[A Case of Localized Amyloidosis of the Right Ureter Treated Effectively by Occulusive Dressing Technique Therapy Using Dimethyl Sulfoxide : Long-Term Follow-Up of Eight Years].

The patient was a 56-year-old female. She was referred to our department for further examination of right hydronephrosis in 2010. Computed tomography (CT) showed right hydronephrosis, and retrograde pyelography (RP) revealed stenosis of the right lower ureter. Urine cytology was negative. Transurethral biopsy of the right ureter was performed using ureteroscopic cup forceps and the histopathlogical diagnosis was ureteral amyloidosis. A whole-body search was performed, including rectal biopsy, but no evidence of amyloidosis was obtained. She was diagnosed with localized amyloidosis of the right ureter. A ureteral stent was indwelled and the patient was given occulusive dressing technique (ODT) therapy using dimethyl sulfoxide (DMSO) for 1 year. After ODT therapy, right hydronephrosis improved. After a 2-year followup, it worsened. ODT therapy was restarted and continued for 2 years. She consulted our department because of fever and right lumbago in April 2017 after a 4-month interruption of ODT therapy. CT revealed progression of the right hydronephrosis. A ureteral stent was indwelled and ODT therapy was restarted. The right hydronephrosis improved after 1 year. ODT therapy using DMSO was effective for localized ureteral amyloidosis, but periodic follow-up was necessary and ODT therapy was also effective when it recurred after the interruption of treatment.

[A Case of Metastasis of Cholangiocarcinoma to the Bladder].

The patient was an 88-year-old male. He was referred to the Department of Internal Medicine because of total body itching and jaundice in July 2011. The serum bilirubin level was elevated, and the serum CA19-9 level was also elevated to 266. 6 U/ml. Computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) revealed a solid tumor between the hepatic hilus and common bile duct, and choler cytodiagnosis was class V ; adenocarcinoma. The patient was diagnosed with hilar cholangiocarcinoma and received conservative treatment with endoscopic nasobiliary drainage (ENBD) due to his advanced age. The patient was then referred to our department because CT revealed right hydronephrosis and thickening of the right side of the bladder wall, which had not been detected on admission in October 2011. Cystoscopy revealed a broad-based edematous tumor on the right side of the bladder. Transurethral resection of the bladder tumor (TURBT) was performed. The histological diagnosis was moderately differentiated tubular adenocarcinoma. Immunohistostaining using CA19-9 was performed, and cancer cells were positive. The final histology led to a diagnosis of metastasis of cholangiocarcinoma to the bladder. The patient died of liver failure in March 2012.

A CASE OF MULTIPLE VISCERAL INJURIES ACCOMPANIED BY RIGHT RENAL PEDICLE INJURY AND LEFT URETERAL DISRUPTION TREATED SUCCESSFULLY BY LEFT URETEROCALICOSTOMY.

We report a 25-year-old male with multiple visceral injuries accompanied by right renal pedicle injury and left ureteral disruption treated successfully by left ureterocalicostomy. He was accidentally crushed by a roller for fishing net hoists while working as a fisherman in May 2011. He was emergently transported to Kurobe City Hospital. He was in shock, but recovered with fluid therapy. CT revealed bilateral hemothorax, liver injury, bowel injury, right renal pedicle injury, left renal injury, and inferior vena cava damage. After bilateral chest drainage, emergent surgery was performed. Laparotomy revealed pancreatic injury, liver injury, disruption of the stomach and jejunum, colonic injury, and retroperitoneal hematoma on the right side. Distal pancreatectomy, hepatorrhaphy, left half resection of the colon, subtotal gastrectomy, and colostomy were performed. However, the bleeding of the right lobe of the liver could not be stopped, and gauze packing on the liver surface was performed for damage control. During the operation, right renal pedicle injury was not treated because the pulsation of the retroperitoneal hematoma was not palpable and the hematoma did not enlarge to the left side across the center; furthermore, his general condition was very poor. After the operation, the patient showed anuria, and hemodialysis was performed twice a week. One week after the operation, removal of the gauze was performed under general anesthesia. The gauze was removed from the liver while sprinkling physiological saline, and there was little bleeding. Tachocomb® (CSL Behring, Tokyo, Japan) was placed on the surface of the liver and a drainage tube was indwelled. Twenty-four days postoperatively, CT revealed left hydronephrosis with right nonfunctioning kidney, and percutaneus left nephrostomy was performed. Antegrade and retrograde pyelograms revealed a left ureteral defect of 8 cm in the upper ureter.The patient was introduced to the Department of Urology of Shinshu University Hospital. Left ureterocalicostomy was performed in January 2012, and the nephrostomy catheter was removed. The temporal colostomy was closed in the Department of Surgery of Kurobe City Hospital in May 2014. He subsequently resumed his normal life.

A CASE OF ADVANCED NON-SEMINOMATOUS TESTICULAR GERM CELL TUMOR ACCOMPANIED PANIC DISORDER.

We report a 33-year-old male with a left advanced non-seminomatous testicular germ cell tumor (NSGCT) accompanied panic disorder. He had experienced palpitation and hyperpnea in crowds in his twenties. He was admitted to the Department of Otorhinolaryngology with the chief complaint of left neck swelling. 18F-fluorodeoxy glucose positron emission tomography/computed tomography (FDG-PET/CT) demonstrated left neck, left supraclavicular, left axillary, and paraaortic lymph node (LN) swelling and left testicular swelling. He was referred to our department. The left testis had enlarged to the size of a fist. He rejected admission at that time, but next day, he was taken to our hospital by an ambulance because he lost consciousness at home. No abnormalities were found in the brain CT and electrocardiogram. He was admitted and left high orchiectomy was performed. The human chorionic gonadotropin (HCG) level had elevated to 9,717 IU/L and alpha fetoprotein level (AFP) had elevated to 427 ng/ml. The histopathological diagnosis was tumors of more than one histological type, mixed forms: seminoma and embryonal carcinoma.He had palpitation and hyperpnea after admission and was diagnosed with panic disorder by a psychiatrist. Psychotropic drugs (fluvoxamine maleate 50 mg/day, alprazolam 0.8 mg/day) were prescribed and the panic attacks disappeared afterwards. The psychiatric social worker supported his mind side. Bleomycin, etoposide, and cisplatin (BEP) therapy was performed for 4 courses. He put on a blanket to his face and came to avoid a conversation with other people during the chemotherapy. He was diagnosed with depression and psychotropic drugs were increased (fluvoxamine maleate 50→75 mg/day, alprazolam 0.8→1.2 mg/day) in quantity.Lymphadenectomies for LN metastases were performed and their histopathological examination revealed the existence of viable embryonal carcinoma in the supraclavicular LN. Etoposide, ifosfamide, and cisplatin (VIP) therapy was performed for 2 courses.The pateint has remained alive without tumor recurrence. Psychotropic drugs were reduced and the recent drug is fluvoxamine maleate 25 mg/day.

[A CASE OF RIGHT PYONEPHROSIS DUE TO URETERAL STONES IN A HEMODIALYSIS PATIENT].

We report a case of a 64-year-old male with right pyonephrosis due to ureteral stones in association with chronic renal failure. The patient had been treated with hemodialysis for fourteen years. He was admitted to the Department of Internal Medicine of Kurobe City Hospital with chief complaints of fever and lumbago in January 2013. CT demonstrated a right pyonephrosis accompanied by right ureteral stones positioned in the middle and lower ureter. The stones could not be detected by KUB. He was consequently referred to the Department of Urology. Firstly, percutaneous nephrostomy for the right kidney was performed, and 200 ml of pyuria was discharged at that time. Urine culture demonstrated Escherichia coli. Secondly, rigid transurethral ureterolithotripsy (TUL) for the right ureteral stones was performed using Lithoclast, and a ureteral stent was indwelled on day 15 after nephrostomy construction. The nephrostomy catheter and ureteral stent were removed 10 and 21 days after the operation, respectively. The constituents of the stone were CaOx (26%) and CaP (74%). Right hydronephrosis improved and the patient showed no pyelonephritis for 1 year postoperatively.

[A case of urachal abscess accompanied by a stone].

A 64-year-old woman presented to our hospital with the chief complaints of abdominal pain and appetite loss, and she was admitted to the internal medicine department. Kidney, ureter and bladder X-ray revealed intrapelvic calcification near the bladder, and so, the patient consulted our department. Computed tomography and magnetic resonance imaging revealed an urachal abscess accompanied by a stone. Open surgery was performed under general anesthesia. The mass adhered tightly to the intestine and bladder. The urachal abscess ruptured during the operation, and pus leaked into the intraabdominal cavity. Partial cystectomy was performed to remove the mass completely. The stone existed in the urachal abscess, and its constituents were CaOxa (51%) and CaP (49%). The pathological diagnosis was urachal abscess without malignancy.

[Case of heterochronous triple urogenital cancer (renal cell carcinoma, bladder cancer, prostatic cancer)].

We report a case of a 73-year-old male with heterochronous triple urogenital cancer. The patient was referred to our hospital because serum PSA was elevated (7.0 ng/ml) in 1998. Prostatic needle biopsy revealed prostatic cancer in the right lobe, and total prostatectomy was performed. The histopathological diagnosis was moderately differentiated adenocarcinoma (TlcNOMO). Non-muscle invasive bladder cancer (NMIBC) was detected during an examination for microhematuria in 2002. Transurethral resection of the bladder tumor (TURBT) procedure was performed, and the histopathological diagnosis was grade 2 urothelial carcinoma (pTa). A right renal mass was detected incidentally on follow-up CT for bladder cancer in 2008. Renal enucleation was performed in 2009. The histopathological diagnosis was grade 2 clear cell renal cell carcinoma (pTlaNXMO). NMIBC was detected on follow-up urethrocystoscopy in 2011. The TURBT procedure was performed, and the histopathological diagnosis was grade 2 urothelial carcinoma (pTa). On follow-up for urogenital cancer patients, it is important to investigate recurrence of the primary cancer and also heterochronous canceration of other urogenital organs.

[A case of a foreign body (sheath dilator) in the urethra and bladder].

An 84-year-old man presented with the chief complaints of fever and disturbance of consciousness at another hospital. A sheath dilator had been inserted into the urethra instead of an indwelling catheter at the hospital. Since he had previously been treated for myelodysplastic syndrome in our Department of Internal Medicine, he was transferred to our hospital. He presented at our Department with the chief complaints of urinary difficulty and lower abdominal fullness. Kidney-ureter-bladder x-ray and computed tomography revealed the sheath dilator in the uretha and bladder. First, we performed a percutaneous cystostomy under local anesthesia. Second, we utilized optical forceps and successfully removed the sheath dilator transurethrally under intravenous anesthesia.

A prospective, randomized, controlled, multicenter study of naftopidil for treatment of male lower urinary tract symptoms associated with benign prostatic hyperplasia: 75 mg once daily in the evening compared to 25 mg thrice daily.

INTRODUCTION: We examined the tolerability of dosage methods of naftopidil in the treatment of male lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH/male LUTS). PATIENTS AND METHODS: A total of 80 patients with BPH/male LUTS who had an International Prostate Symptom Score (IPSS) >or=8 and IPSS quality of life (QoL) >or=2 were enrolled and randomly administered naftopidil for 8 weeks at either 75 mg once daily (OD) in the evening (group O; n = 41) or 25 mg thrice daily (TID) in the morning, afternoon and evening (group T; n = 39). RESULTS: IPSS total score, IPSS-QoL and BPH impact index (BII) were significantly improved for both groups at 8 weeks after starting treatment compared to baseline. IPSS total score and daytime and 24-hour voiding frequencies were significantly improved at 8 weeks after starting treatment for group O in comparison to group T. Group O showed a significantly better degree of change in BII in comparison to group T. CONCLUSIONS: Naftopidil 75 mg OD in the evening was better tolerated than naftopidil 25 mg TID for the objective parameter and BII.

[THREE CASES OF IATROGENIC URETERAL INJURY ASSOCIATED WITH TOTAL LAPAROSCOPIC HYSTERECTOMY].

We report three cases of iatrogenic ureteral injury associated with total laparoscopic hysterectomy. Case 1 was a 50-year-old woman. She underwent total laparoscopic hysterectomy (TLH) for myoma uteri. Postoperatively, a blood test revealed renal dysfunction, and ultrasonography (US) revealed left hydronephrosis. She was referred to our department on the next day of TLH. Computed tomography (CT) revealed left hydronephrosis. Retrograde pyelography (RP) was tried, but the ureteral catheter could not be inserted into the left ureteral orifice. An operation was performed on the second day after THL. The left ureter was ligated near the ureterovesical junction, and so uretero-ureterostomy was conducted. Case 2 was a 38-year-old woman. She underwent TLH for myoma uteri. Postoperatively, she complained of abdominal fullness and diarrhea. A blood test revealed renal dysfunction and US revealed left hydronephrosis on the ninth day after THL. She was referred to our department next day. CT revealed left hydronephrosis and ascitis. RP revealed extravasation of contrast medium from the left ureter. She was diagnosed with left ureteral injury accompanied by extravasation of urine into the intraperitoneal space. Uretero-cystoneostomy was performed. Case 3 was a 45-year-old woman. She underwent TLH for myoma uteri. Postoperatively, a blood test revealed renal dysfunction, and US revealed left hydronephrosis. She was referred to our department on the fifth day after TLH. CT revealed left hdronephrosis and ureteral obstruction of the left lower ureter. An operation was performed under laparoscopy, cystoscopy, and fluoroscopy on that day and the left lower ureter was kinked by threads. Cutting of the threads was performed under laparoscopy. After thread cutting, the kink of the ureter was improved and ureteral stent could be indwelled between the renal pelvis and bladder. After 1 month, the ureteral stent was removed and left hydronephrosis disappeared.

[THREE CASES OF TRANSURETHRAL RESECTION OF THE BLADDER TUMOR (TURBT), PERFORMED FOR BLADDER TUMOR ON THE ANTERIOR WALL, WITH BLADDER RUPTURE OCCURRING AFTER DISCHARGE].

Three cases are reported of TURBT on the anterior wall, with bladder rupture occurring after discharge. Patient 1 was a 68-year-old man. He had macroscopic hematuria and he strained to void a bloody clot on the 10th day after TURBT. Subsequently, right lower abdominal pain occurred. Computed tomography (CT) revealed the extravasation of contrast medium into the prevesical space. He was diagnosed with extraperitoneal bladder rupture, and a urethral catheter was indwelled. Cancer invasion of muscle was diagnosed by pathological examination and total cystectomy was scheduled one and a half months later, but the prostate could not be resected due to hard tissue around the bladder neck. Patient 2 was an 82-year-old man and had a history of radiation therapy for a muscle invasive bladder tumor. He complained of pollakisuria two weeks after TURBT, and renal failure was detected on a blood test. CT revealed ascites, and a urethral catheter was indwelled. Ascites disappeared, but the urethral catheter deviated into the abdominal cavity based on repeated CT the next day, and he was diagnosed with intraperitoneal bladder rupture. Emergent surgery was performed, and the ruptured part was sutured with omentum covering and a cystostomy was created. Patient 3 was an 83-year-old man undergoing treatment for benign prostatic hypertrophy (BPH). He had received bladder instillation therapy of Bacillus Calmette-Guerin (BCG) ten months previously. When urinating 6 days after TURBT, lower abdominal pain developed. CT demonstrated retroperitoneal bladder rupture, and a urethral catheter was indwelled. The urethral catheter was removed 6 days later, but lower abdominal pain occurred again the next day. Thus, the urethral catheter was re-indwelled for a further two weeks.In TURBT on the anterior wall or dome, for the patients who had previously received radiation therapy to the pelvis, or intravesical instillation therapy of the BCG or accompanied by urinary disturbance, such as BPH, it is necessary to consider bladder rupture after discharge.

[TWO CASES OF PEDIATRIC DEEP RENAL INJURY AT A LOCAL HOSPITAL].

We report two cases of pediatric deep renal injury at a local hospital. Case 1 was a 13-year-old girl. She fell from a bicycle and hit her back in a gutter. She complained of left back pain. Computed tomography (CT) revealed left deep renal injury accompanied by peripancreatic hematoma. Emergent surgery was performed and the transected kidney was resected, but pancreatic injury was not noted. Case 2 was a 10-year-old girl. She slipped during walking on her way home from school and hit her back on a concrete block. She complained of left back pain and gross hematuria. CT revealed left deep renal injury. Interventional radiology (IVR) was performed, but arterial bleeding was not noted, and so conservative therapy was performed. Although pediatric deep renal injury might be treated conservatively in general, treatment of such cases should be performed ideally at a hospital with IVR available for general anesthesia, and radiologists on-call in the event of any sudden change in the patient's condition. However, pediatric patients with serious renal injury, including the above, who cannot be transported to an advanced treatment hospital, can be treated through cooperation between skilled interventional radiologists and surgeons even in local hospitals with limited facilities and manpower.

[FOUR CASES OF THE PROSTATIC ABSCESS IN WHICH DRAINAGE WAS EFFECTIVE].

We encountered four prostatic abscess patients. Although antimicrobial therapies were ineffective, drainage was effective in all cases. Patient 1 had lung cancer and diabetes mellitus (DM), and patient 2 developed acute prostatitis after transrectal prostatic biopsy. Culture of the urine and blood revealed extended-spectrum beta lactamase (ESBL) -producing Escherichia coli (E.coli). Patient 3 had previously sustained spinal cord injury, and urinated by self-catheterization. Patient 4 had untreated, severe DM. Patient 1, 2 and 3 had been treated by transurethral resection of the prostate (TURP). Patient 2 complained of ejaculatory incompetence after the surgery, and the symptom caused mental distress. Patient 4 was a 43-year-old man who had undergone transperineal needle aspiration under ultrasound guidance to avoid ejaculatory incompetence. The prostatic abscess disappeared in all cases after drainage without recurrence.

Hand-assisted laparoscopic radical cystoprostatectomy and urethrectomy with ileal conduit construction.

INTRODUCTION: Hand-assisted laparoscopy was first performed in the 1990s by inserting the surgeon's finger or hand through a small tight wound. Although leakage of gas from the incision initially limited the usefulness of the technique, the hand-assisted procedures have advanced extensively since the introduction of the hand-assisted laparoscopy port. Laparoscopic procedure has only rarely been applied to radical cystoprostatectomy. Favorable reports for laparoscopic radical prostatectomy encouraged us to attempt a cystoprostatectomy under hand-assisted laparoscopy. PATIENT: The patient was a 70-year-old male with an invasive bladder tumor and no distant metastasis. Informed consent for undergoing hand-assisted laparoscopic radical cystoprostatectomy and ileal conduit construction was obtained. METHODS AND RESULTS: The bladder was dissected free and extracted whole through the incision for the hand port. The bilateral ureters and a loop of small intestine were withdrawn through the same incision. An ileal segment was isolated and small intestine continuity was recovered. Each ureter was anastomosed to one extreme of the ileal segment that was then reintroduced into the abdomen. The stoma was constructed through the right side port without additional incision. No intraoperative complications were observed. Recuperation was unusually quick and painless, and few postoperative analgesics were needed. CONCLUSIONS: Hand-assisted laparoscopic cystoprostatectomy and urinary diversion could provide the advantage of decreased postoperative morbidity without the long operation time and technical difficulty of a strictly laparoscopic procedure.

Primary adenocarcinoma of the appendix invading the urinary bladder.

We report a case of adenocarcinoma of the appendix invading the urinary bladder in a 75-year-old man. Although cystoscopic examination and computed tomography suggested a primary or secondary bladder tumor, repeated transurethral bladder biopsy could not confirm the neoplasm. At operation a primary neoplasm of the appendix invading the bladder was discovered and en bloc resection of the urinary bladder with the adherent cecum followed by an ileocolonic anastomosis and ureterocutaneostomy was performed. The patient died of carcinoma 13 months later.

Percutaneous endoscopic treatment for calyceal diverticular calculi.

A 29-year-old man complaining of gross hematuria was referred to our department. DIP demonstrated calyceal diverticular calculi of the left kidney. The patient requested ESWL, but the stone had not been discharged after two treatments. He then underwent PNL with dilation of the narrow neck of the calyceal diverticulum under fluoroscope. The neck of the diverticulum was dilated using an amplats dilator. Three months after the surgery, DIP demonstrated that the diverticulum was completely free from calculi and the size of the diverticulum was reduced. He was doing well 24 months after the operation. Calyceal diverticular calculi should be managed not only with ESWL and PNL but also with dilation of the narrow neck of the calyceal diverticulum.

Changes in male reproductive function after high altitude mountaineering.

The male reproductive functions of the members of the Masherbrum (7821 m) Expedition in 1999 were examined via semen analyses and endocrine tests. Specimens were collected from three subjects who had stayed above 5100 m for 21 to 24 days and above 6700 m for 4 to 5 days before departure and 1 month, 3 months, and 2 yr after returning from the expedition. Semen analyses showed no change in the semen volume. Sperm counts decreased after 1 month and had not recovered after 3 months, but they had recovered after 2 yr in all subjects. An increase in abnormally shaped sperm was also observed after 1 month, but had nearly recovered to the preexpedition state after 3 months. Endocrine tests revealed slightly decreased testosterone in the blood after 1 month, which had decreased still further after 3 months. The tests were completely normal after 2 yr. We suggest that a high altitude sojourn may induce reversible spermatogenic and Leydig cell dysfunction.

Percutaneous endopyelotomy for ureteropelvic junction obstruction.

Percutaneous endopyelotomy was performed 13 times on 11 patients with primary and secondary UPJ obstruction between 1994 and 2002. Excretory urogram revealed improvement in ten of eleven patients. One of the ten successfully treated patients required repeated endopyelotomy. Endopyelotomy failed in one patient, who had secondary UPJ obstruction that had been stenosed by granuloma caused by a ureteral stone. As the patient had UPJ obstruction of high insertion type with thinned renal parenchyma, nephrectomy was performed after repeated endopyelotomy. Compared with open pyeloplasty, percutaneous endopyelotomy is less invasive and is cosmetically advantageous.

Laparoscopic ablation of peripelvic renal cysts.

Recently, laparoscopic surgery has been reported for symptomatic renal cysts. A 60-year-old female was referred to Toyama Medical and Pharmaceutical University Hospital with a chief complaint of general fatigue and left back pain. CT demonstrated bilateral peripelvic renal cysts, and DIP demonstrated left hydronephrosis and a medical shift of the left renal pelvis. Laparoscopic ablation of bilateral peripelvic renal cysts was performed under general anesthesia and a round excision was made in the cyst wall via the peritoneum. After surgery, the left back pain disappeared and CT demonstrated resolution of peripelvic renal cysts. Laparoscopic ablation of peripelvic renal cyst is a highly effective and minimally morbid procedure.