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著者らは根治的前立腺摘除術後の尿失禁における前立腺尖部の処理ならび吻合法を改良したので, これを従来法と比較検討した.対象は, 前立腺癌に根治的恥骨後式前立腺摘除術を施行した36例で, うち24例(平均67.6歳)は従来法, 12例(平均64.8歳)は改良法を用いた.両群間で手術時間, 出血量に有意差は認めず, 尖部断端陽性率では差を認めなかった.術後尿失禁の消失率は出血量(1500cc未満と以上), 年齢(65歳未満と以上)では差は認めず, 従来法と改良法ではそれぞれ術後1ヵ月で8.3%, 41.7%, 3ヵ月で25.0%, 91.7%, 6ヵ月で29.2%, 100%, 12ヵ月で58.3%, 100%と改良法で有意に早期消失を認めた.術後合併症は従来法で創し開が4例, 膀胱尿道吻合部結石が1例あり, 改良法では術後血腫が1例, 一時的排尿障害が1例を認めたが, 吻合部狭窄は両群ともに認めなかった.以上, 本改良法は術後の尿失禁を軽減する有効な方法と考えられた, Urinary incontinence impairs the quality of life for patients following radical prostatectomy. We retrospectively reviewed the records of 36 patients who underwent radical retropubic prostatectomy between 1987 and 2002, and achieved the time from operation until urinary continence. A modification in the technique of apical dissection was introduced in 1999 and applied in 12 cases of consecutive radical prostatectomy. The principles for this technique were based on sharp division of the dorsal vein complex, continuous suturing cut edges of lateral pelvic fascia, and anterior anastomotic sutures including lateral pelvic fascia as well as urethra and bladder neck. None of the patients undergoing the new technique used pads at 6 months. With introduction of this technique, the rate of continence at 12 months increased from 58.3 to 100.0%. Our results suggest that the surgical technique of apical dissection is an important factor associated with postprostatectomy in continence.

今回我々は, 2例の腎細胞癌患者に対して腹腔鏡下根治的腎摘除術 （LRN） を施行した. 症例1は72歳男性で, 右腎の直径2. 5cm の腎細胞癌と診断され, また盲腸の粘膜下腫蕩も存在した. 1999年9月28日, 経腹的到達法により LRN と腹腔鏡補助下回盲部切除を同時に施行した. 手術時聞は5時間08分, 出血量は320ml であったが, 回盲部切除に要した時聞を差し引いて LRN に要した時間のみを算定すると3時間19分であった. 術後は特に合併症はみられず, 術後7日目に退院を許可, 術後10日目に退院した. 症例2は81歳男性で, 右腎の直径3. 0cm の腎細胞癌と診断された. 77歳時に胃癌に対して胃全摘術, 79歳時にS状結腸癌にしてS状結腸切除術の既往があった. 再発の有無を検索する目的もあり, 1999年9月30日経腹的到達法により LRN を施行した. 術中癒着剥離操作時に横行結腸損傷を起こし, 小開腹 （5cm） 下に修復を行った. 手術時聞は6時間10分, 出血量は850ml であったが, 癒着剥離および結腸修復に要した時間を差し号引くと, 手術時聞は4時間34分であったと算定された本症例ではさらに2度の追加開腹手術を要した1度目は小静脈にかけたクリップの脱落による腹腔内出血のため, 2度目は腹壁創部の出血のためであったが, 以後の経過は良好で術後8日目に退院した. 今回の症例1では合併症はみられず, また回盲部切除を併施したため経口摂取開始が遅れ退院許可は7日目となったが, LRN だけを行っていたのて、あればより早期に退院可能であったと考えられた. しかし一方, 症例2では大きな合併症がみられた. その原因を追究し, 防止法を明らかにすることが, 本術式を安全で確立された術式として普及させることに重要であると考えられた. わずか2例の経験であるが, LRN は術後の QOL を改善し, 腎細胞癌の治療法として容認できる術式であると確信した.

腎盂形成術を行った腎盂尿管移行部狭窄症23例25腎(男17例, 女6例, 平均15.9歳).術式はAnderson-Hynes法22腎, Y-V plasty, Hellstrom法, simple pelvi-ureterostomy各1腎であった.術後平均8.6年の排泄性腎盂尿管造影による判定で, 水腎症の程度が改善した初回成功例は21腎, 不変及び増悪の不成功は4腎であった.不成功の原因としては, 感染, 尿浸潤, 不適切な縫合による管腔内での肉芽形成を認めた, We retrospectively reviewed the records of 23 patients (25 kidneys) who underwent open pyeloplasty for ureteropelvic junction obstruction (UPJO) between 1980 and 2001, focusing on failures. The patients included 17 men and 6 women, ranging from 3 months to 69 years old (mean 15.9 years). The followup period was 6 months to 19 years (mean 8.6 years). Anderson-Hynes pyeloplasty, Y-V plasty, Hellstrom's operation and simple pelvi-ureterostomy were performed in 22, 1, 1 and 1 kidney, respectively. We successfully repaired 21 of 25 renal units (success rate 84.0%). Of the four patients (4 kidneys) with persistent UPJO occurring in this primary pyeloplasty series, repeat pyeloplasty was performed on 2 patients, nephrectomy on 1 patient and balloon dilatation on 1 patient. Infection and prolonged urinary drainage seem to result in fibrosis of periureteral tissues. Inadequate stitches may cause granuloma in the lumen of the anastomosis. The techniques and complications associated with open pyeloplasty are discussed.

1例のinverted papillomaと6例の逆行型移行上皮癌の症例を呈示した.逆行型移行上皮癌には悪性度浸潤度様々のものがあり, 再発例や多発例もみられ, 発育様式が異なるだけで, 通常の乳頭状移行上皮癌と相対すると思われた, We reported a case of inverted papilloma of the bladder, and six cases (two of ureteral cancer and four of bladder cancer) of transitional cell carcinoma with inverted proliferation. These tumors were superficial and pedunculated as well as transitional papilloma or ordinary papillary transitional cell carcinoma though they showed a non-papillary and polyp-like configuration. Moreover, these urothelial cancers with inverted proliferation were thought to be similar to papillary cancer with regard to grading, multiplicity, invasiveness and recurrence. Therefore, transurethral resection or segmental ureterectomy may be recommended for the tumor of low grade malignancy and radical treatment including systemic chemotherapy may be recommended for the tumor of high grade malignancy.

A case of a parathyroid cyst associated with an adenoma in a different gland is reported. A 55-year-old female was explored with preoperative diagnosis of primary hyperparathyroidism after endoscopic removal of a right ureteral stone. The operation revealed a cyst, 20 x 10 mm in size at the left lower gland, and a solid tumor, 32 x 12 x 7 mm in size and 1, 300 mg in weight in the left upper gland. Histological examination disclosed a parathyroid cyst and an oxyphilic and chief cell adenoma, respectively. Postoperative course was uneventful including normalized serum Ca level. To our knowledge, 59 cases of parathyroid cysts have been reported in the Japanese literature, of which 31 were in the hyperparathyroid status. The most common causes were cystic degeneration of the adenomas. A parathyroid cyst with a concomitant adenoma in a different gland like our case is very rare. This is the first reported case in Japan and the sixth reported case in the world literature.

Urinary incontinence impairs the quality of life for patients following radical prostatectomy. We retrospectively reviewed the records of 36 patients who underwent radical retropubic prostatectomy between 1987 and 2002, and achieved the time from operation until urinary continence. A modification in the technique of apical dissection was introduced in 1999 and applied in 12 cases of consecutive radical prostatectomy. The principles for this technique were based on sharp division of the dorsal vein complex, continuous suturing cut edges of lateral pelvic fascia, and anterior anastomotic sutures including lateral pelvic fascia as well as urethra and bladder neck. None of the patients undergoing the new technique used pads at 6 months. With introduction of this technique, the rate of continence at 12 months increased from 58.3 to 100.0%. Our results suggest that the surgical technique of apical dissection is an important factor associated with postprostatectomy in continence.

We retrospectively reviewed the records of 23 patients (25 kidneys) who underwent open pyeloplasty for ureteropelvic junction obstruction (UPJO) between 1980 and 2001, focusing on failures. The patients included 17 men and 6 women, ranging from 3 months to 69 years old (mean 15.9 years). The followup period was 6 months to 19 years (mean 8.6 years). Anderson-Hynes pyeloplasty, Y-V plasty, Hellstrom's operation and simple pelvi-ureterostomy were performed in 22, 1, 1 and 1 kidney, respectively. We successfully repaired 21 of 25 renal units (success rate 84.0%). Of the four patients (4 kidneys) with persistent UPJO occurring in this primary pyeloplasty series, repeat pyeloplasty was performed on 2 patients, nephrectomy on 1 patient and balloon dilatation on 1 patient. Infection and prolonged urinary drainage seem to result in fibrosis of periureteral tissues. Inadequate stitches may cause granuloma in the lumen of the anastomosis. The techniques and complications associated with open pyeloplasty are discussed.

A 57-year-old woman was admitted with a chief complaint of difficult urination on June 7, 1993. A filling defect and a large diverticulum were revealed on the cystogram. Cystoscopy showed a tumor, obstructing the internal urethral orifice at the bladder neck and a diverticulum at the right posterior wall of the bladder. Under the preoperative diagnosis of a benign bladder tumor with a diverticulum, resection of the tumor and transvesical diverticulectomy were performed by a suprapubic approach. The resected tumor was smooth-surfaced, elastic soft and was measured 2.0 by 1.5 by 1.0 cm in size. Histologically, the tumor was diagnosed as a benign fibroma of the urinary bladder. The postoperative course was uneventful. Non-epithelial benign bladder tumors are rare. To our knowledge, this is the 18th case of bladder fibroma in the Japanese literature. The characteristics of bladder fibroma are briefly described.

We reported a case of inverted papilloma of the bladder, and six cases (two of ureteral cancer and four of bladder cancer) of transitional cell carcinoma with inverted proliferation. These tumors were superficial and pedunculated as well as transitional papilloma or ordinary papillary transitional cell carcinoma though they showed a non-papillary and polyp-like configuration. Moreover, these urothelial cancers with inverted proliferation were thought to be similar to papillary cancer with regard to grading, multiplicity, invasiveness and recurrence. Therefore, transurethral resection or segmental ureterectomy may be recommended for the tumor of low grade malignancy and radical treatment including systemic chemotherapy may be recommended for the tumor of high grade malignancy.

A case of a parathyroid cyst associated with an adenoma in a different gland is reported. A 55-year-old female was explored with preoperative diagnosis of primary hyperparathyroidism after endoscopic removal of a right ureteral stone. The operation revealed a cyst, 20 x 10 mm in size at the left lower gland, and a solid tumor, 32 x 12 x 7 mm in size and 1, 300 mg in weight in the left upper gland. Histological examination disclosed a parathyroid cyst and an oxyphilic and chief cell adenoma, respectively. Postoperative course was uneventful including normalized serum Ca level. To our knowledge, 59 cases of parathyroid cysts have been reported in the Japanese literature, of which 31 were in the hyperparathyroid status. The most common causes were cystic degeneration of the adenomas. A parathyroid cyst with a concomitant adenoma in a different gland like our case is very rare. This is the first reported case in Japan and the sixth reported case in the world literature.