[Roles of BPH impact index in the evaluation of impaired urination in patients with BPH].

OBJECTIVE: To assess the significance and current status of the benign prostatic hyperplasia (BPH) impact index (BII) in the evaluation of subjective symptoms of impaired urination in so-called QOL disease, BPH. PATIENTS AND METHODS: Over the past 2 year-period, in 159 patients with the diagnosis of BPH were asked to reply to each of the international prostate symptom score (I-PSS), QOL index and BII questionnaires. The subjective symptom scores (a total of 246 points) were evaluated from the viewpoint of clinical statistics in the search for any these and to find which questions cover the BII, most. RESULTS: 1) Statistically significant but moderate correlations were observed among I-PSS total score, QOL index and BII. The correlations among Qmax, BII and QOL were very weak. 2) Out of the 11 domains in both IPSS and BII, 2 questions of BII ("bothersomeness caused by urinary problems" and "degree of worry about well-being") and 4 questions of IPSS ("residual sense," " pollakisuria," "weak urinary stream" and "nocturia") were shared as QOL indices. Patient satisfaction was affected also by the questions in the BII. 3) Of the 7 BPH symptoms assessed in IPSS, 4 symptoms ("residual sense," "pollakisuria," "weak urinary stream" and "nocturia") affected the QOL index, and 4 symptoms ("urgency on micturition," "residual sense," "nocturia" and "strain at urination") affected BII. 4) Of the 7 symptoms assessed by IPSS, different symptoms affected each of the 4 BII questions. CONCLUSION: It is needed to assess BPH symptoms not only by the IPSS and QOL index but also based on BII to provide the detailed therapeutic instructions and thorough patients consultation.

[Fatal septic shock caused by transrectal needle biopsy of the prostate; a case report].

A 46-year-old man refer to us because of hemospermia. The prostatic gland was normal in size and consistency at rectal examination. Serum prostate specific antigen was 7.04 ng/ml. Magnetic resonance imaging showed an area of low signal intensity on T2-weighted images in the left peripheral gland, possibly indicative of carcinoma. Transrectal prostate biopsy was performed after intravenous administration of piperacillin. He developed chills and fever (39 degrees C) the next morning following biopsy. He was taken unconscious into the hospital where a diagnosis of septic shock caused by Escherichia coli was made. Five days later, he died. His general condition deteriorated notwithstanding intensive treatment. Postmortem blood cultures were positive for a piperacillin resistant Escherichia coli. Histological examination of the biopsies showed a benign prostatic hyperplasia. Autopsy showed diffuse tissue damage in the heart, lung, liver and kidneys. The prostate had numerous microabscesses. Currently, transrectal prostate biopsy is considered a generally reliable procedure to detect adenocarcinoma of the prostate. Our case seems to the sixth case report of fatal complications.

[Malignant fibrous histiocytoma of perirenal tissue: a case report].

A 75-year-old woman was admitted to our hospital with an extremely large retroperitoneal tumor that had been detected with ultrasound on a routine health check. She had no complaint except lumbar pain. Computed tomography revealed a heterogenous tumor located outside the right kidney which was enhanced gradually. Doppler ultrasound showed mild vascularity in the tumor. We performed tumorectomy and right nephrectomy because the tumor was adherent to the right kidney. The tumor was 16 x 11 x 7 cm in size and weighed 621 g. The histopathological diagnosis was malignant fibrous histiocytoma. The tumor was considered to have arisen from perirenal tissue.

[A case of lung collapse caused by endobronchial metastasis from renal cell carcinoma reinflated with laser and electrosurgical snaring].

A 62-year-old woman, who had undergone left nephrectomy for renal cell carcinoma and had received interferon-alpha for metastasis to the lung, was hospitalized because of cough, dyspnea and anorexia 16 months after nephrectomy. Chest radiography showed collapse of the right lung. We performed bronchoscopy and found a red polypoid tumor completely obstructing the right bronchus. Biopsy specimens showed clear cell carcinoma, similar to previous specimens of renal cell carcinoma. We removed the endobronchial tumor with laser and electrosurgical snaring, after which the right lung reinflated.

[A case of complete self-mutilation of penis].

Self-mutilation of the penis is extremely rare. A 69-year-old man was admitted after having amputated his own penis completely from its root. He had no history of psychiatric illness, but his physical condition on admission was abnormal. We performed urethrocutaneostomy, rather than replantation of the penis, because of the danger that he would reinjure himself. The patient was treated by a psychiatrist under a diagnosis of alcoholic dementia. To our knowledge, this is the 24th case of self-mutilation of the penis reported in the Japanese literature.

[Schwannoma with purely cystic form originating from the adrenal area: a case report].

A 62-year-old woman was hospitalized with complaints of right upper abdominal discomfort. Various imaging studies showed an extremely large suprarenal mass with solitary cystic formation. Partial adrenalectomy was successfully performed through the transperitoneal approach. The resected mass measured 12 x 10 x 10 cm and weighed 600 g. A pathological examination showed an Antoni-B predominant-type benign schwannoma containing a large volume of degenerative fluid. Our search of literature yielded few reports of solitary cystic schwannomas in the retroperitoneal cavity or throughout the body. This unusual cystic manifestation is thought to be a terminal stage of degeneration of a long-standing schwannoma.

[Retrospective analysis of uroepithelial malignancies detected in the renal pelvis and ureter over the past decade at the Jikei University Hospital].

The aim of this study was to investigate recent characteristics and alterations of upper urinary tract cancer based on experience at a single institution over the past decade. Ninety-nine patients with renal pelvic and ureteral cancer resected at the Jikei University Hospital from January 1991 through December 2000 were retrospectively analyzed. Cancer-specific survival by pathologic stage, grade, and various clinical parameters were calculated by the Kaplan-Meier method. Prognostic factors for survival were examined with univariate and multivariate analysis. Cox regression analysis was used for multivariate analysis. Twenty-eight percent of cancers had been detected incidentally without having caused any symptoms. The overall 3-year and 5-year cancer-specific survival rates were 78% and 70%, respectively. The 5-year survival rate was 100% in patients with G1 cancer and 38% in those with G3 cancer. The 5-year survival rate was significantly higher in patients with cancers of lower grade (p = 0.0089), and was also higher in patients with cancers of stage pT1 or lower than in patients with cancers of stage pT2 and higher (p = 0.0038). The survival of patients with recurrence in the bladder was significantly longer than that of patients with recurrence in other organs. Multivariate analysis indicated that patient age and pT were the most important prognostic factors, followed by the presence of symptoms at diagnosis. The incidence of asymptomatic upper urinary tract cancer is increasing at institutions in Japan. We conclude that the cancer grade and stage still have classical predictive value, but that the presence of symptoms at the time of diagnosis is also an important prognostic factor.

[Bilateral pyeloureteritis cystica: a case report].

We report here a case of bilateral pyeloureteritis cystica. A 67-year-old woman was admitted to our hospital with asymptomatic macrohematuria in September 1999. Drip infusion pyelography and enhanced computed tomography demonstrated multiple small, round filling defects in both renal pelvises and ureters. Ureteroscopy and cold punch biopsy were performed, and histological examination revealed pyeloureteritis cystica. This patient was not given adjuvant therapy but was carefully followed up for 3 years and 6 months postoperatively.

[Clinical study of bladder injury].

Since bladder injury has no specific clinical symptoms, accurate diagnosis at first consultation is relatively difficult. To elucidate the clinical characters type of injury, clinical symptoms, laboratory findings, methods of therapy and diagnosis, we reviewed 15 patients with bladder injury over a 9-year-period 1990-1998 (10 were traumatic injuries and 5 spontaneous injuries). We found no specific clinical symptom of bladder injury. Bladder injury may occur anywhere in the bladder wall, but most commonly occurred at the dome of the bladder (60.0%). Gross hematuria was not seen in 40.0% of the cases. The accuracy of diagnosis at first consultation was relatively low (46.7%) and the tendency to make a misdiagnosis as acute abdomen on digestive organs was found. Of the traumatic injuries 60% were afflicted in the drunken state, so alcohol intoxication was considered as an important enviromental factor of bladder injury. Surgical repair of injury sites was employed in 11 cases (73.3%: 7 were intraperitoneal injuries, 4 were extraperitoneal injuries), 4 cases were managed with indwelling urethral catheter. With appropriate treatment, the prognosis is excellent.

[Retrospective analysis of chief complaints of patients with urogenital malignancies over the past decade at the Jikei University Hospital].

We analyzed the chief complaints of patients with four major urogenital malignancies (renal cancer, renal pelvis and ureter cancer, bladder cancer and prostatic cancer) over the past decade (1990-1999) at the Jikei University Hospital. Over the last 10 years, a high percentage of renal cancers were detected incidentally. By contrast, prostatic cancers were more likely (10.5%) than other cancers to be detected on the basis of symptoms of metastasis. However, since 1995 more prostatic cancers are being detected with prostatic-specific antigen screening at the health checkups. Gross hematuria is the chief complaint of most patients with uroepithelial cancers (cancers of the renal pelvis, ureter and bladder cancer). Additionally, renal pelvis and ureter cancers were diagnosed with screening in a few patients in the past five years.

[Polyorchidism with undiscending testis: a case report].

We report here the 21st case of polyorchidism in Japan. A 3-year-old boy with left undiscending testis was referred to our hospital for orchiopexy. At surgery, the undiscending testis was identified as two testes. We performed left orchiopexy, because these tests had no malignancy.

[Clinical characteristics of 16 patients suspected preclinical Cushing's syndrome].

PURPOSE: In 1996, Japanese guidelines for the diagnosis of preclinical adrenal Cushing's syndrome were proposed. However, several patients with preclinical Cushing's syndrome (PCS) didn't clearly show that these diagnostic guidelines were universally applicable. The aim of the present study was to evaluate the validity of these diagnostic guidelines on the basis of our clinical experience. PATIENTS AND METHODS: We performed adrenalectomy for adrenal incidentaloma in 16 patients with suspected PCS at our university hospital from 1990 through 2002. Eight patients met the Japanese criteria for the diagnosis of PCS (PC group) and 8 did not (dexamethasone [DXM] suppression group). Clinical characteristics and pathology profiles were compared between the groups. RESULTS: No patients in the DXM suppression group showed responses of serum cortisol levels on a 1-mg overnight dexamethasone suppression test. Twenty-four-hour urinary levels of 17-hydroxycorticosteroids were significantly higher in the PC group than in the DXM suppression group. In all patients of both groups, adrenal scintigraphy showed marked accumulation of radioisotope in the adhesive, atrophic adrenal cortex. One patient of the DXM suppression group had severe adrenal symptoms after adrenalectomy. Several patients in the DMX suppression group showed clinical improvement after adrenalectomy, as well as did several patients in the PC group. CONCLUSION: Endocrine activity may have been higher in the PC group than in the DXM suppression group. However, because patients who failed a 1-mg DXM suppression test may in fact have autonomous cortisol secretion, adrenalectomy may still be indicated. Autonomous cortisol secretion might not be documented with the 1-mg overnight DXM suppression test; therefore, the results must be interpreted carefully.

[Decrease in anticoagulant factors in patients with prostate cancer treated with diethylstilbestrol diphosphate].

PURPOSE: Estrogen has been highly evaluated as one of the most potent endocrine agents for the treatment of prostate cancer. Unfortunately, a high risk of cardiovascular complications is a clinically important adverse effect of estrogen therapy, and occasionally the complications are fatal. In recent years a high incidence (55%) of thrombotic events has been reported in patients with congenital protein S (PS) deficiency. The aim of this study is to determine the relationship between cardiovascular complications of estrogen therapy and anticoagulant factor levels in the serum of patients with prostate cancer. MATERIALS AND METHODS: Study 1 employed 99 patients with prostate cancer: 39 were untreated, 25 were treated with LH-RH agonist therapy alone, and 35 were treated with oral diethylstilbestrol diphosphate (DESdP) 300 mg per day. We measured the serum levels of anticoagulant factors, parameters antithrombin III (ATIII), protein C (PC), PS, coagulant and fibrinolytic factors in all patients. In study 2, the adverse effects of DESdP therapy on the serum levels of anticoagulant factors were examined in 8 patients with advanced prostate cancer. RESULTS: In study 1, the ATIII and PS levels of the patients treated with estrogen therapy were significantly lower than those in either the untreated patients or the patients treated with an LHRH agonist alone. Especially, both PS antigen (51.5 +/- 16.0%) and PS activity (42.9 +/- 16.0%) were markedly lower in estrogen-treated patients than in the untreated patients (102 +/- 20.8%, 100.6 +/- 20.7%, respectively) or the patients treated with an LH-RH agonist alone (97.9 +/- 16.8%, 91.5 +/- 17.7%, respectively, both p < 0.0001). PS was decreased to below the normal lower limit of normal in 82% (24/35) of the patients on estrogen therapy. In study 2, all 8 cases showed a significant decrease in PS after DESdP therapy. CONCLUSIONS: Our results showed that the PS levels in the oral DESdP group were almost the same as in patients with congenital PS deficiency. We conclude that decreased PS may play a role in the development of cardiovascular complications in prostate cancer patients on estrogen therapy.

[Mucinous adenocarcinoma of the prostate: a case report and review of 32 cases on immunohistochemical study of both PSA and CEA].

Mucinous adenocarcinoma of the prostate is extremely rare and its biological behavior is not well known. We report a case of mucinous adenocarcinoma of the prostate which stained positively for prostate specific antigen (PSA) and negatively for carcinoembryonic antigen (CEA) on immunohistochemical study. Our case contained conventional adenocarcinomas and no signet-ring cells. Thirty two cases of mucinous adenocarcinoma of the prostate which performed on immunohistochemical study of both PSA and CEA, including our case, were reviewed. 17 of the 23 cases of immunoreactive to PSA contained conventional adenocarcinomas, and 3 of the 10 cases of immunoreactive to CEA contained them, respectively. The 6 cases of immunoreactive to CEA only contained signet-ring cells. It indicated that there seemed to be the two types of mucinous adenocarcinoma of the prostate, the one which stained positively for PSA was the subtype of conventional adenocarcinomas, and the other which stained positively for CEA and negatively for PSA was derived from the intestinal metaplasia with atypia of the prostatic urethra.

[Clinical studies on TUR-P using clinical path: report of 50 cases and review of literature].

PURPOSE: This study was undertaken to clarify the usefulness and problems involved in the clinical path of transurethral prostatectomy (TUR-P) in hospital. PATIENTS AND METHODS: The subjects consisted of 50 patients, for whom the Department of Urology, Jikei Medical University Hospital introduced its own clinical path and performed TUR-P during a period of 9 months from July 1999 to March 2000. The mean length of hospital stay, rate of postoperative complications, and the medical insurance claims made by these patients were clarified and compared with those of 73 patients before introduction of the clinical path. RESULTS: With the introduction of the clinical path, the length of hospital stay decreased by an average of 3.4 days and the total medical insurance claims decreased by an average of 18.5%. The rate of postoperative complications before and after introduction was almost equal. CONCLUSION: Our clinical path for TUR-P was well accepted by both patients and comedicals. However, the present medical treatment system in Japan is not as yet prepared to promote the introduction of this clinical path, and it will take some time before this clinical path is introduced on a full scale.

[Invasive squamous cell carcinoma of the bladder: report of 18 cases and review of literature].

PURPOSE: This study was undertaken to determine the most effective treatment for improvement of the prognosis of patients with squamous cell carcinoma of the bladder (SCC). MATERIALS AND METHODS: The subjects included 18 cases of invasive SCC (T2 or worse) we have experienced in the past 10 years. While clarifying the clinical patterns of these cases, the association between stage, therapy, and prognosis was studied. Of the cases of invasive SCC reported in Japan in the recent 20 years, 54 cases in which the stage, therapy, and prognosis were documented were selected, and the association between the therapy and outcome in each stage was studied. RESULTS: In our series, 11 cases are alive without cancer for over 2 years. Of the above patients, 7 underwent cystectomy. Cancer death was experienced in 7 patients. Of these patients, 3 underwent cystectomy, and 6 were classified as stage III or higher. As far as our study of the cases reported in Japan is concerned, the prognosis of the cases having undergone TUR or partial resection of the bladder alone was poor. But, even if patients underwent cystectomy, most of the patients was cancer death in the cases whose cancer was stage III or higher. In the patients receiving some supportive therapy, 4 patients receiving radiation plus cisplatin-based chemotherapy were all alive without for over 2 years. CONCLUSIONS: Total cystectomy is most appropriate as the type of operation for the cases of invasive SCC. But, the cases whose cancer was stage III or higher have high recurrence rate, and must be accompanied with some supportive therapy. We concluded that radiation plus cisplatin-based chemotherapy is a candidate of most effective supportive therapy to improve the prognosis of those patients in the supportive therapy.

[Carcinoma of urachus: report of 15 cases and review of literature--is total cystectomy the treatment of choice for urachal carcinoma?].

PURPOSE: This study was undertaken to determine the most appropriate type of operation for the improvement of the radical cure rate and QOL of patients with urachal cancer. We assessed the association between the stage, type of operation, and prognosis of cases we experienced and those reported in Japan. PATIENTS AND METHOD: The subjects included 15 cases of urachal cancer we have experienced in the past 14 years. While clarifying the clinical patterns of these cases, the association between stage, type of operation, and prognosis was studied. Of the cases of urachal cancer reported in Japan in the recent 20 years, 75 cases in which the stage, type of operation, and prognosis were documented were selected, and the association between the stage and outcome in each type of operation was studied. RESULTS: In regard to stage, all the cases were rated as more than IIIA. As for prognosis, 9 cases (60%) are alive without cancer at the present time with a mean survival time of 7 years. Of the above patients, 3 underwent cystectomy and 6 underwent en bloc segmental resection (herein after referred to en bloc). Recurrence or cancer death was experienced in 5 patients, 2 of which were classified as stage IIIA and 3 as IIID. Of these patients, one underwent en bloc, 3 partial resection of the bladder, and one underwent exploratory laparotomy. As far as our study of the cases reported in Japan is concerned, the prognosis of the cases having undergone only partial resection of the bladder was poor, while of the cases having undergone en bloc or total cystectomy 88-100% were alive without cancer for more than 2 years if their stage was classified as IIIA or below. On the other hand, prognosis was very poor whatever the type of operation in the cases whose cancer was stage IIIC or above. CONCLUSIONS: It appears that the en bloc is most appropriate as the type of operation for the cases of urachal cancer and that the application of total cystectomy is limited to some cases. In performing the en bloc, an extensive resection of the peritoneum, resection of the posterior sheath of the rectus muscle of the abdomen, and dissection of the intrapelvic lymph nodes in addition to the conventional types of operation should be carried out positively.

Sarcomatoid renal cell carcinoma with a chromophobe component producing beta-human chorionic gonadotropin.

We report a case of sarcomatoid renal cell carcinoma with a chromophobe component showing significant elevation of beta-human chorionic gonadotropin (beta-HCG) in the peripheral blood. A 35-year-old man was hospitalized because of a large tumor of the left kidney and elevated serum levels of beta-HCG. Extended nephrectomy was performed, after which the serum beta-HCG level decreased. However, 3 months later, masses were discovered in the left renal bed and in the lung in association with elevated serum levels of beta-HCG. The patient was rehospitalized and received combination therapy with interferon-alpha and doxorubicin-based multiple chemotherapy (cyclophosphamide, vincristine, doxorubicin, and dacarbazine). The recurrent mass responded extremely well to treatment, and beta-HCG normalized. However, the patient died 14 months after nephrectomy because of eventual resistance to chemotherapy. Sarcomatoid renal cell carcinoma containing beta-HCG positive cells were pathologically diagnosed with immunohistochemical staining in the left kidney. Sarcomatoid renal cell carcinoma is a variant of renal adenocarcinoma which has a poor prognosis. This patient had an extremely rare sarcomatoid renal cell carcinoma associated with serum levels of beta-HCG which were elevated and strongly correlated with morphologic cancer activity. beta-HCG might be a useful serum marker for detecting and monitoring this renal cell carcinoma.

Histological features of hypovascular or avascular renal cell carcinoma: the experience at four university hospitals.

BACKGROUND: We aimed to evaluate the pathological features of hypovascular or avascular renal cell carcinoma (RCC), by the retrospective review of the histological features that coincide with hypovascular or avascular RCC. METHODS: Seven hundred and ninety-one patients who underwent both preoperative angiography and nephrectomy were examined. Of these patients, the 126 patients (15.9%) who showed hypovascular or avascular angiographic features were selected. Patients with hemorrhage or cyst(s), or with at least 50% necrosis or more in the tumor, and those with renal tumor metastatic to the kidney were excluded. The criteria proposed by the World Health Organization (1998) were adopted for the histological classification. RESULTS: Papillary RCC was the most frequently observed hypovascular or avascular renal tumor (44 cases; 34.9%). The vascularity differed among the variants, i.e., some cases had a basophilic and solid variant with avascular features, while the remaining cases had wide stromal organization showing hypovascular features. The second most frequently observed hyporascular or avascular RCC was chromophobe cell carcinoma (35 cases; 27.8%). No difference in vascularity was detected between variants, except for 2 cases with sarcomatoid changes (avascular features). The third most frequently observed hypovascular or avascular RCC was cyst-associated RCC (29 cases; 23%). All of the 7 RCCs originating in a cyst showed avascular features, and the remaining 22 cystic RCCs showed hypovascular features. The remaining hypovascular or avascular RCCs were cases of clear cell carcinoma accompanied by sarcomatoid changes (8 cases; 6.3%), spindle cell carcinoma (5 cases; 4.0%), and collecting-duct carcinoma (5 cases; 4.0%). CONCLUSION: Hypovascular or avascular RCC can be categorized as non-clear cell carcinoma and some clear cell carcinoma accompanied by sarcomatoid changes.