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Economical elements including surgical fee and hosipital stay become larger in the selection of surgical methods for the treatment of urinary stones. Then, urologists need to explain to patients the treatment cost to obtain informed consent. By comparing the data from participants' answer to Debate 1 at the 82th annual meeting of the Japanese Urological Association (April 2002, Tokyo) and questionnaire responses from the members of the annual meeting of central division of Japanese Urological Association (November 2002, Nagoya), we surveyed the trends of surgical methods on the treatments of staghorn caliculi and lower ureter stones. Furthermore, we clarified the cost of these methods. Based on the status of world countries, we demonstrate the ideal selection including economical aspects on the selection of endourological method.

前立腺針生検施行654例.1回目で癌が検出されたのは239例で, 陰性例のうち104例に2回目を行い, 16例に検出された.更に3回目が39例中4例, 4回目は10例中3例の検出であった.再検査で最終的に癌が検出された23例(A群)とされなかった81例(B群)において, 年齢, PSA, PSA density, PSA velocityに有意差はなかった.再検査時の所見で, MRIのT2強調像でlow intensityのあるものを陽性とすると, p=0.118, 感度79%, 特異度42%, 経直腸エコーでlow echoic areaのあるものを陽性とした場合はp=0.134, 感度74%, 特異度48%, 直腸診はp=0.027, 感度65%, 特異度59%で, 直腸診にのみ有意差を認めた.生検でatypical findings(AF)とされ再検査を施行した症例では, 9例中6例に癌が検出された.AFの内訳は「高分化腺癌を疑うが検体量少なく判別困難」3例, 「核異型があるが癌とは言い切れない」5例, 「ハイグレードprostatic intraepithelial neoplasia」1例であった, We retrospectively analyzed the results of 104 patients who underwent a second prostate needle biopsy. Between January 1993 and September 2000, 654 needle biopsies were performed and cancer was found in 239 patients. Among the other 415 patients, 104 patients underwent a second biopsy. The average prostate specific antigen (PSA) value was 9.6 ng/ml (2.0-30.9) (Tandem R conversion value). Cancer was detected in 16 out of 104 cases (15%) at the second biopsy, 4 out of 39 (10%) at the third biopsy, and 3 out of 10 (30%) at the fourth biopsy. The age, PSA value, digital examination, echography, and magnetic resonance imaging (MRI) were not helpful in distinguishing the patients with prostate cancer and atypical histological findings at the previous biopsy were the most important information. Among the 9 patients who showed atypical findings at the previous biopsy, 6 (67%) had cancer.

29歳男.後腹膜リンパ節転移巣から発見され原発巣と考えられた左精巣には明らかなviable cellを認めず瘢痕組織のみであり, burned-out testicular tumorと考えられた1例であった.原発巣と考えられた左精巣には特に症状を認めなかった.しかし注意深い触診により萎縮した精巣と小結節を触知可能であり, 更に超音波検査により触診で触れた小結節と一致した部位の小エコー領域を認め, 原発巣検索に超音波検査は有用であった.精巣腫瘍stage IIBと考え, ブレオマイシン, エトポシド, シスプラチンを用いた併用化学療法を3コース施行した.ブレオマイシンによると思われる発疹が出現したため2コース目以降は他の2剤により治療した.残存する後腹膜腫瘍に対し手術を施行した.左腎は腫大リンパ節と強度に癒着し左尿管は腫大リンパ節に巻き込まれるように存在していた為, 後腹膜リンパ節郭清に加え左腎摘除術を併せて行った, A 29-year-old man was referred to our hospital with loss of appetite and a left lower abdominal mass. A small nodule was palpable in his left testis and ultrasonographic examination demonstrated that the nodule was low echoic. Computed tomography showed a large mass in his left retroperitoneal space. We thought the mass was a metastatic lesion from a testicular tumor. Left orchiectomy was done and microscopic examination revealed no viable tumor cells. Only fibrous tissue, small calcified areas, and hyaline bodies were found. As tumor markers were normalized after 3 courses of chemotherapy with bleomycin, etoposide, and cisplatine, the retroperitoneal mass was removed with the left kidney. It consisted of embryonal carcinoma, mature teratoma, and yolk sac tumor. One course of adjuvant chemotherapy was done and the patient has since been free from recurrence. We suppose that the tumor was a so-called 'burned-out' testicular tumor.

聖隷三方原病院で経験した治癒的切除された腎盂尿管癌30例について検討した.1)pT3とpV1が有意な予後因子であった.2)pT2以上, grade 3成分, pV1が有意な再発危険因子であった.3)治癒的切除された腎盂尿管癌に対して化学療法の有効性は認められなかった, We retrospectively studied 30 patients who underwent curative surgery for renal pelvic and/or ureteral cancer between August 1987 and August 1998. Their clinicopathological features were classified by the criteria of the Japanese Urological Association. The 1-, 3-, and 5-year cause-specific survival rates were, respectively, 100, 95.5, and 85.1%, while the disease-free rates were 100, 78.9, and 78.9% by the Kaplan-Meier method. Prognostic factors were evaluated by the log-rank test. The significant prognostic factors were pT3 and pV1 for cause-specific survival (p = 0.0277, p = 0.0025), while pT2 (or higher), grade 3, and pV1 were significant for disease-free survival (p = 0.0271, p = 0.0327, and p = 0.0002). Nine patients who received adjuvant chemotherapy are alive, but 3 patients have relapsed. Chemotherapy did not have a significant effect on the cause-specific survival or disease-free survival.

A case of primary malignant lymphoma of the bladder is reported. A 61-year-old female visited our outpatient clinic with the chief complaints of asymptomatic grosshematuria and was recognized as having a bladder tumor by abdominal ultrasonography. On cystoscopic examination, the tumor was non-papillary and dome-like in shape. Computed tomography revealed that the bladder tumor was invading into the bladder wall. The histopathological study of endoscopic biopsy specimen revealed malignant lymphoma. After further examinations, it was diagnosed as primary malignant lymphoma of bladder, stage IE (Ann Arbor classification). Four courses of CHOP regimen (cyclophosphamide, vincristine, doxorubicin, predonisolone) was performed and no lymphoma cell was found by re-biopsy at the primary site. No local or distant recurrence was found during the 15 months' follow up.

A 70-year-old woman was admitted to our hospital complaining of epigastralgia. Computed tomography, ultrasonography and magnetic resonance imaging revealed a round tumor measuring 6 cm in diameter, which was located in the medial side of the right kidney. It was successfully removed without injury to the surrounding large vessels and organs. Histological diagnosis was benign neurofibroma. This is the 27th case of solitary retroperitoneal neurofibroma reported in Japan.

Between August 1995 and March 1997, 197 patients underwent 257 treatments for 217 stones by extracorporeal shock wave lithotripsy (ESWL) using a Lithodiagnost M (Philips, Holland). There were 149 males and 48 females with an average age of 50.6 years, ranging from 15 to 85 years. There were 53 stones located in the renal pelvis and calices (R2), 20 stones at the pelvi-ureteric junction (PUJ) (R3), 101 stones in the upper ureter (U1), 15 stones in the middle ureter (U2) and 28 stones in the lower ureter (U3). The average number of sessions was 1.18 and the average number of shock waves per stone was 3, 546. Efficacy was evaluated 3 months after the final ESWL. The success rate was 95.4% (207/217), with complete disappearance of stones in 71.4% (155/217) and residual stones of less than 4 mm diameter in 24% (52/217). No severe complications, except for subcapsular renal hematoma in one patient, were observed. These results indicate that almost all upper urinary tract stones can be successfully treated by ESWL monotherapy.

1)27例の非neoadjuvant治療群で, 臨床病期の正診率は48.2%, understagingが44.4%, overstagingが7.4%.42例のneoadjuvant治療群では, 臨床病期の正診率は54.8%, understagingが35.7%, downstaging或いはoverstagingが9.5%であった. 2)治療前PA値は, 病理病期をよく反映しており, pT0とpT3症例, pT0とpN(+)症例及びpT2とpN(+)症例の間には統計学的な差が認められた.又, 再発症例の治療前PA値は, 非再発症例より高かった, Between 1989 and 1991, 815 cases of prostatic carcinoma were registered in the Tokai Urological Cancer Registry. We investigated the clinical features and prognosis of 69 patients who underwent radical prostatectomy. The median age and clinical stage, were 65.9 +/- 4.7 years and A in 7 patients, 66.3 +/- 5.8 years and B in 31, 68.2 +/- 2.7 years and C in 26, 63.4 +/- 13.5 years and N(+) in 5. Neoadjuvant therapy consisting of endocrine therapy and chemoendocrine therapy was administered to 28 and 14 patients, respectively. In comparison to the clinical stage, pathologically, 4 cases (9.5%) showed downstaging or overstaging, 15 (35.7%) understaging and 23 (54.8%) accurate staging in the neoadjuvant therapy group, and, respectively, 2 (7.4%), 12 (44.4%) and 13 (48.2%) in the non-neoadjuvant therapy group. There was a significant difference in the pretreatment prostatic antigen (PA) value between pT0 and pT3 (p < 0.05), between pT0 and pN(+) (p < 0.01) and between pT2 and pN(+) (p < 0.05). In addition, the pretreatment PA value in the recurrence group was higher than that in the non-recurrence group in both neoadjuvant and non-neoadjuvant groups, with a significant difference (p < 0.01) in the neoadjuvant group. Cancer recurrence was noticed in 2 patients given non-neoadjuvant therapy and 3 given neoadjuvant therapy. There was no significant difference in the non-recurrence rate with the pathological stage either with or without neoadjuvant therapy. However, the non-recurrence rate in the neoadjuvant therapy group was higher than that in the non-neoadjuvant therapy group.

A 71-year-old woman with loss of appetite was referred to our hospital. Imaging diagnosis revealed a large, cystically dilated left kidney with a solid tumor inside the cavity and right hydronephrosis. A chest X-ray revealed multiple metastatic lesions. A horseshoe kidney was found intraoperatively and left nephroureterectomy with partial cystectomy was performed. Histological diagnosis was poorly differentiated transitional cell carcinoma. She died of progressive pulmonary metastases 2 weeks after operation. This is the 19th case of a renal pelvic tumor associated with a horseshoe kidney reported in the Japanese literature. The diagnosis was confounded by the extreme dilation and deformity of the hydronephrotic kidney.

44歳男.ABO血液型不適合生体腎移植の1例を経験した.低蛋白, 低アルブミン血症に留意すれば, ABO血液型不適合生体腎移植術前処置としての二重濾過血漿分離交換法(DEPP)による赤血球抗体の除去は有用であると思われた, A 40-year-old female, whose blood type was A, Rh+, was admitted to our hospital for kidney transplantation from her younger brother whose blood type was B, Rh+. Before the transplantation, we performed 4 sessions of double filtration plasmapheresis (DFPP) to remove the anti-B antibodies. The serum anti-B antibody titer lowered from X32 to X4. The kidney transplantation was carried out following the splenectomy. The warm ischemic time was 8 minutes and the cold ischemic time was 47 minutes. Five immuno-suppressive agents including cyclospolin, azathioprine, prednisolone, anti-lymphocyte globulin (ALG), and deoxyspergualin were administered in the initial period. Nine days after the transplantation, an acute rejection occurred, and 15 sessions of hemodialysis were needed. However, Methylprednisolone and OKT3 treatment resulted in recovery of the graft function. Seventy-four days after the transplantation, she was discharged with the serum creatinine concentration of 1.3 mg/dl. The DFPP before transplantation was useful to remove the anti-RBC antibody from the patient receiving an ABO incompatible kidney allograft.

精巣摘除術とエストロゲン療法が主に採用されていた1989年からの3年間に登録された前立腺癌について集計を行い, あわせて予後を調査した.病期C, Dの5年実測生存率は病期C51.6%, 病期D30.3%で, 1980年代前半の厚生省研究班の調査時と比べて変りがなかった, Of 815 patients with prostatic carcinoma registered in Tokai Urological Cancer Registry between 1989 and 1991, 683 patients followed up until April to July 1992 were analyzed. The patients were between 48 and 94 years old (mean 73.2). The clinical stage was A in 96 (14.1%), B in 118 (17.3%), C in 117 (17.1%) and D in 352 (51.5%) patients. The histological study well differentiated adenocarcinoma in 150 (22%) patients, moderately differentiated adenocarcinoma in 305 (44.6%), and poorly differentiated adenocarcinoma in 194 (28.4%) patients. There were 12 undifferentiated adenocarcinomas and 22 were not classified. The incidence of patients with poorly differentiated adenocarcinoma increased with the progression of clinical stage. Hormonal therapy was the main treatment (92.8%) and a variety of hormonal therapies with surgery or chemotherapy were attempted through out the clinical stages. Overall survival rate at 5 years was 48.6%. The 5-year survival rage for stage A, B, C and D carcinoma was 84.7, 93.1, 51.8 and 30.3%, respectively. Significant differences in the survival of patients were noted among stage A or B, stage C and stage D (Logrank test: p < 0.0001). The 5-year survival rate was 70.2% for well differentiated, 53.0% for moderately differentiated, and 32.6% for poorly differentiated adenocarcinoma (Logrank test: p < 0.0001). Disease-specific death was observed in 128 patients (66%), and cardio- or cerebrovascular death accounted for 16 (8%) deaths.

腹膜外アプローチによる腹腔鏡下骨盤内リンパ節切除術は, 少ないトロッカー及び人数で操作可能であり, 閉鎖腔の視野も良く, 炭酸ガス送気(送気圧5mmHg)の影響もなく, 手術侵襲等について更に検討を要する点もあるが, 腹腔からのアプローチに代わりうる方法と考えられた, Between February 1994 and February 1995, we performed retroperitoneal laparoscopic pelvic lymphadenectomy on 7 patients with prostate cancer between 63 and 76 years old, consisting of 6 patients with clinical stage B2, and 1 patient with stage C. Retroperitoneal laparoscopic procedures were performed under general anesthesia. First, the prevesical space was separated by a balloon dissector to create the working space. Then, three trocars were inserted into the retroperitoneal space at the lower abdominal midline. Except for the first patient, only two surgeons were needed to dissect the obturator lymph nodes, under 5 mmHg CO2 insufflation. The mean operating time was 133 minutes for bilateral lymphadenectomy. The mean number of removed lymph nodes was 4.8 on the left side and 4.2 on the right side. The estimated blood loss ranged from 10 to 66 ml. As none of the patients showed node involvement on the microscopic examination of the frozen section, they immediately underwent total prostatectomy. Additionally removed lymph nodes were 0.8 on the left side and 1.5 on the right side. As for intraoperative complications, endotidal CO2 was elevated in the first patient, but the other patients had no complications. Retroperitoneal laparoscopic pelvic lymphadenectomy is a safe and useful procedure, and may facilitate a lymphadenectomy better than a peritoneal procedure.

A woman successfully delivered two children after cadaveric kidney transplantation. She received a kidney graft at the age of 18 years because of end-stage renal failure due to chronic glomerulonephritis. Eighteen months after surgery, she became pregnant. As she was receiving immunosuppressive therapy with cyclosporin, azathioprine, mizoribine and prednisolone, we discontinued mizoribine. The child was delivered by a caesarean section in week 30 of gestation. Both the increase of liver enzymes and the decrease of creatinine clearance were slight and transient. She successfully delivered another child just a few days before the 4th anniversary of her kidney transplantation. Including this patient, we have experienced 11 deliveries by women bearing kidney grafts. Intensive joint management with the obstetric service is necessary to achieve successful delivery without losing the graft.

We report a case of prostate cancer showing a complete remission after LH-RH agonist neoadjuvant therapy. A 69-year-old man was referred to our department complaining of pain on urination and urge incontinence. The serum prostate specific antigen (PSA) level was 41.6 ng/ml. Needle biopsy specimens from both lobes revealed moderately differentiated adenocarcinoma. Chest X-ray, computed tomographic (CT) scan, and bone scintigraphy demonstrated neither distant metastasis nor local invasion. LH-RH agonist was administered on a monthly basis as neoadjuvant therapy. After 4 injections, pelvic lymph node dissection and radical prostatectomy were performed on January 11, 1993. Thorough examination did not reveal any cancer cells in the removed specimen. The patient was discharged 30 days after the operation and has shown no evidence of distant metastasis or local recurrence as long as 19 months later.

We treated two children with 2, 8-dihydroxyadenine urolithiasis for over 7 years. The male prepositus was admitted to the hospital because of anuria when he was 10 months old. Bilateral urinary stones had caused the anuria. The stones were 2, 8-dihydroxyadenine and his APRT activity was low. He has been treated with about 5.0 mg/kg/day of allopurinol without purine diet restriction. His sister, 3 years old at that time, also was found to have a renal stone. She has been treated with about 3.3 mg/kg/day of allopurinol without restricting purine. The allopurinol therapy without purine-restriction resulted in normal growth of both children with neither the recurrence of stone nor renal impairment.

動脈瘤のあるドナー腎を用いた生体腎移植の1例を報告した。1)腎は十分に灌流して冷却すれば阻血によく耐え, 2時間程度であれば血流再開後の腎機能の発現に影響を与えない。2)予想阻血時間が2時間程度なら灌流液は乳酸加リンゲル液で十分である。3)ドナー腎に動脈瘤があっても体外腎手術を適用すれば移植が可能である, A case of living related renal transplantation using a kidney with renal arterial aneurysm is reported. The size of the renal arterial aneurysm was 15 mm in diameter. After ex vivo aneurysm removal, the graft was transplanted to the right iliac fossa. The total ischemic time was 79 minutes, and the urine flow started 5 minutes after declamping. In Japan, eight patients are reported to have successfully received a renal graft after removing its aneurysm extracorporeally. Renal transplantation is possible even when the donor kidney has a renal arterial aneurysm.

72歳男.全身こむら返りが出現し, 芍薬甘草湯が投与され症状は軽快した.その後, 外来で高血圧, 低カリウム血症が出現し, 腹部CTを施行したところ左副腎に最大径1cmの腫瘍が認められた為, 受診した.血漿レニン濃度及び血漿アルドステロン濃度が低値で原発性アルドステロン症が否定的であった為, 内服薬の関与を疑い, 芍薬甘草湯を中止した.低カリウム血症と高血圧は改善した.著明低値を示していた血漿レニン濃度は, 中止後上昇し, やや低めの値ながら正常域に回復した.血漿アルドステロン濃度も中止後速やかに上昇し, 以後安定した.以上の治療経過より, 芍薬甘草湯による偽アルドステロン症と内分泌非活性副腎腫瘍の合併例と診断し, 退院となった.以後外来経過観察中であるが, 内分泌活性の出現及び左副腎腫瘍の増大は認めていない, A 72-year-old man was diagnosed with hypertension, hypokalemia, and left adrenal tumor at another hospital, and was referred to our hospital on suspicion of primary aldosteronism. Investigations revealed low plasma aldosterone concentration, and the left adrenal tumor proved to be nonfunctioning, not hyperfunctioning. "Licorice" had been prescribed for the treatment of recurrent cramps in his calf. After stopping the licorice, his condition changed to normokalemia strongly suggesting that his pseudoaldosteronism had been caused by the drug. We reviewed 140 reports on licorice-induced pseudoaldosteronism in Japan, and found a second patient who might have suffered a similar coincidental nonfunctioning adrenal tumor.

全国多施設の共同研究により, 腎細胞癌に対するn-TNFとn-IFN-αの併用療法による有効性と安全性を検討した.1)腎細胞癌31例においてPRが4例認められ奏効率は12.9%であった.IFN-αが前治療に使用された症例にも有効例が認められたことより, 本併用療法の有用性が示唆された.2)副作用は(35例/36例)に認められ, おもな自他覚的副作用は発熱72.2%, 悪寒・戦慄69.4%, 食欲不振22.2%, 全身倦怠感16.7%であり, おもな臨床検査値異常は白血球減少47.2%, 血小板減少22.2%, GOT上昇16.7%, GPT上昇13.9%であった.ほとんどの症例が解熱剤等の処置あるいは無処置で投与継続可能であった.本併用療法による副作用の増強はほとんどなかった, The combination therapy with natural type human tumor necrosis factor (n-TNF; MHR-24) and human lymphoblastoid interferon-alpha (n-IFN-alpha; MOR-22) was investigated for antitumor effect against renal cell carcinoma in a multiclinic cooperative study throughout Japan. The "Response criteria of Japan Society for Cancer Therapy" were followed for the handling of subjects and the evaluation of antitumor effect. MHR-24 was administered at a daily dosage of 5, 000-10, 000 JRU by intravenous drip and MOR-22 at a dosage of 5, 000, 000 IU daily was administered intramuscularly at the same time. Both drugs were administered for 4 weeks or longer. A total of 36 patients were enrolled as subjects in the study. None of them were classified as ineligible. Five patients, were classified as imperfectly evaluable, and 31, as evaluable for the results of treatment. The responses in the evaluable patients were partial response (PR) in 4 patients, minor response (MR) in 3 patients, no change (NC) in 14 patients and progressive disease (PD) in 10 patients, with a response rate of 12.9%. Adverse reactions to the therapy were investigated in all 36 patients. The frequent subjective and objective reactions that occurred were fever, rigors and shivering, anorexia, and generalized malaise, and the frequent abnormal laboratory findings were leukopenia, thrombocytopenia, elevation of GOT, and elevation of GPT.