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We investigated the optimum initial dose and timing of administration of α1A-adrenoceptor antagonist silodosin for treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH/LUTS). Ninety-eight patients were given a 4 mg dose after breakfast (group A), 4 mg after supper (group B), or 4 mg after breakfast and after supper (group C). At baseline, 4, 8 and 12 weeks after treatment, we assessed International Prostate Symptom Score (IPSS) and quality of life (QOL) index. Twenty-five percent or less improvement of total IPSS and no improvement of QOL index compared with baseline were defined as treatment failure at each evaluation point. Otherwise treatment was considered effective. In group A and group B, patients with treatment failure at 4 or 8 weeks after treatment, the dose of silodosin was increased to 8 mg daily. At the end of the study, 83 patients were evaluable. At 12 weeks after treatment, 20 of the 31 patients in group A and 22 of the 29 patients in group B remained on the 4 mg dose ; silodosin was effective in 65 and 76% of the patients, respectively. When patients with dose escalation were included, silodosin was effective in 81 and 90% of the patients, respectivery. Silodosin was effective in 18 of the 23(78%) patients in group C, although improvement of total IPSS and voiding symptom score of IPSS at 12 weeks after treatment was better in group C than in group A or group B, the difference was not significant. In patients with IPSS less than 20, the degree of improvement of IPSS was similar among the 3 groups. In contrast, in patients with IPSS of 20 or greater the degree of improvement was better in group C than in group B or group C, but the difference was not significant. Storage symptom score of IPSS was significantly improved in all 3 groups without any significant difference among the 3 groups. Three patients (52, 59 and 76 years old) experienced abnormal ejaculation. In conclusion, 4 mg of silodosin daily showed effectiveness against BPH/LUTS, but 8 mg of silodosin daily might be better for patients with severe LUTS.

28歳女.患者は右腰背部痛, 発熱を主訴とした.超音波断層, CTにて右水腎症と尿管下部に腫瘤を認めた, 腫瘤は良性の骨盤内腫瘤と診断され, セカンドオピニオンを求め受診した.逆行性腎盂造影(RP), 尿管鏡を施行したところ, RPでは下部尿管に辺縁整な陰影欠損を認めた.右尿管部分切除術を行い, 術中迅速病理診断にて炎症性偽腫瘍と診断された.尿管膀胱新吻合術を施行したことで, 腎尿管全摘除術を回避し, 上部尿路を温存することができた.病理ではリンパ球, 形質細胞などの慢性炎症細胞浸潤が主体の腫瘤であった.免疫染色でも悪性リンパ腫を示唆する所見を認めず, 尿管に発生した炎症性偽腫瘍と診断した, The patient was a 28-year-old woman. In February 2002, she visited another physician due to acute pyelonephritis. Based on CT findings, a lower ureteral stricture caused by a benign extraureteral tumor was diagnosed. The patient was being monitored by periodic exchange of ureteral stents. In February 2003, the patient visited our department seeking a second opinion. Retrograde pyelography showed an elliptical filling defect in the lower urinary tract. Ureteroscopy showed that the surface of the tumor was mostly smooth, regular and partially papillary. Biopsy was performed, and histological analysis revealed only nonspecific inflammation. In December 2003, based on a diagnosis of benign ureteral tumor, we performed partial resection of the right urinary tract and ureterocystoneostomy. As rapid intraoperative pathological analysis confirmed an inflammatory pseudotumor, total nephroureterectomy was avoided.

対外衝撃波砕石術(ESWL)施行後, Stone street(SS)を発生した症例を対象とし, ステント留置の有用性について検討を行った.対象者530名のうちSSの発生を40例に認め, 事前のステント留置は147例に対し施行された.SS発生率はESWL施行前にステントを留置された(stent)群17.2%, 非留置(in situ)群29.4%であった.20mm以下の無症状の結石はin situで治療することが望ましいと考えられた.21-30mmの結石については, ステントはSSの発生を抑制する可能性があると考えられた.またステント留置中のSS発生例に対しては, ステントの抜去が治療の選択肢の1つとなり得ると思われた, We reviewed the records of the 530 patients with urinary stones (renal stones: 243; ureter stones 287) who received extracorporeal shock wave lithotripsy (ESWL) (MFL5000; Dornier), from January 1995 to July 2002, retrospectively and determined whether the ureteral stent affected the incidence rate of stone street (SS). We also assessed the effect of ureteral stent on the subsequent management for SS. Forty patients (7.5%) developed SS. Twenty patients were inserted a ureteral stent prior to ESWL (stent group), and 20 patients were performed ESWL without a ureteral stent (in situ group). In the stent group, the most common (80.0%) location for SS was in the upper third ureter, while in the in situ group, SS mostly developed in the distal third ureter (60.0%). The incidence of SS did not differ significantly between the two groups when the size of renal and ureter stones was below 30 and 20 mm, respectively. When the renal stones were larger than above 30 mm, the incidence of SS in the stent group was significantly higher than that in the in situ group. SS disappeared spontaneously with stone passage in 10 of the patients in in situ group, but in only 1 patient in the stent group. In the stent group, 15 patients were treated for SS by removal of ureteral stent regardless of stone diameter. We conclude that ESWL should be performed without a ureteral stent when the stone diameter is below 20 mm. When the ureteral stent is thought to interfere with the delivery of stone fragments, the decision to remove it should be made as soon as possible.

36歳男性.患者は頻尿にて近医を受診し, 超音波検査にて骨盤内の腫瘤を指摘され, 紹介入院となった.所見では, 下腹部に可動性のない手拳大の腫瘤を触知し, 血中S100蛋白の軽度高値を認めた.超音波断層法では下腹部に嚢胞状の腫瘤を, CTでは骨盤内の仙骨前面に一部石灰化を伴った内部不均一な16×12×11cmの腫瘤を認め, MRIでは実質部分はT1強調像で低信号, T2強調像で不均一な高信号を示した.更に血管造影では正中仙骨動脈から腫瘍への栄養血管を認め, 生検ではS100免疫染色陽性の良性神経鞘腫で, 開腹下に腫瘍摘出術を行った.腫瘍の骨盤内占拠で術中操作困難のため腫瘍被覆切開で内容を核出し, 強固な仙骨癒着部の一部を残して腫瘍を摘出した.病理診断はAntoni A型の良性神経鞘腫であった.術後血中S100蛋白は低下し, 術後1年6ヵ月経過で再発の徴候はない, A 36-year-old man with a complaint of pollakisuria visited our hospital. A non-displaceable, palm-sized tumor was palpable in the lower abdomen. Laboratory data were normal except for slightly high serum S100 protein. Intravenous pyelography revealed hydronephrosis on the right side and deviation of the bladder to the left. Computed tomogaphy revealed a heterogenous tumor in the pelvis with a cystic lesion and calcification. The tumor was 16 x 12 x 11 cm in size and in contact with the sacrum. The tumor was extirpated following diagnosis as a benign schwannoma by needle biopsy. The pelvic cavity was occupied by the tumor rigidly adhered to the sacrum. Although serious complications, such as bleeding and nerve injury were apprehended, we incised the tumor capsule and enucleated the contents as much as possible. The histopathological diagnosis of the resected specimen was benign schwannoma, type Antoni A. In the last 10 years, 37 cases of pelvic schwannoma have been reported in the Japanese literature. In most of them, surgical extirpation was difficult to perform because of adhesion to the sacrum. If the tumor is confirmed benign from histopathologic findings preoperatively, tumor enucleation may become a therapeutic option.

1997～2001年に当院で尿路結石症と診断された422名を対象に検討した.年間有病率(人口10万対)は, 上部尿路結石は男性では平均231.6名, 女性では128.8名で, 下部尿路結石では, 男性では平均26.1名, 女性では平均10.8名であった.初発再発例を合計すると, 上部尿路結石90.8%, 下部尿路結石9.2%であった.上部尿路結石の年齢階級別罹患率では好発年齢が男女共50歳代にピークが認められた.下部尿路結石の年齢階級別罹患率では男女とも60歳以上に多く認められた.のべ398例の上部尿路結石の治療法は, 経尿道的尿管砕石術施行例が63例で, 他院紹介による体外衝撃波砕石術施行例は45例であった.下部尿路結石における治療法は, 経尿道的砕石術が79.5%に施行されたが, 大きい膀胱結石には開腹術が選択された.結石分析では, 上部尿路結石では男女共にカルシウム含有結石が多く, 下部尿路結石においては男女とも感染結石が多かった, An epidemiological study of 422 stone-formers who visited our hospital from 1997 to 2001 was conducted. The mean annual prevalence and incidence of both upper and lower urinary tract stones were higher than what was found in a nationwide urolithiasis survey carried out in Japan in 1995. The incidence of upper and lower urinary tract stones was 90.8% and 9.2%, respectively. The frequency of lower urinary tract stones was higher than that found in the previously mentioned nationwide study. The male-to-female ratio of upper and lower urinary tract stones was 1.68:1 and 2.25:1, respectively. The frequency in females was higher in this study than that found in the nationwide survey. The peak age for incidence of upper urinary tract stones is 50s in males and females. In the treatment of upper urinary tract stones, ureteroscopic lithotripsy was carried out more often than shock wave lithotripsy (SWL), because our hospital had no SWL device. Many endoscopic lithotripsy procedures were performed to treat stones located in the lower urinary tract. Of the upper urinary tract stones 83.7% were composed of calcium, the incidence of uric acid stones was high (6.6%), whereas the incidence of infectious stones was low (1.9%). For lower urinary tract stones, the frequency of infectious stones was high (52.6%). In the present study, the epidemiological features were as follows: high annual prevalence and incidence, high frequency of lower urinary tract stones, high frequency in females, many endoscopic treatment procedures and high frequency of uric acid stones in the upper urinary tract.

39歳男性.患者は動悸で受診し, 内服薬を自己判断で休薬し, 症状の増悪で入院となった.血液検査では血中カテコールアミン(CA)はエピネフリン(E)およびノルエピネフリン(NE)の異常高値とドーパミン(DA)の高値を認め, 尿中CAはE, NE, DA, バニリルマンデル酸(VMA)が異常高値であった.CTでは右腎上方に7.5×5×7cmの軟部腫瘍を認め, 中心部は不均一な低吸収域を呈していた.MRIのT1ならびにT2強調では腎実質と等信号で内部に高信号域を認め, 131I-MIBGシンチグラフィでは右副腎の病変に一致して強い集積像を認めた.これらより右副腎腫瘍を疑い経腹的右副腎腫瘍摘出術を施行した.術後2時間後に意識レベルが混濁し, 多量の発汗を認め, 血糖値38mg/dlと異常低値が生じたものの, 高カロリー輸液と50%ブドウ糖の点滴静注により, 症状は消失し, 血中と尿中CA値も正常化した.なお, 病理所見褐では色細胞腫であった, We report a case of severe hypoglycemia following resection of pheochromocytoma. A 39-year-old male was admitted to our hospital with a chief complaint of palpitation. Blood pressure and fasting blood glucose were within the normal range. Computed tomography and magnetic resonance imaging revealed a right adrenal tumor (7.5 x 5 x 7 cm) and 131I-MIBG scintigraphy showed marked tumor uptake of isotope. As plasma and urinary catecholamine levels were very high, a clinical diagnosis of pheochromocytoma was established. Doxazosin and propranolol were administered for 43 days prior to adrenalectomy. During intensive care monitoring 2 hours postoperatively, the patient became drowsy and began to sweat. Although blood pressure remained stable, severe hypoglycemia (38 mg/dl) and hyperinsulinism (63.67 microU/ml) were confirmed. Infusion of 50% glucose improved these symptoms and plasma glucose level and insulin secretion normalized within 15 days of surgery. We also reviewed 25 cases of hypoglycemia after resection of pheochromocytoma. We recommend close monitoring of blood glucose for at least 6 hours after adrenalectomy for pheochromocytoma.

症例1(83歳男).CAPD導入100日後に右鼠径部の膨隆を認め, 右鼠径ヘルニアの診断でヘルニア根治術を行った.術前, 術後の透析については, 血液透析管理としていたが, 術後4日目に患者本人の自己判断にて, CAPDを施行し翌日来院した.理学所見では, 下腹部および鼠径部に膨隆, 浮腫などを認めず, その後5回の血液透析を施行した後, 術後16日目にCAPDを再開した.症例2(73歳女).CAPD導入248日目頃より右鼠径部の膨隆を自覚し, 右鼠径ヘルニアの診断でヘルニア根治術を行った.術後6日目よりCAPDを再開した.術後3ヵ月経過したが, 再発を認めず, 現在もCAPDを継続している, We report two cases of subacute inguinal swelling in uremic patients on continuous ambulatory peritoneal dialysis (CAPD). Computed tomography, scintigraphy demonstrated a mass in the right groin. Surgical repair of an inguinal hernia resulted in complete resolution of the inguinal swelling. Both patients could restart continuous ambulatory peritoneal dialysis, without complication.

症例1:19歳男.腹痛と腹部腫瘤を主訴とし, 腹部CT上左後腹膜腔に10cm大の腫瘍, 肝, 肺に多発性の腫瘍を認め, 生検でYolk sac tumorであった.進行性胚細胞腫瘍と診断し, VIP変法を4コース施行し, 残存した病変に後腹膜リンパ節郭清術を施行した.その後, AFPの再上昇と脳転移を生じ頭部放射線照射, 脳動注, BEP療法を中心に全身化学療法を行った.その後左精巣に小石灰化像を認め, 左高位精巣摘出術を行った.10年後に後縦隔リンパ節腫大があり, 腫瘍摘出し, 病理学的には高分化型腺癌であった.症例2:57歳男.検診で胸部X線異常陰影を指摘され, 頸部リンパ節腫大, 肺, 後腹膜腫瘍があり, 原発性性腺外胚細胞腫瘍としてBEP療法が施行された.VIP療法と変法を併せて3コース追加したが後腹膜に残存病変を認め, 後腹膜リンパ節郭清術を施行した.超音波検査上右精巣は結節状の小石灰化像, 左精巣に砂粒状の微小な高エコー像を認め, 両側高位精巣摘出術を行った.2例とも精巣原発が示唆された, Two cases of germ cell neoplasm retrospectively considered to have been of testicular origin are reported. Case 1. A 19-year-old male with brain, liver and retroperitoneal tumors was diagnosed with yolk sac tumor by retroperitoneal tumor biopsy. After multidisciplinary treatment, a region of calcification was detected in the left testis on scrotal sonography and left high inguinal orchiectomy was performed. Case 2. A 57-year-old male with neck, lung and retroperitoneal tumors was diagnosed with yolk sac tumor by supraclavicular biopsy. From initial examination, scrotal sonography revealed a small calcified lesion in the right testis. After chemotherapy, high inguinal orchiectomy and retroperitoneal lymphadenectomy were simultaneously performed. Pathologic evaluation of these testicular specimens revealed calcification and a fibrous scar in correspondence with the clinical diagnosis. These changes were considered as scars of the primary testicular tumor due to burned-out tumor or the result of reaction to chemotherapy. Since a primary tumor of testicular origin may exist in the extragonadal germ cell tumor, it is important to examine the intrascrotal contents in detail in the case of so-called extragonadal germ cell tumors with palpably normal testes. In such cases, there are two possible conditions, an occult testicular tumor and a burned-out testicular tumor. We briefly reviewed 42 such cases in the Japanese literature. It appears that there are very few true extragonadal germ cell tumors, and that the possibility of primary testicular origin metastasizing from viable occult testicular tumor or burned-out testicular tumor with spontaneous regression is high in retroperitoneal germ cell tumors.

夜間多尿を伴った膀胱機能障害に夜間尿道留置カテーテルが有用であった3例を経験した.症例1は45歳女性.てんかん発作で精神科入院中に尿閉となり, 退院後に排尿困難で受診した.尿意低下を認め, α遮断薬投与で自排尿可能となったが, 起床時残尿が多く, 間欠式バルーンカテーテルの夜間尿道留置を開始し, 残尿はほぼ消失した.症例2は28歳女性.出生直後よりL2以下の二分脊椎による排尿機能障害で, 12歳時に左膀胱尿管新吻合術施行後も夜間の尿失禁と頻回の腎盂腎炎を繰り返していた.24時間排尿記録で夜間多尿が判明し, 日中のCICに加え, 間欠式バルーンカテーテルの夜間尿道留置を行い, 腎盂腎炎の再発はなく夜間の尿失禁は消失した.症例3は66歳女性.多発性脳梗塞と同時に便・尿失禁, 排尿困難が出現し, 夫によるCICでも夜間多尿があり, 間欠式バルーンカテーテルの夜間尿道留置を行い, 尿失禁は消失した, Clean intermittent catheterization is a well-known procedure of urinary drainage for patients who are unable to empty the bladder sufficiently. However, some patients with bladder dysfunction and nocturnal polyuria fail to obtain the benefits of intermittent catheterization and have annoying symptoms of nocturnal incontinence and low-compliance bladder, which threaten both their quality of life and renal function. We report the usefulness of nocturnal urethral indwelling catheterization using a specially designed catheter to treat patients (three women) with lower urinary tract dysfunction and nocturnal polyuria. Case 1: A 45-year-old woman with mental retardation suffered from difficulty of micturition and residual urine. A nocturnal urethral indwelling catheter freed her from difficulty with micturition and residual urine. Case 2: A 28-year-old woman with spina bifida and neuropathic bladder dysfunction suffered from urinary incontinence and recurrent pyelonephritis. The recurrent pyelonephritis was prevented and bladder compliance was improved with use of the nocturnal urethral indwelling catheter. Case 3: A 66-year-old woman with cervical myelopathy and multiple episodes of cerebral infarction suffered from nocturnal urinary incontinence. She underwent clean intermittent catheterization by her husband. Use of the nocturnal urethral indwelling catheter solved the problem of her nocturnal incontinence and relieved her husband of her nocturnal care. Nocturnal urethral indwelling catheterization is useful for treatment of nocturnal incontinence and recovery of bladder compliance in patients with lower urinary tract dysfunction and nocturnal polyuria.

46歳男.主訴は肉眼的血尿, 左腰背部痛.腹部超音波検査で左腎下極に直径約8cmの腫瘤性病変を認めた.腎MRIで腫瘤中央部はT1でlow intensity, T2でhigh intensityでの出血と考えられた.辺縁部はT1, T2共にhigh intensityで, 血中エリスロポエチン高値を伴う赤血球増多症とCRP高値を認めた.傍大動脈リンパ節に多発性リンパ節腫大を有している為, T2N2M0 IV期の赤血球増多症を伴った左腎腫瘍と診断された.肉眼的血尿は止血剤投与でまもなく消失した.赤血球増多症の増悪傾向を認めた為, 約800mlの瀉血を施行し根治的左腎摘除術を施行した.左腎下極は手拳大に腫大し, 傍大動脈リンパ節腫大を認めた為, リンパ節郭清を施行した.術後は順調に経過して術前に認められた赤血球増多症や血中エリスロポエチン高値は術後正常化した.他に赤血球増多症の原因を認めず, 臨床経過より後述するエリスロポエチン産生腫瘍の診断基準を満たすことから, 本症例をエリスロポエチン産生腎細胞癌と診断した, The patient was a 46-year-old man with gross hematuria and left lumbar pain. Computed tomography revealed a large left renal tumor with hemorrhage. Serological examination revealed polycythemia and a high erythropoietin level. After left radical nephrectomy, polycythemia and serologically high level of erythropoietin disappeared. Histopathological findings showed renal cell carcinoma composed of spindle cells. Based on the above mentioned clinical course, we diagnosed this case as erythropoietin-producing renal cell carcinoma with polycythemia. It is suggested that erythropoietin not only causes polycythemia but also stimulates proliferation of the tumor, because the majority of erythropoietin-producing renal cell carcinomas have been reported to be highly advanced. This patient had no evidence of disease one year after the operation.

55歳女.突然の右側背部痛を自覚し, 次第に増強して嘔吐も出現した.検査所見で白血球, GOT, GPT, LDHの高値を認め, 造影CTで右腎の上半分に境界不鮮明な造影不良像を認めた.右腎梗塞と診断し, 緊急に血管造影を考慮したが拒否され, 全身投与による線溶療法を選択した.直ちにアクチバシン(tPA)1200万単位を1時間かけて静注し, 更にウロキナーゼ(UK)12万単位を24時間持続静注投与した.tPAは3日間, UKは8日間使用した.第3病日以降GOT, GPT, LDHは低下傾向を示し, 第6病日にはGOT, GPTは正常化し, LDHも低下を続けた.画像所見も梗塞巣に造影効果を認め, 梗塞血管が再開通したものと判断した.第14病日に退院し, その後異常はない, A 55-year-old woman affected by mitralism presented with severe right flank pain of sudden onset. Biochemical examinations showed elevated serum lactate dehydrogenase, and abdominal enhanced computed tomography (CT) demonstrated hypoperfusion of the right kidney. Infarction of the right kidney was highly suspected, and she was immediately treated by systemic intravenous injection of 12, 000, 000 units of tissue plasminogen activator (tPA) per day for 3 days and 120, 000 units of urokinase per day for 8 days. After the thrombolytic therapy, abdominal enhanced CT revealed marked improvement of enhancement of right renal parenchyma and decrease of serum LDH. Although thrombolytic therapy with selective intraarterial infusion is considered to be a useful treatment modality for renal infarction, systemic administration of tPA may also be effective judging from the clinical course of the present case.

43歳男.患者は約17年前から陰嚢左側下極に小腫瘤を自覚していた.腫瘤は精巣, 精巣上体, 精索とは無関係に存在しており, 血液検査および尿検査では異常は認められなかった.陰嚢皮下組織由来の良性腫瘍と診断し, 局所麻酔下に腫瘍茎の基部で切断して皮膚とともに腫瘍を摘出した.その結果, 腫瘍は肉様膜と連続しており, 被膜は不明瞭であった.腫瘍細胞は平滑筋の分化を認め, H-E染色で淡紅色に染まり, 種々の方向に錯綜する索状配列を呈していた.以上より, 肉様膜から発生した単発性陰部平滑筋腫と診断し, 現在まで再発の徴候は認められず, 外来にて経過観察中である, We report a case of solitary genital leiomyoma arising from the tunica dartos of the scrotum. A 43-year-old man complained of a slightly tender left scrotal mass that had enlarged over approximately 17 years. On physical examination, the tumor was pedunculate and attached to the lower pole of the left scrotum. The tumor was clearly separate from scrotal contents such as the testis, epididymis, and spermatic cord. Ultrasonography showed the tumor to be 20.0 X 23.5 mm in diameter. Other laboratory examination findings were normal. Under local anesthesia, the tumor was resected at its base with overlying skin. On histopathological examination, the tumor consisted of interlacing bundles of smooth muscle cells, which were positive for vimentin, desmin, and a-actin. The tumor was diagnosed as leiomyoma arising from the scrotal tunica dartos. As solitary genital leiomyoma of the tunica dartos is rare, we have presented this case history and reviewed 23 cases that occurred in Japan.

39歳男性.患者は, 33歳時から左陰嚢の腫大と発熱を繰り返し, 近医で左精巣上体炎として抗生剤治療を受けていた.その後, 38度台の発熱, 左陰嚢からの排膿で著者らの施設へ受診となり, 陰嚢内膿瘍を疑い膿瘍切除術を施行したが, 膿瘍は精巣上体や尿道と離れており原因特定はできなかった.そして, さらに11ヵ月後, 再度39度台の発熱と左陰嚢から会陰部までの腫脹が生じたため患者は入院となったが, MRIでは膿瘍は精巣と尿道海綿体間にあり, 尿道海綿体との境界が不明瞭であった.そのため内視鏡検査を施行したところ, 球部尿道に経2mmの瘻孔を認め, 膀胱瘻を増設して膿瘍切除術を施行した.病理所見では結合組織内に炎症細胞が浸潤し, 肉芽と膠原線維が著明に増加していた.術後は順調に解熱し, 再感染も認めず治癒した, We report a case of perineal subcutaneous abscess due to urethral fistula in a patient with spinal cord injury. A 39-year-old male visited our hospital complaining of left scrotal swelling and fever. The left scrotum and perineal skin were swollen to the size of a goose egg, and pus was discharged from the perineal swollen bump. Magnetic resonance imaging (MRI) suggested an urethral fistula with a large subcutaneous abscess. The abscess was resected with debridement of necrotic tissue, and a cystostomy was placed. Endoscopy revealed a fistula in the bulbar urethra. The characteristics of this rare entity are discussed.

排尿障害を有する前立腺肥大症の患者24例を対象に, TZP-4238の尿流動態におよぼす影響ならびに有効性, 安全性, 有用性を検討した。1)自覚症状改善度の改善率は52.9%であった。2)尿流率のノモグラムはMFRおよびAFRともに, 投与後, 有意な改善を示した。膀胱内圧では投与後, 最大膀胱容量の有意な減少が認められたが, このとき有効膀胱容量は投与前後で変化が認められなかった。これらを総合した尿流動態の改善率は43.8%であった。3)超音波断層撮影による前立腺計測では投与後, 有意な縮小を認め, 縮小以上の改善度は57.1%であり, その縮小率は15.4%であった。4)有効性評価における改善率は, 58.8%であった, Twenty four cases of benign hypertrophy with bladder outlet obstruction were treated with 17 alpha-acetoxy-6-chloro-2-oxa-4, 6-pregnadiene-3, 20-dione (TZP-4238), and the effects on urodynamic parameters, clinical efficacy, safety, and usefulness were evaluated. Improvement rate of subjective rate of subjective symptoms was 52.9%. Obstructive symptoms improved more prominently than irritation symptoms. A significant improvement in flow rate of nomograms for maximum flow rate (MFR) and average flow rate (AFR) accompanied with the decrease in the prostatic weight were observed. However, no changes were observed on the urethral sphincter electromyography and the urethral pressure profile. A significant decrease of maximum cystometric capacity was observed, although the effective cystometric capacity was not changed. The overall improvement rate for urodynamic parameters was 43.7%. A significant decrease in weight and diameter of the prostate was observed. The prostatic weight decreased in 57.1%, and the average reduction rate was 15.4%. The overall improvement rate concerning clinical efficacy evaluating both subjective symptoms and objective parameters was 58.8%. Adverse reactions were observed in 5 cases. They were judged as not clinically problematic. Taking into account clinical safety and clinical efficacy, the clinical usefulness was 50.0%. TZP-4238 was considered to be an appropriate agent for treating patients with benign prostatic hypertrophy with bladder outlet obstruction.

1)自覚症状のうち骨関節痛は23例全例に存在しており, 手術後は再発例を除く87%に改善を見た。2)骨単純X線所見では, 手術前は手指骨と頭蓋骨の骨変化の程度が大きく, 手術後これらの約90%が改善した。一方, 椎骨と歯槽骨の改善率は低かった。3)SPA法とDIP法による手術後の骨塩量の改善率はそれぞれ75%, 83%で, 同性同年代の正常者と対比した%骨塩量も手術後は有意に増加した。4)手術後の骨塩量の変化は5つのパターンを示し, その分析により移植腺機能の把握に有用である可能性が示唆された。5)上皮小体摘除術後の骨所見は, 直接的には手術の効果を表わすが, 間接的には移植腺の機能をも反映するものと考えられた, We evaluated the changes of the bone lesions and their relative bone findings before and after parathyroidectomy in 23 patients with secondary hyperparathyroidism. Before the operation, all patients had bone and/or joint pain. In radiographic findings, subperiosteal bone resorption of the hand and a salt and pepper coloration of the skull were observed in all patients. Rugger jersey spine and the disappearance of the lamina dura were observed in about 90% of the patients. The bone mineral contents measured by single photon absorptiometry and digital image processing method had decreased in all of the patients compared with the mean values in sex- and age-matched controls. After the operation, the bone and/or joint pain had disappeared excluding three patients with recurrent hyperparathyroidism. The bone changes of the hand and the skull had improved in about 90% of the patients. However, the improvement rate was low in the vertebral and dental bone changes. The bone mineral contents increased significantly compared with the preoperative values. In recurrent cases, transient increase of the bone mineral contents was observed postoperatively. However, their values, were decreased gradually with the elevation of parathyroid hormone level. The evaluation of the bone lesions before and after parathyroidectomy not only indicates the effectiveness of the operation but also illustrates the function of the autotransplanted parathyroid tissues. We conclude that regular examination of the bone lesions after parathyroidectomy, paying attention to recurrent hyperparathyroidism and/or graft function, is mandatory.

特別養護老人ホームの入寮者を対象に痴呆, ADLと排尿障害について調査した。ADLが低いほど, 痴呆度が高度なほど, 尿失禁の割合が増加した。排尿動態検査では, 49名中膀胱機能正常が25名, 過活動が16名, 低活動は8名であった。痴呆はないが尿失禁を認める者は, 膀胱機能の異常を認めた, This report shows the relation between daily activities, dementia and urinary disturbance. The subjects consisted of 44 males and 110 females with an average age of 80 years (ranged from 57 to 102). We evaluated the daily activities, underlying diseases, state of urination and the intelligence by the scale of Hasegawa. The persons with diapers had a higher degree of dementia than those who could go to the lavatory. As the degree of dementia aggravated, the incidence of urinary incontinence significantly increased. Urodynamic studies were performed on 49 persons who had urinary disturbance. There were 25 persons with normal vesical function, 16 with overactive vesical function, and 8 with underactive vesical function. Since all of the incontinent persons without dementia had abnormal vesical function, pharmacologic therapy was expected to be effective for them to improve incontinence. Half of the incontinent persons with dementia had normal vesical function. Mental and physical disabilities seemed to be the main factors causing incontinence in these persons. The multidisciplinary approach including medication, behavior treatment and awareness of the nursing staff is important and effective to reduce urinary incontinence.

The first case was in a 48-year-old man admitted with a chief complaint of macroscopic hematuria and sense of residual urine. A tumor in the diverticulum of the bladder was detected by cystoscopy, computed tomography (CT) and magnetic resonance imaging (MRI). We made the diagnosis of an invasive tumor in the diverticulum of the bladder. Total cystourethrectomy and ileal conduit diversion was performed. Histopathological finding was transitional cell carcinoma including squamous cell carcinoma. Adjuvant chemotherapy was performed. No recurrence and metastasis has been recognized for 12 months. The second case was a 56-year-old man having an intradiverticular tumor diagnosed by cystoscopy, CT, and MRI. Total cystectomy and ileal conduit diversion was performed. Histopathological findings was squamous cell carcinoma. No recurrence has been recognized for 8 months. The last case was an 81-year-old man. The patient had the complication of a primary progressive squamous cell carcinoma of the skin. Transurethral resection of diverticular tumor was performed under the diagnosis of superficial tumor. Histopathological findings revealed transitional cell carcinoma. One hundred and sixty one cases of tumor in the diverticulum of the bladder were reviewed. Importance of aggressive treatment including total cystectomy was emphasized.

症例は39歳の男性で, 1990年に両側黒点・視野欠損, 左側霧視, 口腔内アフタ, アクネ様皮疹が出現, 1年後, 下肢のふるえ, しびれ感, 歩行障害等の錐体路徴候, 小脳失調を認め, 神経ベーチェット病と診断された.排尿症状については3年後に尿失禁が出現し, その程度は次第に増強し, 1994年4月に泌尿器科を受診した.尿流動態検査では, 膀胱内圧測定において初発尿意時膀胱容量は184ml, 最大尿意時膀胱容量は254ml とほぼ正常であった.しかし, 蓄尿時に弱い無抑制収縮と同時に括約筋収縮の増強を認め, 排尿括約筋協調不全の状態で, 下腹部を叩打して排尿を行っていた, Behcet disease is a systemic vasculitis of unknown cause with variable clinical features. The central nervous system may also be involved in about 10% of the patients with Behcet disease. Half of them show marked central nervous system symptoms and are diagnosed as neuro-Behcet disease. Voiding symptom is seen in about 5% of the patients with neuro-Behcet disease. We report a case of neuropathic vesico-urethral dysfunction in a 39-year-old man with neuro-Behcet disease. Its radiological and urodynamic features and treatment are also presented with some discussion.

正常成人の夜間の陰茎勃起現象は, 1時間20～25分ごとに約20～40分間生じている.勃起時の陰茎の周径は約4 cm太くなり, 硬さは約85%(RigiScanの硬度指標)であった.夜間陰茎硬度・周径連続測定方法によりインポテンスの診断, とくに器質性, 機能性勃起不全の鑑別は信頼度の高いものになると思われる, This paper briefly reviews diagnostic examinations for penile erectile dysfunction and mainly refers to a newly developed ambulatory system of RigiScan which enables simultaneous recording of penile circumferential expansion and rigidity, introducing the latest values of variables of penile tumescence and rigidity in the Japanese without erectile dysfunction.

直腸癌根治術後, 尿流体力学検査を含めた諸検査を行い, 外来にて尿路管理を行っている患者48例をretrospectiveに解析した.1)リンパ節郭清の程度が大きいほど, 間歇的自己導尿から自排尿への移行は困難であった.2)低位前方切除術後の71.4%, Miles手術後の51.9%が間歇的自己導尿を離脱し, 自力排尿へ移行しえた.3)強い排尿困難を合併した症例でも, 間歇的自己導尿の早期導入により術後数ヵ月すればカテーテルの助けを借りることなく, 腹圧排尿が可能になる症例が多く, この移行は術後1年以内に集中した.4)最高尿道閉鎖圧は, 自排尿可能(catheter free)群, 間歇的自己導尿群ともに低下していた.5)直腸癌根治手術の術後排尿障害をきたした場合, 自己導尿法を中心とした治療は現在のところ有効な手段である, Of the patients who had had a urodynamic examination during the five year period from 1982 to 1987 in our clinic, 48 patients underwent operations for rectal cancer prior to the study. In 35 of them, the operation mode was known. If the pelvic nerve is damaged by operative modes for rectal cancer, urinary disturbances of severe kinds may occur. In spite of such disturbances, 71.4% of those who had had excision of the low anterior part and 51.9% of those with Miles' operation could be weaned from the clean intermittent self-catheterization and take up spontaneous urination. Even in patients who developed severe dysuria, if catheterized at an early stage, many of them could urinate by abdominal pressure with in several months after operation, without the aid of a catheter. This transition took place mostly within one year after operation. When a patient develops dysuria after radical surgery for rectum cancer, treatment mainly with self-catheterization is an effective method at present.

We report a case of solitary genital leiomyoma arising from the tunica dartos of the scrotum. A 43-year-old man complained of a slightly tender left scrotal mass that had enlarged over approximately 17 years. On physical examination, the tumor was pedunculate and attached to the lower pole of the left scrotum. The tumor was clearly separate from scrotal contents such as the testis, epididymis, and spermatic cord. Ultrasonography showed the tumor to be 20.0 X 23.5 mm in diameter. Other laboratory examination findings were normal. Under local anesthesia, the tumor was resected at its base with overlying skin. On histopathological examination, the tumor consisted of interlacing bundles of smooth muscle cells, which were positive for vimentin, desmin, and a-actin. The tumor was diagnosed as leiomyoma arising from the scrotal tunica dartos. As solitary genital leiomyoma of the tunica dartos is rare, we have presented this case history and reviewed 23 cases that occurred in Japan.

We reviewed the records of the 530 patients with urinary stones (renal stones: 243; ureter stones 287) who received extracorporeal shock wave lithotripsy (ESWL) (MFL5000; Dornier), from January 1995 to July 2002, retrospectively and determined whether the ureteral stent affected the incidence rate of stone street (SS). We also assessed the effect of ureteral stent on the subsequent management for SS. Forty patients (7.5%) developed SS. Twenty patients were inserted a ureteral stent prior to ESWL (stent group), and 20 patients were performed ESWL without a ureteral stent (in situ group). In the stent group, the most common (80.0%) location for SS was in the upper third ureter, while in the in situ group, SS mostly developed in the distal third ureter (60.0%). The incidence of SS did not differ significantly between the two groups when the size of renal and ureter stones was below 30 and 20 mm, respectively. When the renal stones were larger than above 30 mm, the incidence of SS in the stent group was significantly higher than that in the in situ group. SS disappeared spontaneously with stone passage in 10 of the patients in in situ group, but in only 1 patient in the stent group. In the stent group, 15 patients were treated for SS by removal of ureteral stent regardless of stone diameter. We conclude that ESWL should be performed without a ureteral stent when the stone diameter is below 20 mm. When the ureteral stent is thought to interfere with the delivery of stone fragments, the decision to remove it should be made as soon as possible.

The patient was a 28-year-old woman. In February 2002, she visited another physician due to acute pyelonephritis. Based on CT findings, a lower ureteral stricture caused by a benign extraureteral tumor was diagnosed. The patient was being monitored by periodic exchange of ureteral stents. In February 2003, the patient visited our department seeking a second opinion. Retrograde pyelography showed an elliptical filling defect in the lower urinary tract. Ureteroscopy showed that the surface of the tumor was mostly smooth, regular and partially papillary. Biopsy was performed, and histological analysis revealed only nonspecific inflammation. In December 2003, based on a diagnosis of benign ureteral tumor, we performed partial resection of the right urinary tract and ureterocystoneostomy. As rapid intraoperative pathological analysis confirmed an inflammatory pseudotumor, total nephroureterectomy was avoided.

A 36-year-old man with a complaint of pollakisuria visited our hospital. A non-displaceable, palm-sized tumor was palpable in the lower abdomen. Laboratory data were normal except for slightly high serum S100 protein. Intravenous pyelography revealed hydronephrosis on the right side and deviation of the bladder to the left. Computed tomogaphy revealed a heterogenous tumor in the pelvis with a cystic lesion and calcification. The tumor was 16 x 12 x 11 cm in size and in contact with the sacrum. The tumor was extirpated following diagnosis as a benign schwannoma by needle biopsy. The pelvic cavity was occupied by the tumor rigidly adhered to the sacrum. Although serious complications, such as bleeding and nerve injury were apprehended, we incised the tumor capsule and enucleated the contents as much as possible. The histopathological diagnosis of the resected specimen was benign schwannoma, type Antoni A. In the last 10 years, 37 cases of pelvic schwannoma have been reported in the Japanese literature. In most of them, surgical extirpation was difficult to perform because of adhesion to the sacrum. If the tumor is confirmed benign from histopathologic findings preoperatively, tumor enucleation may become a therapeutic option.

An epidemiological study of 422 stone-formers who visited our hospital from 1997 to 2001 was conducted. The mean annual prevalence and incidence of both upper and lower urinary tract stones were higher than what was found in a nationwide urolithiasis survey carried out in Japan in 1995. The incidence of upper and lower urinary tract stones was 90.8% and 9.2%, respectively. The frequency of lower urinary tract stones was higher than that found in the previously mentioned nationwide study. The male-to-female ratio of upper and lower urinary tract stones was 1.68:1 and 2.25:1, respectively. The frequency in females was higher in this study than that found in the nationwide survey. The peak age for incidence of upper urinary tract stones is 50s in males and females. In the treatment of upper urinary tract stones, ureteroscopic lithotripsy was carried out more often than shock wave lithotripsy (SWL), because our hospital had no SWL device. Many endoscopic lithotripsy procedures were performed to treat stones located in the lower urinary tract. Of the upper urinary tract stones 83.7% were composed of calcium, the incidence of uric acid stones was high (6.6%), whereas the incidence of infectious stones was low (1.9%). For lower urinary tract stones, the frequency of infectious stones was high (52.6%). In the present study, the epidemiological features were as follows: high annual prevalence and incidence, high frequency of lower urinary tract stones, high frequency in females, many endoscopic treatment procedures and high frequency of uric acid stones in the upper urinary tract.

We report a case of severe hypoglycemia following resection of pheochromocytoma. A 39-year-old male was admitted to our hospital with a chief complaint of palpitation. Blood pressure and fasting blood glucose were within the normal range. Computed tomography and magnetic resonance imaging revealed a right adrenal tumor (7.5 x 5 x 7 cm) and 131I-MIBG scintigraphy showed marked tumor uptake of isotope. As plasma and urinary catecholamine levels were very high, a clinical diagnosis of pheochromocytoma was established. Doxazosin and propranolol were administered for 43 days prior to adrenalectomy. During intensive care monitoring 2 hours postoperatively, the patient became drowsy and began to sweat. Although blood pressure remained stable, severe hypoglycemia (38 mg/dl) and hyperinsulinism (63.67 microU/ml) were confirmed. Infusion of 50% glucose improved these symptoms and plasma glucose level and insulin secretion normalized within 15 days of surgery. We also reviewed 25 cases of hypoglycemia after resection of pheochromocytoma. We recommend close monitoring of blood glucose for at least 6 hours after adrenalectomy for pheochromocytoma.

We report a case of perineal subcutaneous abscess due to urethral fistula in a patient with spinal cord injury. A 39-year-old male visited our hospital complaining of left scrotal swelling and fever. The left scrotum and perineal skin were swollen to the size of a goose egg, and pus was discharged from the perineal swollen bump. Magnetic resonance imaging (MRI) suggested an urethral fistula with a large subcutaneous abscess. The abscess was resected with debridement of necrotic tissue, and a cystostomy was placed. Endoscopy revealed a fistula in the bulbar urethra. The characteristics of this rare entity are discussed.

Clean intermittent catheterization is a well-known procedure of urinary drainage for patients who are unable to empty the bladder sufficiently. However, some patients with bladder dysfunction and nocturnal polyuria fail to obtain the benefits of intermittent catheterization and have annoying symptoms of nocturnal incontinence and low-compliance bladder, which threaten both their quality of life and renal function. We report the usefulness of nocturnal urethral indwelling catheterization using a specially designed catheter to treat patients (three women) with lower urinary tract dysfunction and nocturnal polyuria. Case 1: A 45-year-old woman with mental retardation suffered from difficulty of micturition and residual urine. A nocturnal urethral indwelling catheter freed her from difficulty with micturition and residual urine. Case 2: A 28-year-old woman with spina bifida and neuropathic bladder dysfunction suffered from urinary incontinence and recurrent pyelonephritis. The recurrent pyelonephritis was prevented and bladder compliance was improved with use of the nocturnal urethral indwelling catheter. Case 3: A 66-year-old woman with cervical myelopathy and multiple episodes of cerebral infarction suffered from nocturnal urinary incontinence. She underwent clean intermittent catheterization by her husband. Use of the nocturnal urethral indwelling catheter solved the problem of her nocturnal incontinence and relieved her husband of her nocturnal care. Nocturnal urethral indwelling catheterization is useful for treatment of nocturnal incontinence and recovery of bladder compliance in patients with lower urinary tract dysfunction and nocturnal polyuria.

Two cases of germ cell neoplasm retrospectively considered to have been of testicular origin are reported. Case 1. A 19-year-old male with brain, liver and retroperitoneal tumors was diagnosed with yolk sac tumor by retroperitoneal tumor biopsy. After multidisciplinary treatment, a region of calcification was detected in the left testis on scrotal sonography and left high inguinal orchiectomy was performed. Case 2. A 57-year-old male with neck, lung and retroperitoneal tumors was diagnosed with yolk sac tumor by supraclavicular biopsy. From initial examination, scrotal sonography revealed a small calcified lesion in the right testis. After chemotherapy, high inguinal orchiectomy and retroperitoneal lymphadenectomy were simultaneously performed. Pathologic evaluation of these testicular specimens revealed calcification and a fibrous scar in correspondence with the clinical diagnosis. These changes were considered as scars of the primary testicular tumor due to burned-out tumor or the result of reaction to chemotherapy. Since a primary tumor of testicular origin may exist in the extragonadal germ cell tumor, it is important to examine the intrascrotal contents in detail in the case of so-called extragonadal germ cell tumors with palpably normal testes. In such cases, there are two possible conditions, an occult testicular tumor and a burned-out testicular tumor. We briefly reviewed 42 such cases in the Japanese literature. It appears that there are very few true extragonadal germ cell tumors, and that the possibility of primary testicular origin metastasizing from viable occult testicular tumor or burned-out testicular tumor with spontaneous regression is high in retroperitoneal germ cell tumors.

A 55-year-old woman affected by mitralism presented with severe right flank pain of sudden onset. Biochemical examinations showed elevated serum lactate dehydrogenase, and abdominal enhanced computed tomography (CT) demonstrated hypoperfusion of the right kidney. Infarction of the right kidney was highly suspected, and she was immediately treated by systemic intravenous injection of 12, 000, 000 units of tissue plasminogen activator (tPA) per day for 3 days and 120, 000 units of urokinase per day for 8 days. After the thrombolytic therapy, abdominal enhanced CT revealed marked improvement of enhancement of right renal parenchyma and decrease of serum LDH. Although thrombolytic therapy with selective intraarterial infusion is considered to be a useful treatment modality for renal infarction, systemic administration of tPA may also be effective judging from the clinical course of the present case.

The patient was a 46-year-old man with gross hematuria and left lumbar pain. Computed tomography revealed a large left renal tumor with hemorrhage. Serological examination revealed polycythemia and a high erythropoietin level. After left radical nephrectomy, polycythemia and serologically high level of erythropoietin disappeared. Histopathological findings showed renal cell carcinoma composed of spindle cells. Based on the above mentioned clinical course, we diagnosed this case as erythropoietin-producing renal cell carcinoma with polycythemia. It is suggested that erythropoietin not only causes polycythemia but also stimulates proliferation of the tumor, because the majority of erythropoietin-producing renal cell carcinomas have been reported to be highly advanced. This patient had no evidence of disease one year after the operation.