[SUCCESSFUL INGUINAL ORCHIECTOMY IN A PATIENT WITH A PAINFUL METASTATIC SPERMATIC CORD TUMOR: A CASE REPORT].

A 71-year-old man was referred to our department due to inflammation in the right scrotum. A tumor in the right spermatic cord was suspected on palpation, and abdominal computed tomography revealed a 4-cm mass in the tail of the pancreas and a low-density lesion in the liver segment 6. In addition, the patient's serum level of CA19-9 was high, at 135.7 U/mi. We referred the patient to our institution's Department of Gastroenterology, where he was diagnosed as having a liver metastasis from pancreatic cancer. Despite three courses of gemcitabine and erlotinib combination therapy for pancreatic cancer, his serum level of CA19-9 increased to 744.0 U/m, indicating no response to chemotherapy. Because uncontrollable pain developed in the right scrotum and right inguinal area during the course of treatment, inguinal orchiectomy was performed for pain management and pathological diagnosis. Careful examination revealed a hard, whitish tumor occupying the right spermatic cord and extending from the epididymis to the internal inguinal ring. Because a palpable mass in the peritoneum near the internal inguinal ring was detected, part of the peritoneum was resected concurrently. Pathological findings were remarkable with spermatic cord metastasis and peritoneal dissemination from pancreatic cancer. Pain subsided postoperatively and no analgesics were needed. Pancreatic cancer accompanied by spermatic cord metastasis and peritoneal dissemination is extremely rare. Surgical resection in the present case provided effective treatment of the intractable pain due to spermatic cord metastasis. To the best of our knowledge, this is only the 14th case reported in Japan of spermatic cord metastasis from pancreatic cancer as a primary cancer.

Role of male pelvic floor muscles and anterior fibromuscular stroma in males on α(1)-blocker treatment: a magnetic resonance imaging study.

Dynamic motion of the pelvic floor muscles during voiding was analyzed using real-time magnetic resonance imaging. To evaluate the contraction of the pelvic floor muscles, striated urethral sphincter distance, levator ani muscle thickness and anterior fibromuscular stroma distance were measured. The percent contraction of the striated urethral sphincter from before voiding to just before initiation of voiding was 14% in the normal group and 5% in the voiding dysfunction group. The percent contraction of the anterior fibromuscular stroma from before voiding to just before initiation of voiding was 11% in the normal group and 1% in the voiding dysfunction group; the percent contraction of the muscles was significantly greater in the normal group (P < 0.05). Striated urethral sphincter and anterior fibromuscular stroma contraction at initiation of voiding open the bladder neck and urethra. This plays an important role in the smooth initiation of voiding.

[Rehabilitation for intravaginal ejaculatory dysfunction with using a masturbation aid].

OBJECTIVES: Recently the incidence of intravaginal ejaculatory dysfunction is increasing among infertile couples in Japan. Some unusual ways of masturbation and psychogenic issues were reported to cause this disorder. Patients, who had done masturbation in an unusual way for long time since their adolescence, were difficult to gain normal intravaginal ejaculation by the behavior therapy which was used for erectile dysfunction. We, therefore, used a masturbation aid (TENGA) for rehabilitation of ejaculation to overcome this condition. PATIENTS AND METHODS: From January, 2010 through March, 2011, a total of 16 patients with intravaginal ejaculatory dysfunction underwent rehabilitation of ejaculation using TENGA. Patients' satisfaction and achievement of intravaginal ejaculation were evaluated by the questionnaire. RESULTS: Twelve patients (75%) could ejaculate in the masturbation aid (TENGA). Five patients (31%) succeeded to ejaculate in the partner's vagina after rehabilitation. CONCLUSIONS: A masturbation aid (TENGA) was a useful tool to correct the way of masturbation and achieve normal intravaginal ejaculation. This masturbation aid can be one of the effective options for the treatment of intravaginal ejaculatory dysfunction.

[Diagnostic study of the usefulness of virtual endoscopic images and 3-D modeling for lower urinary tract obstruction].

PURPOSE: I observed bladder and urethral morphology and lumen by making a virtual endoscopy (VE) of the bladder and a urethra for patients with lower urinary tract symptoms. I have herein reported the procedures to use this model to evaluate the condition of patients more precisely. PATIENTS AND METHODS: Of those referred for investigation of lower urinary tract symptoms, subjects were 22 boys (5-13 years old, mean 9) in whom voiding cystourethrography (VCUG) was suspected for urethral obstruction between March, 2009 and October, 2010. Eleven of these 22 cases were extracted at random and underwent voiding computed tomography (VCT). Except one dropped out, the 21 cases were assigned to a VCT/VCUG combination group or a VCUG-single group. We confirmed the two groups, the rate of agreement of imaging views and cystourethroscopy (CS) views, and the effectiveness of endoscopic operation. RESULT: I made the following imaging diagnoses in the VCT/VCUG combination group: congenital obstructive posterior urethral membrane (COPUM), n = 7; Cobb's collar, n = 1; and COPUM and Cobb's collar combined, n = 3. In contrast, in the VCUG-single group, I diagnosed COPUM, n = 5; bulbar region urethral stricture, n = 2; posterior urethral expansion, n = 2; and bladder form abnormality, n = 1. The rate of agreement between preoperative diagnosis and CS views on imaging was 72.7% in the VCT/VCUG combination group, and 33.3% in the VCUG-single group. All patients underwent transurethral incision (TUI) of the urethral obstruction. In the VCT/VCUG combination group, effectiveness of the TUI was assessed as good in 2 cases and moderate in 6 cases giving an overall effectiveness rate (good + moderate) of 72.7%. In the VCUG-single group, effectiveness was rated as moderate in 5 cases (overall effectiveness rate = 50%). CONCLUSION: I developed a method of VE for lower urinary tract obstruction of children and examined the effectiveness. This method was found to be more effective than conventional urinary tract imaging. With the developments in the equipment, this method may in future be useful as an adjunct to CS and urodynamic studies.

Mullerian duct cyst: a curable entity of male infertility. Two case reports.

Purpose: Mullerian duct cyst is a rudiment of a Mullerian duct in the fetal period which causes ejaculatory duct obstruction and male infertility. Case report: We report two patients with Mullerian duct cyst that presented with low ejaculate volume, oligoasthenoteratozoospermia and azoospermia syndrome. Transrectal ultrasound (TRUS) and magnetic resonance image (MRI) revealed a midline prostatic cystic structure. In each case, we performed a TRUS guided transperineal aspiration of the cyst. Seminograms of the patients improved and one of their wives got spontaneously pregnant 3 months after the surgery. Conclusion: We should assume the TRUS guided aspiration of Mullerian duct cyst.

[A case of a giant adrenal myelolipoma in a man with spinal cord injury].

A 38-year-old man in a wheelchair for spinal cord injury from a traffic accident was referred to our hospital with complaint of dull right flank pain. The patient had a history of skin ulcer formation on both toes due to poor circulation. Abdominal ultrasonography and computed tomographic scan revealed a huge retroperitoneal tumor compressing the right kidney. Serum levels of cortisol, adrenocorticotropic hormone, aldosterone, adrenalin, noradrenalin, urinary levels of vanillylmandelic acid, homovanillic acid, 17-ketosteroid and 17-hydroxycorticosteroid were all within normal limits. Combining all preoperative diagnostic information, the possibility of retroperitoneal liposarcoma could not be thoroughly ruled out. The patient consented to undergo resection of the tumor with the right kidney. Prior to the scheduled operation simulation of the positioning on the operation table was done to evaluate the compressing pressure. During operation decompressing pads were used to minimize the compressing pressure and intermittent pneumatic compression was also used to prevent pressure ulcer and facilitate circulation to the lower extremities. Five thousands units of heparin (FragminR, Pfizer, USA) was used daily to prevent deep vein thrombosis until the patient could use his wheelchair. Perioperative rehabilitation was conducted by a team of physical therapists. The excised tumor weighed 1,320 g. Pathologic diagnosis was an adrenal myelolipoma. Convalescence was uneventful and the patient was discharged on the 10th post operative day. Between 1992 and 2006, 80 cases of adrenal myelolipoma were reported in Japan. Our case was found to be the second largest one. We reviewed these 80 cases and discussed the diagnosis and treatment strategy of the adrenal myelolipoma. We also discussed the perioperative management for patients with spinal cord injury.

[Clinico-statistical analysis of renal cell carcinomas in patients on hemodialysis].

Eleven patients on hemodialysis that were surgically treated for renal cell carcinomas during the recent 10 years at our institutes were clinically analyzed. Patients' ages at presentation ranged from 35 to 70 years with an average of 54.8 years. Nine of the 11 patients were males and 2 were females. Periods between the introduction of hemodialysis and the presentation ranged from 1 to 21 years with an average of 11.7 years. The most frequent cause of hemodialysis was chronic glomerulonephritis. Five patients presented with macroscopic hematuria, which was the most frequent clinical manifestation. Transperitoneal nephrectomy through a lumbar oblique incision was performed in 9 of 12 surgical procedures. Transperitoneal resection and retroperitoneal endoscopic resection were performed on 2 patients and 1 patient, respectively. Blood transfusion was performed on 2 patients with retroperitoneal hemorrhage before or after operation and 2 patients with pre-existing renal anemia. Pathologically, 9 patients had pT1a disease. Patients were followed up for up to 7 years and 11 months. One patient died of the disease and 2 patients died of unknown causes. In conclusion, surgical removal of renal cell carcinomas was well tolerated, safe and effective treatment in patients under hemodialysis.

[A case of leiomyosarcoma of the spermatic cord].

A 44-year-old male was referred to our hospital for further treatment of lung and adrenal metastases from leiomyosarcoma occurring in the left spermatic cord. He had undergone high orchiectomy 5 months before, but no adjuvant therapy was done. Although systemic CYVADIC therapy (cyclophosphamide, vincristine, doxorubicin hydrochloride, dacarbazine) was performed in our hospital, he died of metastatic disease 10 months after the initial therapy. Leiomyosarcoma arising in the spermatic cord is a rare entity. We present a case of leiomyosarcoma of the spermatic cord, and to our knowledge, this is the 23rd case reported in Japan.