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In order to treat the iatrogenic ureteral stricture of more than 8 cm length after transurethral ureterolithotripsy, we planned to perform ureterocystoneostomy with psoas hitch and Boari flap. Because of the longer defect of the affected ureter than presurgically expected and the rigid and thickened ureteral stump resulting from chronic inflammation, anti-reflux technique by forming submucosal tunnel could not be achieved as in the standard Boari flap and we reluctantly anastomosed the ureteral stump to the end of the tubularized bladder wall flap in end-to-end fashion. In order to secure the anti-reflux mechanism we created a submucosal tunnel in the posterior bladder wall according to the technique reported by Casale and Rink where it originally worked as anti-incontinence mechanism of catheterizable vesicostomy. The follow-up examinations showed no recurrence of ureteral stricture nor occurrence of vesicoureteral reflux.

A 38-year-old woman with neurogenic bladder caused by myelomeningocele, who had been on clean intermittent self-catheterization for years, complained of gross hematuria. Computerized tomography, urinary cytology and cystoscopy failed to reveal causative lesions and the hematuria ceased spontaneously. Because gross hematuria recurred 2 years later, we examined the patient again and detected calcification of the urinary bladder. Mucosal lesions suspicious of bladder tumor were detected during the transurethral surgery for the calcified lesion, and we promptly performed biopsy. As a result, she was diagnosed with invasive bladder squamous cell carcinoma. Radical cystectomy and urinary diversion were performed and the histopathological diagnosis was pT3aN0. Adjuvant therapies were not performed. No recurrence has been observed for 36 months after the surgery.

In order to treat the iatrogenic ureteral stricture of more than 8 cm length after transurethral ureterolithotripsy, we planned to perform ureterocystoneostomy with psoas hitch and Boari flap. Because of the longer defect of the affected ureter than presurgically expected and the rigid and thickened ureteral stump resulting from chronic inflammation, anti-reflux technique by forming submucosal tunnel could not be achieved as in the standard Boari flap and we reluctantly anastomosed the ureteral stump to the end of the tubularized bladder wall flap in end-to-end fashion. In order to secure the anti-reflux mechanism we created a submucosal tunnel in the posterior bladder wall according to the technique reported by Casale and Rink where it originally worked as anti-incontinence mechanism of catheterizable vesicostomy. The follow-up examinations showed no recurrence of ureteral stricture nor occurrence of vesicoureteral reflux.

A 40-year-old man complaining of voiding symptoms was referred to our hospital for further examinations and treatment of giant bladder diverticulum and possibly underlying neurogenic bladder dysfunction. Because computed tomography and magnetic resonance imaging revealed the presence of a tumorous lesion covering the bladder diverticulum, transurethral biopsy was performed to elucidate its pathological characteristics. Through the histopathological examination of the biopsy specimens the tumorous lesion was diagnosed as ganglioneuroma which was benign. The whole diverticulum with the concomitant tumor lesion was surgically excised. Full examination of the surgical specimen concluded the final histopathological diagnosis of the tumor to be plexiform neurofibroma. As multiple café-au-lait spots were found on the patient's skin, he was clinically diagnosed with neurofibromatosis type 1.

We report a case of misdirection of a catheter for clean intermittent catheterization (CIC) into the ureter. A four-year-old girl with neurogenic bladder due to myelomeningocele had been managed with CIC by her parents for several years. From about a month before her visit, macroscopic hematuria appeared intermittently followed by abdominal pain and fever-up for a short time which ceased spontaneously. As cystography demonstrated bilateral vesicoureteral reflux, we performed endoscopic intraureteral injection of Deflux[TM] and during the operation we confirmed influx of bloody urine from the right ureteral orifice but not from the left one. As computed tomography revealed a tubular foreign body located in the upper portion of the right ureter, another endoscopic operation was performed and it was removed successfully. The removed foreign body was identified as a disposable catheter that was used for CIC.

A 75-year-old man, highly suspected as having malignant lymphoma originating from his left testis, underwent exploratory orchiectomy for a definitive diagnosis. Laboratory examinations before the surgery showed high lactate dehydrogenase (652 IU/l), elevated serum creatinine level (1.85 mg/dl) and sIL-2R level (8, 930 U/ml). As the postoperative course passed uneventfully, the patient was discharged from the hospital on the eighth day after the surgery. Ten days after the surgery the patient was transferred to the emergency room of the hospital complaining of severe abdominal pain and malaise. Laboratory examinations revealed highly elevated lactate dehydrogenase (2, 807 IL/l), uric acid (24.9 mg/dl) and serum creatinine (5.31 mg/dl). Computed tomography demonstrated rapid growth of the retroperitoneal mass and occurrence of bilateral hydronephroses. Under the diagnosis of spontaneous tumor lysis syndrome, the patient was urgently treated with hemodialysis, steroidal pulse and rituximab following percutaneous nephrostomy for the right kidney. After improvement of the laboratory data, the patient was transferred to another hospital for the treatment of malignant lymphoma.

A 84-year-old female visited our hospital with the chief complaint of asymptomatic gross hematuria. The computed tomography and magnetic resonance imaging revealed a large invasive tumor in the right renal pelvis. Metastatic workup was negative. On imaging studies and voided urine cytology, diagnosis of right renal pelvic cancer (cT3N0M0) was made. Laparoscopic right nephroureterectomy was performed. Histopathological examinations revealed a small cell carcinoma of the renal pelvis. The patient declined adjuvant chemotherapy and died 5 months after surgery. Primary small cell carcinoma of the renal pelvis is a rare disease. To our knowledge, this is the 29th case of primary small cell carcinoma of the renal pelvis in the world literature.

A 38-year-old woman with neurogenic bladder caused by myelomeningocele, who had been on clean intermittent self-catheterization for years, complained of gross hematuria. Computerized tomography, urinary cytology and cystoscopy failed to reveal causative lesions and the hematuria ceased spontaneously. Because gross hematuria recurred 2 years later, we examined the patient again and detected calcification of the urinary bladder. Mucosal lesions suspicious of bladder tumor were detected during the transurethral surgery for the calcified lesion, and we promptly performed biopsy. As a result, she was diagnosed with invasive bladder squamous cell carcinoma. Radical cystectomy and urinary diversion were performed and the histopathological diagnosis was pT3aN0. Adjuvant therapies were not performed. No recurrence has been observed for 36 months after the surgery.

The predictive factors for biochemical recurrence (BCR) were investigated in patients with positive surgical margin of the extirpated prostate by radical retropubic prostatectomy (RRP). The records of 365 patients who underwent RRP in our hospital between January 2002 and December 2014 were retrospectively analyzed. Patients who had received additional therapy before or after RRP, who had not been followed up for more than a year after surgery, and who had pN1 lesions were excluded from the study. Positive surgical margin was observed in 112 cases. Prostate specific antigen (PSA) before surgery ≥20 ng/ml, biopsy positive core ratio ≥40%, Gleason score of the surgical specimen ≥8, and postoperative PSA nadir ≥0.01 ng/ml were identified as significant predictors of BCR.

To identify the predictive factors for positive surgical margin after radical prostatectomy, we retrospectively analyzed the records of 381 patients who underwent radical prostatectomy in our hospital between January 2002 and December 2014. Patients who had received hormonal therapy before surgery were excluded from the study. Positive surgical marginwas observed in121 cases (31.8%), and prostate specific antigen (PSA) before surgery ≧10 ng/ml (HR1.89 : 95%CI 1.17-3. 07) and BMI≧25 kg/m2 (HR2.73 : 95%CI 1.60-4. 68) were identified as significant predictors of positive surgical margin. The existence of PSM significantly correlated to the operation time of 240 minutes or longer (HR2.27 : 95%CI 1. 35-3.79), pT2c or higher local stage (HR2.08 : 95%CI 1.17-3.72) and 7 or higher Gleason score of the resected specimen(HR1.63 : 95%CI 1.03-2.59).

Recently, wide spreading of fluoloquinolone resistant Escherichia coli is a serious problem inthe treatment of urinary tract infection. To investigate the causative bacterial strains of female acute uncomplicated cystitis (AUC) in the community and their sensitivity to antimicrobial agents, we retrospectively reviewed the medical records of 215 female AUC patients treated at our clinics from April 2014 to June 2015. Two hundred and nineteen strains were isolated as the causative bacteria from the patients’urine samples, including E. coli of 179 strains (82%) followed by Klebsiella pneumoniae (5.5%). One hundred and forty five strains (81%) of the isolated E. coli were sensitive to levofloxacin, whereas 32 strains (17.9%) were levofloxacin-resistant. To fosfomycin, the isolated E. coli showed the highest sensitivity (93.9%) among all antimicrobial agents tested. In univariate analysis, factors associated with levofloxacinresistant E. coli included two or more episodes of cystitis within the past year and levofloxacin use at the latest episode of cystitis. Inmultivariate analysis, two or more episodes of cystitis withinthe past year were found to be associated with levofloxacinresistan ce (p＝0.004). To prevent the increasing prevalence of infections caused by antibiotic-resistant bacteria, it is important to confirm the sensitivity of the causative agents for optimal antimicrobial therapy. The community-based surveillance data should be collected and considered when selecting empirical antimicrobial agents.

A 40-year-old man complaining of voiding symptoms was referred to our hospital for further examinations and treatment of giant bladder diverticulum and possibly underlying neurogenic bladder dysfunction. Because computed tomography and magnetic resonance imaging revealed the presence of a tumorous lesion covering the bladder diverticulum, transurethral biopsy was performed to elucidate its pathological characteristics. Through the histopathological examination of the biopsy specimens the tumorous lesion was diagnosed as ganglioneuroma which was benign. The whole diverticulum with the concomitant tumor lesion was surgically excised. Full examination of the surgical specimen concluded the final histopathological diagnosis of the tumor to be plexiform neurofibroma. As multiple café-au-lait spots were found on the patient's skin, he was clinically diagnosed with neurofibromatosis type 1.

We report a case of misdirection of a catheter for clean intermittent catheterization (CIC) into the ureter. A four-year-old girl with neurogenic bladder due to myelomeningocele had been managed with CIC by her parents for several years. From about a month before her visit, macroscopic hematuria appeared intermittently followed by abdominal pain and fever-up for a short time which ceased spontaneously. As cystography demonstrated bilateral vesicoureteral reflux, we performed endoscopic intraureteral injection of Deflux[TM] and during the operation we confirmed influx of bloody urine from the right ureteral orifice but not from the left one. As computed tomography revealed a tubular foreign body located in the upper portion of the right ureter, another endoscopic operation was performed and it was removed successfully. The removed foreign body was identified as a disposable catheter that was used for CIC.

A 75-year-old man, highly suspected as having malignant lymphoma originating from his left testis, underwent exploratory orchiectomy for a definitive diagnosis. Laboratory examinations before the surgery showed high lactate dehydrogenase (652 IU/l), elevated serum creatinine level (1.85 mg/dl) and sIL-2R level (8, 930 U/ml). As the postoperative course passed uneventfully, the patient was discharged from the hospital on the eighth day after the surgery. Ten days after the surgery the patient was transferred to the emergency room of the hospital complaining of severe abdominal pain and malaise. Laboratory examinations revealed highly elevated lactate dehydrogenase (2, 807 IL/l), uric acid (24.9 mg/dl) and serum creatinine (5.31 mg/dl). Computed tomography demonstrated rapid growth of the retroperitoneal mass and occurrence of bilateral hydronephroses. Under the diagnosis of spontaneous tumor lysis syndrome, the patient was urgently treated with hemodialysis, steroidal pulse and rituximab following percutaneous nephrostomy for the right kidney. After improvement of the laboratory data, the patient was transferred to another hospital for the treatment of malignant lymphoma.

A 84-year-old female visited our hospital with the chief complaint of asymptomatic gross hematuria. The computed tomography and magnetic resonance imaging revealed a large invasive tumor in the right renal pelvis. Metastatic workup was negative. On imaging studies and voided urine cytology, diagnosis of right renal pelvic cancer (cT3N0M0) was made. Laparoscopic right nephroureterectomy was performed. Histopathological examinations revealed a small cell carcinoma of the renal pelvis. The patient declined adjuvant chemotherapy and died 5 months after surgery. Primary small cell carcinoma of the renal pelvis is a rare disease. To our knowledge, this is the 29th case of primary small cell carcinoma of the renal pelvis in the world literature.

Objective: We previously developed genitourinary (GU) cancer-specific scoring system for prediction of survival in patients with bone metastasis (the Bone-Fujimoto-Owari-Miyake [B-FOM] scoring model) based on five prognostic factors: the type of primary tumor (prostate cancer (PCa) vs renal cell carcinoma (RCC) and PCa vs urothelial carcinoma (UC)), poor performance status (PS), visceral metastasis, high Glasgow-prognostic score (GPS), elevated neutrophil-to-lymphocyte ratio (NLR). The aim of this study was to externally validate and further improve the performance of the B-FOM score. Methods: The external validation cohort comprised 309 patients with GU cancer with bone metastasis from multiple institutions. Clinical factors were analyzed using Kaplan-Meier method and COX regression hazard model. Performance of a modified B-FOM score was compared to that of other scoring models by the Kaplan-Meier method and the area under the curve (AUC) of receiver operating characteristic curves. Results: The median follow-up period of development and validation cohort were 25 and 17 months, respectively. Kaplan-Meier curve demonstrated that the type of primary tumor (RCC and UC vs PCa), poor PS, presence of visceral metastasis, high GPS, elevated NLR were significantly associated with shorter cancer-specific survival. Risk groups were successfully stratified by the modified B-FOM score classification. Moreover, the AUC of the modified B-FOM scoring model for predicting mortality at 6, 12, and 24 months were 0.895, 0.856, and 0.815, respectively, which were the highest among evaluated models. Conclusions: The B-FOM scoring model is a simple and accurate prediction tool. By using this scoring model at the time of the diagnosis of bone metastasis in patients with GU cancers, an individualized optimal treatment strategy can be selected., 博士（医学）・甲第835号・令和4年3月15日, © 2020 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license(https://creativecommons.org/licenses/by-nc-nd/4.0/).

Metastasis of renal cell carcinoma (RCC) to urinary bladder is extremely rare. We report a case of metastasis arising from RCC to the urinary bladder 7 years after treatment of bilateral RCC. A 74-year-old man was diagnosed with bilateral multiple renal tumors (T1aN0M1, PUL, OSS) with two lesions in the right kidney and a solitary lesion of the left kidney in 2008. He underwent laparoscopic radical nephrectomy for the right side in September 2008. The next month, ex vivo partial nephrectomy and auto-transplantation was performed for the left kidney because the tumor was located very close to the collecting system. Metastatectomies for the lung and bone followed and the histopathological findings of all lesions were clear cell carcinoma. The following years went well without any recurrence. Seven years after the surgery, the patient complained of asymptomatic gross hematuria and cystoscopy revealed a solitary non-papillary tumor of the bladder. Transurethral resection of the tumor was performed in June 2015 and the histopathological diagnosis of the resected specimens was clear cell carcinoma. Because the additional immunohistochemical examinations were positive for CD10 and negative for CK7, we diagnosed the bladder tumor as metastasis arising from RCC. Direct dissemination of the tumor cells into the urinary tract during partial nephrectomy followed by implantation to the bladder mucosa is a probable mechanism of metastasis in this case.

A 70-year-old man was referred to our department for further examination and treatment of a painless penile mass of about 2cm. The patient first noticed the mass onlya few weeks before presentation. Diagnostic biopsy was interpreted as leiomyosarcoma. Through systemic examinations the clinical stage of his disease was diagnosed as cT2N0M0 and we performed total penectomy. Histopathological examination for the totallyresected tissue disclosed the concomitant presence of regions compatible to squamous cell carcinoma and the results of immunohistochemistrywere compatible with the diagnosis of squamous cell carcinoma, sarcomatoid subtype of the penis. One month after the surgery, multiple metastases to left inguinal lymph nodes and lungs developed, for which systemic chemotherapy by doxorubicin was ineffective and the patient died of respiratoryinsufficiencyfive months after presentation.

A 57-year-old man with fever-up and multiple nodules in the peripheral area of the lungs on the chest CT was referred to the department of respiratory medicine of our hospital for further examination. The whole body CT disclosed a space-occupying lesion in the left frontal lobe of his brain, an irregular mass in the left kidney, and swelling of paraaortic lymph nodes. A pathological diagnosis could not be made from the results of the bronchoscopic examination and percutaneous needle biopsy for the renal mass. Left nephrectomy and lymph node dissection were carried out because of possible renal malignancy with distant metastases. The renal lesion was diagnosed as xanthogranulomatous pyelonephritis histopathologically. After the nephrectomy, the multiple lung nodules disappeared spontaneously leaving scars in some lesions. Septic pulmonary embolism was highly suspected on the basis of the clinical course. The brain nodule also decreased in size significantly and is currently under careful surveillance.

The predictive factors for biochemical recurrence (BCR) were investigated in patients with positive surgical margin of the extirpated prostate by radical retropubic prostatectomy (RRP). The records of 365 patients who underwent RRP in our hospital between January 2002 and December 2014 were retrospectively analyzed. Patients who had received additional therapy before or after RRP, who had not been followed up for more than a year after surgery, and who had pN1 lesions were excluded from the study. Positive surgical margin was observed in 112 cases. Prostate specific antigen (PSA) before surgery ≥20 ng/ml, biopsy positive core ratio ≥40%, Gleason score of the surgical specimen ≥8, and postoperative PSA nadir ≥0.01 ng/ml were identified as significant predictors of BCR.

To identify the predictive factors for positive surgical margin after radical prostatectomy, we retrospectively analyzed the records of 381 patients who underwent radical prostatectomy in our hospital between January 2002 and December 2014. Patients who had received hormonal therapy before surgery were excluded from the study. Positive surgical marginwas observed in121 cases (31.8%), and prostate specific antigen (PSA) before surgery ≧10 ng/ml (HR1.89 : 95%CI 1.17-3. 07) and BMI≧25 kg/m2 (HR2.73 : 95%CI 1.60-4. 68) were identified as significant predictors of positive surgical margin. The existence of PSM significantly correlated to the operation time of 240 minutes or longer (HR2.27 : 95%CI 1. 35-3.79), pT2c or higher local stage (HR2.08 : 95%CI 1.17-3.72) and 7 or higher Gleason score of the resected specimen(HR1.63 : 95%CI 1.03-2.59).

OBJECTIVE: To investigate the impact of obstructive sleep apnea syndrome (OSAS) on night-time secretion of brain natriuretic peptide (BNP) and antidiuretic hormone (ADH) in older men with nocturia accompanied by nocturnal polyuria. MATERIALS AND METHODS: One hundred six men with nocturia aged ≥ 60 years underwent full-night polysomnography to determine whether they had OSAS. Blood count, standard chemistry panel, BNP, urinary ADH, urinary creatinine (u-Cre), and urinary osmolarity were measured at 6:00 AM, and a frequency volume chart was recorded on the same day that polysomnography was performed. RESULTS: We evaluated 83 patients after excluding 18 with mild OSAS and 5 with nocturnal polyuria index, 博士（医学）・乙第1349号・平成26年12月3日, Copyright © 2014 Elsevier Inc. All rights reserved.

A 38-year-old man visited our hospital complaining of lower urinary tract symptoms. He had undergone extracorporeal shockwave lithotripsy to remove a right renal stone two times when he was 24 years old. Since examinations revealed right staghorn calculi and a giant bladder stone, vesicolithotomy was carried out. The removed stone measured 95×75×55 mm and weighed 250 g. We hypothesized that a fragment of the upper urinary tract stone had reached the bladder which could not be discharged spontaneously, and grew in the bladder. After the operation, uroflowmetry and voiding cystourethrography were performed and the results indicated no abnormalities in the lower urinary tract function.

A 60-year-old female was referred to our hospital for the treatment of chronic urinary retention which had compelled her to continue clean intermittent self catheterization (CIC) for several years. After further examination including physical examinations, urodynamic study, cystography, and urethrocystoscopy, she was diagnosed with primary bladder neck obstruction (PBNO). Transurethral resection of the bladder neck (TURBN) was performed to relieve the bladder outlet obstruction and she was free from CIC thereafter. Another 61-year-old female on CIC was also referred to our hospital and diagnosed with PBNO through detailed examinations including urodynamics. She was also successfully relieved of CIC after TURBN. Primary bladder neck obstruction is a condition which can be effectively treated by a less-invasive procedure when properly diagnosed by urodynamic examination. Urologists must keep this rare condition in mind as a possible cause of chronic urinary retention in women.

Recently, wide spreading of fluoloquinolone resistant Escherichia coli is a serious problem inthe treatment of urinary tract infection. To investigate the causative bacterial strains of female acute uncomplicated cystitis (AUC) in the community and their sensitivity to antimicrobial agents, we retrospectively reviewed the medical records of 215 female AUC patients treated at our clinics from April 2014 to June 2015. Two hundred and nineteen strains were isolated as the causative bacteria from the patients’urine samples, including E. coli of 179 strains (82%) followed by Klebsiella pneumoniae (5.5%). One hundred and forty five strains (81%) of the isolated E. coli were sensitive to levofloxacin, whereas 32 strains (17.9%) were levofloxacin-resistant. To fosfomycin, the isolated E. coli showed the highest sensitivity (93.9%) among all antimicrobial agents tested. In univariate analysis, factors associated with levofloxacinresistant E. coli included two or more episodes of cystitis within the past year and levofloxacin use at the latest episode of cystitis. Inmultivariate analysis, two or more episodes of cystitis withinthe past year were found to be associated with levofloxacinresistan ce (p＝0.004). To prevent the increasing prevalence of infections caused by antibiotic-resistant bacteria, it is important to confirm the sensitivity of the causative agents for optimal antimicrobial therapy. The community-based surveillance data should be collected and considered when selecting empirical antimicrobial agents.

We report a case of tubercular prostatic abscess in a male patient who had undergone intravesical Bacillus Calmette-Guerin therapy for bladder carcinoma in situ. The abscess was successfully treated with transurethral resection of the prostate for drainage and subsequent antituberculous regime of chemotherapy.