[A Case of Metachronous Rupture of Right Testis and Right Epididymis].

The patient was a 15-year-old male. Four months prior to his visit to our department, he was hit in the right scrotum by a baseball, which caused right scrotal swelling and pain. He visited a urologist who prescribed analgesics. During follow up observation, right scrotal hydrocele appeared and a puncture procedure was performed two times. Four months later, while climbing a rope for strength training, his scrotum became entangled by the rope. He immediately felt right scrotal pain and visited a urologist. Two days later, he was referred to our department for a thorough examination. Scrotum ultrasound revealed right scrotal hydroceles and swollen right cauda epididymis. The patient was treated conservatively with pain control. The next day, the pain did not improve, and surgery was decided since testicular rupture could not be completely ruled out. Surgery was performed on the third day. The caudal portion of the right epididymis was injured approximately 2cm, the tunica albuginea had been ruptured and the testicular parenchyma had escaped. The surface of the testicular parenchyma was covered with a thin film, suggesting that 4 months had elapsed since the tunica albuginea injury. The injured area of the epididymis tail was sutured. Subsequently, we removed the remaining testicular parenchyma and restored the tunica albuginea. Twelve months postoperatively, right hydrocele and testicular atrophy were not observed.

[Solitary Fibrous Tumor of the Urinary Bladder which was Incidentally Found by MRI : A Case Report].

A 72-year-old female complained of pain in the left hip and consulted a local orthopedic surgeon. Magnetic resonance imaging (MRI) was conducted for the left hip. MRI revealed a subchondral insufficiency fracture of the left femoral head and pointed out a bladder tumor 65 mm in size. Hence, the patient was referred to our department for further examination. Cystoscopy revealed a smooth surface tumor protruding from the left side of the bladder neck. Therefore, transurethral resection of bladder tumor (TURBT) was performed. Pathological finding showed spindle-shaped cells surrounded by collagen fibers. Immunostaining demonstrated that CD34 and Bcl-2 were positive. The final diagnosis was a solitary fibrous tumor (SFT). A TURBT was performed 3 years after initial TURBT for recurrence of a 25 mm tumor in the bladder trigone. The pathological diagnosis was SFT. Since the last surgery, which was performed 30 months ago, no recurrence has been observed.

[Acute Scrotal Swelling Caused by IgA Vasculitis : A Case Report].

The patient was a 4-year-old boy. He consulted our hospital's Dermatology Department for diffuse pruritic erythema on his extremities. Toxicoderma was suspected and a topical steroid was prescribed. Nine days later, when the boy was taking a bath, his mother noticed swelling of his scrotum and consulted a local pediatrician. The pediatrician suspected acute scrotal swelling and referred him to our department the same day. Purpura was found on the bilateral scrotum and prepuce ; edema was also present. Physical examination revealed mild tenderness of the bilateral scrotum. Purpura was present from the right inguinal region to the ipsilateral femoral region. Color Doppler ultrasonography confirmed the presence of blood flow in both testes, and edematous changes were found on the scrotal skin. On the basis of the clinical course of the skin lesions as well as physical and ultrasonographic findings, the condition was diagnosed as acute scrotal swelling caused by IgA vasculitis. After four days of rest, significant improvement in scrotal and preputial edema as well as in the right inguinal region was observed.

[A Case of Ureteroarterial Fistula Successfully Treated with Endovascular Stent Graft].

We report a case of right uretero-external iliac artery fistula. A 46-year-old woman diagnosed with left ovarian cancer with peritoneal dissemination underwent simple hysterectomy, bilateral adnexal removal, partial omentectomy and appendectomy. Sixteen months after the operation, a computed tomography scan showed right hydronephrosis due to the development of tumor within the pelvis. A ureteral stent was placed into the right ureter in order to preserve renal function. The ureteral stent was replaced at regular intervals. Five months after the ureteral stent placement, the patient was hospitalized urgently with gross hematuria. She was diagnosed with right uretero-external iliac artery fistula based on the angiographic examination that was conducted to detect the source of hemorrhage. She was treated successfully with endovascular stent grafting in the right external iliac artery. She has since shown no episode of hematuria.

[A Case Report of Granulomatous Renal Masses Following Intravesical Instillation of Bacillus Calmette-Guérin Therapy].

Transurethral resection of bladder tumor (TURBT) was performed on the bladder tumor of a 68-yearold male patient. Bacillus Calmette-Guérin (BCG) intravesical therapy was performed to prevent recurrence (Immunobladder : ○R 80 mg once/week×6 times). A 40 mm tumor was noted in the left kidney by renal ultrasound performed two months after the completion of BCGintravesical therapy. Computed tomography (CT) showed non-enhanced multiple mass lesions in the left kidney. Renal tuberculous granuloma, hypovascular renal cell carcinoma or malignant lymphoma was suspected and CT-guided needle biopsy was performed. The patient was diagnosed with renal tuberculous granuloma that developed after BCGintravesical therapy as epithelioid cell granulomas were noted in the biopsy results. Treatment with anti-tuberculosis drugs was started and the tumor showed signs of shrinkage.

[Two Cases of Spontaneous Rupture of the Urinary Bladder Associated with Radiation Cystitis, Repaired with Omentum Covering].

We experienced two cases of spontaneous rupture of the urinary bladder associated with radiation cystitis. Case 1 and Case 2 were a 45-year-old female and a 71-year-old female, respectively. Both of them were admitted to our hospital with complaints of high grade fever and severe lower abdominal pain. They had a past history of total hysterectomy followed by radiationtherapy more than10 years ago. The cystography and the subsequent computed tomography revealed spontaneous rupture of the urinary bladder. We performed the operationto repair the perforationsite with omentum covering. Case 1 had a good postoperative course with intermittent self-catheterization after removal of urethral catheter. However, she died of cerebral hemorrhage during hospitalization. Although case 2 needed an indwelling urethral catheter due to the difficulty of intermittent self-catheterization, she had no recurrence of rupture for six months after the operation. Inthis way, total hysterectomy followed by radiationtherapy seems to be a risk factor for the spontaneous rupture of the urinary bladder. When we see a patient with acute abdomen, who has a history of hysterectomy followed by radiation, rupture of the urinary bladder can be a differential diagnosis.

[A case report of eosinophilic cystitis treated with oral suplatast tosilate].

A 61-year-old female was referred to our hospital presenting with micturition pain and urinary frequency, which was not relieved by antibiotics. A cystoscopic examination revealed an erosion, reddening and edematous lesion in the left bladder wall. Pathological examination of transurethral biopsy showed erosion and cystitis. After biopsy, micturition pain and urinary frequency became worse. The pathological examination was reviewed, and the diagnosis of eosinophilic cystitis was made. Administration of a corticosteroid had provided a short duration of relief, but her symptoms recurred within the five weeks of treatment. Therefore, she was treated with a combination of corticosteroid and suplatast tolilate, followed by monotherapy with suplatast tolilate. The relief of the symptoms by suplatast to lilate therapy continued for five months. However, the symptoms relapsed. Re-administration of steroidal agents was considered, but the patient suffered from uncontrolled diabetes. Therefore, she was treated with a combination of suplatast tosilate, anti-allergic drugs and mirabegron. Fourteen months after treatment with suplatast tosilate, no disease progression was noted.

Docetaxel in combination with estramustine and prednisolone for castration-resistant prostate cancer.

BACKGROUND: The aim of this study was to investigate the efficacy and toxicity of docetaxel-based chemotherapy, and to investigate pretreatment factors that can predict overall survival (OS) in patients with castration-resistant prostate cancer (CRPC). METHODS: From June 2005 to July 2010, 70 patients with CRPC underwent docetaxel-based chemotherapy at Wakayama Medical University and related hospitals. Docetaxel was given at a dose of 70 mg/m(2) once every 3 weeks or 35 mg/m(2) twice every 3 weeks. Oral estramustine 560 mg was given concurrently for five consecutive days during weeks 1 and 2 of each cycle, and prednisolone 10 mg was given every day. Dexamethasone 8 mg was premedicated intravenously before docetaxel administration. RESULT: The patients received a median of four cycles of treatment (range 1-31). In the serum prostate-specific antigen response, 13 (18.6%) patients achieved a complete response and 29 (41.4%) achieved a partial response. Median OS and time to progression were 14 months and 6 months, respectively. Median follow-up period was 9.5 months. Two independent pretreatment risk factors that predicted OS were visceral metastasis including lymph node metastasis and anemia. Grade 3/4 neutropenia and anemia occurred in 25.7 and 8.6% of the patients, respectively. Four treatment-related deaths were seen during the observation period. CONCLUSION: The combination of docetaxel, estramustine and prednisolone was effective in Japanese patients with CRPC; however, this combination therapy should be carefully indicated to elderly and/or poor performance status patients due to its toxicity. Visceral metastasis and anemia were identified as independent risk factors which could predict OS.

IL-23 gene therapy for mouse bladder tumour cell lines.

OBJECTIVES: • To evaluate the antitumour effects of IL-23 gene transfer into mouse bladder carcinoma (MBT2) cells. • To investigate the mechanisms underlying the subsequent constitutive secrection of IL-23 by the MBT2 cells MATERIALS AND METHODS: • An expression vector containing IL-23 gene was introduced into MBT2 cells by liposome-mediated gene transfer, and secretion of IL-23 was confirmed by ELISA. • The in vivo antitumour effect of IL-23-secreting MBT2 cells (MBT2/IL-23) was examined by injecting the cells into syngeneic C3H mice. • A tumour vaccination study using mitomycin C (MMC)-treated IL-23-secreting MBT2 cells was carried out, and the usefulness of in vivo CD25 depletion for an additional vaccine effect was also investigated. • The mechanisms underlying the antitumour effects were investigated by antibody depletion of CD8 or CD4 T cells, or natural killer cells, and cells infiltrating the tumour sites in vivo were assessed using immunohistochemistry. RESULTS: • Stable transformants transduced with MBT2/IL-23 secreted IL-23 into the culture supernatant. • Genetically engineered IL-23-secreting MBT2 cells were rejected in syngeneic mice. • MBT2/IL-23-vaccinated mice inhibited the tumour growth of parental MBT2 cells injected at a distant site and this vaccine effect was enhanced by combination with in vivo CD25 depletion by an antibody. • The main effector cells for the direct antitumour effect of MBT2/IL-23 were CD8 T cells, which was shown by in vivo depletion and immunohistochemical study. CONCLUSIONS: • IL-23-secreting MBT2 cells were rejected in syngeneic mice by the activation of CD8 T cells. • MMC-treated MBT2/IL-23 can have a tumour vaccine effect for parental MBT2 cells, and this effect was enhanced by combination with in vivo CD25 depletion.

Insulin resistance increases the risk of urinary stone formation in a rat model of metabolic syndrome.

OBJECTIVE: To investigate the association between metabolic syndrome and urinary stone disease, and whether insulin resistance associated with adiposity affects the risk of urinary stone formation, using a rat model of metabolic syndrome. MATERIALS AND METHODS: Four-week-old male Otsuka Long-Evans Tokushima 'Fatty' (OLETF, a model of human type 2 diabetes and metabolic syndrome) rats, and Long-Evans Tokushima (LETO, a non-diabetic control) rats (10 each) were given a standardized diet and free access to water. Body weight and serum and urinary biochemistry were determined every 4 weeks. Ten-week-old male OLETF and LETO rats were divided into three groups of nine each and treated with vehicle or oral administration of 3 or 10 mg/kg/day pioglitazone, an agent that improves insulin resistance. After 4 weeks, body weight and serum and urinary biochemistry were determined. RESULTS: The OLETF rats had significantly lower urinary pH and citrate excretion, and higher urinary uric acid and calcium excretion, than the LETO rats, with increases in body weight, serum triglyceride, glucose and insulin. The administration of pioglitazone to the OLETF rats for 4 weeks significantly increased urinary pH dose-dependently. There was no change in the urinary excretion of citrate, uric acid, calcium, oxalate or magnesium. CONCLUSION: These results indicate that metabolic syndrome causes the changes in urinary constituents, leading to increased risk of both uric acid and calcium stone formation. Improvement in insulin resistance, a central cause of metabolic syndrome, might prevent uric acid stone formation by raising urinary pH.

[Extra-adrenal pheochromocytoma with the manifestation of catecholamines cardiomyopathy: a case report].

A 22-year old female had an episode of acute heart and respiratory failure requiring mechanical ventilation ducing a trip overseas. Echocardiography demonstrated akinesis of the apical area (left ventricle ejectionfraction(LVEF) =15%). Since computed tomography (CT) with coronary angiography to rule out acute coronary syndrome showed no abnormalities, she was diagnosed with morphological stress cardiomyopathy due to akinesis of the apical area. After returning to Japan, she was admitted to our hospital for further examination. She had an increased level of catecholamines in 24-hour urine. ¹³¹Imetaiodobenzyguanidine scintigraphy, CT scan and fluorodexyglucose positron emission tomography revealed a retroperitoneal mass. From these results, a diagnosis of extra-adrenal pheochromocytoma with catecholamine-induced cardiomyopathy was made. Histological diagnosis of the laparoscopically resected tumor was pheochromocytoma. After the operation, the level of catecholamines in 24-hour urine was normalized.

Bacillus Calmette-Guérin cell-wall skeleton enhances the killing activity of cytotoxic lymphocyte-activated human dendritic cells transduced with the prostate-specific antigen gene.

UNLABELLED: To determine whether dendritic cells (DC) transduced with the prostate-specific antigen (PSA) gene can induce PSA-specific cytotoxic lymphocytes (CTL) against prostate cancer cells, and whether bacillus Calmette-Guérin (BCG) cell-wall skeleton (CWS) can enhance the maturation of DC-PSA and the killing activity of subsequently induced PSA-specific CTL. MATERIALS AND METHODS; We generated an adenovirus encoding the PSA gene (AxCA-PSA) using the cosmid-terminal protein complex method. DC were infected with AxCA-PSA using the centrifugal method. The ability of CTL to lyse target cells expressing PSA, i.e the PSA-positive prostate cancer cell line, LNCap, and PSA-transduced autologous phytohaemagglutinin (PHA) blasts expressing PSA, was assessed using the 51Cr-release assay. The maturation of DC-PSA stimulated by BCG-CWS was assayed by flow cytometry. The cytotoxic activity enhanced by BCG-CWS was assessed by the 51Cr-release assay. RESULTS: DC-PSA induced PSA-specific CTL with 85% cytotoxic activity against LNCaP (effector: target ratio, E:T, of 50:1). However, the cytotoxic activity against PSA-negative cells was very low. Anti-CD8 and anti-major histocompatibility (MHC) class I antibodies blocked PSA-specific cytotoxicity. The PSA-specific killing was reproducible against autologous PHA blast cells expressing PSA, independently of human leukocyte antigen haplotype. Furthermore, the combination of DC-PSA with BCG-CWS remarkably enhanced the PSA-specific cytotoxicity against PHA blasts expressing PSA (15-30% at an E:T ratio of 50:1). CONCLUSION: These findings suggest that DC-PSA can induce MHC class I-restricted PSA-specific CD8+ CTL responses and that DC-PSA matured by BCG-CWS enhance PSA-specific cytotoxicity. The combination of DC-PSA with BCG-CWS might be a useful approach for treating advanced prostate cancer.

PSA at postoperative three months can predict biochemical recurrence in patients with pathological T3 prostate cancer following radical prostatectomy.

OBJECTIVES: To identify the prognostic factors and determine which pT3 prostate cancer patients can be safely followed up after surgery without any adjuvant treatment. METHODS: A retrospective review was carried out on 106 patients with pT3 prostate cancer. All preoperative and postoperative parameters, including the postoperative serum prostate-specific antigen (PSA) level at 3 months after surgery, were assessed by univariate and multivariate analyses. RESULTS: Mean follow-up period was 18 months. The overall biochemical recurrence-free rate was 53.7% and 34.1% at 12 and 36 months, respectively. On univariate analysis, all preoperative clinical factors were significantly correlated with biochemical progression. On multivariate analysis, pathological Gleason score, pathological stage and postoperative PSA were significant predictors. Among those with undetectable PSA after surgery, 38 patients (88.4% of 43) did not have disease progression during the follow-up period. On the other hand, of the 27 patients with detectable PSA that was not defined as progressive (range 0.01-0.20), 22 (81.5%) had biochemical disease progression. The progression free probability was significantly different between these two groups (P-value < 0.0001). CONCLUSIONS: pT3 prostate cancer patients showing low pathological Gleason score, without seminal vesicle invasion, and undetectable postoperative PSA values have low probability of PSA progression. Careful follow up including periodic PSA assessment and clinical observation represents an adequate strategy in the management of these patients.

[Primary adrenal leiomyosarcoma: a case report].

A 78-year-old female complained high fever and vomiting. The ultrasonographic examination revealed a giant tumor above the left kidney. She was referred to our hospital for further examinations and treatments. Radiographic examination showed a solid mass of 10 cm in diameter, smooth surface, and sharply-delimited, above the left kidney corresponding to the left adrenal gland. Other organs showed no evidence of disease. Hormonal examination was normal. She was diagnosed as left non-functioning adrenal tumor, and underwent surgery. The resected specimen was 11 x 10 x 7 cm, 460 g with a part of normal adrenal tissue on the surface. Histopathological examination revealed it as leiomyosarcoma. She has no evidence of disease twenty months after the operation. Primary adrenal leiomyosarcoma is extremely rare. To the best of our knowledge, there were only 22 reported cases including ours in the English and Japanese literature.

[A case of neonatal testicular torsion].

An infant normally delivered at the 38th week of gestation was referred to our department one day after birth for a firm and painless right hemiscrotal mass with bluish coloration. Since contralateral scrotum showed swelling, we performed emergency surgery on that day. The right spermatic cord was constricted due to extravaginal torsion, and degree and direction of torsion was unclear since the spermatic cord was already organized. Right testis showed irreversible necrotic change, requiring orchiectomy. We confirmed that left testis was intact and performed orchidopexy. Since high incidence of contralateral asymptomatic torsion has been reported in patients with prenatal testicular torsion, emergency surgery should be considered when contralateral scrotum shows abnormal findings.

[Giant paraurethral leiomyoma in the female: a case report].

We report a case of giant paraurethral leiomyoma weighing more than 100 g in a 19-year-old woman. She had been complaining of micturition pain and a mass at the external genitals. Magnetic resonance imaging showed a 5 cm mass surrounding the urethra, which appeared low intensity on T1-weighted images and higher intensity than that of the surrounding muscles in the pelvis on T2-weighted images. Biopsy was performed and the pathological diagnosis was leiomyoma. The mass was removed transvaginally and transperitoneally, which did not invade to urethra or vaginal wall. The resected specimen exhibited 8 x 7.5 x 3.6 cm in size and 105 g in weight. Pathological diagnosis was leiomyoma with no invasion to surrounding tissue. This is the 132nd case of female paraurethral leiomyoma in Japan, and there were only five cases (6%) of giant paraurethral leiomyoma weighing more than 100 g. We discuss the clinical and pathological features of this disease.

[Preoperative parameters, including percent of positive biopsy cores, in predicting pathological findings after radical prostatectomy].

OBJECTIVES: We investigated whether preoperative parameters predict pathological stage at radical prostatectomy for patients with clinically localized prostatic cancer. MATERIALS AND METHODS: We studied a total of 160 men with clinically localized prostatic cancer (less than or equal to clinical T2) who underwent radical rertropubic prostatectomy at Wakayama Medical University. Clinical Ts patients are not included in this study. Preoperative parameters include patient age, Body Mass Index, preoperative serum PSA value, biopsy Gleason score, clinical stage, the percent of positive biopsy cores (%PosBx) and the percent of positive biopsy cores on the dominant side (%DomPosBx). Univariate and multivariate analysis were performed to examine the prognostic significance of these preoperative parameters. Significant independent factors were combined to create a table to predict pathologically organ confined disease. RESULTS: Univariate analysis showed preoperative serum PSA value (p< 0.001), biopsy Gleason score (p =0.001), clinical stage (p = 0.026), %PosBx (p= 0.002) and %DomPosBx (p=0.003) were significantly related to the pathological stage. On multivariate analysis, serum PSA value (p< 0.01), biopsy Gleason score (p<0.05) and %DomPosBx (p<0.05) were significant independent predictors of pathological stage. CONCLUSION: We provide two model combinations using preoperative clinical factors, one is a combination of serum PSA and biopsy Gleason score and the other is a combination of serum PSA and %DomPosBx, which define a new preoperative model for predicting pathological organ confined prostatic cancer. These combinations are useful and provide important information for urologists to determine the appropriate treatment strategy for clinically localized prostatic cancer.

[Inflammatory pseudotumor of the prostate: a case report].

We report a rare case of inflammatory pseudotumor of the prostate. A 42-year-old man with a history of hematospermia and chronic prostatitis presented with difficulty in voiding. Cystoscopy demonstrated a large non-papillary tumor occupying the prostatic urethra along with two bladder stones. Magnetic resonance imaging (MRI) demonstrated a 7-cm prostatic mass protruding toward the bladder and the rectum. Transrectal biopsy of the prostate demonstrated a fibrous lesion containing inflammatory cells without evidence of malignancy. We performed transurethral resection of the prostatic lesion to release the bladder outlet obstruction, followed by cystolithotripsy. Histopathological examination of the surgical specimen demonstrated a benign fibromuscular lesion with spindle cell proliferation, leading to a diagnosis of inflammatory pseudotumor. Postoperatively, the patient voided normally without any signs of recurrence on follow-up at five months. Inflammatory pseudotumor is an unusual benign lesion of unknown etiology. Only 10 previous cases of the disease involving the prostate have been reported in English and Japanese literature. Prostatic involvement of inflammatory pseudotumor may show a presentation similar to malignant prostatic sarcoma. Thus, accurate identification of this benign process is important in order to avoid unnecessary radical surgery.

Cholestatic jaundice as a paraneoplastic manifestation of prostate cancer.

Paraneoplastic syndrome associated with prostate cancer is extremely rare. We report a patient who presented with cholestatic jaundice without biliary duct obstruction, hepatic involvement, or infection. After a few detailed examinations, prostate cancer was diagnosed. After treatment with bicalutamide and leuprolide, the patient's symptoms and laboratory abnormalities were reversed. Cholestatic jaundice was regarded as a paraneoplastic manifestation in this patient. The patient remains symptom-free after 14-month followup. Paraneoplastic syndrome should be considered in case of cholestatic jaundice without biliary duct obstruction, hepatic involvement, or infection.

Squamous cell carcinoma of the urachus producing granulocyte colony-stimulating factor.

Urachal carcinoma is a rare cancer. This is the first report of a case of squamous cell carcinoma of the urachus producing granulocyte colony-stimulating factor. The patient underwent partial cystectomy with urachal remnant resection and pelvic lymphadenectomy. No evidence of tumor recurrence or metastasis was found at 17 months after surgery.