[A Case of Prostate Cancer Diagnosed by the Bone Biopsy of the Right Iliac Metastatic Lesion].

A 73-year-old man was referred to our hospital because of a high prostate specific antigen (PSA) level. The PSA level at our hospital was 63.5 ng/ml. Pelvic magnetic resonance imaging (MRI) showed findings strongly suggestive of multiple pelvic bone metastases, but no obvious malignant findings in the prostate. A 12-core prostate biopsy was performed and no cancer was detected. Computed tomography and bone scintigraphy showed findings suspicious of bone metastases in the sternum, thoracolumbar spine, pelvic bone, and sacrum. Spine MRI revealed a mass in the vertebral body from the eighth thoracic vertebra to the first lumbar vertebra. A biopsy of the right iliac crest showed adenocarcinoma and was positive for PSA staining, leading to the diagnosis of multiple bone metastases of prostate cancer. Abiraterone acetate in combination with androgen deprivation was started. He received medication and radiation therapy to his sternum for pain relief. Spine MRI after 4 months showed decreased vertebral body weights and serum PSA levels were ＜0.003 ng/ml after 5 months. Seventeen months after treatment, PSA remains below 0.003 ng/ml, and the patient is currently pain-free.

[SMALL RENAL CELL CARCINOMA METASTASIS TO THE IPSILATERAL PERIRENAL FAT SYNCHRONOUSLY: A CASE REPORT].

Small renal cell carcinoma with metastases is rare; thus, to the best of our knowledge, this is the first case of synchronous metastasis to the ipsilateral perirenal fat.A 70-year-old man visited our hospital because of early gastric carcinoma. Contrast-enhanced computed tomography revealed a right renal tumor and two small nodules in the ipsilateral perirenal fat. The renal tumor was 3 cm in diameter and consistent with clear cell renal cell carcinoma. The enhancement pattern of the nodules was similar to that of the renal tumor, we diagnosed cT1aN0M1. Transperitoneal laparoscopic radical nephrectomy of the right kidney was performed. Postoperative pathological analysis showed clear cell renal cell carcinoma of the right kidney, pT1a, G2>1, INFa, v0, ly0, and two nodules in ipsilateral perirenal fat had comparable pathological findings. At 11th month of postoperative follow-up, CT revealed multiple nodules in the left pleura. Pembrolizumab plus axitinib was administered every 3 weeks. Multiple pleural metastases disappeared 3 months after the therapy; however, grade 2 (CTCAE v5.0) diarrhea and hoarseness emerged. Owing to the persistence of symptoms despite axitinib cessation, pembrolizumab was also discontinued. After 2 months of withdrawal, the patient's symptoms resolved spontaneously. After consultation with the patient, he was followed up with no further treatment. He is alive with no evidence of recurrence 36 months after surgery.

[Left Essential Renal Hematuria, that Cannot Be Stopped by Ureteroscopy, Successfully Treated with the Instillation of Hydrogen Peroxide into the Renal Pelvis : A Case Report].

We report a case of left essential renal hematuria successfully treated with the instillation of hydrogen peroxide into the renal pelvis. A 68-year-old man was referred to our hospital with the chief complaint of gross hematuria. Our diagnosis was left renal essential hematuria. We could not find the bleeding point using a flexible ureteroscope. Due to prolonged gross hematuria, we performed instillation of hydrogen peroxide into the renal pelvis and the gross hematuria completely disappeared. Retrograde hydrogen peroxide instillation therapy is useful and safe for essential renal hematuria.

The Association between Glomerular Diameter and Secondary Focal Segmental Glomerulosclerosis in Chronic Kidney Disease.

INTRODUCTION: When nephron loss occurs, the glomerular filtration rate (GFR) is suggested to be maintained by glomerular hypertrophy, but excessive hypertrophy can rather lead to the formation of focal segmental glomerulosclerosis (FSGS), thereby causing progressive kidney damage. However, it is not clear how much glomerular hypertrophy leads to the formation of FSGS. We examined the association between glomerular diameter and FSGS lesions in chronic kidney disease (CKD) patients. METHODS: We recruited 77 patients who underwent renal biopsy during 2016-2017; however, those identified with primary FSGS and glomerulonephritis with active glomerular lesion were excluded. We evaluated the maximal glomerular diameter (Max GD), an indicator of glomerular size, in each renal biopsy specimen and examined its association with FSGS lesion. RESULTS: The median age, blood pressure, and estimated GFR of the patients were 53 years, 122/70 mm Hg, and 65 mL/min/1.73 m2, respectively. The optimal cutoff threshold of Max GD for predicting the presence of FSGS lesions, assessed by receiver operating characteristic curve analysis, was determined to be at 224 µm (area under the curve, 0.81; sensitivity, 81%; specificity, 72%). Multivariate logistic regression analyses demonstrated that Max GD ≥224 µm was significantly associated with the presence of FSGS lesions, independent of other confounding factors (odds ratio, 11.70; 95% confidence interval, 1.93-70.84). DISCUSSION/CONCLUSION: Glomerular hypertrophy (Max GD ≥224 µm) has been associated with FSGS lesions in CKD patients and may reflect the limits of the compensatory process.

[A Case of Metachronous Bilateral Epididymal Tuberculosis after BCG Instillation Therapy].

Beginning in May 2016, an 83-year-old male underwent three transurethral resections for recurrent bladder cancer. In June 2017, following a positive urine cytology exam, a random biopsy of the bladder was performed. The histopathological findings revealed urothelial carcinoma, high grade, pTis. Treatment consisted of bacillus Calmette-Guerin (BCG) instillation. In February 2018, he complained of left scrotal swelling and pain ; and, was diagnosed with left epididymitis. However, based on resistance to the antibiotic agent, epididymal tuberculosis after BCG therapy was suspected and resection of the left testis and epididymis was performed. Histopathological findings revealed epididymal tuberculosis. Three months after the left orchiectomy, the patient complained of right scrotal swelling and pain. Based on antibiotic resistance and the positive findings of a urinary mycobacterium tuberculosis polymerase chain reaction assay, metachronous right epididymal tuberculosis was suspected and the patient underwent resection of the right epididymis. While the histopathological findings did not indicate tuberculosis, the urinary mycobacterium culture was positive. The patient was diagnosed with right epididymal tuberculosis and after surgery was administered an antituberculosis drug.

Incidental detection of Corynebacterium jeikeium endocarditis via regular blood examination in an afebrile hemodialysis patient.

Herein, we describe a rare case of Corynebacterium jeikeium endocarditis that silently progressed in a 65-year-old man undergoing hemodialysis. Because routine monthly blood examination revealed high C-reactive protein levels, blood cultures were collected, although he had no symptom and was afebrile. After 2 days, a Gram-positive rod was detected in one set of the blood culture. Furthermore, transthoracic echocardiography revealed new aortic regurgitation (AR) and vegetations, and, therefore, infective endocarditis was suspected. Transesophageal echocardiography showed vegetations with a maximum diameter of 8 mm on his aortic valve, with some valve destruction. C. jeikeium was identified in three sets of blood cultures. Administration of daptomycin was started because he had vancomycin allergy. Judging from the high risk of embolization due to vegetations, emergency aortic valve replacement was performed on the second day. C. jeikeium was detected in a resected cardiac valve specimen and blood. This case emphasizes that physicians should always consider the possibility of infective endocarditis even in hemodialysis patients without any symptoms.

[A Case of Bilateral Renal Tumors, Renal Cell Carcinoma and IgG4- Related Retroperitoneal Fibrosis].

A 69-year-old man was referred to our hospital for a right renal pelvic tumor noted on a computed tomography (CT) scan at another hospital. Urine cytology was negative. Dynamic CT revealed a right renal pelvic tumor and, accidentally, a small left renal tumor enhanced in the arterial phase and washed out in the venous phase. No defect in the urinary tract was found on retrograde urography, and upper urinary cytology was negative. The patient's level of IgG4 was high, but other tumor markers were negative. We judged the right renal pelvic tumor to be an extrapelvic lesion, probably IgG4-related disease. We temporarily followed up the right renal pelvic tumor but performed retroperitoneal left partial nephrectomy for the small left renal tumor. Histopathology led to a diagnosis of clear cell renal cell carcinoma. Follow-up CT showed no change in the right renal pelvic tumor. We diagnosed the right renal tumor as IgG4-related disease and began steroid administration. After one monthof administration, the IgG4 value and the size of the tumor were reduced.

[Urothelial Carcinoma within a Calyceal Diverticulum Difficult to Distinguish from Cystic Renal Cell Carcinoma].

A 64-year-old man visited our hospital because of right renal cyst and microscopic hematuria which was found in a medical checkup. Contrast computed tomography (CT) and contrast magnetic resonance imaging (MRI) suggested cystic renal cell carcinoma. A laparoscopic nephrectomy was performed, and the surgical specimens showed urothelial carcinoma within the calyceal diverticulum. At a later date, ureterectomy was performed. The surgical specimens had no malignant findings. There has been no recurrence. To our knowledge only 10 cases of urothelial carcinoma within the calyceal diverticulum have beenreported inJapan. A few cases have beenreported overseas.

[Urethrocutaneous Fistula Caused by a Vesical Foreign Body in an Adolescent Boy : A Case Report].

In daily medical practice, we occasionally encounter patients with a foreign body in the urinary bladder. However, the identification of such a foreign body in an adolescent and the occurrence of an urethrocutaneous fistula caused by the foreign body are extremely rare. Only two cases have been reported previously. Herein we present a case of a foreign body in the urinary bladder and an urethrocutaneous fistula in a young patient. A 14-year-old boy with fever, left scrotal pain and urinary incontinence was referred to our department. Intravenous pyelography and micturition cystourethrography findings revealed a vesical foreign body and an urethrocutaneous fistula. He mentioned that he had inserted two dozen magnets into the urethra for masturbation one year previously. As the foreign bodies were spherical small magnets, we performed transurethral surgery and successfully removed the magnets. His postoperative course was uneventful and he was discharged from our department on the seventh day after surgery. Three months following surgery, the fistula had closed spontaneously.

[A Case Report : Primary Urothelial Carcinoma of the Prostate Producing Interleukin-6 Detected from a Fever].

A 72-year-old man visited a hospital because of a fever and fatigue. His fever persisted and computed tomography revealed a tumor of the prostate. The patient was referred to our hospital with a suspicion of prostate cancer. The blood test showed increased serum C-reactive protein (CRP) level without any infectious findings. Tumor markers including prostate specific antigen were within the normal range and urine cytology was negative. Prostate needle biopsy revealed urothelial carcinoma. No tumor was detected in other areas of the urinary tract. Therefore we diagnosed the patient with primary urothelial carcinoma of the prostate, cT3N0M0. Serum interleukin-6 (IL-6) elevated up to 68 ng/ml. We were not able to detect any metastatic lesions and performed radical cystoprostatectomy and ileal conduit. Serum CRP and IL-6 levels decreased and the fever declined. There has been no relapse 52 months after the surgery.

[Vesical Perforation Caused by a Foreign Body : A Case Report --A Clinical Review of 41 Cases in Japan-].

In daily medical practice, we occasionally encounter a foreign body present in the urinary bladder. However, the occurrence of vesical perforation caused by a foreign body is rare. A 53-year-old man with vesical pain and macrohematuria was referred to our department because of the presence of a foreign body in his urinary bladder. He seemed to have inserted the foreign body from the urethra during use of a stimulant drug according to his story. Cystoscopy revealed that the plastic foreign body had a few barbs and had penetrated the bladder through the left lateral wall. On performing computed tomography, we did not detect any injuries to other organs or hematoma formation. Therefore, we performed elective suprapubic cystostomy and removed the plastic foreign body. The patient's postoperative course was favorable, and he left our department on the sixth day after surgery.

[A Case of Clear Cell Adenocarcinoma Arising from a Female Urethral Diverticulum].

Adenocarcinoma arising from the female urethral diverticulum is very rare, as only about 100 cases have been reported worldwide. An 82-year-old woman presented with asymptomatic macrohematuria. A transvaginal examination revealed a firm circular mass on the anterior vaginal wall. Cystourethroscopy showed a urethral tumor, which was determined to be clear cell adenocarcinoma after transurethral resection of the urethral tumor. However, we could not resect all of the tumor, so anterior pelvic exenteration and ileal conduit urinary diversion were performed. The final pathological diagnosis was clear cell adenocarcinoma arising from the urethral diverticulum. However multiple lymph node metastases appeared 10 months after surgery. The patient refused additional therapy and died 23 months after surgery.

[A CASE REPORT: LITHIASIS OF THE LEFT ECTOPIC PELVIC KIDNEY].

We report a case of lithiasis of the left ectopic pelvic kidney. A 70-year-old man was admitted to our department for left lower back pain. He has been aware of gross hematuria since three or four years before. Computed tomography demonstrated the left ectopic pelvic kidney with a 16-mm stone and a 5-mm stone in the renal pelvis which was accompanied by hydronephrosis. Ten days later, the renal pelvic stones moved to the renal calices and the symptoms disappeared. Though a pyeloureteral junction obstruction was not evident, renogram showed a obstruction pattern of the left kidney. He had been followed up for six years, then the stone was impacted in the renal pelvis and hydronephrosis worsened. Open pyelolithotomy was performed. His clinical course was uneventful and no evidence of recurrence has been observed.

[Primary Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma with Large Cell Transformation of the Prostate : A Case Report].

Primary mucosa-associated lymphoid tissue (MALT) lymphoma of the prostate is rare. MALT lymphoma with large cell transformation like a diffuse large B-cell lymphoma (DLBCL) of the prostate is extremely rare. To the best of our knowledge, only one case has been previously reported. A 65-year-old man with difficulty on urination was referred to our department, in April 2014, because of abnormal findings of magnetic resonance imaging (MRI) and positron emission tomography-computed tomography imaging. Routine laboratory tests including prostate specific antigen and soluble interletkin-2 recepter were within normal limits, and the physical examination was unremarkable. In July 2007 and August 2009, he was submitted for a transrectal prostate biopsy, and then a histological examination for chronic prostatitis. In addition to the biopsy, transurethral resection of the prostate was performed. Histological examination revealed primary MALT lymphoma with large cell transformation of the prostate. Complete clinical investigation, including bone marrow biopsy, did not show any involvement of other sites by lymphoma, he received 3 cycles of chemotherapy consisting of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) followed by radiation therapy with a total dose of 46 Gy. The patient has been in complete remission for 6 months after the chemoradiation therapy.

[Case of Behcet's disease diagnosed by bilateral epididymitis].

A 24-year-old man visited our emergency room with testicular pain and left shoulder pain, and was admitted to our hospital for diagnosis of bilateral epididymitis. Antibiotics and anti-inflammatory medication were started, but the symptoms did not improve. During hospitalization, ulcerous lesions, erythema nodosum, folliculitis-like exanthema and multiple oral aphtha appeared. Then, we consulted the department of dermatology. As he had a combination of arthritis and epididymitis, he was diagnosed with the abortive form of Behcet's disease. After diagnosis, we began administering colchicine. Then, all symptoms improved in a few days, and he has remained free of the disease after the discontinuation of colchicine.

[Intrarenal Bacillus Calmette-Guerin perfusion therapy was effective for carcinoma in situ of the upper urinary tract after ileal conduit replacement : a case report].

A 63-year-old man who had undergone radical cystectomy and ileal conduit formation for invasive bladder cancer 3 years before presented with continuous positive urinary cytology in the ileal conduit. His diagnosis was carcinoma in situ (CIS) of the left upper urinary tract. He was treated with Bacillus Calmette-Guérin (BCG) perfusion therapy using a single-J ureteric stent. BCG (80 mg) in 100 ml saline was instilled in a one-hour period weekly for 6 weeks. Usage of another catheter was effective for continuing the therapy. Urinary cytology in the left upper urinary tract and the ileal conduit became negative after the therapy. There was no evidence of recurrence or metastasis of urothelial carcinoma 6 months after the therapy.

[Castleman's disease of the kidney: a case report].

Castleman's disease is a rare disorder characterized by benign proliferation of lymphoid tissue. A 61-year-old man was referred to our department for a renal mass incidentally detected by magnetic resonance imaging. Computed tomography showed a 18 × 20 × 14 mm mass in the upper pole of the right kidney, which enhanced at the early phase and washed out at the late phase. On the diagnosis of renal cell carcinoma, laparoscopic partial nephrectomy was performed. Pathological examinations revealed a hyaline-vascular type of Castleman's disease confined to the kidney.

[Panhypopituitarism caused by an intrasellar cystic mass in late-onset hypogonadism clinic].

A 74-year-old man who was referred to our late onset hypogonadism clinic presented with sweating and loss of appetite. His aging males' symptoms (AMS) and international index of erectile function (IIEF-5) scores were 59 and 2, respectively. His hormonal examination revealed extremely low free testosterone values. The patient was started on androgen replacement therapy, but his symptoms did not improve. Additional hormonal examinations revealed low values for other anterior pituitary hormones. Magnetic resonance imaging revealed an intrasellar cystic mass with suprasellar extension. We considered this mass caused hypothalamic hypopituitarism. A load test for anterior pituitary hormones revealed panhypogonadism. His symptoms improved after administration of adrenal and thyroid hormones and androgen. Five months after start of drug administration, his AMS score improved to 29, but IIEF-5 score showed little change. As a matter of course, not only androgen but all pituitary-related hormones are needed for hypopituitarism patients.

[Primary adenocarcinoma of the seminal vesicle difficult to differentiate from rectal carcinoma : a case report].

A 78-year-old man with urinary retention visited our hospital in June 2011. He presented with intestinal bleeding one month later and was admitted immediately. Contrast enhancement computed tomography revealed a lobulated intrapelvic tumor and liver metastasis. The prostate specific antigen level was normal, but his carcinoembryonic antigen level was elevated. Based on these results, his tumor was diagnosed as rectal carcinoma. On day 26, total pelvic exenteration and pelvic lymph node dissection to arrest bleeding were performed. We created an ileal conduit for urinary diversion and performed a sigmoid colostomy. The final histopathological assessment confirmed that he had primary adenocarcinoma of the seminal vesicle. The patient received the best supportive care because he rejected postoperative adjuvant chemotherapy and hormonal therapy. He died three months postoperatively. Primary adenocarcinoma of the seminal vesicle is very rare. The prognosis for this carcinoma is poor.

[Poor outcome due to spontaneous rupture of renal cell carcinoma : a case report].

A 54-year-old man experienced sudden onset of severe pain in his left lower back. Because the pain persisted for two days, he visited our hospital. Abdominal computed tomography revealed a hematoma around his left kidney, which was diagnosed as spontaneous rupture of a renal tumor. He was immediately admitted and was scheduled to undergo elective surgery. However, because his hemoglobin level decreased suddenly on Day 9 and rebleeding from the renal tumor was suspected, we chose to perform left radical nephrectomy following emergency transcatheter arterial embolization of his left renal artery. The resected specimen was a solid brownish-red mass surrounded by hematoma, and the histopathological findings revealed that it was a renal clear cell carcinoma (G3＞G2, INFα, pT1b, and pV0). On Day 51, he was found to have a local recurrence of carcinoma, and died five months after surgery. Spontaneous rupture of renal cell carcinoma is relatively rare : this is the 104th report on surgery for this carcinoma in Japan.