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In recent times, the number of patients receiving antiplatelet drugs for the prevention of cardiovascular and cerebrovascular diseases has been increasing. We examined the possibility of early initiation of antiplatelet therapy after urological operations. Between April 2008 and February 2009, 62 patients who received antiplatelet drugs and underwent urological surgeries (open surgery, transurethral surgery and laparoscopic surgery) and prostate biopsies were examined. Of the 62 patients, 59 were randomized into 2 groups ; 32 patients receiving antiplatelet treatment initiation within 24 hours (early group) and 29 patients receiving this treatment more than 24 hours (late group) after the urological operation. The end point of this study was the re-cessation of antiplatelet therapy because of the development of postoperative complications (hematuria, blood loss, etc.) and cardiovascular and cerebrovascular events within 1 month. There was no significant difference in the urological events observed between these groups, including 2 of the 32 (6.3%) patients in the early group and 3 of the 27 (11.1%) in the late group. Cardiovascular and cerebrovascular diseases were not noted in any of the patients within 1 month. In conclusion, we think that it is possible to initiate antiplatelet therapy within 24 hours after urological operations and prostate biopsies in the absence of active blood loss. Early initiation may prevent the risk of cardiovascular and cerebrovascular disease in the future.

A 30-year-old female was referred to our hospital complaining of left flank pain. She was diagnosed with a giant hydronephrosis in a horseshoe kidney. We performed a retroperitoneoscopic nephrectomy on the non-functioning moiety of the horseshoe kidney. After the placement of a ureteral catheter, she underwent a retroperitoneal nephrectomy. The feeding vessels consisted of four arteries and four veins. The thin isthmus of the horseshoe kidney was divided using scissors, without the need for electrocautery, and hemostasis was achieved using monopolar shears. Laparoscopic nephrectomy on a horseshoe kidney is a difficult surgery given the aberrant vessels and isthmus, so it tends to be avoided for reasons of safety. However, if appropriate preoperative imaging is carried out and the procedure is conducted in a careful manner, it can be made a safe and minimally invasive operation.

We report a case of signet-ring cell carcinoma of the urinary bladder. A 60-year-old man was hospitalized because of total macrohematuria. Cystoscopic examination revealed a non-papillary sessile tumor on the posterior wall of the urinary bladder. The pathological diagnosis was stage pT1 signet ring cell carcinoma. Upper gastrointestinal endoscopy and computed tomographic scanning revealed no involvement of other organs. Radical cystectomy and creation of an ileal neobladder were performed. The histopathological stage was pT3aN0M0. Adjuvant chemotherapy (TS-1) was performed and the patient is currently free from disease at eight months after the surgery. This disease is usually diagnosed at an advanced stage and has a poor prognosis. To our knowledge, this is the first case report on the creation of an ileal neobladder for the treatment of primary signet-ring cell carcinoma of the urinary bladder.

We report a case of acute scrotal hematoma associated with idiopathic thrombocytosis. A 75-year-old man visited our hospital for the treatment of a left scrotal mass that had been increasing in size ; the mass had developed after the puncture of left testicular hydrocele. The patient was diagnosed with acute scrotal hematoma on the basis of ultrasonography findings. The patient underwent an emergency operation for the removal of the hematoma. On2 days after the surgery we noticed anin crease inthe size of the hematoma. The patient had a 4-year clinical history of idiopathic thrombocytosis for which he had not received any treatment. Although the platelet count was slightly high at the time of the operation, complete hemostasis did not occur because of the existence of platelet dysfunction. The second hematoma was treated conservatively. To our knowledge, this is the first case report on the acute scrotal hematoma associated with idiopathic thrombocytosis.

12歳男。自転車走行中にバイクと接触し, 左側腹部痛を来たした。検査所見で白血球増加, 貧血, LDH・CK上昇を, CTで左腎上極の断裂と周囲の血腫形成を認めた。血管造影を施行し, 左腎上極へ分枝した動脈からの出血を認め, コイルによる選択的動脈塞栓術(TAE)を行った。しかし受傷後2日目に左側腹部痛増強と肉眼的血尿が出現し, 血管造影で同じ動脈からの出血を認め, 再度TAEを行った。受傷4日目も炎症所見と発熱が続き, 貧血が進行したためCTを施行した。血腫は縮小傾向であったが, 左上断裂腎からの尿漏を認め, 感染症の併発を考えて断裂腎に対するTAEを試みた。左腎上極へ分枝した動脈をスポンジセルを用いて塞栓したところ, 徐々に解熱, 炎症反応改善が得られ, 23日目のCTでは血腫縮小傾向を認めた。受傷5ヵ月目のCTでは断裂腎は萎縮し残存していたが造影効果は認めず, 血腫は完全に吸収され, 残存腎の機能は十分に温存されていた。尿漏や水腎症などもなく経過順調である。, A 12-year-old-man presented with left flank pain after a traffic accident on October 14, 2006. Computed tomography (CT) revealed major left renal hematoma and transection (IIIb). Selectively transarterial embolization (TAE) was performed to control upper transected renal bleeding on the same day, and again to do rebleeding two days later. Because CT revealed left perirenal urinoma caused by upper transected kidney on October 18, TAE was performed for the upper transected kidney not to function. Five months after left renal injury, CT demonstrated the left kidney successfully preserved without hydronephrosis, urinoma and hematoma. The patient was well and could be conservatively treated without hypertension and other complications. In previous reports, only a part of renal injury (III) cases with conservative treatment converted to nephrectomy, whereas approximately half of them with surgical treatment resulted in nephrectomy. Therefore, it is important to treat them as conservatively as possible and to preserve renal function, even in cases of major renal blunt injury.

28歳女。外陰部の無痛性腫瘤を主訴に受診し、排尿障害は認めなかった。MRIより腟前庭部に径2.5×3.0cm大の充実性腫瘍を認め、T1強調像は低信号、T2強調像は不均一な高信号を呈し、傍尿道腫瘍と診断し尿道腫瘍摘出術を施行した。病理所見より、HE染色で粘液様基質の中に異型の乏しい紡錘形細胞の疎らな増生と大小の血管構造の散在を認め、免疫組織染色は陽性でありaggressive angiomyxomaと診断した。術後5年4ヵ月に増大する外陰部の腫瘤で受診し、腟前庭部に径3.0cm大腫瘍を認め、MRI所見も前回同様で傍尿道aggressive angiomyxomaの局所再発を疑い摘出術を施行した。HE染色、免疫染色ともに前回同様の所見で局所再発と診断した。術後4ヵ月現在再発・転移は認めていないが、長期の経過観察が必要である。, We report a case of local recurrent aggressive angiomyxoma presenting as a para-urethral tumor. A 28-year-old woman visited our hospital with a complaint of a painless vulval mass. Magnetic resonance imaging (MRI) of the pelvis showed the para-urethral tumor to be 2.5 x 3.0 cm. The tumor was resected, and diagnosed histopathologically as aggressive angiomyxoma. The patient showed a painless vulval mass again at 64 months after the first resection. MRI of the pelvis showed the paraurethral tumor to be 2.5 x 3.0 cm. The tumor was resected, and diagnosed histopathologically as aggressive angiomyxoma. The patient showed no recurrence at 4 months after the second resection.

78歳男性。患者ははじめ左鼠径部の腫脹を自覚し, 更に便秘および下血が生じ, 著者らの施設にある消化器外科へ受診, 直腸癌と診断された。今回, 左鼠径部腫脹の精査加療目的で著者らの泌尿器科へ紹介となり, 超音波・CT・MRIの結果, 左精索腫瘍と診断された。直腸癌に対するHartmann手術と同時に左高位精巣摘除術を施行したところ, 病理組織学的には直腸低分化型腺癌に併発した精索脂肪肉腫であった。術後6ヵ月経過した時点では精索脂肪肉腫の再発, 転移は認められなかったが, 患者は最終的に直腸癌の増悪のために死亡となった。, We report a case of liposarcoma of the spermatic cord associated with rectum cancer. A 78-year-old man visited our hospital with a complaint of painless left inguinal mass. He also showed constipation and bloody bowel discharge, rectum cancer was diagnosed by further evaluation. Ultrasonography, computed tomography and magnetic resonance imaging revealed a 2 x 4 x 6 cm mass in the left spermatic cord. Left high orchiectomy for the left inguinal tumor and Hartmann's procedure for rectum cancer was performed. Histologically, the mass in the left spermatic cord was well differentiated liposarcoma and rectum cancer was poorly differentiated adenocarcinoma. He died from rectum cancer with no evidence of recurrence of liposarcoma of the left spermatic cord after follow up for 6 months.

A 91-year-old man presented with nocturnal frequency and urge incontinence of a few days duration due to involvement of prostate cancer (PCa) accompanied by a large cyst in the left lobe of the prostate gland and urinary bladder wall. Channeling transurethral resection of prostate was performed to relieve the main symptoms and the resected material was histologically diagnosed as papillary cystadenocarcinoma arising from the epithelium of microscopic retention cysts. Following shrinkage of the large cyst, the patient is doing well on a combination regimen of a luteinizing hormone-releasing hormone analogue and bicaltamide. Papillary cystadenocarcinoma of the prostate was originally defined as papillary PCa arising from, not accompanied by, prostatic cysts. Cysts associated with PCa are subdivided into primary (or true) and secondary (or pseudo) cysts. Cancer cells in primary cysts originate from the epithelial lining. Papillary growth type cysts belong to this group and are regarded as papillary cystadenocarcinoma. The secondary (or pseudo) cysts, which have no epithelial lining and consist of hemorrhagic and/or necrotic contents are associated with invasive PCa. In the present case, the microscopic retention cysts revealed by histologic examination were of the primary type. This case of papillary cystadenocarcinoma, arising from a primary cyst, is the 13th such report from among previously reported cases in Japan., 91歳, 男性。主訴は数日前から続く夜間頻尿と尿失禁。PSA 325ng/mlと高値で, 前立腺の左葉が石様硬であった。DIPとUCGでは膀胱と尿道は右側へ偏位し, 左腎は無機能であった。MRIでは前立腺から膀胱の左側へまたがる径5cmの嚢胞を伴った腫瘍を認めた。前立腺生検では高分化型前立腺癌を認めた。排尿困難改善のためchanneling TURを施行したところ, 病理診断は貯留嚢胞上皮から発生した乳頭状嚢胞腺癌(Gleason score 6, C2)であった。内分泌治療は間欠的に施行し, 治療開始後41ヵ月現在, 嚢胞壁は縮小し, 再燃・転移なく通院加療中である。嚢胞を伴う前立腺癌は比較的稀で, 嚢胞壁が癌化する原発性嚢胞と癌が中心壊死・出血を起こし形成される二次性嚢胞に分類されている。自験例では原発性嚢胞と考えられる貯留嚢胞上皮が癌化した非常に稀な前立腺乳頭状嚢胞腺癌であり, 本邦13例目であった。(著者抄録)

84歳女。左腎盂腫瘍の精査目的で当科受診した。顕微鏡的血尿および膿尿を認め, 尿細胞診classV, Escherichia coli陽性であった。IVPにて左腎盂および膀胱に陰影欠損を認めCTにて左腎盂に径3×4cm大腫瘍を膀胱左壁に3×2.4cm大, 右側壁に2.2×1.2cm大の腫瘍を認め, 膀胱鏡では右側壁, 左後壁に非乳頭状基性腫瘍を確認した。根治的切除を目的としてTUR-BTを施行し同時に左壁内尿管を尿管口とともに切除し2週間後, 用手補助後腹膜鏡下左腎尿管全摘除術を施行した。病理所見より, 膀胱腫瘍LCA陽性, B細胞マーカー陽性で腫瘍基部は腫瘍の細胞を認めず, 腎盂癌はurothelial carcinoma, adenocarcinoma, Pt2, G2で左腎盂癌を伴った膀胱原発MALTリンパ腫と診断した。膀胱内に腫瘍が多発しており術後治療として膀胱部へ計36Gyの放射腺照射を追加し終了後14ヵ月経過して再発, 転移を認めていない。, We report a case of primary mucosa-associated lympoid tissue (MALT) lymphoma of the urinary bladder associated with left renal pelvic carcinoma. A 84-year-old woman showed microscopic hematuria during follow up for hypertention. Left renal pelvic tumor was found and she was referred to our hospital for further evaluation and managemant. She showed pyuria and Escherichia coli was detected by urine culture. Intravenous pyelography and computed tomography revealed the left renal pelvic tumor and solid bladder tumor. Transurethral resection of bladder tumor and left total nephroureterectomy were performed. Histologically, the left renal pelvic tumor was urothelial carcinoma > > adenocarcinoma, G2, pT2 and the bladder tumor was MALT lymphoma. Ga-scintigraphy showed no hot uptake suspicious of metastatic lesion. Then, external beam radiotherapy (36 Gy) was performed to the urinary bladder. She has been alive for 14 months with neither renal pelvic tumor nor MALT lymphoma showing any evidence of disease progression.

尿路上皮癌で、術後のM-VAC療法後に再発を来たした4例および効果不良と判定された5例、計9例14病変に対し、gemcitabine+cisplatin併用化学療法(GC療法)を行った。症例の内訳は、リンパ節転移症例5例、肺転移症例2例、局所再発1例、多発転移を伴う手術不能例1例であった。GC療法は3～6コース、全体で46コース施行され、6コース完遂例は6例であった。非完遂例は治療無効が2例、希望により3コースで終了1例であった。有害事象は、白血球減少がgrade 2:3例、grade 3:6例、血小板減少はgrade 1:2例、grade 2:5例、grade 3:1例、grade 4:1例であった。また、全46コース中27コースで骨髄抑制のため3回のうち1回のgemcitabine投与が休薬された。CTおよび骨シンチで判定した症例別の近接効果はCR:3例、PR:3例、NC:1例、PD:2例で、再発例4例ではCR:2例、PR:1例、PD:1例、効果不良例5例ではCD:1例、PR:2例、NC:1例、PD:1例であった。病変別ではCR:4病変、PR:6病変、NC:2病変、PD:2病変であった。GC療法後の平均生存期間は15.2ヵ月で、responseを得たCR症例の予後は無再発生存2例、癌死1例、PR症例は担癌生存2例、癌死1例であった。, We evaluated the efficacy of gemcitabine-cisplatin (GC) therapy as a second line chemotherapy for recurrent urothelial cancer previously treated with or resistant to methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) therapy. Four patients who had recurrent cancer after adjuvant M-VAC therapy and five patients with resistant lesions to M-VAC were treated by GC. Of the nine patients, three completely responded to GC and three obtained partial response. These complete responders were cancer-free for 34, 32 and 24 months. In one partial responder, the metastatic masses have been decreasing in size for 12 months after completion of GC therapy. Our findings suggested that GC would be useful as a second line chemotherapy for urothelial cancer previously treated with M-VAC.

79歳男.前立腺肥大症と診断され, 内服治療を行ったが, 排尿悪化に伴い経尿道的前立腺切除術(TURP)を椎麻酔下で施行した.術後の著明な出血により術後7日目に尿道カテーテルを抜去したが39～40℃の発熱が持続し, E.cloacae, MRSAの検出をみた.9日目より腰痛を自覚しMRIでL4～5椎間腔の狭小化を認め, 腰痛症又は腰椎ヘルニアを疑うが脊椎炎の所見は認めなかった.imipenem(IPM), teicoplanin(TEIC)を2週間CRPは陰性化しなかったが解熱, WBC低下と血液・尿培養の陰性化を受け, galifloxacin(GFLX)に変更したが再び発熱とWBC, CRPが上昇し, 腰痛悪化で歩行困難となった.Gaシンチ施行により術後39日目に化膿性背椎炎と診断し, E.cloacaeが検出された.3週間治療内服後CRPの陰性化, 腰痛は軽減し歩行可能となり術後6ヵ月目に退院した, We report a case of pyogenic spondylitis caused by Enterobacter cloacae as a rare complication of transurethral resection of the prostate (TURP). A 79-year-old man underwent TURP. Immediate after removal of urethral catheter on postoperative day (POD) 7, he developed high fever > 40 degrees C with increased acute inflammatory reaction. Urine and blood culture detected E. cloacae and methicillin-resistant Staplylococcus aureus. He complained of lumbago since POD 9. Two-week administration of imipenem and teicoplanin resulted in resolution of fever as well as laboratory data, so intravenous antibiotics were changed to oral gatifloxacin. However, his lumbago worsened and gait disturbance appeared. On POD 39, diagnosis of pyogenic spondylitis was finally obtained by Ga-scintigraphy and magnetic resonance imaging. Aspiration of the intervertebral disk (L4-5) revealed E. cloacae as the causative organism of pyogenic spondylitis. His condition improved after conservative treatment with teicoplanin, meropenem and ciplofloxacin for 9 weeks.

1991～2002年に経尿道的切除, 全身化学療法, 放射線療法による膀胱温存を試みた局所浸潤膀胱癌31症例を対象に, 集学的膀胱温存療法について検討した.1)5年疾患特異的生存率は67%, 同10年では28%であった.2)23例で膀胱温存のまま経過観察に入り, 3例で膀胱内局所再発を認めた.他に上部尿路CISが1例, リンパ節あるいは遠隔転移5例であった.3)深達度T2症例の局所的著効(CR)獲得率はT3～4a症例と比較して良好であり, 更にT2症例の5年疾患特異的生存率は71%, T3～4a症例は57%であった.4)集学的治療ではCRが得られず, 患者希望により膀胱全摘出術から部分切除術に変更した2例のうち1例は術後47ヵ月再発なく経過したが, 1例は約16ヵ月後に癌死した.5)膀胱温存23例中9例が頻尿を自覚し, うち4例に容量100ml以下の萎縮膀胱が出現した.治療状況から萎縮膀胱の原因の一つに放射線治療が考えられ, この出現を予防する観点からも化学療法でCRを得た症例への放射線療法追加の必要性を今後検討すべきであると考えられた, Twenty-three out of 31 patients with clinical T2-4a N0 M0 bladder cancer and given a trial of trimodality therapy including transurethral resection (TUR), systemic chemotherapy and radiation between 1991 and 2002 completed this therapy. The other 8 dropped out because of insufficient clinical effect. Local bladder recurrence was seen in 3 patients and the bladder preservation rate was 64.5%. Nineteen of the 23 patients showed a complete histological response on a subsequent TUR specimen, the other 4 were not examined for histological response. Thirteen of the 19 patients showed a complete histological response after maximal TUR and systemic chemotherapy, while 6 did after TUR, chemotherapy and radiotherapy. Bladder cancer was T2 in, 15, T3 in 1, and T4a in 3 patients. The CR rate for T2 cancer was significantly higher than that for T3-4a cancer. The 5-year disease-specific survival of the 23 patients treated with preservation therapy was 67.1%. Some of the patients with locally advanced bladder cancer may benefit from this preservation therapy.

72歳女性.近医の腹部エコーにて右腎嚢胞性腫瘤を指摘され, 著者らの施設へ紹介入院となった.入院時, 軽度肝機能障害を認め, 腎エコー, DIT, CT, MRIでは右腎に径10cm大の巨大な腫瘤を認めた.3次元CTにて腎動脈本幹起始部近傍に発生した紡錘状型巨大腎動脈瘤と診断し, 経腹式腎摘除術を施行した.病理組織学的に腎動脈瘤は動脈硬化によるもので, 術後経過は良好であった, A 72-year-old woman consulted our hospital for a cystic mass in the right kidney. Ultrasonography and drip infusion pyelography revealed a right renal cystic mass 10 cm in diameter and right hydronephrosis. Computed tomography (CT) and magnetic resonance imaging revealed a giant mass with partial calcification in the right renal hilus. The mass was diagnosed the fusiform aneurysm 10 cm in diameter occurring in the main stem of right renal artery by selective abdominal angiography and 3-dimensional CT. We performed total nephrectomy and the histological finding was atherosclerosis. A total of 485 cases of renal artery aneurysm have been reported in Japan. These cases and 15 cases of renal artery aneurysm more than 5.0 cm in diameter are herein reviewed.

症例1(51歳女性).患者は外陰部腫瘤の増大で受診となった.外尿道口後壁から腟前庭にかけて充実性弾性軟の鶏卵大腫瘤を認め, MRIでは尿道後方, 腟前方に3cmの腫瘤が認められた.そしてT1強調で筋と同信号, T2強調ではやや高信号であるも内部は均一であった.一方, CTでは外尿道口後方に3cm大の筋肉よりややdensityの低い腫瘤を認めた.経腟的に腫瘍摘除術を行なったところ, 病理診断では平滑筋腫であった.術後9年以上経過現在, 再発は認められていない.症例2(44歳女性).患者は外陰部の不快感と違和感の増悪で近医を受診し, 外尿道口後背側の腫瘤を指摘され紹介受診となった.所見では, 外尿道口後壁から腟前庭にかけて充実性, 弾性軟のクルミ大の腫瘤を認め, MRIでは尿道後壁と腟前庭の間にT1で低信号, T2で低～中程度の信号の均一な3cmの腫瘤を認めた.経腟的に腫瘍的除術を行なったところ, 病理診断は平滑筋腫で, 術後2年以上経過現在, 再発は認められていない, We report two cases of female paraurethral leiomyoma. Two Japanese women (51 and 44 years old) were referred to our department with the complaint of a painless mass at the external genitalia. Both tumors were resected transvaginally and histopathologicaly diagnosed as leiomyoma without any evidence of infiltration into the surrounding tissue. One hundred and twenty-eight cases of female paraurethral leiomyoma are collected from the Japanese literature and are discussed.

Metastasis to the bone of the hand is rare. In addition, metastasis to the bone of the hand from bladder cancer is extremely rare. We herein report a case of distal phalanx metastasis from bladder cancer. A 64- year-old man who was diagnosed with bladder cancer (cT2bN0M0) received total cystectomy (pT3bN2). Two months after the surgery, a roentgenogram revealed lung metastasis. Then we administered 2 cycles of chemotherapy using gemcitabine and cisplatin. Computed tomography revealed a partial response. However, several months after chemotherapy, we noted that his left ring finger was swollen and showed erythema. We made a diagnosis of metastasis to the distal phalanx of the left ring finger and amputated the finger. Pathological findings showed no conflict with metastasis from bladder cancer. Postoperative course was good, but he died about three months after the diagnosis of metastasis.