealed a 10 mm mass in the rectus abdominis muscle at the camera port site used for the partial nephrectomy. An open lumpectomy was then performed and the histopathological diagnosis was CCRCC. One year later, a 40 mm sized mass was detected in the mesentery of the small intestine by CT, which was removed laparoscopically with part of the mesentery and diagnosed as CCRCC. Since that surgery, the patient has been free from recurrence for 8 years. Case 2. A male in his 60s underwent a left retroperitoneal laparoscopic nephrectomy procedure for a left renal tumor. The histopathological diagnosis was CCRCC, pT1aN0M0, G1, v0, with negative resection margins. At 31 months after surgery, CT revealed a 32 mm mass in the retroperitoneal cavity at the right hand port site used for the laparoscopic nephrectomy. The mass was removed with part of the twelfth rib and erector spinae muscles in a lump, and the histopathological diagnosis was CCRCC. Since that surgery, the patient has been free from recurrence for 19 months. For the treatment of solitary port site recurrence of renal cell carcinoma after a laparoscopic radical/partial nephrectomy, we recommend surgical resection for a good prognosis.

A 66-year-old woman who had been receiving medication for hypertension and hyperlipidemia was referred to our hospital for evaluation of a left adrenal tumor (12×8 mm) that was incidentally detected on computed tomography. Her 24-hour urinary catecholamine level was elevated, and metaiodobenzylguanidine (MIBG) scintigraphy revealed increased uptake in the area around the left adrenal gland, necessitating laparoscopic adrenalectomy for preoperative diagnosis of left adrenal pheochromocytoma. Intraoperatively, we detected a para-aortic tumor behind the adrenal gland, and this lesion was excised together with the adrenal gland. However, manipulation of the para-aortic tumor led to elevation in the blood pressure to 170 mmHg. Histopathological examination of the resected specimens revealed an adrenocortical adenoma and a para-aortic ganglioneuroma, consisting of ganglion cells, nerve fibers, and Schwann cells. The patient's blood pressure normalized immediately postoperatively, and MIBG scintigraphy revealed a negative result. Endocrine active ganglioneuromas are rare, and to our knowledge, currently only 8 cases (including ours) have been reported in the Japanese and English literature.

A 60-year-old man visited our hospital to treat a large cystic mass in the pelvis which had been found by abdominal ultrasonography in December 201X. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a multilocular cyst with a maximum diameter of about 10 cm. CT-guided drainage and sclerotherapy with minocycline reduced the size of tumor by 40%, but symptoms such as difficulty of defecation and urinary frequency appeared a year and a half later due to re-enlargement of the cysts. Laparoscopic resection of the multilocular cysts was performed, and all cysts were removed almost completely using transrectal ultrasonography. The multilocular cyst was positive for NKX3.1 by immunohistochemical staining, and was diagnosed as a giant multilocular prostatic cystadenoma. After surgery, the symptoms such as difficulty of defecation and urinary frequency were relieved promptly. One year after the surgery, the patient was free from recurrence of the disease.

A 66-year-old woman who had been receiving medication for hypertension and hyperlipidemia was referred to our hospital for evaluation of a left adrenal tumor (12×8 mm) that was incidentally detected on computed tomography. Her 24-hour urinary catecholamine level was elevated, and metaiodobenzylguanidine (MIBG) scintigraphy revealed increased uptake in the area around the left adrenal gland, necessitating laparoscopic adrenalectomy for preoperative diagnosis of left adrenal pheochromocytoma. Intraoperatively, we detected a para-aortic tumor behind the adrenal gland, and this lesion was excised together with the adrenal gland. However, manipulation of the para-aortic tumor led to elevation in the blood pressure to 170 mmHg. Histopathological examination of the resected specimens revealed an adrenocortical adenoma and a para-aortic ganglioneuroma, consisting of ganglion cells, nerve fibers, and Schwann cells. The patient's blood pressure normalized immediately postoperatively, and MIBG scintigraphy revealed a negative result. Endocrine active ganglioneuromas are rare, and to our knowledge, currently only 8 cases (including ours) have been reported in the Japanese and English literature.

Although fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) has been widely used as a powerful tool in clinical oncologic imaging, its application in urological malignancies is limited. Recently, choline PET/CT has been successfully used for prostate cancer restaging. Here, we report the utility of choline PET/CT for the detection and monitoring of metastatic disease in two cases of renal cell carcinoma (RCC). A 53-year-old woman and a 45-year-old woman underwent FDG and choline PET/CT for evaluation of metastatic lesions in lymph nodes and bone following left and right RCC, respectively, and choline PET/CT demonstrated significantly higher uptake when compared with FDGPET/CT in both cases. Choline PET/CT accurately reflected the remission and progression of diseases in their clinical course, indicating that choline PET/CT could be a useful imaging modality in metastatic RCC.

We report a 65-year-old male with histopathologically proven prostate cancer and multiple pelvic node metastases using a robotic-assisted radical prostatectomy procedure plus extended pelvic lymph node dissection. Positron emission tomography (PET) scan findings demonstrated a moderate accumulation of 11C-choline in a metastatic left obturator node sized 8 × 8 mm, though only a faint uptake of fluorodeoxyglucose (FDG) was noted. 11C-choline PET/computed tomography (CT) may be useful for the diagnosis of a tiny metastatic lymph node not demonstrated by CT, magnetic resonance imaging, or FDG-PET/CT and to determine the need for an extended pelvic lymph node dissection.

Between November 2011 and November 2014, we performed a tunica albuginea incision with tunica vaginalis flap coverage (TAI＋TVFC) on 5 out of 15 patients who underwent surgery for testicular torsion. Of those 15 patients, 7 underwent orchidopexy alone (Group A), 5 underwent TAI＋TVFC (Group B), and 3 underwent an orchidectomy procedure (Group C). All were followed for 1 year and preservation of testicular volume ＞50% on the contralateral side in ultrasound measurements was considered as salvaged. During the follow-up examinations, no testicular atrophy was noted in Group A. In Group B, tension and testis color were immediately improved in all 5 patients after TAI＋TVFC, while blood perfusion was also improved after the operation. Also 3 patients in Group B were considered to be salvaged, while testicular atrophy occurred in 2 after 8 or more hours from onset until surgery. Our results indicated that TAI＋ TVFC is useful for restoring blood flow after surgery for testicular torsion, although the so-called‘Golden time’for torsion surgery has a significant impact in such cases.

The aim of this study was to compare 11C-choline PET/CT and bone scintigraphy (BS) for detection of bone metastases in patients with prostate cancer. Twenty-one patients with histologically proven prostate cancer underwent 11C-choline PET/CT and BS before (n = 4) or after (n = 17) treatment. Patient-, region-, and lesion-based diagnostic performances of bone metastasis of both 11C-choline PET/ CT and BS were evaluated using a five-point scale by two experienced readers. Bone metastases were present in 11 (52.4%) of 21 patients and 48 (32.7%) of 147 regions; 111 lesions were found to have bone metastases. Region-based analysis showed that the sensitivity, specificity, accuracy, and area under the receiver-operating-characteristic curves (AUC) of 11C-choline PET/CT were 97.9%, 99.0%, 98.6%, and 0.9989, respectively; those of BS were 72.9%, 99.0%, 90.5%, and 0.8386, respectively. Sensitivity, accuracy, and AUC significantly differed between the two methods (McNemar test, p = 0.0015, p = 0.0015, and p < 0.0001, respectively). 11C-choline PET/CT detected 110/111 metastatic lesions (99.1%); BS detected 85 (76.6%) (p < 0.0001). According to the CT morphological type, the visualization rates of 11C-choline-PET/ BS were 100%/90.3% for the blastic type, 91.7%/8.3% for the lytic type, 100%/100% for the mixed type, and 100%/53.3% for the invisible type, respectively. Significant differences in blastic, lytic, and invisible types were observed between the two methods (p = 0.013, p = 0.0044, and p = 0.023, respectively). In conclusion, 11C-choline PET/CT had greater sensitivity and accuracy than BS for detection of bone involvement in patients with prostate cancer.

Choline is a new PET tracer, which uptake may occur via a choline-specific transporter protein and be accelerated during the proliferation of tumor cells. We report a 61-year-old woman with a metastatic pancreatic tumor from renal cell carcinoma, measuring 35×40 mm. PET scans demonstrated accumulation of 11C-choline in the metastatic pancreatic tumor, but no accumulation of 18F-FDG. Choline PET/CT may play a useful and complementary imaging modality, especially when FDG-PET/CT does not show expected findings or when the evaluation of tumor viability is needed, in patients with renal cell carcinoma.

Figure S1. The cumulative rate of paternity in reoperated patients with or without obstruction compared with patients without reoperation. A. and B.: Fig. 4c and d are repotted with Study control data subdivided into two cohorts, patients without reoperation and patients reoperated only for non-obstructing complications. Note that the two cohorts of the Study control show similar curve in either analysis. (PPTX 79 kb)

We compared 11C-choline and FDG PET/CT scan findings for the staging and restaging of prostate cancer. Twenty Japanese prostate cancer patients underwent 11C-choline and FDG PET/CT before (n=5) or after (n=15) treatment. Using a five-point scale, we compared these scanning modalities regarding patient- and lesion-based diagnostic performance for local recurrence, untreated primary tumor, and lymph node and bony metastases. Of the 20 patients, documented local lesions, and node and bony metastases were present in 11 (55.0%), 9 (45.0%), and 13 (65.0%), respectively. The patient-based sensitivity/specificity/accuracy/area under the receiver-operating-characteristic curve (AUC) values for 11C-choline-PET/CT for diagnosing local lesions were 90.9% /100%/ 95.0% / 1.0, whereas those for FDG-PET/CT were 45.5% /100%/ 75.0% / 0.773. Those for 11C-choline-PET/CT for node metastasis were 88.9% /100%/ 95.0% / 0.944, and those for FDG-PET/CT were 44.4%/100%/75.0%/0.722. Those for 11C-choline-PET/CT for bone metastasis were 84.6%/100%/90.0%/0.951, and those for FDG-PET/CT were 76.9% /100%/ 85.0% / 0.962. The AUCs for local lesion and node metastasis differed significantly (p=0.0039, p=0.011, respectively). The lesion-based detection rates of 11C-choline compared to FDG PET/CT for local lesion, and node and bone metastases were 91.7% vs. 41.7%, 92.0% vs. 32.0%, and 94.8% vs. 83.0% (p=0.041, p=0.0030, p

A man in his 50s was referred to our hospital after recurrent severe urinary tract infection. He had undergone anoplasty for anorectal malformation during early infancy. He noticed urinary leakage from the anus for a long time. Under diagnosis of congenital rectourethral fistula, we performed fistula closure. The fistula was transsected via transperineal incision and each stump was closed. A gracilis muscle flap approximately 30 cm long was harvested from the left thigh, brought into the deepest part between the separated rectum and urethra through a subcutaneous tunnel and fixed there. The urinary leakage from the anus disappeared, and the infection resolved. Application of gracilis muscle flap for congenital diseases is rare, but was useful in the present case.

A 47-year-old woman came to our hospital with left lower abdominal pain in April 2013. An abdominal computed tomographic (CT) examination revealed left hydronephrosis secondary to a 7 cm retroperitoneal cyst near the left common iliac artery and ureter. Serum tumor markers including CEA, CA19-9, and CA125 were negative. Although CT guided needle aspiration of the cyst successfully relieved severe left flank pain, the cyst again increased in size, causing left hydronephrosis, though examinations for fluid tumor markers and cytology were negative. Two months later, the patient underwent open fenestration. The final pathological results demonstrated a mesothelial cyst without malignant findings. Six months after the operation, the patient was doing well without recurrence of symptoms.

Although fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) has been widely used as a powerful tool in clinical oncologic imaging, its application in urological malignancies is limited. Recently, choline PET/CT has been successfully used for prostate cancer restaging. Here, we report the utility of choline PET/CT for the detection and monitoring of metastatic disease in two cases of renal cell carcinoma (RCC). A 53-year-old woman and a 45-year-old woman underwent FDG and choline PET/CT for evaluation of metastatic lesions in lymph nodes and bone following left and right RCC, respectively, and choline PET/CT demonstrated significantly higher uptake when compared with FDGPET/CT in both cases. Choline PET/CT accurately reflected the remission and progression of diseases in their clinical course, indicating that choline PET/CT could be a useful imaging modality in metastatic RCC.

We prospectively investigated the safety and efficacy of sunitinib using a modified regimen (2 weeks on/1 weekoff) in 24 patients (22 males, 2 females ; age range 39-86 years, median 64 years) with metastatic renal cell carcinoma (RCC). During the observation period (3-62 weeks, median 21 weeks), thrombocytopenia was seen in 13 (54.2%), leukopenia in 11 (45.8%), hand-foot syndrome in 5 (20.8%), hypertension in 4 (16.7%), and hypothyroidism in 3 (12.5%) patients, while grade 3 or higher adverse events were found in 4 (16.7%), 1 (4.2%), 1 (4.2%), 2 (8.3%), and 0 patients, respectively. Of the 21 patients evaluable for response, 5 (23. 8%) showed partial response, 8 (38.1%) stable disease, and 8 (38.1%) progressive disease. This new modified regimen may lead to a reduction in adverse events for treatment of patients with metastatic RCC as a substitute for the standard dosing regimen of sunitinib.

A 37-year-old woman with an incidentally found abdominal mass was referred to our hospital. A fixed, non-tender mass was palpated in the right upper quadrum of her abdomen. There was no elevation of tumor markers. Computed tomography revealed a mass extending from the hepatic vein level to renal hilar level. The tumor completely obstructed the inferior vena cava (IVC). T1-weighted magnetic resonance imaging (MRI) showed that the mass was isointense with muscles. T2-weighted MRI image with contrast medium demonstrated collateral circulation. Upon diagnosis of the IVC tumor, we removed the right kidney and the tumor en bloc without reconstructing IVC. The tumor diameter was 11.6×5.5×4.7 cm. Pathological examination established a diagnosis of IVC leiomyosarcoma. She is alive without sign of recurrence after operation for seven months. There were 143 reports of IVC leiomyosarcoma in Japan. In 31% of them, IVC was not reconstructed.

A 23-year-old man and a 62-year-old man suffering from cystinuria underwent extracorporeal shock wave lithotripsy (ESWL) for right renal stone and left ureteral stone, respectively. They had double-J stents placed before ESWL, but since attempts to retrieve the stents were unsuccessful due to encrustation, they were referred to our clinic. Multimodal endourologic and open approaches including ESWL, transurethral ureterolithotripsy, and pyelolithotomy were required to render them stent- and stone-free. The guidelines do not recommend routine stenting before ESWL ; therefore, the indication and duration of indwelling stents should be minimized. Multimodal options including not only ESWL and endoscopic surgery but also open surgery, should be attempted for the management of encrusted stents. Close monitoring and follow up are important to the prevent complications of ureteral stents.

In 2008, a 65-year-old woman was referred to our department because of a right renal tumor detected by computed tomography (CT) that was associated with macroscopic hematuria. She underwent right hemicolectomy for ascending colon cancer in 2003, and right lower lobectomy for lung metastasis of colon cancer in 2004. CT, magnetic resonance imaging, fluorodeoxyglucose positron emission tomographycomputed tomography and bone scintigraphy did not indicate any other metastatic lesion except the right renal mass ; therefore, open right nephrectomy was performed. Results of the histopathologic examination demonstrated renal metastasis of colon cancer. Although administration of chemotherapy was continued, the patient died of multiple metastases 8 months after the right nephrectomy.

Patients administered anti-cholinergic agents, as first-line therapy for an overactive bladder (OAB) are often unable to continue medical treatment because of dry mouth. We assessed oral health in patients with OAB using the General Oral Health Assessment Index (GOHAI), an oral health-related quality of life questionnaire. We investigated 75 patients with OAB who were receiving continuous administration of anti-cholinergic agents. The OAB symptom score, as well as GOHAI and our original dry mouse score were determined by self-administered questionnaires. The mean age of the subjects was 70.9±10.2 years, the median period of anti-cholinergic agent use was 20 (1-116) months and the mean OAB symptom score was 6.3±3.1. The GOHAI score for all patients was 51.9±8.4 and not significantly different from the national normal value (p＝0.22). On the other hand, the score in patients with a severely dry mouth was 49.2±8.6, which was worse than the national normal value (p＝0.04). The psychosocial functioning score in patients with a severely dry mouth was significantly lower than in those with a slightly dry mouth (p＝0.02). Our results indicate that dry mouth in patients with OAB is significantly associated with worsening of oral health. GOHAI is useful as a screening test to assess the quality of life in patients with OAB.

Between November 2011 and November 2014, we performed a tunica albuginea incision with tunica vaginalis flap coverage (TAI＋TVFC) on 5 out of 15 patients who underwent surgery for testicular torsion. Of those 15 patients, 7 underwent orchidopexy alone (Group A), 5 underwent TAI＋TVFC (Group B), and 3 underwent an orchidectomy procedure (Group C). All were followed for 1 year and preservation of testicular volume ＞50% on the contralateral side in ultrasound measurements was considered as salvaged. During the follow-up examinations, no testicular atrophy was noted in Group A. In Group B, tension and testis color were immediately improved in all 5 patients after TAI＋TVFC, while blood perfusion was also improved after the operation. Also 3 patients in Group B were considered to be salvaged, while testicular atrophy occurred in 2 after 8 or more hours from onset until surgery. Our results indicated that TAI＋ TVFC is useful for restoring blood flow after surgery for testicular torsion, although the so-called‘Golden time’for torsion surgery has a significant impact in such cases.

A 73-year-old male, admitted to a local hospital because of fever and consciousness disturbance, was referred to our institute. He had a history of long-term steroid administration and diabetes mellitus. Under diagnosis of severe right pyonephrosis associated with severe inflammatory response syndrome as well as disseminated intravascular coagulopathy, he was transferred to our hospital. Computed tomography and magnetic resonance imaging showed a mass 5 cm in diameter at the right ureteropelvic junction and lymph node swelling at the renal hilum, suggesting obstructive pyonephrosis by a malignant tumor such as renal pelvic cancer. Since the patient failed to respond to conservative medical treatment including polymyxin B hemoperfusion, hemodialysis, and antimicrobials, we performed right nephrectomy. Histopathological examination demonstrated that the tumor obstructing the pelvis arose from the parenchyme under the muscle layer, and was diagnosed as unclassified renal cell carcinoma while the renal pelvic epithelium was normal. Although his general condition and laboratory data transiently improved after nephrectomy, he died of carcinomatousperitonitis30 days postoperatively. We advocate that, in the case of pyonephrosis with a lesion highly suspected to be an infiltrating neoplasm, nephrectomy is justified as first choice to control the septic condition.

A 40-year-old man had undergone right hemicolectomy and sigmoidectomy under the diagnosis of ascending andsigmoidcolon cancer andright nephroureterectomy under the diagnosis of right ureteral cancer, in 1997andin 2002, respectively. In 2007, He visitedour hospital with a complaint of bloody stool andhematuria. Colon fiberscopy, ureteropelvicscopy andcystoscopy demonstratedcolon cancer, left renal pelvis cancer and bladder cancer, respectively, as diagnosed by biopsies, followed by restative colectomy, left nephroureterectomy andcystectomy. The final histopathological examination showedwell differentiated adenocarcinoma (pSM) in the colon, and urothelial carcinoma in the left renal pelvis (pT2) and the bladder (pT1). Since his uncle andeld er brother hadsufferedfrom stomach cancer andcolon cancer, respectively, he was diagnosed with hereditary nonpolyposis colorectal cancer (HNPCC : Lynch syndrome). He has been well doing without recurrence for 3 years after the surgery.

A 70-year-old man visited a urological clinic on May 2008 complaining of dysuria and nocturia since 2 years prior. He was diagnosed as having gross benign prostatic hypertrophy, and was referred to a nearby hospital for transurethral resection of prostate (TURP). During TURP, a papillary tumor was found in the prostatic urethra on the left side and a biopsy was performed. A pathological examination revealed urothelial carcinoma G3. Cystoprostatectomy was planned, but the patient refused the procedure. Therefore, he underwent three courses of MVAC intra-arterial chemotherapy (methotrexate, vinblastin, doxorubicin, cisplatinum) at our hospital. After chemotherapy, no tumor was found in the prostatic urethra and a pathological report of repeat TUR showed no tumor. Currently, the patient is alive and there has been no evidence of recurrence for 1 year and 10 month.

We reported a rare case of intrascrotal lymphangioma in an adult. A 31-year-old man visited a urological clinic with a chief complaint of left scrotal swelling since a few days ago, and was pointed out to have a left intrascrotal cystic mass. The patient was sent to our hospital for further examination in 23 April 2008. The left scrotal mass was palpated elastic hard below the left testis and its surface was irregular. Light transillumination test showed positive. Ultrasonography revealed a cystic mass 7.0×4.4×4.5 cm with multiseptate accumulation at the lower pole of the left testis. Magnetic resonance imaging showed low intensity by T1WI and high intensity by T2WI, suggesting a protein-rich component. We suspected left intrascrotal lymphangioma and extirpated the scrotal mass under lumbar anesthesia. Pathological examination demonstrated lymphangioma. The patient had no evidence of recurrence after 1 year.

A 69-year-old man visited our hospital in February 1996 with a chief complain of left scrotal swelling. The left scrotal content was hard by palpation and ultrasonography showed a hypo-echoic lesion. Left high orchiectomy was performed with suspicion of a testicular tumor. Pathological examination demonstrated a diffuse large B-cell lymphoma (DLBCL) originating from the left testis, and then he underwent 5 courses of chemotherapy consisting of THP-COP (THP-adriamycin, cyclophosphamide, vincristin, predonisone). Following the treatment for five years, he had no evidence of recurrence. Nine years later, in October 2005, he noticed right scrotal swelling. He underwent right high orchiectmy with suspicion of a contralateral testicular malignant lymphoma. Pathological examination revealed DLBCL. He underwent chemotherapy (rituximab-THP-COP) and achieved complete remission again. He is doing well without recurrence of disease for three years after the last treatment.

A 57-year-old man had undergone right nephrectomy at 10 years of age and bladder augmentation using the ileum at 20 years for treatment of urinary tract tuberculosis. He also had undergone intermittent catheterization after a traffic accident at 49 years of age. He presented at another hospital with a complaint of asymptomatic macroscopic hematuria. Cystoscopy revealed a lobulated tumor in the bladder. Transurethral resection of bladder tumor was performed, but complete resection was difficult. Histopathological examination of the specimen revealed a well differentiated adenocarcinoma. He was referred to our hospital for total cystectomy and percutaneous left nephrostomy. The tumor arose from the bladder wall near the anastomotic site between the bladder and the ileal segment. Histopathological examination revealed a well differentiated adenocarcinoma infiltrating into the muscle layer (pT2a). Postoperatively, he has been free of recurrence for one year. This is the 19th case of adenocarcinoma following bladder augmentation using the ileum reported in the Japanese literature.

A 37-year-old man was referred to our hospital with the chief complaint of infertility. Semen analysis at another clinic had demonstrated severe oligozoospermia and he had a history of bilateral orchiopexy for undescended testes. Scrotal ultrasonography revealed a hypoechoic heterogeneous mass (1.5 cm in diameter) within the left testis. With a provisional diagnosis of testicular tumor, left high orchiectomy was performed. Pathological examination of the tumor revealed seminoma. At 12 months after surgery, there has been no evidence of recurrence. Clinicians should be aware of the link between male infertility and testicular cancer, particularly following orchiopexy., 37歳男。5歳時に両側停留精巣に対し精巣固定術を施行した。挙児希望のため妻と産婦人科を受診し、高度乏精子症を指摘され当科紹介受診した。MRIより左精巣腫瘍と診断し、当院産婦人科で精子凍結保存を施行した。腫瘍マーカーはAFP1.9ng/mlであったがβ-HCG 0.2ng/mlは軽度の高値を示した。左高位精巣摘除術を施行し、病理組織学的所見は白膜内に限局した腫瘍は淡明な胞体を有する細胞が胞巣状に増殖し、間質にはリンパ球の浸潤を伴うseminoma、pure formの所見で脈管侵襲像は認めなかった。周囲精管内に精子形成像はなく一部にcarcinoma in situ(CIS)細胞を認めた。術後17日目のβ-HCGは不変であったが、CTではリンパ節腫大や遠隔転移は認めずpT1N0M0と診断した。術後 10ヵ月の精液量3ml、3000/ml、運動率0%で血中ホルモン値FSHは術前の2倍に増加したがtestosteron値の変化は無く凍結精子を用いた顕微受精を施行中であった。術後12ヵ月を経て対側精巣を含め再発は認めなかった。

62歳男。患者は肝機能障害で通院中, 造影CTで左半側を占める長径20cmの水腎症が認められた。患者希望により経過観察としたが, 約1年後, 突然左側腹部痛, 腹部膨満感が出現した。造影CTでは23×17×31cmの正中を超えて広がる左巨大水腎症が認められ, 腎盂内に出血を起こしていると考えられたが, この時点で腫瘍性病変やリンパ節の腫脹は指摘できなかった。緊急に左腎瘻造設術を施行したところ, 黒褐色血性の約7000mlの腎盂内容液の排出がみられ, 腎瘻からの尿細胞診で尿路上皮癌class Vが検出された。そして, この腎盂内容液排出後, MRIで腎盂内を調べたところ腫瘍と思われる隆起性病変がみられ, 肝・傍大動脈リンパ節・胸腰椎に転移巣を認めた。また, 胸部CTでは微少多発転移巣が確認された。以上より, 本症例は巨大水腎症を伴う左腎盂癌, 多発転移と診断され, 全身化学療法ならびに放射線療法を開始したところ, 肝転移巣は徐々に増大し, 治療開始1年3ヵ月後には肝不全を起こし, 患者は最終的に死亡となった。, A 62-year-old man consulted us for further examination of left giant hydronephrosis which was accidentally found by abdominal ultrasonography. The patient chose observation instead of left nephrectomy. One year later, he re-visited us with a complaint of sudden abdominal pain. Computed tomography (CT) revealed left giant hydronephrosis containing high-density fluid which was suspected of hemorrhage in the renal pelvis. Percutaneous nephrostomy yielded discharge of 7000 ml of hemorrhagic fluid and urine cytology revealed class V. Systemic examination by CT and magnetic resonance imaging (MRI) showed renal pelvic tumors in the left kidney as well as multiple metastatic lesions in the lung, liver and bone. Pathological examination of the left renal pelvic tumors obtained by biopsy showed high-grade urothelial carcinoma. Although systemic and intra-arterial chemotherapy showed partial response in the metastatic lesions, he died of cancer 1 year and 3 months after the first diagnosis.

2007年1年間に施行した尿路内視鏡手術114症例, 清潔手術92症例, 準清潔手術20症例に対し, 周術期感染症阻止薬の術前単回投与を行い, 手術部位感染(SSI), 尿路感染(UTI), 遠隔感染(RI), 術後合併症の発生頻度を前方視的に調査した。その結果, 尿路内視鏡手術ではUTI発生率が2.7%で, RIは認めなかった。清潔手術での発生率はSSI:1.1%, RI:2.2%, UTI:0%, 準清潔手術ではSSI:5%, RI:0%, UTI:5%であった。よって, 泌尿器科領域における尿路内視鏡手術, 清潔手術, 準清潔手術に対する周術期感染症予防抗菌薬の効果は, 術前単回投与で十分に期待できると考えられた。, A single-dose ofantimicrobial prophylaxis (AMP) was administered parenterally for prevention of perioperative infection in a total of 206 urologic surgeries including 114 endoscopic-instrumental, 92 clean, and 20 clean-contaminated procedures between January and December, 2007, and surgical site infections (SSI), urinary tract infections (UTI), and remote infections (RI) were prospectively surveyed. The definition of a single-dose of AMP allowed the administration of a second dose of an antimicrobial during a surgical procedure that exceeded 3 hours but not parenteral or oral administration at the end of the procedure, in the recovery room, or at a later time over a period of more than 24 hours. UTI was observed in 3 cases (2.7%) after endoscopic-instrumental procedures and in 1 case (5%) after clean-contaminated procedures while no case was associated with UTI in clean procedures. SSI was seen in 1 case each after clean procedures (1.1%) and after clean-contaminated procedures (5%), and RI was seen in 2 cases (2.2%) after clean procedures. A single-dose regimen of AMP was effective for prevention ofperioperative infections including SSI, UTI, and RI in endoscopic-instrumental, clean, and clean-contaminated surgical procedures in urology.

72歳男。全身倦怠感, 呼吸困難が出現し, 他院にて肺水腫および腎機能障害を認め, CT, MRIで左高度萎縮腎と右尿管を巻き込んだ仙骨前面の腫瘍による右水腎症を認めた。骨盤内腫瘍およびそれに伴う腎後性腎不全と診断され, 右腎瘻造設術を施行し, 腎機能および肺水腫は改善, 骨盤内腫瘍の精査加療目的で2ヵ月後に当院転院となった。腹部CTより仙骨前面に沿って第5腰椎から仙骨下端におよび右尿管を巻き込んだ軟部腫瘤陰影を認めた。MRI・T2強調画像で不均一な高信号を呈し, 順行性腎盂造影では腫瘍による圧迫で右尿管の閉鎖を認めた。CTガイド下針生検より線維化組織内にリンパ球などの炎症細胞浸潤像を認め, 炎症活動期にある特発性後腹膜線維症と診断した。プレドニゾロン(PSL)30mg/日から開始し, 約1ヵ月で10mg/日まで減量した。投与開始後33日のMRIでは3.5×4.4×10.3cmの腫瘍が1.2×2.9×10.3cmと著明に縮小し, 赤沈値も低下し, 右尿管通過障害の改善も認めた。右水腎症の再発もなく転院より約1ヵ月半後にPSL継続で退院した。治療6ヵ月目のMRI・T2強調画像で高信号を呈しているため, 退院後約8ヵ月の現在もPSL5mg/日を内服継続中であった。, A 72-year-old man was admitted to another hospital because of general fatigue and dyspnea secondary to renal insufficiency. Abdominal computed tomography (CT) and magnetic resonance imaging showed left atrophic kidney, right hydronephrosis, and an intra-pelvic mass of soft-tissue density located anterior to the sacrum, involving the right ureter at the level between the 5th lumber vertebra and the sacrum. He was referred to our hospital after percutaneous nephrostomy was constructed into right kidney. CT-guided needle biopsy revealed the idiopathic retroperitoneal fibrosis, leading us to give him steroid therapy. Three weeks later, radiographic findings showed a remarkable reduction of the mass and the improvement of the right ureteral stricture.

44歳男性。左陰嚢内の無痛性腫瘤を主訴とした。各種腫瘍マーカーはすべて正常であり, 触診, 超音波検査およびMRI所見からは良性腫瘍を考えたが, 悪性腫瘍の可能性も考慮し, 手術が施行された。術中迅速診断では悪性所見は認めず, 腫瘍核出術を行なったところ, 精巣は温存, 病理組織学的には精巣白膜より発生したadenomatoid tumorであった。, A 44-year-old man was referred to our hospital with a chief complaint of a painless left intrascrotal mass, palpable at the lower portion of the left testis. Serum levels of tumor markers, human choriogenic gonadotropin (hCG), hCG-beta, and alpha fetoprotein were within the normal limits. Ultrasonography revealed a hyperechoic mass 13 mm in diameter, which was demonstrated as a hypovascular tumor by Gadrinium-enhanced magnetic resonance imaging. Since the tumor was diagnosed as a benign tumor by frozen section examination intraoperatively, testis-sparing surgery was performed. Histological examination revealed adenomatoid tumor originating from the tunica alubuginea of testis. Adenomatoid tumor of the testis is a rare benign tumor, and the present case is the 36th one in the Japanese literature.

78歳女性。患者は高血圧および糖尿病で近医へ通院中, 腹部超音波にて左腎下極背側の腫瘤を指摘され, 精査加療目的で著者らの施設へ紹介入院となった。臨床検査では異常所見は認められなかったものの, CTおよびMRIでは腎被膜由来の腫瘍, または後腹膜腫瘍が強く疑われた。後腹膜鏡下腎部分切除術を施行した結果, 術中迅速病理では悪性所見はみられず, 病理組織学的に腎被膜から発生した筋脂肪腫と診断された。現在, 術後1年6ヵ月経過で再発はみられていない。, A 53-year-old female visited us with an asymptomatic renal mass, which was incidentally found on abdominal ultrasonography (US). US showed a heterogeneous renal mass measuring 5 cm in diameter. Computed tomorraphy and magnetic resonance imaging showed that the tumor was mixed with muscle and fat tissue, faintly enhanced, and located at the lower portion of the left kidney. Although renal angiomyolipoma (AML) was suspected from these findings, we could not rule out a malignant tumor. Therefore, she underwent a laparoscopic partial nephrectomy. Histopathological examination revealed the tumor composed of smooth muscle and mature adipose tissue without cytological atypia arising from the renal capsule. The tumor contained no AML-like blood vessels, and was negative for HMB-45 staining. The final diagnosis was myolipoma arising from the renal capsule. Myolipoma is a rare benign neoplasm in the soft tissue of retroperitoneum and abdominal cavity. Since it is difficult to distinguish myolipoma from other benign and malignant tumors with fat tissue only by imaging studies, a surgical approach should be considered.

17歳男性。患者は突然の右側腹部痛を主訴に近医を受診, CTにて右腎出血を指摘され, 精査加療目的で著者らの施設へ紹介となった。入院時, 血圧の上昇および炎症反応の軽度上昇, 低K血症, 血清レニン活性ならびにアルドステロンの上昇を認め, 腹部CT・MRI・血管造影検査にて腎腫瘍内出血と診断された。出血部に対し塞栓術を行なったところ, 術後, 腹部痛は消失し, 血圧はARB内服にて安定した。以後, 外来にて経過観察としていたが, 悪性腫瘍を完全に否定できず, 血圧コントロールが困難になることも考慮し, 右腎部分切除術が施行された。その結果, 病理組織学的に傍糸球体細胞腫であり, 術後は血圧および血清レニン値, アルドステロンが正常化した。現在, 1年経過で再発はみられず, 良好である。, A 17-year-old man was admitted to our hospital with a chief complaint of right flank pain. Both computed tomography and magnetic resonance imaging demonstrated a tumor hemorrhage in a mass located at the upper pole of the right kidney. He had a high blood pressure of 220/100 mmHg associated with high serum renin activity (36.2 ng/ml/hr). Partial nephrectomy was performed and histopathological examination revealed a juxtaglomerular cell tumor. Postoperatively, his blood pressure was markedly improved and the serum renin activity immediately fell into the normal range. Previously, 32 cases of juxtaglomerular cell tumor have been reported in the Japanese literature, and to our knowledge, this is the first case was found with a tumor hemorrhage.

80歳男。入院前日に無症候性肉眼的血尿を認め入院した。表在リンパ節は触知せず, 直腸診では前立腺の軽度腫大を認めるが硬結, 圧痛は認めなかった。軽度貧血, 炎症反応上昇を認めPSA高値, 尿細胞診クラスIIであった。肉眼的血尿は保存的加療により数日で消失した。膀胱鏡, 静脈性腎盂造影を行ったが出血源を認めず抗血小板薬内服が血尿の原因と考え退院した。退院1ヵ月後採血でPSAが更に上昇したため骨盤MRI, 経会陰的前立腺生検を行った。MRIでは前立腺に悪性腫瘍を疑わせる所見を認めなかったがT2強調画像, 拡散強調画像で右恥骨に高信号を呈する領域が存在し転移性病巣と考えた。経会陰的前立腺生検を行ったが病理学的に明らかな悪性所見は認めなかった。しかしその後もPSAは上昇し初回生検3ヵ月後更に高値を示し, 骨シンチを施行したところEODの骨転移像が認められた。, An 80-year-old man visited our clinic with the chief complaint of asymptomatic macroscopic hematuria secondary to anticoagulant medicine. Although digital rectal examination was normal, a high serum prostate specific antigen (PSA) level (85.9 ng/ml) led us to perform sextant prostate biopsy, resulting in negative for cancer. Three months later, since the serum PSA increased to 169 ng/ml with high serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 levels. Twelve-core prostate biopsy was performed again, but the result was negative. Pelvic magnetic resonance imaging (MRI) showed a metastatic lesion on the right pubic bone, which was biopsied, and turned out to be poorly differentiated prostate cancer in histology. Maximum androgen blockade failed to control PSA. Finally he died of pneumonia 55 days after the bone biopsy. To our knowledge, there were only two case reports diagnosed as prostate cancer by biopsies of the metastatic lesions in Japanese literature, but none in the English literature. These findings suggest that high serum levels of CEA and CA19-9 in patients with prostate cancer are indications of hormone-refractory prostate cancer resulting in poor prognosis.

45歳男。左側腹部痛を主訴に近医に受診し, 腹部CTで左腎を下方に圧排する約8cmの腫瘤をみとめ特発性腎破裂と診断され入院した。経過観察中に肝内複数の低吸収領域の出現を認め精査加療目的で当科受診となった。軽度の炎症反応, 腎腫瘍マーカーと肝腫瘍マーカーの上昇を認めた。約1.5ヵ月後のCTより肝の5mmの低吸収領域は約2cmの不均一に造影される腫瘤に新たに2ヶ所の腫瘍性病変を認め血腫は左腎上方背側に進展しており腎細胞癌および肝転移を強く疑うもAFP, PIVK-IIの高値より原発性肝癌も否定できなかった。当科入院1ヵ月後に根治的左腎摘除術および肝部分切除術を施行した。血腫内に腫瘍性病変は認められず, 左腎に径2cmの腫瘍性病変を認め静脈内へ浸潤し, 肝部分切除標本に腎と同様の細胞を認め腎細胞癌および, その肝転移(G2, INFβ, pT3N1M1)と診断した。術後アジュバンド療法を施行し, 約1ヵ月後の腹部CTで新たな肝転移巣の出現を認め, IL-2の追加投与を行うも効果なく術後, 約1年に多発肝転移及び骨転移にて死亡した。, A 45-year-old man felt sudden pain in the left abdomen while taking a bath. Computed tomography (CT) showed a huge hematoma above the left kidney, which was diagnosed as spontaneous rupture of the kidney. Two months later, several low-density areas were observed in the liver on CT. Suspecting renal cell carcinoma (RCC) with multiple liver metastasis, we performed left radical nephrectomy and partial hepatectomy. A pathological study revealed a small RCC of 2 cm in diameter in the middle of the left kidney. In spontaneous renal rupture secondary to renal tumors, imaging studies such as CT or MRI sometimes fail to demonstrate primary lesions.

2003年1月から2005年9月迄に経験したリザーバー動注療法を施行した局所浸潤性膀胱癌T2～3, N0M0症例13例(T2は5例, T3は8例)を対象に, 治療成績を検討した.組織型は全例が尿路上皮癌であり, 腫瘍細胞の分化はG2が5例, G3が8例であった.動注用リザーバーは大腿部皮下に設置し, MVAC動注化学療法及びCDDP動注併用放射線療法のプロトコールにしたがった.病変数は13名で15個であり, 病変の数でみるとCRが6, PRが8であり全体での有効率は93.3%(14/15)であった.MVAC動注群は5病変で, CR1病変, PR4病変であり, CDDP動注併用放射線療法群は10病変でCRが5病変, PRが4病変であった.リザーバーポート留置による合併症は局所感染が18%にみられ, 穿刺部仮性動脈瘤の形成を1例に, 閉塞用コイル留置によると思われる臀部痛を1例に認めた.CRを得た6病変は平均12.3ヵ月の経過観察にて1病変のみ再発を認めたが, 遠隔転移例や癌死の例は認めていない.平均12ヵ月の経過観察ではPR症例では癌死は1例のみであった, We assessed the effectiveness of intra-arterial MVAC chemotherapy or a combination of intra-arterial chemotherapy and external beam radiotherapy based on diagnostic images and histological (transurethral) examination in 15 cases with T2-3NOM0 between January 2003 and September 2005. When the clinical response was assessed one month after the treatments, a complete response (CR) was achieved in 20% (1/5) and 50% (5/10) by intra-arterial MVAC chemotherapy and a combination of intra-arterial chemotherapy and external beam radiotherapy, respectively. Total radical cystectomy was required on one patient during the follow-up period of 4-26 months. Although our result showed that the combination of external beam radiation therapy and intraarterial cisplatin effectively contributed to the preservation of the bladder with localized invasive bladder cancer, radical cystectomy is required when CR is not achieved after this treatment.