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A total of 121 Japanese patients scheduled for prostate biopsy were randomly and double-blindly assigned to be given a single oral dose of 100 mg Tramadol mixed with 20 ml of sugar syrup or placebo, 30 minutes before the procedure. Pain severity was measured by verbal rating scale (VRS) and visual analog scales (VAS). We also analyzed cardio-respiratory parameters and complications. Of 121 patients, 117 replied validly to VRS and VAS ; and 91 of 117 patients replied to the cohort questionnaire for analysis of the late disorder, patient’s impression, prolonged pain and past history of hemorrhoid treatment. Tramadol showed no significant effect on pain severity indicated by VRS and VAS, and no change in cardiorespiratory parameters. Furthermore, 70 patients without a history of hemorrhoid treatment, showed no significant analgesic benefits of Tramadol during the biopsy. In total, 3 patients had side effects of vomiting (CTCAE : grade 1)6), which subsided spontaneously. The oral administration of a single dose of 100 mg Tramadol 30 minutes before a transrectal needle biopsy of the prostate was safe, but was not effective to calm down the pain severity.

A case of neuroendocrine (NE) differentiated prostate cancer is reported herein, which was progressed with NE differentiation during hormonal treatment in adenocarcinoma of the prostate. A 65-year-old man was admitted to our department with increased serum prostate specific antigen (PSA) (150 ng/ml). A prostate biopsy was performed and histological examinations indicated poorly differentiated adenocarcinoma with a Gleason score of 5＋4＝9. Further examinations showed metastases to systemic bones. The clinical stage was T3bN0M1b and hormonal therapy using leuprorelin was started. Eighteen months after hormonal therapy, the serum PSA level declined to 1.702 ng/ml. He subsequently experienced edema in his legs. Computed tomography (CT) demonstrated enlargement of the prostate and swelling of multiple pelvic lymph nodes. Immunohistochemical examination of a re-biopsy specimen revealed a neuroendocrine carcinoma. The neuron-specific enolase (NSE) level was 50.9 ng/ml. The treatment measure was changed from hormonal therapy to combination chemotherapy comprising cisplatin (CDDP) and irinotecan (CPT-11). Pelvic radiotherapy (50 Gy) was then performed. Two courses of the chemotherapy resulted in a great reduction of the tumor volume. However, he had liver metastases 3 months later. His condition worsened rapidly and he died at 8 months after definite diagnosis.

A 69-year-old female presented with hypertension and a solid mass in the bladder on ultrasonography. Cystoscopy revealed a submucosal tumor in the right lateral wall of the bladder. A transurethral resection was performed. Histologically, pathologic examination revealed a malignant pheochromocytoma. She refused surgical therapy and radiation therapy. She had no treatment for two years. She suddenly complained of gross hematuria. T2-weighted magnetic resonance imaging showed a bladder tumor of high intensity and extra-bladder invasion. She was treated with chemotherapy (CVD) for 26 cycles. Since the tumor size was reduced, she was referred to our hospital for operative indication. Partial cystectomy was performed. Histologically, the tumor was a pheochromocytoma of the urinary bladder. Ten months after the operation, she has no clinical evidence of recurrence.

Between January 1997 and February 2005, a total of 106 patients with superficial bladder cancer were treated with transurethral resection of bladder tumor followed by intravesical instillation of Tokyo 172 strain bacillus Calmette-Guerin (BCG) once a week for six weeks. The endpoints were tumor recurrence, tumor progression, and disease-specific survival. At a median follow-up of 27 months (range 2 to 105 months), 67 patients (63.2%) were recurrence-free and superficial recurrence including disease progressed with local invasion was noted in 39 patients (36.8%). The non-recurrence rate at one and three years were 75.9 and 54.6%. Twenty-four patients received an additional course of BCG instillation, and 14 (58.3%) showed no further recurrence. Thus, the overall success rate of 2 courses of BCG instillation was 76.4% (81 of 106 patients). Nine patients (8.5%) had progression and died of cancer. There was no significant differernce in recurrence rate among tumor characteristics. However, there was a significant differernce in survival rate between non-invasive and invasive tumor shape (p=0.0189). Univariate analysis (Cox's proportional hazard model) demonstrated that tumor shape was associated with survival (p=0.0486). Multivariate analysis demonstrated that gender and tumor shape were associated with survival (p=0.0183, 0.025). Adverse effects included bladder irritability in 16 patients (15.1%), gross hematuria in 15 (14.2%), fever in 24 (22.6%), contracted bladder in 1 (0.9%) and interstitial pneumonitis in 1 (0.9%). Interstitial pneumonitis improved after pulse steroid therapy. BCG was found to be very useful for the treatment of superficial bladder cancer. Intravesical BCG instillation was effective for first recurrent superficial bladder cancer because of the low recurrence rate after a second instillation of BCG.

Retroperitoneal liposarcoma is rare. Here we describe a case of retroperitoneal liposarcoma in a 61-year-old male. Preoperative computed tomography revealed an intraabdominal huge mass, and a clinical diagnosis of liposarcoma. Intraoperatively, the mass involved the right kidney and bladder, completely surrounding the right ureter. The tumor and the lower half ureter were removed. Successful reconstruction of a neoureter was performed with the Boari flap coupled with nephropexy and a psoas hitch. The detailed salient steps performed in this case are reported, together with a review of the literature., 61歳男。全身倦怠感を主訴とした。腹部に巨大な腫瘤を触れ、炎症所見、CRP値の上昇を認めた。CTにて巨大腫瘍を認め、MRIで第一腰椎の高さから骨盤部にかけて長径で30cmの腫瘍を認めた。手術を施行すると、腫瘍は周辺臓器と癒着し、右尿管を巻き込んで存在していた。右尿管を腫瘍とともに一塊として摘除したが、術中所見で後腹膜のあらゆる部位への直接浸潤を認め、腫瘍全摘除術は可能であったが根治性はないと判断した。そこで、術後化学療法施行の際の腎機能温存のため、右腎を温存することとした。Boari flapに腎を固定し、psoas hitchを併用した尿管-膀胱新吻合を行って尿路を再建した。病理組織学的に悪性線維性組織球症の所見を認め、liposarcoma、 dedifferentiated typeと診断した。術後2ヵ月で右側の水腎は認めず、順調に経過した。

表在性膀胱癌に対する抗癌剤塩酸エピルビシン(EPI)を用いて, 異なる投与法での再発予防効果について検討した。表在性膀胱癌は経尿道的膀胱腫瘍切除術(TURBT)後6ヵ月頃に再発リスクが高まるとされる仮説を検証するため, 1999～2003年にTURBT後に表在性膀胱癌と判明した54症例を対象に, 術後途中3ヵ月の休薬を含む9ヵ月にわたる長期投与群と, 術後短期投与群に分けて比較した。割付けは乱数表により無作為に2群に分けた。その結果, 再発率に有意差は認めなかった。再発因子の単変量解析では腫瘍深達度と悪性度で有意差が認められ, 長期投与群が短期投与群よりも再発予防効果が有意に高かった。両群合わせて22例が再発し, 両群で1例ずつ局所浸潤を認めた。, Intravesical chemotherapy is performed after transurethral resection of bladder tumor (TURBT) for superficial bladder cancer. We conducted a prospective randomized controlled study on the prophylactic effects of intravesical instillation of epirubicin (EPI) against recurrence to determine the effective administration schedule. Between April 1999 and March 2003, 54 patients with superficial bladder tumor (pTa or pT1, and G1 or G2 cancer) were assigned to two groups (25 in Group A, 29 in Group B) after TURBT. The schedule of instillation (intravesically 40 mg of EPI dissolved in 40 ml saline) was subsequently once every two weeks for 3 months (7 times) starting one week after TURBT (Group A, short period), and subsequently added every two weeks for 3 months starting 6 months after TURBT (Group B, long period). The patients were followed up by cystoscopy and urinary cytology. There was no significant difference in non-recurrence rates after either one year (A; 62.5%, B; 82.8%) or three years (A; 53.6%, B; 67.3%). A univariate analysis demonstrated that tumor grade and staging were significant predictors of high risk for recurrence. A multivariate analysis performed by using the Cox's proportional hazard model showed that the schedule of instillation was an independent prognostic factor for reccurence. In the present study, only 2 patients showed progression and one patient died of UC. There was no adverse event that forced discontinuation of the therapy. In conclusion, epirubicin instillation influenced the prevention of recurrence, but the benefit of long-term period was not confirmed.

73歳, 男。肉眼的血尿が出現し, 膀胱鏡検査にて膀胱内左側壁から左尿管口付近にかけて径4cm大の乳頭状広基性腫瘍を認め, 尿細胞診はUrothelial carcinoma(UC), class Vであった。MRI検査では膀胱後壁正中から左側壁に広範に腫瘍が存在し, 筋層断裂と周囲脂肪織への浸潤が疑われた。骨シンチにて第11胸椎に転移巣を認めた。TURBTで腫瘍を切除し, UC, G2>G3で筋層浸潤を認め, T3bN0M1と診断した。CDDP, ADR, MTX, VBLによるM-VAC化学療法を施行し, 骨シンチにて転移巣の消失を認めた。その後のCTで左水腎症, 膀胱腫瘍の増大, 尿管進展により左下部尿管の壁肥厚を認めた。後腹膜鏡補助下左腎尿管全摘術および膀胱全摘除術, 右腎管皮膚瘻造設術を行った。術後約4ヵ月, 左股関節部に疼痛を自覚し, 左腰背部の第2ポート部に一致して径6×4cmの腫瘤を認めた。また, 左大腰筋腹側に42mm大の腫瘍性病変と左恥骨に骨外浸潤する腫瘍を認めた。生検より尿路上皮癌転移巣と判明し, ポート部再発を含む多発性転移と診断した。放射線照射で疼痛は緩和し歩行可能となった。2ヵ月現状維持のまま経過観察中である。, We report a case of port-site metastasis of bladder cancer after left retroperitoneoscopy-assisted nephroureterectomy and cystectomy. The patient was a 73-year-old man with a chief complaint of gross hematuria. The diagnosis was invasive bladder cancer with bone metastasis. He received two courses of chemotherapy (methotrexate, vinblastine, adriamycin, cisplatin), and this resulted in resolution of the bone metastases. Two months later, abdominal and pelvic computed tomography showed a bladder tumor invading the left lower ureter with hydronephrosis. Left retroperitoneoscopy-assisted nephroureterectomy and cystectomy were performed. The patient was unable to undergo systemic chemotherapy because of renal dysfunction. Four months later, a lateral abdominal wall tumor was found at a port-site, and needle biopsy confirmed this to be metastatic urothelial carcinoma. Clinicians need to be aware of port-site metastasis, particularly in patients with UC, and take steps to prevent it during laparoscopic procedures.

33歳, 男。会陰部痛を認め, 近医のMRIでは前立腺は6.5×8cm大に腫大し, 内部は不均一に造影効果を認めた。胸部CTでは結節陰影を数個認め, 転移性肺腫瘍と考えられた。精査加療目的で当科に入院した。前立腺は超鶏卵大, 左右不対称, 圧痛著明であった。血清前立腺特異抗原は軽度上昇していた。骨盤部造影CTでは血流に富む巨大な腫瘤が骨盤内を占め, 内腔に壊死巣と思われる低吸収域を認めた。経直腸的前立腺針生検にて間葉系腫瘍が疑われたが, 確定診断に至らなかった。排尿障害改善目的でpalliative transurethral resectionを施行し, 病理組織学的にprostatic stromal sarcoma, 臨床病期T2bN0M1と診断した。etoposide, ifosfamide, cisplatinによる全身化学療法VIPを施行し, 肺転移巣の50%縮小を認めたが腫瘍は急速に増大した。腫瘍内容が腹腔内に膀胱頂部から破裂流出したため, 手術療法, 姑息的腫瘍血管の塞栓術は断念した。腎機能悪化のため左腎瘻造設を行った。臀部痛, 腰痛は増強し, その後悪液質のため死亡した。, Prostatic stromal sarcoma (PSS) is an unusual lesion that is reported only occasionally. Here we describe a case of prostatic stromal sarcoma in a 33-year-old man who had complained of perineal pain. The serum prostate-specific antigen (PSA) level was above the normal limit at 5.8 ng/ml, and abdominal computed tomography (CT) revealed a giant mass in the retrovesical region. Chest CT demonstrated lung metastases. Specimens obtained by transrectal needle biopsy of the prostate suggested a mesenchymal tumor, but a precise diagnosis required a larger specimen. Palliative transurethral resection (TUR-P) was performed because of obstruction of the urogenital tract, and the final diagnosis was made from this specimen. The tumor contained yellowish gelatinous materials, and the stromal element appeared histologically malignant, with increased cellularity, mitotic figures and pleomorphism. The histological diagnosis was PSS, and the patient received VIP (etoposide, ifosfamide, cisplatin) chemotherapy regimen. However, the pelvic mass continued to increase in size, and the patient's condition rapidly deteriorated and he died. Sarcoma of the prostate gland showing aggressive behavior is quite rare. The detailed histological and immunohistochemical findings in this case are reported, together with a review of the literature.

Molecular-targeted drugs are agents that act on molecules which are specifically expressed in cancer, or on molecules whose expression is increased in cancer compared to normal tissue, and suppress the growth, infiltration and metastasis of cancer while affecting normal tissue as little as possible by selectively impairing function in cancer tissue. The major molecular targets in cancer therapy include oncogene products, growth factors and their receptors, signal-transducing molecules, hormone receptors, cell cycle-related proteins, telomerase-related molecules, apoptosis-related molecules, angiogenesis-related molecules, anticancer drug resistance/sensitivity factors, transcription factors, and molecules related to infiltration and metastasis. This paper reports on the molecular-targeted drugs currently considered for bladder cancer.

52歳男。4年前に肝硬変(ウイルス性C型肝炎)と腎機能障害の経過観察中のCT, MRI検査で左腎上極に径4cm大腫瘤を指摘された。脾機能亢進症状で血小板減少を認めたため部分的脾動脈塞栓術(PSE)施行後5週目に経腰的左腎摘出術を施行し左副腎は温存した。腫瘍部は5×5×4cm大で病理所見ではrenal cell carcinoma, granular cell carcinoma, G2pT1b, StageIであった。2～3ヵ月毎の経過観察で再発・転移兆候は認めなかったが, 手術後約3年半のMRIで右副腎に径2.5cm大の腫瘤を認め増大傾向にあるため精査加療目的入院となった。T1WIで中間信号, T2WIでやや高信号域, CTより右副腎は2.5×3cm 大に腫大し, 副腎皮質シンチで両副腎に取り込みを認め, 6ヵ月後に後腹膜鏡下右副腎摘除術を施行した。腫瘍は4×4.5×2cm大の割面は黄褐色でRCC clear cellの転移病巣で, 病理所見よりrenal cell carcinomaと判明した。術後9日目に退院し, 免疫療法は施行せず, 術後7ヵ月現在再発・転移の兆候は認めていない。, We report a case of adrenal metastasis from renal cell carcinoma. A 52-year-old man was referred to our hospital for a left renal mass. A computed tomography revealed a left renal tumor. Liver cirrhosis and splenomegaly were observed. Blood tests revealed pancytopenia; platelet count was 2.5 x 10(4)/mm3. The patient was treated by partial splenic embolization (PSE) in an attempt to ensure a safe nephrectomy. After the embolization, his platelet count increased to 6.1 x 10(4)/mm3, and left nephrectomy was performed successfully. Histopathological finding was renal cell carcinoma (RCC). We concluded that PSE before surgery was useful for the patients with thrombocytopenia due to hypersplenism. Four years after surgery, computed tomography revealed the presence of a mass on the right adrenal gland. He was suspected of having a non-functioning adrenal tumor. Metastasis of the RCC was suspected and right adrenalectomy was performed by a laparoscopic procedure. Histologically, the mass was identified as a RCC metastasis. It is clinically rare for an RCC metastasis to the contralateral adrenal gland to occur.

60歳男。主訴は血清クレアチニンホスホキナーゼ高値で, 自覚症状はなかった。抗Jo-1抗体陽性であり, 皮膚筋炎の診断で悪性腫瘍合併の有無を検索中, 腹部造影CT検査にて右腎門部に60mm大の腎動脈瘤を認めた。3次元CT血管造影にて右腎動脈瘤は嚢状型と考えられた。放射線interventional radiology下による動脈瘤塞栓術が選択され, デタッチ・デタッチャブルコイルによるフレーミングおよびinterlocking detachable coilなどによるパッキングを施行した。術後合併症, 腎機能の低下は認めず, 外来にて経過観察中である。, A 60-year-old man was admitted to our department with a left renal artery aneurysm that was detected while performing an examination for dermatomyositis. A 3-dimensional image showed a saccular renal aneurysm whose diameter was 6 cm. He required operative intervention. Because of the location (near the renal hilum), selective transcatheter embolization using an interlocking detachable coil was performed for endovascular treatment. The postoperative course was uneventful. This method appears to be a good choice for the treatment of renal artery aneurysm, considering its safety and the likelihood of success.

44歳男性。患者は29歳時に他科で右精巣腫瘍・後腹膜リンパ節転移に対する集学的治療施行後, 尿管狭窄を来し尿管カテーテルを留置された。今回, 尿管ステントの定期的交換中に肉眼的血尿, 貧血が出現し, 著者らの施設へ受診となった。単純CTなど精査の結果, 尿管カテーテル交換操作が誘因となったDJカテーテルによる尿管大動脈瘻と診断され, 瘻孔の縫合閉鎖および腎瘻造設が行なわれた。術後は経過良好で, 現在, 紹介先クリニックにて経過観察中である。, We report a case of a patient with a fistula between the left ureter and abdominal aorta. The patient was a 44-year-old male who had undergone radiation therapy (intraoperative: 25 Gy, external beam: 50 Gy) and chemotherapy (CDDP: 250 mg) for retroperitoneal lymph node metastasis from seminoma. His postoperative course was complicated by stenosis of bilateral ureters, which were treated by indwelling double J-stents. Fifteen years after the operation, gross hematuria occurred from the left ureteral orifice when exchanging the left ureteral double J-stent. Computed tomographic scan demonstrated left ureteral-abdominal aortic fistula formation at the crossing point. Massive hemorrhage was suspected to have prompt fistula formation between the left ureter and the aorta. At exploration, there was a fistula of about 7 mm in diameter at the anterior surface of the aorta, and the stent was presumably inserted from it. The aortic fistula was successfully closed. In addition, the left ureter was ligated proximal to the fistula and percutaneous left nephrostomy were performed. His postoperative course was uneventful. We should be aware that uretero-arterial fistula can occur as a serious complication of ureteral catheter exchange after prolonged ureteral stenting and radiation therapy.

52歳男。39歳時に右腎腫瘍にて根治的右腎摘除術を施行され、術後は特に再発・転移の徴候はなかった。今回、起立性眩暈(立ちくらみ)、全身倦怠感を自覚し、貧血、体重減少、便潜血陽性で、上部消化管内視鏡検査を行い十二指腸に腫瘍性病変を認めた。同部位の生検にて低分化腺癌と診断された。画像検査で膵鉤部に腫瘤を認め、CTでheypervascularityを呈していた。十二指腸下行脚から水平脚にかけて浸潤を伴い、上膵十二指腸静脈から門脈本幹にかけて腫瘍塞栓を認めた。また、膵体尾部にも腫瘤を認めた。病理所見より腎細胞癌の膵・十二指腸再発転移と診断し、免疫療法としてIFN投与を予定した。しかし、食欲低下や嘔気が出現し、絶食、輸液管理とした。胃内ガス貯留が著明となり、機械的イレウスのため姑息的に胃空腸吻合術を施行した。術後天然型IFNα投与を開始したが、反復する消化管出血により貧血が進行し適宜輸血を行った。全身状態が悪化したためIFN投与は中止し、悪液質の進行にて癌死した。, A 52-year-old male was admitted to our hospital complaining of orthostatic vertigo, fatigue and weight loss, who underwent right total nephrectomy for renal cell carcinoma(RCC) with curative operation 13 years ago (in 1992). Endoscopic examination revealed a submucosal tumor with erosion in the duodenum. The diagnosis made from the biopsy specimens was metastatic RCC in the duodenum. Abdominal CT scan revealed that his metastasis has spread to the pancreas. Five million units of interferon a was administered intramuscularly three times a week for 1 month. He received blood transfusions and palliative care. He died 5 months later because of disease progression. Metastases of RCC have been often reported in the lungs, the liver, and the bones, but rarely in the gastrointestinal tract. This is a very rare case of metastatic RCC in the duodenum, which was diagnosed 13 years after curative right nephrectomy. Since late recurrence is characteristic of renal cell carcinoma, careful long-term follow-up is needed. To our knowledge, this is the 19th case of duodenal metastasis from RCC reported in the literature.

68歳男。無症候性肉眼的血尿が出現し膀胱癌と診断され、以後13年間に再発・転移を繰り返し、経尿道的切除術、抗癌剤の膀胱腔内注入療法、放射線療法、膀胱全摘除術が行われていた。膀胱全摘から約2年後に前頭部、前胸部、背部、右腋窩、右上唇部に発赤を伴う隆起性病変が出現し、楔状切除を行い、病理組織学的所見より膀胱癌の皮膚転移と診断された。また、呼吸器内科での気管支鏡検査で左上葉気管支入口部に転移巣を認めた。胸部X-Pでは左無気肺を呈しており、造影CTでは右肺上葉に結節陰影、左肺門部リンパ節腫大を認めた。左肺門部腫瘤に対し放射線照射を行い、左無気肺は改善したが、全身倦怠感が出現し、腹部CTで肝・骨・左副腎・膵に転移巣が判明し、悪液質の進行にて死亡した。, Bladder carcinoma with skin metastasis is extremely rare. We herein report a case of a bladder tumor with skin metastasis. A 68-year-old man was referred to our hospital with macroscopic hematuria. Cystoscopy revealed a trigone papillary tumor. Transurethral resection of bladder tumor (TURBT) was performed and the pathological diagnosis was transitional cell carcinoma (TCC), pT1, G3. Thereafter, he received several courses of TURBT, intravesical chemotherapy (pirarubicin, bacillus Calmette-Guerin and mitomycin C) and intra-arterial chemotherapy because of recurrence. Thirteen years later, he underwent total cystoprostatectomy with neobladder formation. Histological examination revealed muscle-invasive bladder cancer with a staging of T3bNOM0. Two years and three months later, multiple firm nodules with eruptions appeared on the skin in several regions; they were resected and the histological findings revealed TCC. This indicated metastatic spread from the primary bladder TCC. He received only supportive treatment during this period due to renal dysfunction. He died four months after the manifestation of the skin metastasis due to multiple metastases.

Surgical therapy is not only a therapeutic method but also an important procedure to provide useful information in determining a postoperative treatment strategy. Compared with postoperative cancer staging based on specimens obtained during surgery, more than 30% of cancers were inaccurately staged preoperatively, even when a current advanced diagnostic imaging technique was used. Compared with postoperative histological 30-40% of cancer staging were inaccurately staged based on a preoperative biopsy. These misstaging cases pose a significantly important problem. Approximately 15% and 30% of clinical stage C prostate cancers have been rated as pT2 and pN(+), respectively. Patients with pT3 prostate cancer who underwent radical prostatectomy had 5-year and 10-year overall survival rates of 82% and 67%, respectively, which were comparable to those in patients with pT2 prostate cancer (82% and 67%, respectively). However, patients with prostate cancer rated as pT4 and pN(+) had very poor outcomes with 5-year overall survival rates of 42.4% and 32.6%, respectively. Therefore, even in patients with stage C prostate cancer, surgical therapy should be recommended if no infiltration of adjacent tissue has been noted and the operation is applicable; and an optimal postoperative therapeutic strategy should be selected based on the accurate pathological staging and histological grading using postoperative pathological specimens. Such approaches will prevent unnecessary hormone therapy in patients with pT2 prostate cancer and prevent missing optimal timing for radical cure, as well as allowing appropriate therapy to be selected for patients with pT4 and pN(+) prostate cancer, for whom prognosis may be poor.

症例1(25歳男).左側腹部痛を主訴とした.生後2ヵ月時に腎尿細管性アシドーシス(RTA)と診断され, 3歳時には両側性蝸牛性感音性難聴, 4歳時には腎石灰化症と診断された.これまでクエン酸, カリウム製剤の投薬を受けていたが, たびたび低K血症症状と高CRK血症を来した.検査所見では代謝性アシドーシス, 尿濃縮能低下, 尿酸性化能低下を認め, 遠位尿細管性アシドーシス(dRTA)と診断された.KUBで両側腎に粟粒大・散在性の石灰沈着像を多数認め, 第3腰椎左側に尿管結石像を認めた.dRTAが原因の尿管結石と診断し, 体外衝撃波結石破砕術を施行したところ破砕良好であった.症例2(症例1の長兄, 31歳男).2歳6ヵ月時にdRTAと診断された.感音性難聴, 腎性くる病, 腎石灰化症と診断され, 腎結石として度々自排し, 成分はリン酸Caであった.ビタミン D療法, アルカリ製剤内服治療中である.dRTAの同胞発症例の報告は検索した限り, 本症例が我が国で3例目と稀であるが, これらの合併症を有する兄弟発生例は実際は多く存在していると思われる, A 25-year-old man was admitted to our hospital because of left lumbago. An abdominal X-ray film demonstrated multiple calculi in the medullary positions of both kidneys and an impacted calculus in the left ureter. He was diagnosed with bilateral nephrocalcinosis and nerve deafness due to distal renal tubular acidosis (RTA) in childhood and was treated with alkali agents for several years. Extracorporeal shock wave lithotripsy was performed successfully against the left ureteral calculus. His older brother had also been diagnosed with RTA and nephrocalcinosis at the age of 2 years and 6 months. Nephrocalcinosis due to RTA associated with nerve deafness in brothers is rarely reported.

持続勃起症の原因は主として, 動脈性持続勃起症と静脈性持続勃起症とに分類される.これらの分類によって治療法が異なるため, その分類は重要である.しかし, 今回, 分類不能な持続勃起症として経過し, 治療途中で精巣腫瘍からの陰茎転移による持続勃起症であると診断されたきわめて稀な症例(86歳男)を著者らが経験したので, それを報告した, Priapism is thought as a condition of penile erection that persists beyond or is unrelated to sexual stimulation. Commonly two different entities of priapism are known, one is low-flow priapism and the other is high-flow priapism. It is important to distinguish these two conditions for the subsequent different treatments. We report a rare case of an indistinguishable priapism caused by penile metastasis of testicular cancer.

8歳男.発熱, 腹部膨満, 腹部腫瘤触知を主訴とし, 精査目的で入院した.腹部超音波検査で嚢胞性変化を伴う右腎腫瘤を認めた.腹部CT検査では腹部右半分を占める嚢胞性蜂巣状腫瘤が認められた.MRI検査では嚢胞内容はT1強調画像で高信号, T2強調画像で低信号を呈し, 血液成分の貯留を疑わせた.排泄性腎盂造影では右腎陰影は腫大し, 腎盂腎杯の圧排, 偏位および造影剤の排泄遅延を認めた.IAPが異常高値であることや嚢胞間隔壁が軽度造影されたことより右腎原発悪性腫瘍を疑い, 右根治的腎摘除術を施行した.病理組織学的に腫瘍は嚢胞壁, 間質ともに淡好酸性の胞体を有する淡明型腫瘍細胞で満たされており, 核異型, 核分裂像は軽度でtubular structureを呈していた.以上より, cystic renal cell carcinoma, G1, INFα, pT2と診断した.術後IAP値は正常化し, 術後11日で退院した.後療法としてインターフェロンを投与中である.8ヵ月を経過し再発転移の徴候はない, Renal cell carcinoma is a common renal malignancy in adults but it is extremely rare in children. An 8-year-old boy visited our hospital with the complaint of right abdominal palpable mass. Computed tomographic (CT) scan revealed a right renal multilocular cystic mass which displaced the normal renal parenchyma. A right radical nephrectomy was done and pathological findings revealed cystic renal cell carcinoma. He received postoperative therapy with the administration of alpha interferon and has been well with no evidence of recurrence nor metastasis during 8 months after surgery. To our knowledge this is the youngest case of cystic renal cell carcinoma reported.

68歳男性.患者は全身倦怠感と食欲低下および1年前から徐々に腹部冒満感を来たすようになり, 著者らの泌尿器科へ入院となった.腹部CTの所見では右腎の位置に一致して巨大な内部均一, low densityな腫瘤を認めた.直ちに経皮的腎瘻増設術を施行し6500ml以上の血性内溶液を得た.内容液の細胞診の結果はclass IIIであり, CA19-9値は内容液のみならず血清中においても著明に増加していた.その後, 右腎摘除術を施行した.摘除標本では右腎は著明なUPJ stenosisを呈していた.病理組織学的検査の結果では悪性所見は認めず線維化を主体としたものであった, We report a case of right giant hydronephrosis. A 68-year-old man was admitted to our hospital with chief complaints of general fatigue, loss of appetite and a one-year history of progressive fullness on whole abdomen. Abdominal computed tomography scan exhibited a huge, homogeneous, low density mass originating from the right kidney. We performed right percutaneous nephrostomy and drained over 6, 500 ml bloody fluid. Cytological examination of the drained fluid revealed atypical nuclear appearance defined as class III. Increased values of carbohydrate antigen 19-9 were observed both in the fluid as well as in the serum. We performed right nephrectomy. Macroscopic appearance of the resected kidney showed marked stenosis at the portion of ureteropelvic junction. Histological analysis of the stenotic portion demonstrated marked fibrosis without findings of malignancy.

21歳女.主訴は腹痛, 肉眼的血尿.自動車の助手席に乗車中, 電柱に衝突してダッシュボードに腹部を強打した.受傷6時間後のCTでは右後腹膜腔に著明な造影剤の漏出が認められた.RPを施行したところ, CT時に静注した造影剤の抽出は認めたものの, 腎盂尿管移行部で尿管は途絶し, 腎盂は造影されず, 造影剤の大部分は後腹膜腔に漏出した.右上部尿管損傷と診断し, 受傷約15時間後に緊急手術を施行した.右尿管は腎盂尿管移行部で完全に断裂しており, 腎周囲から骨盤腔に至る広範囲の後腹膜腔に尿が貯留していた.断裂した右尿管と右腎盂をAnderson-Hynes法に準じて縫合し, 右腎盂内まで尿管ステントカテーテルを留置した.術後17日目のRPでは吻合部の狭窄や尿溢流は認められず, 尿管ステントを抜去した.また, 術後21日目のDIPでは15分像で軽度の吻合部狭窄を認めるものの, 右腎機能及び右尿管の通過性は良好に保たれていた, A 21-year-old woman who had been injured in a traffic accident appeared with abdominal pain and macroscopic hematuria. Computed tomography (CT) performed 6 hours after the injury showed extravasation of contrast medium in the right retroperitoneal space. Retrograde pyelography (RP) showed the interruption of right ureter at the site of ureteropelvic junction. We performed an abdominal operation 15 hours after the injury under the diagnosis of right ureteral avulsion. We observed a completely separated right ureter at the ureteropelvic junction, and performed an end to end anastomosis. The patient was discharged three weeks after surgery, and has not had any problems for three years.

血清PSA値4～10ng/mlを示す症例について前立腺癌診断におけるtotal PSA(tPSA), PSA density(PSAD), free to total PSA ratio(F/T比)の有用性を検討した.1999年5月から2001年4月迄に経直腸的エコー下前立腺生検を施行した43例を対象とし, ROC曲線を用いて各検査法の有用性を検討した.43例中, 前立腺癌:12例(27.9%), 非癌:31例(72.1%).tPSA, PSAD値, F/T比のmean±SEMは癌症例で各々7.308±0.636ng/ml, 0.271±0.039ng/ml/cm3, 16.225±4.911%であるのに対し, 非癌症例は6.300±0.289ng/ml, 0.178±0.020ng/ml/cm3, 15.213±0.980%であった.全症例におけるPSAD, tPSA, F/T比のROC曲線右下部分の面積を比較すると有意差をもってPSADのみが高かった(p, Total serum prostate-specific antigen (PSA) levels, free-to-total PSA ratio (F/T ratio) and PSA density (PSAD) were compared to clarify the clinical significance of these parameters in the diagnosis of prostate cancer (CaP) with intermediate PSA concentrations (4-10 ng/ml). PSAD and F/T ratio were obtained during the period from May 1999 to April 2001 from 43 patients with serum PSA concentrations of 4-10 ng/ml who underwent ultrasound-guided systematic sextant biopsies. PSAD was compared with total serum PSA and F/T ratio via receiver operating characteristic (ROC) curves for diagnosis of CaP. Diagnosis of CaP and non-CaP was made in 12 (27.9%) and 31 (72.1%) of the 43 patients, respectively. Mean serum PSA, PSA density and F/T ratio were 7.308 +/- 0.636 ng/ml, 0.271 +/- 0.039 ng/ml/cm3 and 16.225 +/- 4.911% in patients with CaP and 6.300 +/- 0.289 ng/ml, 0.178 +/- 0.020 ng/ml/cm3 and 15.213 +/- 0.980% in those with non-CaP, respectively. The ROC curve analysis demonstrated that PSAD predicted the biopsy outcome significantly better than F/T ratio and total PSA in all 43 patients (p < 0.05). In distinguishing CaP patients, the cutoff value of 0.16 ng/ml/cm3 for PSAD yielded a specificity level of 71.0% at a sensitivity level of 83.3%. Our study revealed that PSAD is a significant predictor in distinguishing CaP from non-CaP in Japanese men.

29歳男, 残尿感, 会陰部痛を主訴として受診.直腸診にて波動を有する前立腺を触知した.MRIでは右腎は欠損し, 同側の精嚢は拡張し嚢胞状変化を伴っていた.経直腸的精嚢穿刺術を施行し, 内容液は血性膿汁であった.初診時, 血清CA19-9が145.8U/mlと異常高値であったが抗生剤投与と穿刺術にて正常化し, 症状も消失した, A case of CA19-9-producing seminal vesicle cyst with ipsilateral renal agenesis is reported. A 29-year-old man was admitted to our hospital for perineal pain and urinary retention. Digital rectal examination revealed a large soft mass that fluctuated in the area of the prostate and seminal vesicles. Magnetic resonance imaging revealed a right kidney defect, and ipsilateral dilation and cystic enlargement of the right seminal vesicle. Transrectal puncture of the seminal vesicle cyst was performed. The contents were pus and old red blood cells. Initially, the serum CA19-9 level was extremely high (145.8 U/ml) but was normalized by the treatment with antibiotics after the puncture. The symptoms subsided without recurrence.

66歳男.左腰背部痛が増強し, 左尿管腫瘍, 膀胱腫瘍, 左重複腎盂尿管を指摘された.排泄性腎盂造影で左上半腎所属尿管は描出されず, 左下半腎所属尿管は軽度拡張し, 膀胱左側に陰影欠損像を認めた.膀胱鏡で左尿管口を1個確認し, その頭側に径3cmの有茎性乳頭状腫瘍を認めた.この腫瘍を経尿道的に切除したところ, 切除部に尿管口を認めた.病理所見で, 核が大型化した異型性の強いN/C比の大きな腫瘍細胞を粘膜上皮内に認めたが, 膀胱固有筋層への浸潤はなく, 移行上皮癌, grade 2, pTaと診断した.1週後に左腎尿管全摘除術及び膀胱部分切除術を施行した.上半腎所属中部尿管に3.0×3.5cmの白色調の非乳頭状広基性腫瘍を認めた.病理所見で核異型の強い悪性細胞が尿管固有筋層を越えて浸潤し, 移行上皮癌, grade 3, pT3であった.術後18ヵ月目に腹部CTで大動脈分岐部に50×40mmの腫瘤を認め, 再発と診断した.切除不能で化学療法を施行し, 術後22ヵ月で生存中である, A 66-year-old man presented at our hospital with left back pain. Intravenous pyelography, computerized tomography and magnetic resonance imaging revealed ureteral tumors of the complete left double renal pelvis and the ureter. An endoscopic examination disclosed a papillary tumor from the left ureteral orifice of the lower pole of the kidney. A transurethral resection of the tumor was done, and the pathological features revealed transitional cell carcinoma (PTa, grade 2). A left nephroureterectomy and a partial cystectomy were also carried out; macroscopic examinations showed a non-papillary tumor on the middle portion of the left ureter originating from the upper pole of the kidney. Microscopic examinations revealed transitional cell carcinoma (PT3, grade 3, PL1, PV1). Adjuvant chemotherapy (M-VAC) was administered but discontinued because of severe side effects. Dispite recurrence with retro-peritoneal lymph node metastasis, the patient is alive and again undergoing M-VAC chemotherapy 22 months after the initial surgery. However, the evaluation of the chemotherapy was "no change".

We report a case of Klinefelter syndrome with the chief complaint of male infertility. Normal pregnancy and delivery resulting from conventional testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI) waspos sible by a previousdoctor when he was31 yearsold. He wasreferred to our hospital for treatment of infertility when he was 41 years old. Abdominal ultrasonography demonstrated a low echoic region with a relatively uniform content in the left testis and a central low echoic small mass surrounded by a high echoic region in the right testis. In excised tissue of the left testis, only a single seminiferous tubule containing spermatozoa was found and sperm was successfully retrieved by microdissection TESE.

A 71-year-old man underwent left nephrectomy for metastasis from renal cell carcinoma (RCC) of the small intestine. In spite of post-operative therapy (interferon-alpha or interleukin-2), multiple lung metastases and intestinal hemorrhage by metastatic tumor of small intestine appeared 9 years after the operation. To control the bleeding from the small intestine, the small intestine was partially excised and the histopathological diagnosis was metastasis of RCC. He died 10 months later because of disease progression. Metastasis of RCC to the small intestine is rare. To our knowledge, this is the 40th case of small intestinal metastasis from RCC reported in the literature.

症例は26歳男で, 7年前にvon Hippel-Lindau(VHL)病に合併した骨髄・小脳血管芽腫及び側頭骨乳頭腫に対して摘出術を受け, 以後外来通院していたが, 両側陰嚢内の無痛性腫瘤を触知した.超音波で両側精巣上体に内部不均一な多房性腫瘤を認めると共に, 膵頭部及び両腎に数個の嚢胞を, 右腎外側に径3cmの内部均一な充実性腫瘍を認めた.MRIでは右腎腫瘍はT1強調像でlow, T2強調像でhigh intensityを呈し, 造影効果は認めなかった.摘出術において, 右腎腫瘍は右腎中央に存在し, 2.5×2.5×2cm, 割面黄色で, 白色の線維性被膜でよく被包されていた.両側精巣上体頭部腫瘍は, 右1×3×1cm, 左1×2×1cmで, 腺構造が密に存在し, ところどころで内腔に向かって核異型のない上皮の乳頭状増殖を認めた.またVHL遺伝子の検査を行ったところ, exon 2 351にGからAへの点突然変異を認めた.術後経過は良好で再発はない, We present a case report of von Hippel-Lindau disease associated with renal cell carcinoma and bilateral cystadenoma of the epididymis. A 26-year-old man appeared with painless tumors of the bilateral scrotal contents. Ultrasonography and other radiographic examinations including computed tomographic scan and dripinfusion pyelography showed multiocular tumors in the bilateral epididymis and a right renal tumor 3 cm in diameter. The tumors of the bilateral epididymis were surgically resected and of the right renal tumor enucleated. Histopathological examination revealed cystadenoma of the epididymis and renal cell carcinoma (clear cell carcinoma, G1, pT1a). He has not received adjuvant therapy, and is doing well with no evidence of metastatic disease 2 years after surgery.

Heparanase, which is an extracellular matrix degradative enzyme, degrades heparan sulfate and heparan sulfate proteoglycans, which are chief components of extracellular matrix and vascular basement membrane. The gene structure of this enzyme was recently determined. The biological functions of this enzyme in vivo were as follows: 1) this enzyme accelerates cancer cell invasion and metastasis though the degradation of vascular basement membrane and extracellular matrix by cancer cells; 2) this enzyme releases and activates heparin-binding growth factors such as bFGF and VEGF from heparan sulfate proteoglycans, and induces angiogenesis; 3) the degradative products of heparan sulfate proteoglycans by this enzyme suppress the biological function of activated T-lymphocytes. Therefore, heparanase is thought to be a favorable molecule for acceleration of cancer invasion and metastasis. The expression of heparanase is strongly correlated with the metastasis of melanoma and fibrosarcoma. Thus, heparanase may play important roles in invasion and metastasis of cancer.

A 59-year-old man visited another hospital with a chief complaint of malaise. Radiological examinations revealed a renal cell carcinoma associated with horseshoe kidney. He was referred to our hospital. The patient was successfully treated with open partial nephrectomy following isthmus division. Histological findings exhibited grade 2, pT1a, clear cell type, renal cell carcinoma. He is free of disease at twelve monthsafter the operation.

表在性膀胱癌35例に対しBCG膀胱内注入療法を施行した.BCG膀注は既往の抗癌剤膀注療法に抵抗した症例にも有効であり, 再発延長効果のある可能性が考えられた.BCG膀注後再発例においても2コースで優れた再発予効果を示し, 病期進展を抑制する可能性があることが示唆された, Intravesical instillation of Tokyo 172 strain bacillus Calmette-Guerin (BCG) after transurethral resection of bladder tumor (TUR-Bt) was applied to 35 patients with superficial bladder cancer. The patients received 80 mg of BCG in 40 ml saline infused into the bladder once a week for 6 weeks. Actuarial non-recurrence rates for all 35 patients were 81.7% and 58.4% at one and two years after the BCG therapy, respectively. The recurrence of the bladder cancer after the BCG therapy was observed in 12 patients 3-27 months later. Seven patients received an additional course of BCG instillation, and 6 (86%) showed no further recurrence. Thus, the overall success rate of 2 cycles of BCG instillation was 83% (29 of 35 patients). Moreover, in some cases intravesical BCG instillation was effective for recurrent superficial bladder cancer after intravesical instillation of anti-cancer agents and prolonged the period until recurrence. The progression rate was only 5% (2 of 35 patients). These results suggest that intravesical BCG therapy for superficial bladder cancer helps prevent disease progression.

The patient, a 73-year-old woman, had undergone hysterectomy and irradiation therapy 26 years ago. On September 4, 1997, the patient was referred to our hospital, and presented with low grade fever and lower abdominal dull pain of a one-month duration. Radiologic and vaginal examinations revealed bilateral hydronephrosis and a giant stone lying down between the bladder and vagina. Vaginal incontinence showed the presence of the vesico-vaginal fistula. She underwent bilateral ureterocutaneostomy and cystolithotomy. A giant vesico-vaginal stone was removed by using a hammer and chisel. It weighed 180 g. The stone was composed of calcium phosphate and magnesium ammonium phosphate. Persistent infection of the bladder and the vagina may have been a possible etiological factor of the vesico-vaginal stone formation. Three weeks after the operation, bilateral hydronephrosis was improved.

A 44-year-old man visited a local urologist complaining of continuous pain and tumescence at penis persisting for 3 days. He was diagnosed with priapism. A caverno-glandular and caverno-saphenous shunt was performed. He presented to our hospital 3 days later, because the symptoms especially tumescence continued. We confirmed the diagnosis of low-flow priapism from cavernosography and intracavenal blood-gasometry and performed caverno-spongiosum shunt. Detumescence was finally achieved after the operation.

17歳男。右背部痛を主訴に受診した。超音波検査で1.6cm大の腫瘍性病変を認め、膀胱鏡では右尿管口外側に有茎性乳頭状腫瘍を認めた。排泄性腎盂造影(IVP)では上部尿路に異常はなく、膀胱部に陰影欠損は見られなかった。表在性膀胱腫瘍の診断で、経尿道的膀胱腫瘍切除(TUR-Bt)を実施した。術後経過は良好で再発予防のため塩酸ピラルビシン30mgの膀胱内注入療法を週2回、計8回実施し、術後約1年経過し再発は認めていない。本症例はIVP陰性であったものの超音波検査で15mm大の腫瘤影を認めた。右尿管口部に一致しドップラー法で尿管瘤からの尿の流出像共所見が取れたため、膀胱鏡を一旦躊躇したが、念のため膀胱鏡検査を実施したことが早期発見に繋がった。腰痛との関連は無いと考えられ、スクリーニングで実施された超音波検査が有用であったと考えられた。, A 17-year-old male was referred to our hospital with the chief complaint of right back pain. Cystoscopic examination revealed a papillary tumor on the posterior wall following detection on screening ultrasound examination revealed a tumor in the bladder. Transurethral resection of the bladder tumor was performed. Histological examination of the excised tumor revealed transitional cell carcinoma, grade 1, pTa. No recurrence has been observed for about 1 year postoperatively.

79歳男.無症候性肉眼的血尿を主訴とした.既往には, 27歳時に左腎結核による左腎摘除術があった.尿細胞診は陰性であったが, 膀胱鏡検査で左尿管口存在部に径2～3cmの非乳頭状有茎性腫瘍を認めた.経尿道的膀胱腫瘍切除術を行った.腫瘍は左尿管口より突出し, 移行上皮癌(G1≫G2, pTa)であった.術後の造影CT, MRI検査で左総腸骨動脈交差部以下の遺残尿管内に造影される腫瘍陰影を認めた.全身検索では明らかな転移巣は認められず, 残存尿管摘出術, 及び膀胱部分切除術を行った.切除尿管は18cm長で, 内腔には, 尿管口断端より上方5cmにわたり乳頭状広基性腫瘍がみられた.urothelial carcinoma(G2>G3, pT2, pNx, pMx, pR0, pL0, pV0)であった.術後補助療法を行わなかったが経過は順調で, 術後2ヵ月を経て, 明らかな再発, 転移の徴候はない, Primary tumor originated from ureteral stump following nephrectomy for benign disease is extremely rare. A 79-year-old male was referred to our department for asymptomatic macroscopic hematuria. He had undergone left simple nephrectomy for renal tuberculosis 52 years ago. Cystoscopic examination revealed a ureteral tumor on the residual ureteral orifice. Under the diagnosis of left ureteral stump tumor, which was subsequently enhanced on computer tomographic scan and magnetic resonance imaging, he received partial cystectomy and excision of the left ureteral stump. The histological examination revealed grade 2 to 3 urothelial carcinoma with muscle invasion (pT2). He received no adjuvant chemotherapy. He is now alive and free from recurrence 2 months post-operatively. This is the 21st case reported in the Japanese literature.

67歳女性.患者は外陰部出血・糜爛, 外陰部痛を主訴に, 精査加療目的で著者らの施設へ入院となった.入院時, 外尿道口に母指頭大, 暗赤色調の腫瘤が突出して存在し, 表面平滑, 弾性硬, 易出血性であった.尿道膀胱鏡で腫瘍は外尿道口に限局し, 骨盤部造影CTでは, 尿道部に辺縁よくenhanceされ内部不均一に造影される腫瘍が描出された.以上より, 尿道腫瘍と診断し, 腫瘍を含めた尿道部分切除術, 新外尿道口の作成を行った.病理組織学的に原発性尿道腺癌と診断され, 術後, 排尿状態は良好であり, 5ヵ月経過現在, 再発転移はみられていない, A 67-year-old female was referred to our hospital with the chief complaint of genital bleeding. Physical examination revealed a thumb's-head-sized tumor at the external urethral meatus. Histopathological examination of the biopsy specimen suggested papillary carcinoma. She underwent partial urethrectomy with negative surgical margins. The final pathological diagnosis of the tumor was papillary adenocarcinoma, of Stage A according to Grabstald's classification. She is alive with no evidence of recurrence at 5 months after surgery.

70歳男性.患者は検診時に胸部X線上の異常陰影, PSAの異常高値を指摘され, 著者らの施設へ紹介入院となった.入院時, 胸部X線・CTでは多発性結節影を認め, 骨盤部CTではリンパ節腫大を認めた.更に骨シンチでは右恥骨部に異常集積を認め, 前立腺生検では中分化から低分化腺癌の増殖を認めた.以上より, 肺・骨盤内リンパ節・骨転移を伴う前立腺癌stage D2と診断し, 内分泌療法(CAB療法)を開始した.治療開始6ヵ月後でPSAは感度以下となり, 16ヵ月現在, 肺転移巣は縮小瘢痕化し, リンパ節腫大および右恥骨部の異常集積も消失した, We report a case in a 70-year-old patient indicated to have a metastatic lesion from a chest X-ray taken during a medical examination. His blood prostatic specific antigen level was very high at 100 ng/ml (normal, less than 4.0 ng/ml). Palpation of the prostate disclosed enlargement to hen's egg size with an irregular surface and indurations bilaterally. Transrectal sextant needle biopsy of the prostate was performed, revealing moderately differentiated adenocarcinoma. Computed tomography (CT) scan and bone scintigraphy showed intrapelvic lymphnode adenopathy and metastasis to the right pubic bone. Under a diagnosis of stage D2 prostate cancer, we initiated endocrine therapy (luteinizing hormone-releasing hormone analogue depot every 4 weeks and bicalutamide). Androgen blockage was very effective and after 6 months, the PSA level had decreased markedly to below 0.2 ng/ml. Sixteen months later, pulmonary metastasis completely disappeared. He is currently free from recurrence and progressing well.

31歳女.無症候性肉眼的血尿が出現した.超音波断層法で腎, 膀胱に異常所見は認めなかった.妊娠の可能性が否定できないため, X線撮影は施行しなかった.経過観察を行ったが, 左腰背部の仙痛発作が出現し, 妊娠の可能性が否定されたため, IVPを施行した.左腎盂の描出が悪く, カラードプラ法で腎下極はモザイクパターンの血流信号を示し, 左腎動静脈瘻と診断した.腎静脈内にパルスドプラで動脈波形を検出した.選択的左腎動脈造影を施行し, 続いて支配動脈へマイクロカテーテルを挿入した.プラチナコイル3個を用い, 選択的動脈塞栓術を施行した.塞栓術後より血尿は消失し, 発熱, 腰痛, 高血圧といった合併症は認めず, 退院した.1年2ヵ月を経過した現在も血尿は認めず, 超音波検査にて経過観察を行っているが再発の兆候は認めない, Congenital arteriovenous fistula(AVF) of the kidney is a rare condition. We report a case of renal AVF with chief complaints of macroscopic hematuria, and treated with transcatheter arterial embolization (TAE) using coils. The patient was diagnosed as having left renal AVF by Color Doppler ultrasound. The signs and symptoms disappeared after embolization. The clinical course of a case is reported and the literature is reviewed. Color Doppler ultrasound is required to give a definite diagnosis of renal AVF.

A case of a CA19-9-producing ureteral cancer is reported. A 58-year-old man presented with gross hematuria. Retrograde pyelography showed an irregular filling defect in the right ureter. The serum CA19-9 level was 932 U/ml (normal < 37). Right total nephroureterectomy was performed. The histological diagnosis was grade 3 transitional cell carcinoma. Immunohistochemical analysis showed CA19-9 to be expressed not only in the cancer cells but also in the normal transitional cell epithelium of the renal pelvis.

46歳男.肉眼的血尿, 右下腹部痛, 背部痛, 欠尿を主訴とした.血液生化学検査にて腎機能低下, 貧血, 血小板減少を認め, 腹部エコー, KUBにて両側水腎症および左尿管内の結石を認めた.以上の所見より, 両側尿管閉塞による腎後性腎不全と診断した.両側single-J尿管ステントを留置したところ, 直後より利尿良好となり, 入院7日目に腎機能は改善傾向を示し, 左経尿道的尿管結石砕石術を行った.右尿管鏡検査にて腫瘍性病変を認め, 生検を行い, 病理学的に線維上皮性ポリープと診断した.術後3日目に左尿管ステントを抜去し, 右腎盂内にdouble-J尿管ステント留置し, 3ヵ月毎の交換を行うこととした.5ヵ月経過後, 腎機能は安定している, A 46-year-old man was admitted to our hospital complaining of macroscopic hematuria with dull pain in the right flank. Laboratory finding showed renal dysfunction and abdominal ultrasound sonograph revealed bilateral hydronephrosis (right > left). Retrograde pyelography showed left ureteral calculi and a filling defect in the middle portion of the right ureter. Renal function improved after bilateral single-J ureteral stent placement. Selective wash cytology of right renal pelvis was class II. Ureteroscopy demonstrated right ureteral obstruction with smooth-surfaced protruded tumor and cold cup biopsy was performed. Histopathological diagnosis was a fibroepithelial polyp but with no malignancy. In addition, left transurethral lithotripsy was performed under ureteroscopy. After the endoscopic examination, a double pigtail stent inserted into the right ureter. We performed conservative management by repeat urine cytologies and retrograde pyelography due to thrombocytopenia. The urine cytologies all proved negative and retrograde pyelography showed no abnormal changes. A ureteroscopic procedure is considered to be useful for the diagnosis of ureteral polyps. Transurethral resection of ureteral polyps with a ureteroscope is recommended for treatment.

65歳男.患者は左鼠径部に無痛性の腫瘤を自覚し, 1ヵ月後, 増大していた.胸部X線写真にて, 右上肺野に陳旧性肺結核病巣を認め, 左精索腫瘍の診断にて, 手術が行われた.腫瘤は精巣上体に接して精索内に存在し, 精索血管と強固に癒着していた.腫瘤のみを摘出することは困難であると判断し, 左高位精巣摘除術が施行された.精索結核と診断し, Ziehl-Neelsen染色を行ったが結核菌は確認できなかった.ツベルクリン反応は中等度陽性であった.抗核療法を6ヵ月間の予定で開始し, 術後2ヵ月経過現在, 新たな局所再発は認められていない, A 65-year-old man visited our hospital with a complaint of a left inguinal mass. He had had a past history of tuberculosis. A left spermatic cord tumor was suspected. Left high orchiectomy was performed. The mass did not connect with the testis or epididymis. The removed mass measured 4 x 2 x 1.5 cm in size. Microscopic examination showed a granulomatous lesion with Langhans giant cells. Tuberculin skin test was moderately positive. From these findings we diagnosed the patient with tuberculosis in spermatic cord. Antituberculous chemotherapy was subsequently initiated. Two months after surgery, recurrence has not been found.

大気の寒冷と相関のあるといわれる精巣捻転症39例について, 発症時の気温を検討した。14例は春季に, 13例が秋季に, 12例は冬季に起こっていた。発症時間は4:00p.m.から深夜が29例(54%), 深夜から8:00a.m.が13例(35.1)で日中は僅か3例(10.8%)であった。患者の住む消防署の気象データから, 気温は29例(76.3%)が当県の平均気温15°C以下で発症していた。発症頻度は温度と相関した, A study on correlation between testicular torsion and atmospheric temperature was made based on 39 patients observed at Tokai University Hospital. Testicular torsion did not occur in any of the 39 patients in the summer (June to August), but occurred in 14 patients in spring (March to May), in 13 patients in autumn (September to November), and in 12 patients in winter (December to February). The onset hour was between 04:00 p.m. and midnight in 20 patients (54.1%), between midnight and 08:00 a.m. in 13 patients (35.1%), and between 08:00 a.m. and 04:00 p.m. (in the daytime) in only 3 patients (10.8%). In each of 38 patients, the atmospheric temperature at the onset hour was investigated on the basis of meteorological observations made by the fire department located in the region of the patient's residence. The data indicated that testicular torsion in 29 patients (76.3%) occurred below 15 degrees C (below the average temperature in Kanagawa Prefecture). Furthermore, a correlation (Spearman's coefficient above 95%) between reduction in temperature and onset frequency was noted. Evidently these findings suggest that the incidence of testicular torsion tends to increase with reduction in temperature.

A case report of primary osteosarcoma of the bladder is herein presented. A 75-year-old man presented with asymptomatic macrohematuria. Cystoscopic examination revealed a large tumor with a broad base arisen on the anterior wall. Pelvic computed tomographic scan showed multiple calcifications in the tumor itself. Total cystectomy and ileal conduit were performed. Histopathological diagnosis was osteosarcoma. The patient died 10 weeks after surgery. Metastasis to lung, heart, lymphnode, ureter and peritoneum were identified by autopsy. Primary osteosarcoma of the bladder is a rare tumor, only 25 cases have been reported previously. The prognosis of this tumor is very poor. Nineteen of these patients died within 6 months.

Primary localized amyloidosis of renal pelvis is very rare, and only 12 cases have been reported. More than half of the reported cases were treated by nephrectomy, and the preoperative diagnosis could not be made correctly because of its resemblance to renal pelvic tumor. The ureteroscopy is a useful diagnostic means in such a condition. This case is unusual in that a papillary transitional cell carcinoma was present coincidentally.

Inherited metabolic diseases resulting in urolithiasis secondary to urinary excretion of insoluble substances are rare but often present as urinary obstruction of renal insufficiency. We herein report a case of partial adenine phosphoribosyltransferase deficiency associated with 2, 8-dihydroxyadenine urolithiasis. In family members the propositus and his younger brother are homozygotes for defective APRT genes, and who exhibits the type II phenotype designated APRT*J (Japanese type).

症例は76歳女性で, 左側腹部鈍痛を自覚し近医を受診して腹部超音波所見で左水腎症を指摘され, 精査加療目的で紹介入院となった.腹部CTで一部造影される内部不均一な直径4cmの腫瘍を認め, 腫瘍と左腸腰筋との境界は不明瞭であった.MRIでは水平断像のT2強調像でCTと同部位に腸腰筋と比べhigh intensityな腫瘍を認め, 一部腸腰筋内への浸潤が疑われた.前額断像においては腫瘍による左尿管への圧排像が認められた.以上の所見から後腹膜腫瘍の診断で, 左腎摘除術および後腹膜腫瘍摘除術を施行した.摘出標本は5×3×2.5cmで表面平滑, 充実性で弾性硬であり淡黄色を呈していた.病理組織学的所見から平滑筋肉腫と診断された.術後は患者が高齢であることから補助療法は施行せず, 術後14ヵ月目に左小骨盤腔に腫瘍の再発を認めたが, 腫瘍増大傾向は緩徐で, 術後29ヵ月を経過した現在, 他に再発所見は認めていない, A 76-year-old woman presented with dull pain in left flank. Excretory urogram showed no function of left kidney. Retrograde pyelography, ultrasonography, computed tomography and magnetic resonance imaging demonstrated hydronephrosis of the left kidney and a mass lesion surrounding the ureter. The tumor was removed together with the upper region of the left ureter and kidney. The tumor was 5 x 3 x 2.5 cm in diameter and the pathological diagnosis was a leiomyosarcoma. Although recurrent tumor arose in the pelvis at 14 months after the operation, the patient has been in good general condition without showing any other evidence of recurrent lesion. This case may indicate the importance of early resection of retroperitoneal leiomyosarcoma.

51歳女.本症例は腎炎腎結石を伴った膿腎症型で病変が傍腎組織に及び, 結果として, 腰背部にまで膿瘍を形成した極めて稀な症例と考えられる, A 51-year-old female exhibited fever, left flank pain and left flank mass in March, 1993. Drip infusion pyelography (DIP) revealed a non-functioning left kidney with shadows of calculi, and abdominal computerized tomography (CT) showed renal calculi and multilocular cystic lesions in the left kidney extending through the perinephric space into the mass on the left flank. Percutaneous nephrostomy and percutaneous drainage were performed, followed by left nephrectomy. Histopathological findings revealed xanthogranulomatous pyelonephritis. There have been a few case reports of xanthogranulomatous pyelonephritis forming nephrocutaneous fistula in the back.

27歳男, 本邦20例目であり, 本邦最大の大きさ.ミュラー管嚢胞への精管異所開口は本邦2例目, A case of giant mullerian duct cyst is reported. The patient was a 27-year-old male, complaining of microscopic hematuria. A giant cystic abdominal mass was palpable. After screening examination including ultrasound tomography, intravenous pyelography, computed tomography and magnetic resonance-imaging, mullerian duct cyst was suspected. Operation for this cyst was performed with median incision. The cyst measured 25 x 21 x 14 cm. The surface as smooth and consistency was soft. Included fluid was slightly turbid and yellowish measuring 2, 200 ml. This was considered to be the largest mullerian duct cyst case reported in the Japanese literature.

A 72-year-old man underwent total cystectomy with single stoma cutaneous ureterostomy for the treatment of transitional cell carcinoma of the bladder. The patient came to the outpatient clinic every 2 weeks to exchange ureteral catheters. Six months after the operation, he was admitted to our hospital again due to edema of bilateral legs, fever, and loss of appetite. The patient had metastasis of intrapelvic and paraaortic lymph nodes associated with cachexia, and was given intravenous hyperalimentation and treatment to control pain. Suddenly, he complained of left flank pain. When the ureteral catheter was removed, massive bleeding occurred from the stomal orifice. A fistula between the artery and ureter was suspected. Six days later, the patient died due to acute renal failure. After his death, retrograde ureterography was performed to confirm the fistula. A fistula was found between the left common iliac artery and left ureter.

A 52-year-old male visited our department for a painless swelling from the right side of the anus to the right scrotum that he first noticed 5 years earlier. Palpation revealed a small fist-sized elastic solid mass with a smooth surface from the central area to the inferior pole of the right scrotum. This mass was clearly demarcated from the contents of the scrotum and not adherent to the scrotal skin. A diagnosis of a tumorous lesion in the scrotum was made, and the tumor was resected. Histopathological examination demonstrated a scrotal epidermoid cyst. To our knowledge, this is the 17th case reported in Japan.

A 46-year-old man who has a child from a previous marriage without artificial reproductive technologies was referred to our hospital with a chief complaint of infertility. He had suffered from bilateral orchitis after parotitis six years ago. On physical examination, both testes were soft and 4 ml in size. Semen analysis showed azoospermia and the serum follicle stimulating hormone value was high (36.9 mIU/ml). Microdissection testicular sperm extraction was performed, and motile sperm were successfully retrieved. The histological examination showed increased thickness of the basement membrane and, peritubular fibrosis in most seminiferous tubules, with few focal areas of normal spermatogenesis.