Modified anatrophic nephrolithotomy.

The anatrophic nephrolithotomy described by Smith and Boyce is an excellent method of preserving a maximum number of functioning nephrons by minimizing injuries to both the renal parenchyma and its blood supplies. However, clamping of the main renal artery is inevitable and may damage renal function despite regional hypothermia. We devised a modified technique of nephrolithotomy with selective clamping of the segmental artery and no necessity for regional hypothermia.

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.

[Occupation and urothelial cancer: the background and the clinical figure].

Occupational urothelial carcinomas which were developed by benzidine and beta-naphthylamine have been diagnosed and treated in 60 workers. The number of cases of bladder tumor, ureteral tumor and bladder with upper urinary tract tumor was 49, 2 and 9, respectively. Death from urinary tract carcinoma was 5 (8.3%) and 12 out of 60 died from other diseases, 8 from other organ carcinomas and 4 from none cancer diseases. Organ preserving therapy for occupational urinary tract carcinoma should be selected because of high recurrence tendency, especially cisplatin-radiation or BCG instillation therapy. In future, new candidates will decrease but the fact of the patients becoming older will be important including other organ carcinomas, when we follow them up. Case control study was done by examining replies to questions answered by non-tumor-developing group and tumor developing group. Questions included alcohol, water and cigarette consumption, working duration and difference of chemical substance. A statistically significant result was obtained only in difference of production or messenger of the chemical substance (p = 0.001).

[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.

[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.

[A case of small simple renal cyst associated with renal cell carcinoma].

A 61-year-old male was admitted to our clinic for the purpose of further examination of the small renal mass discovered incidentally by ultrasonography. Subtraction angiography disclosed a small renal cell carcinoma of the upper-lateral margin of the left kidney dramatically. Enucleating surgery of the tumor was performed successfully (about 2 cm in diameter). Histological examination revealed a small simple renal cyst associated with renal cell carcinoma. The patient is well without evident metastasis 1 year postoperatively. Since this is a very rare case in the literature, we report this case and discuss the preoperative diagnosis of small renal cell carcinoma. We believe that ultrasonography is a simple and very useful method for mass screening of small urological malignancies.

[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.

[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.

[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.

[Inverted papilloma of the renal pelvis].

A 60-year-old man with inverted papilloma of right renal pelvis is presented. On visit to hospital for benign prostatic hyperplasia with prostatic stone, he was found to have microscopic hematuria and intravenous pyelography and retrograde pyelography demonstrated a filling defect with papillary contour. We diagnosed a right renal pelvic tumor, which showed to be low grade because of negative cytology. Therefore, we performed tumor resection with renal preservation. Pathological diagnosis was inverted papilloma. From the Japanese and foreign literature, 16 cases of renal pelvic inverted papilloma were collected. They were reviewed clinically and pathologically, and the therapy was discussed.

[Familial vesicoureteral reflux].

Between August 1979 and January 1983, 43 cases of primary vesicoureteral reflux were treated in our hospital. Among them 9 cases of 4 families occurred familially. They were all siblings: 3 boys and 6 girls aged between 2 years and 10 years. Five cases except for 4 probands of each sibling were discovered after aggressive prospective family study, but they had no clinical symptoms that suspected vesicoureteral reflux; one of them was found to be in a preuremic condition. The other 2 siblings were examined by a prospective family study but demonstrated no vesicoureteral reflux. Therefore, vesicoureteral reflux could be demonstrated in 5 of the 7 siblings who had been examined by a prospective family study. This rate was significantly high (71%). Discussion is made about the necessity of prospective family study to discover asymptomatic patients with vesicoureteral reflux in the family, and the literature is reviewed.

Bilateral primary non-Hodgkin's lymphoma of the adrenal glands with adrenal insufficiency: a case report.

A 72-year-old woman with bilateral non-Hodgkin's lymphoma of the adrenal glands causing adrenal insufficiency is reported. The left-side lymphoma (diffuse large B-cell lymphoma) was removed surgically but the right-side lymphoma could not be removed. Complete response was obtained with subsequent combined chemotherapy and was maintained for 6 months with repeated chemotherapies. However, the patient died of liver recurrence 1 year after admission. In cases of malignant lymphoma forming a bulky mass, surgery with subsequent chemotherapy appears to reduce the cancer volume and improve the therapeutic outcome.

[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.

[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.

[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.

[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.

[Treatment of prostatic carcinoma with daily subcutaneous injection of the LH-RH analogue, ICI 118630].

Between April, 1984 and March, 1985 in 14 centers, 33 patients with prostatic cancer of our 14 centers were randomized to subcutaneously receive either 125, 250, or 500 micrograms/day of ICI 118,630, an LH-RH analogue, for 12 weeks, and the clinical efficacy, safety and endocrinal effects of the drug by dose were examined. An objective partial response was obtained in 44.4% of the 125 micrograms-treated group, in 50.0% of the 250 micrograms-treated group, and 42.9% of the 500 micrograms-treated group, showing no significant difference between the groups. General subjective response rates in these three groups were respectively 75.0%, 62.5%, and 85.7%, not differing from each other significantly. No significant difference was observed in endocrinal effect which was seen in 58.3%, 66.7%, and 100% of 125 micrograms, 250 micrograms, and 500 micrograms groups, respectively. Medical castration was attained in 4.1 +/- 2.0 weeks on average. Adverse reactions observed included fever up to 37 degrees C in 1 of the 13 (7.3%) patients treated with 125 micrograms, and hot feeling at the injection site and flare in 1 of the 8 (12.5%) patients treated with 500 micrograms, which were all mild. These patients responded to further ICI 118,630 therapy without requiring any treatment for the adverse reactions.

[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.

[A clinical evaluation of AMS Hydroflex in the treatment of impotence].

The AMS Hydroflex penile prosthesis was implanted in 34 organic impotence patients between June 20, 1986 and Aug. 6, 1990. Patients ages ranged between 26 and 71 with an average of 50.5. The causes of impotences were; 17 cases of post-radical pelvic surgery, 7 cases of injury, 6 cases of diabetes and 4 of others. First evaluation was made after 12 weeks of implantation in terms of patient satisfaction with sexual intercourse and post operative complication. Sixteen patients (47.1%) were highly satisfied with intercourse, 13 (38.2%) satisfied with intercourse, 2 (5.9%) slightly dissatisfied even with successful intercourse, 1 (2.9%) with no improvement and 2 (5.9%) could not follow. Utility of the prosthesis, e.g. effectiveness and safety was; high utility in 20 (58.8%), good utility in 11 (32.4%), slight utility in 1 (2.9%), no favorable in 1 (2.9%) and no judgement in 1 (2.9%). The overall effectiveness and safety of the Hydroflex was demonstrated based on the above findings. Long term evaluation was made from the initial implantation of the device up to the termination of the trial with average of 19.2 months and was mentioned altogether.

[The clinical evaluation of hochuekkito for symptoms of malignant neoplasm patients].

Hochuekkito was administered in 2.5 g doses three times a day to 162 patients who complained of anorexia or lassitude because of genitourinary cancer. The efficacy rate was 63.0%. The rate of effectiveness on anorexia was 48.4% and that on lassitude was 36.6%. Side effects were observed in 12 patients (7.4%), but most of them were mild gastrointestinal disorders. No severe adverse effects were noted.