[Clinical study of enterovesical fistulas].

We conducted a retrospective review of 16 patients who were diagnosed with enterovesical fistula in our hospital between January 2000 and July 2013. The patient's median age was 74 years old and 4 were female. Most of the chief complaints were pneumaturia and fecaluria. There was a vesicosigmoidal fistula in 12 patients, an ileovesical fistula in 2, and a rectovesical fistula in 2. The main underlying cause was diverticulitis in 9 patients and a sigmoid colon carcinoma in 3. Diagnoses were made based on the findings of cystoscopy, barium enema, abdominal computed tomography and so on. Treatment varied in each case depending on the etiology and the patient's condition. The procedure was mostly open surgery, but laparoscopic sigmoidectomy was performed preserving the bladder in the two most recent cases.

A case of infectious thoracic aortic aneurysm after intravesical Bacillus Calmette-Guérin instillation therapy for a superficial bladder cancer.

Intravesical Bacillus Calmette-Guérin instillation therapy after transurethral resection of bladder tumor is considered as the most effective treatment for prophylaxis against the recurrence of high-risk, non-muscle bladder cancer. However, intravesical Bacillus Calmette-Guérin instillation therapy has some characteristic complications. Here, we report a case of infectious thoracic aortic aneurysm related to prior intravesical Bacillus Calmette-Guérin instillation, which consequently allows the spread into the adjacent lung tissue and secretion in sputum of Mycobacterium bovis.

Solitary synchronous gastric metastasis of renal cell carcinoma.

INTRODUCTION: There have been some reports describing metastasis to the stomach from renal cell carcinomas. However, there are few reports describing solitary synchronous gastric metastasis of renal cell carcinomas. CASE PRESENTATION: The patient was a 70-year-old woman who underwent an upper gastrointestinal endoscopy to examine her progressive weight loss. There was a submucosal tumor in the stomach, which was biopsied. The gastric tumor was pathologically proven to be a metastatic clear cell renal cell carcinoma. Furthermore, contrast-enhanced computed tomography showed right renal cell carcinoma invading the renal vein (cT3aN0M0). The patient underwent right radical nephrectomy and endoscopic resection for the treatment of the primary renal cancer and the gastric metastatic lesion, respectively. The resected specimen of the stomach had a clear resection margin. CONCLUSION: Endoscopic resection for early stage gastric metastatic lesions of renal cell carcinomas is a reasonable approach because it is a minimally invasive surgical technique.

Incidence of upper urinary tract stone during 15 years in Tajima area, Japan: a hospital-based study.

Time trend of incidence of upper urinary tract stone during 15 years was evaluated by hospital-based cohort study in Tajima area, northern part of Hyogo prefecture, Japan, which has only two general hospitals with Department of Urology. Due to isolation in terms of traffic network and geographic circumstances, almost all patients with urinary stone in Tajima area are referred to the two hospitals. During the period 2005-2007, patients of the two hospitals with radiologically proven upper urinary tract stone were included in this study. The survey included the age and gender, location of stones, history of urinary stone, treatment received, and stone composition, if available. Annual incidence of upper urinary tract stone was estimated using the data of population census of Japan 2005 and compared with the data of Tajima during 1991-1993. 1,305 patients were included in this study. Age-adjusted incidence (+/-95% CI) was 157 (+/-22.4) for men, and 57 (+/-12.6) for women, compared with 141 (+/-20.7) for men, and 63 (+/-13.4) for women during 1991-1993. In total, 30.7% of patients received interventional treatment including shock wave lithotripsy, endoscopic lithotripsy and open surgery, whereas 25.3% in 1991-1993. Calcium oxalate/phosphate stone was 89.6%, struvite stone was 4.5%, cystine stone was 1.0%, uric acid stone was 4.0%, and others were 1.0%. In Tajima area, incidence of upper urinary tract stone has not changed during 15 years.

Malignant rhabdoid tumour in an adult kidney: A case report.

Malignant rhabdoid tumours (MRTs) in the kidney are rare paediatric tumours that are extremely rare in adults. We herein report the case of an adult patient with a renal MRT. A 79-year-old Japanese woman was found to have a tumour sized 63×48 mm in the left kidney, in addition to multiple metastatic bone and lymph node lesions. The needle biopsy specimen obtained from the patient's kidney revealed tumour cells with rhabdoid characteristics: The cells appeared large, round or polygonal, with eccentrically located nuclei and prominent nucleoli. Immunohistochemically, the tumour cells were positive for vimentin, epithelial membrane antigen, CAM 5.2, and p53, and negative for INI1, cytokeratin (CK)7, CK20, α-methylacyl-CoA racemase, S100, CD45, renal cell carcinoma marker, anaplastic lymphoma kinase, α-smooth muscle actin, desmin, MyoD, myogenin, human melanoma black 45 and melan A. Therefore, the tumour was diagnosed as an MRT located in the kidney. Although the patient was treated with axitinib, a tyrosine kinase inhibitor, the renal tumour and its metastatic lesions continued to progress, and the number of metastatic lesions increased. The patient succumbed to the disease 5 months after the first hospital visit. The disease progression was rapid, with a poor prognosis, consistently with previous reports that of MRTs in the adult kidney.

[Squamous cell carcinoma of the bladder presenting with spontanenous intraperitoneal bladder rupture: a case report].

A-90-year-old woman visited complaining of nausea, vomiting, and abdominal pain. She had abdominal rigidity and signs of generalized peritonitis. On computed tomography (CT) gastrointestinal perforation was denied and irregular thickness of the bladder wall was pointed out. Cystography was performed, but bladder rupture was not confirmed. Post-cystogram-CT revealed the leakage of contrast material in the peritoneal cavity from the urinary bladder. Spontaneous intraperitoneal bladder rupture was diagnosed. Cystoscopy was performed, but no information could be obtained due to severe cloudy urine. Open laparotomy was performed. At surgery, cloudy fluid was aspirated from the abdominal cavity. Abdominal organs were normal when explored, but a small perforation was found on the vault of the bladder and primary closure was performed. Postoperatively, cystoscopy was performed again after the medication with antibiotics. A huge, nonpapillary tumor was seen on the left lateral wall. Tumor biopsy was performed. Histological examination of specimens revealed squamous cell carcinoma. On abdominal CT, invasive bladder carcinoma, left hydronephrosis and hydroureter were pointed out. Considering her age, general health status and prognosis, only right ureterocutaneostomy was performed.

[Gluteal muscular metastasis from renal pelvic tumor].

We present a case of gluteal muscular metastasis from a renal pelvic tumor. A 57-year-old man had undergone right nephroureterectomy and received 2 courses of adjuvant chemotherapy (MEC: methotrexate, epirubicin, cisplatin) for invasive renal pelvic tumor. Five months after the operation, computed tomography (CT) revealed pulmonary metastasis and right adrenal gland recurrence. He underwent 2 courses of chemotherapy (gemcitabine, paclitaxel). Postchemotherapy-CT scan showed a 2.2 cm mass in the right gluteal muscle. Since the size of the pulmonary metastasis and right adrenal gland recurrence showed no change, the gluteal mass was excised. Pathological diagnosis was metastatic urothelial carcinoma. Adjuvant chemotherapy (TIN: paclitaxel, ifosfamide, nedaplatin) 3 courses were performed, but postchemotherapy-CT scan showed a new 2.4 cm mass in the right gluteal muscle. He received radiation therapy (total 30 Gy) for the new gluteal mass. The common metastatic sites of renal pelvic tumor are lungs, liver, bone, and lymph nodes. Gluteal muscle is an uncommon site of metastasis of urothelial carcinoma. This is the 1st case of gluteal muscle metastasis from renal pelvic tumor in the literature.

[Multi-institute survey on actual conditions of urologic management for severe bladder dysfunction after hysterectomy].

We conducted a multi-institute survey on the conditions related to urologic management of severe voiding dysfunction after hysterectomy for uterine cancer with or without postoperative irradiation. Our first study population was a group of adult female patients currently managed by urologists, using clean intermittent catheterization (CIC). Of the 287 patients in this group, 99 (34%) had suffered from uterine cancer. Of these patients, 94 underwent hysterectomy for this disease; 44 and 30 were treated with or without postoperative radiation, respectively, while postoperative irradiation status was unknown for 20. Median follow-up after surgery was 21 (0.2-52) years and median interval from operation to the introduction of CIC was 4.0 (0-49) years. CIC tended to be introduced later for patients with postoperative radiation than those without it. Seventy-four patients, who required invasive urologic interventions other than CIC for voiding dysfunction after hysterectomy, are the second study population. Most of these (82%) had received postoperative irradiation. Continuous Foley catheter placement was the most frequent procedure. Long-term follow-up and urologic management for voiding dysfunction is required for patients undergoing hysterectomy.

[A case of angiomyolipoma in a horseshoe kidney].

The patient was 52 years old. She had undergone a breast cancer operation 4 years before this visit. On computed tomography (CT), a left renal tumor in a horseshoe kidney was incidentally pointed out. CT scan showed a 1.8-cm enhanced tumor in the upper pole of the left kidney. It was hyperechoic on ultrasonography. Since renal cell carcinoma could not be excluded preoperatively, left partial nephrectomy was performed. Pathological diagnosis was a renal angiomyolipoma. The incidence of horseshoe kidney is 1 in 400. The occurrence of hydronephrosis, infection and calculous disease is not uncommon. However, a case of angiomyolipoma simultaneously with a horseshoe kidney is very rare, this being the 7th case in the literature.

[Ureteral avulsion: a rare complication of ureteroscopy].

A case of ureteral avulsion as a complication of ureteroscopy is presented. A 55-year-old woman was admitted to the hospital with the complaint of hematuria. The intravenous pyelography revealed a calculus measuring 16 x 12 mm located in the left upper ureter. Transurethral ureterolithotripsy was performed with 8 F rigid ureteroscopy. A safety guide wire was inserted and left ureteral olifice was dilated to 9 F. The ureteroscopy was smoothly introduced just under the stone. The stone was fragmentated with a pneumatic lithotripter. A part of the stone was pushed back to the renal pelvis, so the ureteroscope was passed to that stone and fragmentation was done as much as possible. The ureteroscopy was gently pulled out to the bladder, but the distal ureter was torn at the ureteral orifice and could be seen at the urethral orifice. Pelvis, upper ureter and middle ureter were intact, so open intervention for repair was not performed. A 6Fr double pigtail stent was placed over the safety guidewire. Cystscopy indicated a part of the distal ureter was protruded from the ureteral orifice. Eight weeks later, the protruded part of ureter was necrotic and calcified for ischemia. Transurethral resection of necrotic ureter was performed. Histologically, resected ureter changed necrotic tissue for ischema. Postoperatively intravenous pyelography did not reveal left hydronephrosis and cystoscopy indicated that the left ureteral orifice was almost normally repaired.

[Renal cell carcinoma with malignant pleural mesothelioma after asbestos exposure: a case report].

A 66-year-old man visited complaining of cough and sore throat. He had been exposed to asbestos 43 years ago. Chest X-ray revealed left pleural effusion and abnormal shadow in the right lung field. Chest computed tomography (CT) showed multiple enhanced nodules in the right pleural cavity. Abdominal CT showed a 3-cm enhanced tumor in the lower pole of the left kidney. Left radical nephrectomy was performed. Pathological diagnosis was renal cell carcinoma. Postoperatively pleural biopsy was performed by using thoracoscopy. White plaque was seen at the costal pleura and surface of lung. Pathological diagnosis was malignant pleural mesothelioma based on using mesothelium-associated antibodies: calretinin (+), CK5/6 (+), D2-40 (+), HBME-1 (+), TTF-1 (-), MOC31 (-), CEA (-). Combination therapy (extrapleural pneumonectomy, chemotherapy, and radiotherapy) was initiated. Malignant mesothelioma is a devastating neoplasm with a strong etiological relationship with asbestos exposure. The incidence is rising in industrialized countries, with the peak expected in the year 2020. However, renal cell carcinoma with malignant pleural mesothelioma is very rare and this is the 2nd case in the Japanese literature.

Mucinous tubular and spindle cell carcinoma with a high nuclear grade and micropapillary pattern: A case report.

Mucinous tubular and spindle cell carcinoma (MTSCC) is rare in renal cell carcinoma (RCC) and usually demonstrates a low nuclear grade and a better prognosis compared with other RCCs. The authors present a case report of MTSCC containing an area of Fuhrman nuclear grade 3, in addition to an area with a micropapillary pattern. An 82-year-old man consulted a hospital due to macrohematuria, and a tumor in the right kidney was detected. The tumor was resected and histologically examined. The tumor consisted of various growth patterns: Elongated tubular structure, a papillary structure containing a micropapillary pattern and solid pattern with spindle cells. The tumor cells demonstrated Fuhrman nuclear grades 2 and 3. Invasion into the lymph vessel and metastasis into the regional lymph node were observed. Thus, the tumor was diagnosed as a high grade MTSCC. Five months following resection, a computed tomography scan suggested metastasis of the tumor into the para-aortic lymph nodes and liver, and the patient succumbed to brain metastasis. When MTSCC of kidney is observed, careful histological observation is important to avoid missing a high nuclear grade area.

[Prostate cancer detection by prostate biopsy among Japanese with prostate-specific antigen below 4.0 ng/ml].

The cases of prostate cancer diagnosed at our hospital after the introduction of transrectal ultrasound-guided prostate biopsy were analyzed to ascertain the cancer detection rate among individuals with a prostate-specific antigen (PSA) below 4.0 ng/ml and to assess the pathological characteristics of the prostatectomy specimens. During the period from January 1997 to December 2003, 1,167 individuals received prostate biopsies at our hospital. Before March 2003, the PSA cut-off level for biopsy was set at 4.0 ng/ml, but a biopsy was sometimes performed if a rectal examination revealed abnormalities or the patient desired a biopsy with a PSA below 4.0 ng/ml. After April 2003, all individuals with a PSA over 3.1 ng/ml were biopsied. The results of the prostate biopsy and the pathology data on radical prostatectomy specimens were compared between individuals with a PSA below 4.0 ng/ml and those with a PSA of 4.1-10 ng/ml. The prostate cancer detection rate among individuals with a PSA between 3.1 and 4.0 ng/ml was 19.4% (12/62) before March 2003 and 15.6% (7/45) after April 2003. The number of cancer-positive core was significantly lower among individuals with a PSA below 4.0 ng/ml. On prostatectomy specimens the percentage of surgical margin positive cases was significantly higher among individuals with a PSA below 4.0ng/ml (17 cases) than those with a PSA of 4.1-10 ng/ml (67 cases), although there was no significant difference between these two groups in terms of the pathological stage and Gleason score. Our results indicate that the prostate cancer detection rate is also high among Japanese men with a PSA below 4.0 ng/ml. The biopsy results and pathological features for prostate cancer with a PSA below 4.0 ng/ml did not differ markedly from prostate cancer with a PSA in the gray zone (4.1-10.0 ng/ml).

Nephrogenic adenoma in elderly patients: Three case reports.

Nephrogenic adenoma (NA), referred to as nephrogenic metaplasia, is a rare benign lesion of the urinary tract. NA is histologically characterized by tubular and papillary formations lined by low cuboidal to columnar epithelial cells. NA is also immunohistochemically characterized by positivity for paired box (PAX) 2, PAX8 and cytokeratin 7, and negative for p63 and prostate-specific antigen. In this study, we present 3 cases of NA arising in the urinary bladder of elderly male patients with predisposing factors: patient 1 had undergone transurethral lithotripsy due to a ureteral stone; patient 2 had undergone transurethral resection of a urothelial carcinoma in the urinary bladder; and patient 3 had been treated with Bacillus-Calmettle-Guérin due to a urothelial carcinoma in the urinary bladder. The characteristics of the NAs of our 3 cases were histologically and immunohistologically consistent with previously reported cases, although 1 patient exhibited a pseudoinvasive pattern. Since NA is a tumor-like benign lesion, it should be clearly differentiated morphologically and immunohistologically from other tumors arising in the urinary tract and from invasion by prostate cancer.

Encrusted cystitis with ammonium acid urate calculi: a case report.

We present a case of encrusted cystitis with ammonium acid urate calculi. An 88-year-old man was referred to our hospital to determine the cause of hematopyuria. He was a patient at another hospital for treatment of interstitial pneumonia with predonisolone. After admission to our hospital, kidney, ureter, bladder X-ray, computed togography and cystoscopy revealed calcification of about two-thirds of the mucosa of the bladder, and biopsy of the bladder revealed bacterial colonies with inflammation and calcification. Calculographic analysis revealed ammonium acid urate calculi. After treatment with antibiotics and irrigation with solita T1, an acidic solution of pH 3.5-6.5, inflammation and calcification were significantly reduced.

[A case of pyonephrosis caused by a protein calculus in a patient on hemodialysis].

We report a case of pyonephrosis caused by a protein calculus in a patient on hemodialysis. A 56-year-old man had been treated with dialysis for five years because of end-stage renal failure. The patient complained of right lumbar back pain and fever. Computed tomography and an ultrasonography revealed right hydronephrosis. Pyonephrosis was strongly suspected. A single-J catheter was indwelt, cloudy pus with a terrible smell was discharged. After reducing inflammation, a right nephrectomy was performed. The analysis of stone component revealed mostly a protein calculus, which was a black and turf-like substance in the calices. Patients undergoing dialysis often develop urinary calculi. Some calculi are composed of beta2-microglobulin-origin amyloid, which is very difficult to find with diagnostic imaging.

[Combination therapy with estramustine and docetaxel for hormone refractory prostate cancer].

Six patients with hormone refractory prostate cancer were orally administered 560 mg of Estramustine daily in 2 equally divided doses for four or five days. In addition 70 mg/m2 of Docetaxel was infused through intravenous drip from day 1, decreasing to 40-60 mg/m2 if any side effects such as bone marrow depression were observed. One cycle was three weeks in hospital and one month after discharge. Patients were treated until progression or the development of treatment-limiting toxicity. In five of the six patients (83.3%), serum prostate specific antigen (PSA) was decreased by more than 50%. Currently, this therapy is ongoing in four outpatients. A side effect of leucopenia (grade 2 or 3) was observed in all patients. Granulocyte-colony stimulating factor (G-CSF) formulation was given as treatment. One case was withdrawn due to loss of appetite after one cycle. This therapy is considered to be effective against hormone refractory prostate cancer. However, further examination is needed about dosage and dosing regimen of Estramustine and Docetaxel.

[A case of corpus cancer presenting with positive urine cytology].

A 76-year-old woman was admitted with a chief complaint of gross hematuria. Although no abnormality was found on excretory pyelography, class IV transitional cell carcinoma was suspected based on urinary cytology. However, no malignancy was observed on cystoscopy or on biopsy of the mucosa of the urinary bladder. Thereafter, class IV or class V carcinoma was continuously found by urinary cytology, and cervical lymphadenopathy was also observed. Since computed tomography showed the uterus enhanced heterogenously, the possibility of a gynecological tumor was considered. Poorly differentiated endometrioid adenocarcinoma was found on histological examination of the endometrium, and similar adenocarcinoma was also found on biopsy of cervical lymph node. Furthermore, infiltration of adenocarcinoma into the proper lamina of urinary bladder was found. These findings suggested that this tumor originated in the uterine body, followed by lymph node metastasis and infiltration into the urinary bladder. Concerning the route of emergence of carcinoma cells in urine, joining in urine via vagina seemed most likely. When malignant cells are found in urine, tumors of the urinary system should primarily be suspected, but at the same time, the possibility of a gynecological tumor should be kept in mind.

[A case of pyoderma gangrenosum involving the prostate gland after radiation therapy for prostate cancer].

A 76-year-old man complained of difficulty in urination and miction pain with abacterial pyuria after radiation therapy for prostate cancer. Transurethral resection of the prostate was performed and histopathologically widespread necrosis was observed in the prostate. Thereafter retention of urine and fever occurred and computed tomography scan revealed an abscess of the penile corpus. The abscess was drained, but the fever continued. He developed an abacterial lung abscess and abacterial necrotic ulcerating lesions on his back, his left leg and his lower abdomen. Macroscopic findings demonstrated typical features of pyoderma gangrenosum. Steroid treatment was initiated and the response to steroid therapy was dramatic. Finally urinary diversion using an ileal conduit was performed. We found few cases of pyoderma gangrenosum involving lesions other than those of the skin in the literature. This is the first report of pyoderma gangrenosum involving the prostate gland after radiation therapy for prostate cancer.