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A 51-year-old male was hospitalized at another hospital for aspiration pneumonia during gastrostomy management due to sequelae related to a cerebral hemorrhage. The patient was referred to our hospital because of gross hematuria and renal dysfunction following fasting and antibiotic administration. Serum creatinine was 10.54 mg/dl. Prothrombin time (PT) and PT-international standard ratio (PT-INR) were beyond the measurement range, while activated partial thromboplastin time (APTT) was 125 seconds, and protein induced by vitamin K absence or antagonist-II (PIVKA-II) was 117, 591 mAU/ml. Computed tomography (CT) imaging showed blood clots in both upper urinary tracts and urinary tract obstruction was considered to be the cause of renal dysfunction. Based on the findings following fasting and long-term administration of antibiotics, including the N-methyl tetrazole thiol (NMTT) group, we considered that the cause was vitamin K deficiency. The patient was immediately treated with menatetrenone (20 mg). Four days after beginning administration, PT, PT-INR, and APTT were improved, and gross hematuria had disappeared. Thereafter, urine volume was increased and renal function became normalized, while PIVKA-II was decreased to the normal range. When a fasting patient has a bleeding tendency during antibacterial administration, it is necessary to consider treatment with vitamin K deficiency.

Between November 2011 and November 2014, we performed a tunica albuginea incision with tunica vaginalis flap coverage (TAI＋TVFC) on 5 out of 15 patients who underwent surgery for testicular torsion. Of those 15 patients, 7 underwent orchidopexy alone (Group A), 5 underwent TAI＋TVFC (Group B), and 3 underwent an orchidectomy procedure (Group C). All were followed for 1 year and preservation of testicular volume ＞50% on the contralateral side in ultrasound measurements was considered as salvaged. During the follow-up examinations, no testicular atrophy was noted in Group A. In Group B, tension and testis color were immediately improved in all 5 patients after TAI＋TVFC, while blood perfusion was also improved after the operation. Also 3 patients in Group B were considered to be salvaged, while testicular atrophy occurred in 2 after 8 or more hours from onset until surgery. Our results indicated that TAI＋ TVFC is useful for restoring blood flow after surgery for testicular torsion, although the so-called‘Golden time’for torsion surgery has a significant impact in such cases.

A man in his 50s was referred to our hospital after recurrent severe urinary tract infection. He had undergone anoplasty for anorectal malformation during early infancy. He noticed urinary leakage from the anus for a long time. Under diagnosis of congenital rectourethral fistula, we performed fistula closure. The fistula was transsected via transperineal incision and each stump was closed. A gracilis muscle flap approximately 30 cm long was harvested from the left thigh, brought into the deepest part between the separated rectum and urethra through a subcutaneous tunnel and fixed there. The urinary leakage from the anus disappeared, and the infection resolved. Application of gracilis muscle flap for congenital diseases is rare, but was useful in the present case.

A 47-year-old woman came to our hospital with left lower abdominal pain in April 2013. An abdominal computed tomographic (CT) examination revealed left hydronephrosis secondary to a 7 cm retroperitoneal cyst near the left common iliac artery and ureter. Serum tumor markers including CEA, CA19-9, and CA125 were negative. Although CT guided needle aspiration of the cyst successfully relieved severe left flank pain, the cyst again increased in size, causing left hydronephrosis, though examinations for fluid tumor markers and cytology were negative. Two months later, the patient underwent open fenestration. The final pathological results demonstrated a mesothelial cyst without malignant findings. Six months after the operation, the patient was doing well without recurrence of symptoms.

We prospectively investigated the safety and efficacy of sunitinib using a modified regimen (2 weeks on/1 weekoff) in 24 patients (22 males, 2 females ; age range 39-86 years, median 64 years) with metastatic renal cell carcinoma (RCC). During the observation period (3-62 weeks, median 21 weeks), thrombocytopenia was seen in 13 (54.2%), leukopenia in 11 (45.8%), hand-foot syndrome in 5 (20.8%), hypertension in 4 (16.7%), and hypothyroidism in 3 (12.5%) patients, while grade 3 or higher adverse events were found in 4 (16.7%), 1 (4.2%), 1 (4.2%), 2 (8.3%), and 0 patients, respectively. Of the 21 patients evaluable for response, 5 (23. 8%) showed partial response, 8 (38.1%) stable disease, and 8 (38.1%) progressive disease. This new modified regimen may lead to a reduction in adverse events for treatment of patients with metastatic RCC as a substitute for the standard dosing regimen of sunitinib.

A 37-year-old woman with an incidentally found abdominal mass was referred to our hospital. A fixed, non-tender mass was palpated in the right upper quadrum of her abdomen. There was no elevation of tumor markers. Computed tomography revealed a mass extending from the hepatic vein level to renal hilar level. The tumor completely obstructed the inferior vena cava (IVC). T1-weighted magnetic resonance imaging (MRI) showed that the mass was isointense with muscles. T2-weighted MRI image with contrast medium demonstrated collateral circulation. Upon diagnosis of the IVC tumor, we removed the right kidney and the tumor en bloc without reconstructing IVC. The tumor diameter was 11.6×5.5×4.7 cm. Pathological examination established a diagnosis of IVC leiomyosarcoma. She is alive without sign of recurrence after operation for seven months. There were 143 reports of IVC leiomyosarcoma in Japan. In 31% of them, IVC was not reconstructed.

A 23-year-old man and a 62-year-old man suffering from cystinuria underwent extracorporeal shock wave lithotripsy (ESWL) for right renal stone and left ureteral stone, respectively. They had double-J stents placed before ESWL, but since attempts to retrieve the stents were unsuccessful due to encrustation, they were referred to our clinic. Multimodal endourologic and open approaches including ESWL, transurethral ureterolithotripsy, and pyelolithotomy were required to render them stent- and stone-free. The guidelines do not recommend routine stenting before ESWL ; therefore, the indication and duration of indwelling stents should be minimized. Multimodal options including not only ESWL and endoscopic surgery but also open surgery, should be attempted for the management of encrusted stents. Close monitoring and follow up are important to the prevent complications of ureteral stents.

Patients administered anti-cholinergic agents, as first-line therapy for an overactive bladder (OAB) are often unable to continue medical treatment because of dry mouth. We assessed oral health in patients with OAB using the General Oral Health Assessment Index (GOHAI), an oral health-related quality of life questionnaire. We investigated 75 patients with OAB who were receiving continuous administration of anti-cholinergic agents. The OAB symptom score, as well as GOHAI and our original dry mouse score were determined by self-administered questionnaires. The mean age of the subjects was 70.9±10.2 years, the median period of anti-cholinergic agent use was 20 (1-116) months and the mean OAB symptom score was 6.3±3.1. The GOHAI score for all patients was 51.9±8.4 and not significantly different from the national normal value (p＝0.22). On the other hand, the score in patients with a severely dry mouth was 49.2±8.6, which was worse than the national normal value (p＝0.04). The psychosocial functioning score in patients with a severely dry mouth was significantly lower than in those with a slightly dry mouth (p＝0.02). Our results indicate that dry mouth in patients with OAB is significantly associated with worsening of oral health. GOHAI is useful as a screening test to assess the quality of life in patients with OAB.

A 73-year-old male, admitted to a local hospital because of fever and consciousness disturbance, was referred to our institute. He had a history of long-term steroid administration and diabetes mellitus. Under diagnosis of severe right pyonephrosis associated with severe inflammatory response syndrome as well as disseminated intravascular coagulopathy, he was transferred to our hospital. Computed tomography and magnetic resonance imaging showed a mass 5 cm in diameter at the right ureteropelvic junction and lymph node swelling at the renal hilum, suggesting obstructive pyonephrosis by a malignant tumor such as renal pelvic cancer. Since the patient failed to respond to conservative medical treatment including polymyxin B hemoperfusion, hemodialysis, and antimicrobials, we performed right nephrectomy. Histopathological examination demonstrated that the tumor obstructing the pelvis arose from the parenchyme under the muscle layer, and was diagnosed as unclassified renal cell carcinoma while the renal pelvic epithelium was normal. Although his general condition and laboratory data transiently improved after nephrectomy, he died of carcinomatousperitonitis30 days postoperatively. We advocate that, in the case of pyonephrosis with a lesion highly suspected to be an infiltrating neoplasm, nephrectomy is justified as first choice to control the septic condition.

We have performed transurethral enucleation with bipolar system (TUEB) on 60 patients since April 2008. The patients were 61 to 81 years old (average 71.7 years old), and estimated prostate volumes were 25 cm3 to 80.43 cm3 (average 51.1 cm3). The weight of prostate removed was 8 g to 56 g (average 27.4 g) during the operations which lasted between 40 min to 200 min (average 117.5 min). The International Prostate Symptom Score (IPSS), quality of life index (QOL) maximum flow rate (Q max) and average flow rate (Qave) were recorded before operation, and at 1 and at 3 months after operation. The results indicated a high safety with TUEB compared to TUR-P even for beginners. In conclusion, TUEB may become the most common approach in the treatment of BPH.

A 74-year-old man visited our hospital, because of high prostate specific antigen (PSA). Retropubic radical prostatectomy was performed for prostatic cancer. Suddenly right inguinal lesion pain appeared at 25 days after operation with disturbance of gait. Pelvic magnetic resonance imaging (MRI) demonstrated inflammatory change in right pubic bone, pectineal muscle, adductor muscle, which suggested the diagnosis of osteomyelitis of the pubis. After long-term administration of antibiotic therapy, osteomyelitis of the symphysis pubis and gait possible. There was no recurrence of osteomyelitis of the symphysis pubis at one year after operation. In addition to our case, we review the 8 cases of osteomyelitis of the pubis after radical prostatectomy previously reported in Japanese publications.

We retrospectively analyzed the records of 21 patients with penile carcinoma treated between January 1993 and February 2007. According to TMN classification (UICC 2002), 9, 8, 2 and 2 patients belonged to stages I, II, III and IV, respectively. During the follow up period of 4 to 144 months (median 15 months), the overall 5-year survival rate was 75.8%. All three patients having N2 died within one year. Lymph node metastasis (p=0.001) and organ metastasis (p=0.007) were found to be unfavorable prognostic factors for patients with penile cancer.

45歳男。左側腹部痛を主訴に近医に受診し, 腹部CTで左腎を下方に圧排する約8cmの腫瘤をみとめ特発性腎破裂と診断され入院した。経過観察中に肝内複数の低吸収領域の出現を認め精査加療目的で当科受診となった。軽度の炎症反応, 腎腫瘍マーカーと肝腫瘍マーカーの上昇を認めた。約1.5ヵ月後のCTより肝の5mmの低吸収領域は約2cmの不均一に造影される腫瘤に新たに2ヶ所の腫瘍性病変を認め血腫は左腎上方背側に進展しており腎細胞癌および肝転移を強く疑うもAFP, PIVK-IIの高値より原発性肝癌も否定できなかった。当科入院1ヵ月後に根治的左腎摘除術および肝部分切除術を施行した。血腫内に腫瘍性病変は認められず, 左腎に径2cmの腫瘍性病変を認め静脈内へ浸潤し, 肝部分切除標本に腎と同様の細胞を認め腎細胞癌および, その肝転移(G2, INFβ, pT3N1M1)と診断した。術後アジュバンド療法を施行し, 約1ヵ月後の腹部CTで新たな肝転移巣の出現を認め, IL-2の追加投与を行うも効果なく術後, 約1年に多発肝転移及び骨転移にて死亡した。, A 45-year-old man felt sudden pain in the left abdomen while taking a bath. Computed tomography (CT) showed a huge hematoma above the left kidney, which was diagnosed as spontaneous rupture of the kidney. Two months later, several low-density areas were observed in the liver on CT. Suspecting renal cell carcinoma (RCC) with multiple liver metastasis, we performed left radical nephrectomy and partial hepatectomy. A pathological study revealed a small RCC of 2 cm in diameter in the middle of the left kidney. In spontaneous renal rupture secondary to renal tumors, imaging studies such as CT or MRI sometimes fail to demonstrate primary lesions.

75歳男。71歳時に多発性膀胱癌にて根治的膀胱全摘除術を施行され、この際前立腺から偶発癌を認めた。LH-RHアナログを術後10ヵ月目まで使用し、以後は再発、転移なく経過していたが、今回、亀頭に自覚症状を伴わない紅斑局面が出現した。病理組織所見で表皮内にPaget細胞を認め、乳房外Paget病と診断された。陰茎全摘除術を施行し、摘除標本の病理組織所見でPaget細胞は亀頭から尿道内へも連続し、尿道舟状窩まで存在し、更に尿道粘膜下の導管内に乳頭状に増殖する腫瘍細胞を認めた。この腫瘍細胞は尿道切除断端まで連続して存在し、以前の前立腺摘出標本にも切除断端遠位端の尿道周囲導管内に辺縁域の腺房型腺癌とは異なり乳頭状に増殖する腫瘍細胞を認めた。免疫組織化学染色ではPaget細胞がcytokeratin 20に陽性を示したためPaget現象と診断した。Androgen receptor染色は前立腺導管内の腫瘍細胞、尿道粘膜下導管内の腫瘍細胞共に陽性、PSA染色は前立腺導管内の腫瘍細胞は陽性、尿道粘膜下導管内の腫瘍細胞は陰性を示した。PSAの染色性は異なるが、Androgen receptorの染色性と組織像の類似性、連続性から、前立腺導管癌が尿道粘膜下を進展し亀頭にPaget現象を呈したものと診断された。術後9ヵ月経過現在、再発転移は認めない。, A 75-year-old male visited our division with asymptomatic erythema on the glans penis which he first noticed six months earlier. The patient underwent total cystoprostatectomy under the diagnosis of urothelial carcinoma of the urinary bladder four years earlier. At the time, the prostatectomy specimen incidentally revealed a prostatic acinar adenocarcinoma at the bilateral peripheral zone. A skin biopsy of the erythema revealed intraepithelial Paget's cells, and the patient underwent total penectomy under the diagnosis of extramammary Paget's disease. Histopathological examination revealed continuous intraepithelial Paget's cells from the glans penis to the urethral navicular fossa, and a ductal carcinoma was detected beneath the urethral mucosa to the excisional margin. Because the Paget's cells expressed cytokeratin 20, the tumor was diagnosed as Pagetoid spread rather than Paget's disease. Re-examination of the previous prostatectomy specimen revealed prostatic duct adenocarcinoma with prostatic acinar adenocarcinoma. Therefore, the final diagnosis was prostatic duct adenocarcinoma with Pagetoid spread to the glans penis. Follow up at nine months revealed neither local recurrence, nor distant metastases, although no adjuvant therapy has been given.

61歳女。腰痛を自覚し, 左後腹膜腔に腫瘍病変を認めて精査加療目的で入院となった。経度炎症反応腎腫瘍マーカーの上昇を認め, CTにて左腎を腹側から後方へ圧排する最大径20cmの腫瘤を認め, 腫瘍は大動脈前方まで発育し, 左腎, 膵臓, 下行結腸を圧排し, 下行結腸の狭窄もみられ, さらに径2cmの右副腎腫大も認められた。右後腹膜腫瘍, 右副腎転移の疑いと診断され, 後腹膜腫瘍摘除術を施行し, 左腎, 下行結腸との強い癒着を認め, 同時に左腎摘除術, 左半結腸切除術とさらに右副腎摘除術を施行した。術中腸間膜に多数のリンパ節腫大を認め腸間膜リンパ節転移が示唆された。腫瘍は26×20×16cm大で短紡錘形の腫瘍細胞を認め, αSMA染色, Desmin染色ともに陽性で平滑筋肉腫と診断した。右副腎は副腎腺腫であった。術後約3週間で退院するも約2週間に腸閉塞を発症し, 術後54日目に死亡した。進行性後腹膜腫瘍に対しては術前または手術後早期に化学療法を選択の一つとして考慮すべきと考えられた。, This is a case report of retroperitoneal leiomyosarcoma in a 61-year-old woman. She presented with a chief complaint of back pain. Computed tomography showed a left huge retroperitoneal tumor. The tumor was removed with left nephrectomy and left hemi-colectomy. Histological examination demonstrated leiomyosarcoma 26 x 20 x 16 cm in diameter and, 3.84 kg in weight. She died of local recurrence causing ileus 2 months after the surgery. Fifty-four cases of retroperitoneal leiomyosarcoma including the present case in the Japanese literature are reviewed.

86歳女。無症候性肉眼的血尿、排尿困難を主訴とした。尿所見上、肉眼的血膿尿があり、尿培養にて大腸菌が検出された。膀胱鏡所見で粘膜は全周性に発赤、白苔を伴ない気、気泡の形成を認めた。気腫性膀胱炎の診断にて緊急入院となり、来院時、尿閉状態であったため尿道バルーンカテーテルを留置し、SBT/ABPC 3g/dayの点滴を開始した。CTでは膀胱内および膀胱壁に沿ったガス像と鏡面像を認めた。入院後2日目には血尿は消失し、入院3週間後の骨盤CTでは膀胱内の気泡消失を認めた。入院4週間後にバルーンを抜去し、その後自排尿可能となった。, A 86-year-old woman presented with asymptomatic gross hematuria, and visited our hospital, and a vesicorectal fistula was suspected from a computed tomographic (CT) scan. She had a lower abdominal mass and urinary retention on arrival. Pclvic CT demonstrated intramural gas in the urinary bladder, which suggested a diagnosis of emphysematous cystitis. Cystoscopy demonstrated reddish mucosa and gas within the bladder wall. The gross hematuria was improved and the intramural gas disappeared on a CT scan after urinary drainage and antibiotic therapy. Although emphysematous cystitis is almost always cured with conservative therapy, an accurate diagonosis and prompt treatment are required because rarely emphysematous cystitis can result in rupture of the urinary bladder and lead to septic shock.

55歳女性.患者は突然の右側腹部痛を主訴に近医を受診, 腹部CTにて右腎血腫が疑われ, 著者らの施設へ紹介入院となった.入院時の腹部CTにて腎血管脂肪腫の自然破裂と診断し, 右腎動脈造影にて腎下極末梢の小動脈瘤を確認後, 腫瘍塞栓術を行った.しかし, 第3病日目には4単位の輸血にもかかわらず, 貧血の急速な進行と右胸水貯留, 呼吸状態の悪化を認めたため, 緊急手術を施行した.手術所見では腎下極から腎外に発育する腫瘍の破裂を認め, Gerota筋膜内には血腫の貯留がみられたため, 右腎摘除術を行ったところ, 良好な術後経過が得られた, A 55-year-old woman presented with sudden right lower abdominal pain. Computed tomography demonstrated retroperitoneal hematoma associated with minus-density area, diagnosed as spontaneous rupture of angiomyolipoma. Super-selective transarterial embolization was performed, but anemia and right abdominal pain became worse in spite of conservative therapy including transfusion, indicating re-rupture of the renal tumor. Although partial nephrectomy was planned, right nephrectomy was finally performed because of massive intraoperative bleeding. Accurate diagnosis and prompt treatment are required when life-threatening rupture of renal tumor is suspected.

56歳男.約3年前に出現した右上腹部圧迫感を主訴に受診し, 腹部CTで右腎腫瘍を指摘された.画像検査で悪性腫瘍が否定できない充実性腫瘍と診断し, 用手補助腹腔鏡下右腎摘除術を施行した.腫瘍は充実性で明らかな出血壊死像は見られず, 胞巣状に増殖する腺管状に配列した好酸性腫瘍細胞を認め, 後天性嚢胞性腎疾患(ACDK)に合併した腎オンコサイトーマと診断された.術後は経過良好で, 右上腹部圧迫感が消失した.約6ヵ月後に献腎移植術を施行し, 移植術から約18ヵ月経過現在, 移植腎機能は良好で, 腎腫瘍の再発徴候は認めていない, A case of renal oncocytoma associated with acquired cystic disease of kidney (ACDK) in a 56-year-old man is reported. He had received hemodialysis for 15 years because of chronic renal failure. Computed tomography (CT) was performed because of distention in the upper abdomen, revealing a right renal tumor. He underwent laparoscopic right nephrectomy, and was diagnosed with renal oncocytoma. There have been reported 8 cases of renal oncocytoma in hemodialysis patients, and our case was the third one associated with ACDK in the literature.

68歳男.患者は直腸診にて前立腺の中等度肥大を認め, PSA値が高値であった.更に右下腹部に虫垂切除時の手術瘢痕および右鼠径部に鶏卵大, 表面平滑, 弾性軟, 可動性のある腫瘤を認めた.膀胱造影では, 膀胱に連続した右鼠径部に介在する膀胱ヘルニアが描出された.以上より, 前立腺癌に合併した膀胱ヘルニアと診断し, 根治的前立腺全摘除術と同時に膀胱ヘルニア修復術が施行された.その結果, 摘出前立腺の病理所見はGleason score 8点であり, 精嚢浸潤を認めた.所属リンパ節に転移を認めず, 病期はpT3bN0M0であった.術後にホルモン療法が施行され, 術後5ヵ月現在, 前立腺癌ならびに膀胱ヘルニアとも再発を認めていない, We report a case of bladder hernia. A 68-year-old man was admitted to our hospital for the management of prostate cancer. An egg-sized soft mass was palpated at his right inguinal region. Magnetic resonance imaging and cystography revealed that the mass was a bladder hernia. During radical prostatectomy, we had to resect the bladder hernia for safe regional lymphadenectomy. This hernia was the extraperitoneal type. The stage of prostate cancer was pT3b N0 M0. This is the third reported case of inguinal bladder hernia associated with prostate cancer in Japan.