[Spontaneous peripelvic urine extravasation associated with ileocecal cancer: a case report].

A case of spontaneous peripelvic extravasation with ileocecal cancer is reported. A 60-year-old man with right flank pain was referred to our department. Dripinfusion pyelography showed right peripelvic extravasation. Neither computed tomography (CT) nor retrograde pyelography revealed any ureteral stones or tumors. Urinary cytology was negative. One month later, right retrograde pyelography demonstrated the filling defect in the right ureter, but no stones, ureteral tumors or other tumors related to the ureter were detected by CT. An exploratory laparotomy was done. We found an ileocecal tumor invading to the right ureter and disseminated to the peritoneum. Histological diagnosis was mucinous carcinoma.

Incidence of prostatic intra-epithelial neoplasia in Osaka, Japan.

High-grade prostatic intra-epithelial neoplasia (HGPIN) is the most likely precancerous lesion for prostatic carcinoma. A high incidence of its association with cancer has been reported in Western countries. On the other hand, information regarding its incidence is limited in Japan, where the mortality due to prostate cancer is much lower. We reviewed 53 clinical stage T2 or T3 prostatic cancers of Japanese patients living in Osaka, Japan (mean age, 67.2 years). These cases were subdivided into a pre-operatively non-castrated group (34 cases) and a medically or surgically castrated group (19 cases). HGPIN was found in 27 cases. The incidence of HGPIN was significantly lower in the castrated group (21.0%) compared with the non-castrated group (67.6%). In the non-castrated group, patient age, pathological stage, Gleason score, tumor size and serum prostate-specific antigen showed no significant correlation with HGPIN. Advanced pathological stage and tumor size tended to decrease the incidence of HGPIN, although this was not statistically significant. When the study group was limited to stage T2 tumors of the non-castrated group, the incidence of HGPIN was 81.0%. HGPIN in Japan may also be clinically and etiologically significant as a precursor of clinical cancer.

Preclinical Cushing's syndrome due to adrenocorticotropin-independent bilateral adrenocortical macronodular hyperplasia with concurrent excess of gluco- and mineralocorticoids.

A 48-year-old with bilateral adrenal incidentalomas was studied. Although the serum cortisol level was normal, autonomous cortisol secretion was shown by the loss of diurnal rhythm, no suppressibility by dexamethasone, and complete suppression of plasma adrenocorticotropin levels. Imaging analyses revealed bilateral adrenal masses, showing isotope uptake. He was diagnosed as preclinical Cushing's syndrome due to adrenocorticotropin-independent bilateral adrenocortical macronodular hyperplasia, confirmed histologically. Despite the undetectable plasma adrenocorticotropin level and renin activity, serum mineralocorticoids levels were not suppressed, which were decreased after subtotal adrenalectomy. It was suggested that hyperplastic adrenal glands could produce both gluco- and mineralocorticoids concomitantly.

[Clinical phase III study of cimetropium bromide (DA3177) on the pain with upper urinary calculus: a double-blind study in comparison with scopolamine butylbromide. DA3177 Study Group].

A double-blind study was conducted to evaluate the efficacy, safety and usefulness of cimetropium bromide (DA3177) in the patients with pain caused by upper urinary calculus at a daily dose of 75 mg t.i.d. (Group D, 97 patients) in comparison with scopolamine butylbromide at a daily dose of 60 mg t.i.d. (Group B, 101 patients). According to patient's impression, the rate of "moderately improved" or better was significantly higher in Group D (68.7%) than in Group B (53.5%; Wilcoxon 2 sample test: p = 0.0044). For pain, the rate of "moderately improved" or better was 69.1% in Group D and 60.4% in Group B. In global improvement, the rate of "moderately improved" or better was significantly higher in Group D (70.1%) than in Group B (61.4%; Wilcoxon 2 sample test: p = 0.0469). The rate of "no problem in safety" showed no significant difference between Group D (91.5%) and Group B (93.3%). Adverse reactions occurred in 8.5% in Group D and 6.7% in Group B. The major adverse reactions were "dry mouth", "abdominal distension", "constipation" and "nausea". The rate of "useful" or better was 68.7% in Group D, and 60.4% in Group B. In conclusion, DA3177 was confirmed to be a useful drug for patient with pain caused by upper urinary calculus.

Alterations of the p53 gene in occupational bladder cancer in workers exposed to aromatic amines.

Epidemiologic studies have revealed an increased risk for development of transitional cell carcinoma (TCC) among dye workers/painters occupationally exposed to aromatic amines such as benzidine, beta-naphthylamine, orthotoluidine, and aniline. In the present study, p53 gene mutations in 26 patients with bladder lesions occupationally exposed to aromatic amines were examined by single-strand conformation polymorphism analysis of PCR-amplified DNA segments, followed by direct sequencing. All were male, and age at admission ranged from 43 to 75 (median 66) years. Twenty-nine biopsy specimens were from primary lesions; 17 (61%) of these lesions were from TCC including one carcinoma in situ (CIS); 11 were from dysplasia; and 1 was taken from normal-looking transitional epithelium adjoining TCC. TCC lesions included 12 with low-grade (Grade 1 or 2) and 5 with high-grade (Grade 3 or CIS) changes. Twenty-four recurrent lesions were biopsied in 16 patients: TCC was found in 12 lesions (50%), CIS in 1 (4%), and dysplasia in 11 (46%). All lesions were localized within the submucosa except for two, which invaded into the muscle layers. PCR-single-strand conformation polymorphism analysis demonstrated that mutations (a) occurred in both dysplasia and in normal-looking epithelium, in addition to TCC lesions; (b) were at different sites in the p53 gene in concurrent or metachronous lesions; and (c) occurred in exon 5 in approximately 70% of lesions, especially at codons 151 and 152. C to T transitions were predominantly seen. These findings clearly show differences in the pattern of p53 mutation in occupational versus nonoccupational bladder lesions. Because both common and unique point mutations were found in p53 in concurrent and metachronous lesions, our results suggest that the multifocality of occupational bladder cancer arises both from multiple clonal lesions (field change) and from the dissemination of a single clone.

[Clinical experience of total prostatectomy using DDV-L (deep dorsal venous ligator].

BACKGROUND: We evaluated blood loss in operation and postoperative urinary incontinence to total prostatectomy using the DDV-L. METHODS: We performed total retropubic prostatectomy for 38 patients from May 1979 to May 1995. In 14 patients from October 1994 to May 1995 the DDV-L was used. The DDV-L is used in transurethral approach, disposable device to ligate the deep dorsal vein complex by delivering the needle to lateral of deep dorsal vein complex. RESULTS: We composed the 14 patients which was used the DDV-L with the 14 patients which was from April 1990 to July 1994 was not used that. The mean operating time of 14 patients which was used the DDV-L was 178.5 min, 14 patients which was not used that was 188.0 min. The mean blood loss of 14 patients which was used th DDV-L was 735.7 ml, 14 patients which was not used that was 1250.2 ml. We transfused blood into 2 of 14 patients which was used the DDV-L (14.0%), 10 of 14 patients which was not used that (71.4%). The one of 14 patients which was used the DDV-L (7.5%) and 5 of 14 patients which was not used that (35.7%) had postoperative urinary incontinence needing pad. CONCLUSION: Accordingly the operating results of 14 patients which was used the DDV-L was undoubtedly better that of 14 patients which was as regards blood loss in operation, postoperative urinary incontinence. We can perform easily the management of deep dorsal vein complex by DDV-L, so we can cut of urethra without excess hemostasis and electronic coagulation, and leave enough long membranous urethra. We consider the DDV-L is helpful to total prostatectomy.

Renal cell carcinoma: preoperative assessment for enucleative surgery with angiography, CT, and MRI.

PURPOSE: Our purpose was to assess various imaging methods in detecting a pseudocapsule of renal cell carcinoma (RCC), which is critical for successful tumor enucleation. METHOD: In 42 patients with histopathologically proven RCC, images obtained at angiography (n = 42), CT (n = 30), and MRI (n = 19) were investigated retrospectively. All patients underwent treatment (enucleation: n = 15; nephrectomy: n = 27). The imaging criteria for the presence of a pseudocapsule were as follows: a surrounding radiolucent rim on angiography, a low or high density rim on CT, and a low intensity rim on MRI. All images were retrospectively reviewed by three radiologists without knowledge of the clinical and histological findings. RESULTS: Thirty-three of 42 RCCs showed a pseudocapsule on the surgical specimen. A pseudocapsule was detected in 67% of tumors (22/33) on angiography, 26% (6/23) on CT, 27% (4/15) on T1-weighted MRI, 93% (14/15) on T2-weighted MRI, 67% (8/12) on dynamic enhanced T1-weighted MRI, and 15% (2/13) on delayed enhanced T1-weighted MRI. CONCLUSION: T2-weighted MR images are superior for visualizing a pseudocapsule of RCC and for providing reliable selection criteria for tumor enucleation.

Arterial embolization to control renal hemorrhage in patients with percutaneous nephrostomy.

Two patients with renal hemorrhage treated by arterial embolization are reported. In one patient, one kidney was injured and the another had poor function. The other patient had one kidney. Although both patients had hematuria and underwent percutaneous nephrostomy, the bleeding location was not detected angiographically. Repeated embolization and irrigations through a nephrostomy catheter following each embolization arrested the bleeding.

[Diagnosis and therapy of incidental renal cell carcinoma].

Renal cell carcinoma (RCC) especially incidentally found RCC has been markedly increased in the world due to development of ultrasound or computerized tomography (CT) instruments. Controversy existed on the nephron sparing treatment for incidental RCC. We have operated the incidental RCC using a technique of tumor enucleation shelling out with 5 mm normal surrounding parenchyma. It is important to demonstrate its pseudocapsule for indication of the procedure. For the purpose MRI (T2) is the most reliable method in comparison with angiography, CT and ultrasound. In 42 cases of incidental RCC, 22 cases were nephrectomized and 19 cases were enucleated. One was not operated on. In our cases there was no local recurrence, metastasis or impaired renal function for over one year. However, some problems still remain such as local recurrence (0% approximately 10%), multicentricity (7%) and residual renal function in the literature. Therefore, we propose the following 4 points for indications of tumor enucleation, (1) asymptomatic completely and incidentally, (2) < or = 4 cm in diameter, (3) stage 1 (T1, T2) with pseudocapsule, (4) peripheral location.

[Multilocular cystic renal cell carcinoma treated with tumor enucleation: a case report].

We report a 65-year-old man with a multilocular cystic renal cell carcinoma which was found incidentally. Computed tomography (CT) demonstrated a 3.0 cm x 3.0 cm multilocular cystic mass at the upper pole of the left kidney. Dynamic MRI demonstrated that the septic wall of the multilocular cystic mass was enhanced. Renal angiography showed a hypovascular tumor. We diagnosed that the tumor was multilocular cystic renal cell carcinoma with a tumor capsule and performed tumor enucleation. The histopathological examination showed that the cystic and septic wall consisted of renal cell carcinoma, clear cell subtype, grade 1. From the review of the literature, the prognosis of multilocular cystic renal cell carcinoma was good, so we selected nephron sparing surgery for this case.

[Laser-TURP with a lateral firing fiber for contact irradiation].

We have operated 25 BPH patients with transurethral Nd-YAG laser ablation for prostate from June of 1993 till December of 1993. We used UltraLine fiber for contact laser irradiation of the prostate. This is a lateral firing quartz fiber with high density laser energy output, and so made it possible for us to vaporize prostatic tissue rapidly and deeply. We used 60 Watts of power for all cases. For the prostates larger than 50 cm3, limited resection after laser ablation allowed early relief of patients' symptoms. Two months after the treatment, average flow rate improved from 3.7 ml/sec to 7.8 ml/sec. Volume of residual urine decreased from 48.4 ml to 17.0 ml. Twenty-four percent decrease of prostatic volume was also recognized with transrectal sonography. Only 4 patients complained of transient urinary retention, although another 3 or 5 days catheter placement relieved their symptoms. Bleeding was negligible and the other postoperative complications were not recognized at all. Laser-TURP is a new treatment that is effective, less morbid and economical, compared with the ordinary TUR-P. So it will soon become an alternative method to electrocautery TUR-P.

[Asymptomatic pheochromocytoma: a report of three cases].

We present three cases of asymptomatic pheochromocytoma treated at Sumitomo Hospital. They had no hypertensive episode. The tumors of Case 1 and Case 3 were incidentally detected by abdominal ultrasonography at the Health Screening Center of Sumitomo Hospital. The tumor of Case 2 was incidentally detected by abdominal ultrasonography in the health examination of his company. Case 1. A 49-year-old male was hospitalized in Apr. 1992 because of further examination of a right adrenal mass. He underwent right adrenalectomy and its histological examination revealed pheochromocytoma. Case 2. A 45-year-old male was referred to our department for further examination of a left adrenal mass in Aug. 1993. On admission, endocrinological examination was almost normal. He underwent surgical removal of the tumor and its histological examination revealed pheochromocytoma. During the operation, blood pressure and pulse rate were almost unchanged. Case 3. A 51-year-old female was hospitalized in Oct. 1993 because of further examination of a left retroperitoneal mass. She underwent surgical removal of the tumor and its histological examination showed paraganglioma.

[Bilateral adrenal myelolipoma: a case report].

A case of bilateral adrenal myelolipoma is presented. The patient was a 40-year-old man in whom a retroperitoneal tumor was unexpectedly found by ultrasonography. Computed tomography revealed bilateral adrenal masses, 14.0 cm in diameter on the right side, and 5.0 cm on the left side, with heterogeneous low density components. Magnetic resonance imaging also revealed a high intensity mass with heterogeneity. Laboratory examination of adrenal function revealed normal results. We confirmed myelolipoma of bilateral adrenal gland, and performed right adrenalectomy, and left tumor enucleation. The right tumor was 14.0 x 12.5 x 10.0 cm in size and 920 g in weight, and the left tumor 5.0 x 4.5 x 4.0 cm in size and 50 g in weight. Pathology disclosed an admixture of mature adipose tissue and hematopoietic elements resembling bone marrow. Histopathological diagnosis was adrenal myelolipoma. This case was the 6th to be reported in the Japanese literature as bilateral adrenal myelolipoma.

[Clinical evaluations of tumor enucleation for incidental renal cell carcinoma].

We performed tumor enucleation in 21 patients of renal tumors from Jan. 1980 to Feb. 1993. Of them 19 had renal cell carcinoma. We reviewed the results of clinical experiences. Preoperatively, all patient underwent ultrasound, computerized tomography (CT) and angiography, and evaluated tumor characteristics in terms of its localization, size and pre or absence of pseudocapsule. All cases were shown to be well encapsulated. Of them 17 were asymptomatic and detected incidentally, whereas remaining one case was bilateral renal cell carcinoma clinically characterized by gross hematuria. This case was treated by radical nephrectomy on the right side and enucleation of the tumor on the left side. All cases had localized renal cell carcinoma (stage 1) of low grade (15 cases of grade 1 and 3 of grade 2), and the diameter of the tumor averaged 3.4 cm. Of 18 cases 2 died, one died of causes unrelated to RCC and the other of the metastasis of bilateral RCC after nephrectomy. The 16 cases are presently free of disease for maximal follow up period of 92 months. We consider that tumor enucleation will be indicated for tumors found incidentally, surrounded by pseudocapsule, of small size (less than 3.0 cm in diameter), and of low grade and low stage, and that tumor enucleation for renal cell carcinoma could be curative yet preserve renal function in selected patients.

[Primary malignant lymphoma of the urinary bladder].

We report 2 cases of primary malignant lymphoma arising in the urinary bladder. The first case was a 64-year-old woman complaining of gross hematuia during the follow-up period of transitional cell carcinoma (grade 2, stage pTa) of the bladder that was treated with TUR in 1989. Her bladder tumor of this time was broad based, not papillary, and situated on the right side wall with bleeding. The pathological diagnosis of transurethral biopsy specimens was non-Hodgkin lymphoma, diffuse large, B cell type. Four courses of CAP chemotherapy was so effective that she has been free of the disease up to now. The second was a 51-year-old woman presenting with painless gross hematuia. A solid, round and intramural tumor, which was recognized on the left side wall by cystoscopy, was resected endoscopically as much as possible. Three courses of VEPA chemotherapy was done because pathologically it was non-Hodgkin lymphoma, diffuse medium, B cell type, although no evidence of other tumors in any organs was fortunately detected with further examinations. She has been doing well without recurrence for 9 months after discharge from the hospital. Primary malignant lymphoma of the bladder is unusual. About 70 cases have been reported in foreign countries, but only 23 cases in Japan. When malignant lymphoma is confined to the bladder, radiation and chemotherapy can be curative, and yet preserve the function of the bladder.

[Treatments of staghorn calculi].

The treatment of staghorn calculi is still difficult even though urolithiasis treatment can now be performed by endourology and extracorporeal shock-wave lithotripsy (ESWL) without open surgery. Because of the variety in volume and pattern of the staghorn calculi, especially with or without dilated renal pelvis and calyces, selection of treatment methods is important. The combined method of percutaneous nephrolithotomy (PNL) and ESWL has been highly effective in the complete removal of most staghorn calculi. Developments of the ESWL instrument and tools have increased the success of less invasive ESWL monotherapy with placing of stent or percutaneous nephrostomy for staghorn calculi with nondilated calyces. Also the treatment methods should be selected depending upon the components of the staghorn calculi. Dissolution and solidity, which are affected by the components, are also important factors. Complete removal of staghorn calculi is very difficult, and almost impossible to be performed in only one occasion including other surgical procedures as a series and this is the existing insurance provision. Therefore, we await the creation of a new insurance provision for the treatment of staghorn calculi.

[Treatment of staghorn calculi--ESWL monotherapy].

We investigated 41 cases (44 kidneys) of renal staghorn calculi treated in our hospital between November, 1988 and July, 1992. The efficacy of each treatment was 83.3% for extracorporeal shock-wave lithotripsy (ESWL) monotherapy (27 kidneys), 40% for percutaneous nephrolithotomy (PNL) with ESWL (5), 100% for dissolution with ESWL (6), 50% for pyelolithotomy with ESWL (2), 100% for nephrolithotomy with ESWL (1), and 100% for only dissolution (1). In the ESWL monotherapy group except for 3 cases that had complete staghorn calculi with severe caliectasis, the efficacy was between 70% and 100%, and the term of hospitalization was only about 1 month. The complications of ESWL monotherapy were stone street itself and high fever caused by it. However, renal function, could be successfully preserved by the timely drainage with D-J stent or nephrostomy tube. Thus, in most cases of staghorn calculi as well as other urolithiasis, ESWL monotherapy seemed to be more effective and safe than combined therapy of PNL and ESWL.

[Vesicourethral function study and application of urinary alarm in progressive supranuclear palsy].

We performed a vesicourethral function study on seven patients with progressive supranuclear palsy. In storage phase, 6 patients had decreased urinary sensation and overactive detrusor. Although bladder compliance was normal in all patients, maximum cystometric capacity was decreased in 3 patients. In micturition phase, detrusor contraction was underactive in 4 patients and acontractile in 1 patient. Sphincter electromyogram showed detrusor-sphincter-dyssynergia in 1 patient, no decrease in 3 patients and synergistic decrease in 1 patient. Six patients had urinary incontinence partially due to those neurological abnormality, partially due to dementia and lower activity of daily living. To facilitate the care of such functional incontinence, we devised a urinary alarm. The urinary alarm is a device to detect urine in a diaper. One can know the micturition in a diaper without being informed of micturition by the patient and change diapers as soon as possible. It was also useful to examine their frequency/volume chart.

[Comparison of the vesicourethral function between progressive supranuclear palsy and Parkinson's disease].

We compared the vesicourethral function between progressive supranuclear palsy (7 cases) and Parkinson's disease (vesicourethral function study in 8 patients with dysuria and questionnaire study in 44 patients). The frequency of urinary incontinence in the 44 patients with Parkinson's disease was 38.7%. Vesicourethral function study showed hypersensitivity, low bladder capacity, detrusor hyperreflexia and normal sphincter EMG. The frequency of urinary incontinence in supranuclear palsy was 85.7%. Vesicourethral function study showed hyposensitivity and detrusor hyperreflexia in 6 cases, and 4 of these 6 cases had residual urine due to impaired detrusor contraction in micturition phase and/or abnormal sphincter EMG. Compliance was normal, but bladder capacity was decreased in progressive cases. Impaired contraction and hyposensitivity made it more difficult to control the urinary incontinence in supranuclear palsy than in Parkinson's disease. Dementia and lower ADL were frequently accompanied with supranuclear palsy (rare in Parkinson's disease). These were other factors that worsen the control of incontinence.

Differential expression of a human sperm-specific isozyme in seminoma cells transplanted in Scid-nu(str) mice.

An isozyme of human sperm-specific lactate dehydrogenase, LDH-X (C4) (EC 1.1.1.27), which is expressed only in differentiated germ cells (spermatozoa, spermatids and primary spermatocytes after midpachytene), appeared in the xenografted tumor cells of human seminoma and its metastatic lesions (lymph node and kidney) in scid (severe combined immunodeficiency)-nude(streaker) double mutant mice, though it was not expressed in the original tumor of the patient. The morphological pattern of seminoma cells also changed in the xenografts and metastatic lesions as in normal spermatogenesis. Thus, the human seminoma cells showed differential expression of the sperm-specific isozyme in parallel with their morphological changes. However, the sperm-specific isozyme disappeared in the mitotically dividing seminoma cells which were newly established from the LDH-X positive xenograft.