Impact of loop-tail ureteral stents on ureteral stent-related symptoms immediately after ureteroscopic lithotripsy: Comparison with pigtail ureteral stents.

Purpose: To evaluate urination-related quality of life (QoL) in patients with an indwelling ureteral stent immediately after ureteroscopic lithotripsy (URSL) for upper urinary calculi. We compared the effects of loop-tail and pigtail ureteral stents on urination-related QoL. Materials and Methods: Of 135 patients who underwent URSL between May 2014 and March 2015 at our hospital, we retrospectively analyzed the records of 70 patients (42 men, 28 women; median age, 63 years) in whom the stent tail was positioned inside the bladder without crossing the midline and who completed the core lower urinary tract symptoms score (CLSS) questionnaire pre- and postoperatively. Results: There were significant differences in incomplete emptying (p=0.048) and bladder pain (p=0.041) between patients with loop-tail versus pigtail ureteral stents after URSL. In the multivariate analysis, stent type had a stronger association with incomplete emptying (p=0.022) and bladder pain (p=0.018) than age, sex, body mass index, stent side, operation time, diameter of ureteral access sheath, and stent type. Conclusions: Patients with loop-tail ureteral stents had better urination-related QoL in the immediate post-URSL stage than patients with pigtail stents.

[Improvement in Hyperglysemia Following Unilateral Adrenalectomy for ACTH-Independent Macronodular Adrenal Hyperplasia (AIMAH) : A Case Report].

Adrenal corticotropin (ACTH) -independent macronodular adrenal hyperplasia (AIMAH) is a rare cause of Cushing's syndrome. Bilateral adrenalectomy is the treatment of choice, but lifetime steroid replacement is essential. Here we report a case of AIMAH whose hyperglycemia was improved following unilateral adrenalectomy. A 42-year-old woman with serious intellectual disability and intractable epilepsy presented with polydipsia. Casual blood glucose and hemoglobin A1c (HbA1c) were 322 mg/dl and 8.5%, respectively. The cortisol level was high and ACTH level was low. Abdominal computed tomography and magnetic resonance imaging revealed unsuspected macronodular enlargement of bilateral adrenal glands (left 8 cm, right 4 cm in maximal diameter) and she was diagnosed with AIMAH. Both adrenal glands showed intense 131 I-adosterol accumulation predominantly in the left side and left-unilateral laparoscopic adrenalectomy was performed. Both insulin and oral antidiabetic drugs could be cancelled postoperatively, and HbA1c decreased to 5.7%. Steroid was not replaced but she never experienced adrenal crisis. We conclude that unilateral adrenalectomy is a safe and effective treatment for certain cases of AIMAH.

[A Case of Traumatic Dislocation of the Penis].

We report a rare case of a traumatic dislocation of the penis. The patient was a 39-year-old man who was ambulanced to our hospital because of a motorbike accident. He was diagnosed to have a pelvic fracture. He was admitted to our department because of his urinary retention and lower abdominal pain. Only the penile skin was left as the genital organ, and neither the penis nor the glans penis was palpable. As the computed tomography scan of the abdomen revealed the dislocation of the penis under the skin in the foreside of the pubic bone, urinary retention due to the traumatic dislocation of the penis was diagnosed, and a percutaneous cystostomy was performed. After improvement of his general condition, the patient was transferred to our department for the evaluation of the perineal region, including the lower urinary tract, and for the treatment of the traumatic dislocation of the penis. First, as hematoma and abscess in the left spermatic cord were suspected by magnetic resonance imaging of the pelvic region, removal of the hematoma and abscess in the left spermatic cord as well as an anterograde cystoscopy were performed under lumbar anesthesia, and the absence of urethral injury was confirmed. After infection control, repositioning of the penis was jointly performed with the Department of Plastic Surgery of our hospital under general anesthesia. After the operation, spontaneous urination was observed and erectile function was observed to be normal.

[A Case of Pyoderma Gangrenosum of the Penis Difficult to Distinguish from Fournier Gangrene].

Here, we report a case of pyoderma gangrenosum of the penis which was difficult to distinguish from Fournier gangrene. The patient was a 54-year-old male who was aware of redness and swelling of the glanspenis for 1 month prior to a consultation at our department. Although he was diagnosed with herpes and treated at a nearby hospital, his symptoms did not improve. Subsequently, the patient visited our department following the onset of pain and fever. During his initial consultation, he had a fever of 39 °C as well as redness and swelling of the glans penis with partial spontaneous purulent discharge. His blood test revealed an elevated white blood cell count (20, 000/µl) and C-reactive protein (19.1 mg/dl). Because Fournier gangrene was suspected, administration of broad-spectrum antimicrobial agents was initiated but proved to be ineffective. An abscess (2 cm in diameter) was also noted in the umbilical region.Enterococcus faecalis was detected by the bacterial culture ; and therefore, Fournier gangrene was diagnosed. A partial penectomy was performed to control the infection. Pathological findings showed only non-specific inflammation ; however, fever persisted postoperatively and blood test results showed no improvement. Furthermore, new abscess lesions emerged on the right heel and back. Because the re-performed abscess bacterial culture test result was negative, pyoderma gangrenosum was suspected, and he was started on oral prednisolone (20 mg/day). On the following day, his fever subsided and his blood test results also showed improvement. A final diagnosis of pyoderma gangrenosum was ultimately made.

Influence of Pelvicaliceal Anatomy on Stone Clearance After Flexible Ureteroscopy and Holmium Laser Lithotripsy for Large Renal Stones.

PURPOSE: This study was performed to evaluate the impact of pelvicaliceal anatomy on stone clearance in patients with remnant fragments in the lower pole after flexible ureteroscopy and holmium laser lithotripsy (fURSL) for renal stones >15 mm. PATIENTS AND METHODS: This retrospective study included 67 patients with radiopaque residual fragments (>2 mm) in the lower pole after fURSL for large renal stones (>15 mm). The preoperative infundibular length (IL), infundibular width (IW), infundibulopelvic angle (IPA), and caliceal pelvic height (CPH) were measured using intravenous urography. Multivariate analysis was performed to determine whether any of these measurements affected stone clearance. RESULTS: Of the 67 patients, 55 (82.1%) were stone free (SF) 3 months after fURSL. The anatomic factors significantly favorable for an SF status were a short IL, broad IW, wide IPA, and low CPH. On multivariate analysis, the IPA had a significant influence on an SF status after fURSL (p=0.010). An IPA <30° was a negative risk factor (p=0.019). Postoperative complications occurred in nine patients (13.4%), including Clavien grade I complications in two patients (2.9%), grade II in six patients (8.9%), and grade IIIa in one patient (1.8%). Almost all complications were minor. CONCLUSIONS: An IPA <30° is the only negative risk factor for stone clearance after fURSL for large renal stones according to our multivariate analysis. Additional studies are required to further evaluate the characteristics of the pelvicaliceal anatomy influencing stone clearance.

[Laparoscopic excision of a retroperitoneal ganglioneuroma : a case report ].

A 32-year-old female with a history of hypertension and paroxysmal supraventricular tachycardia (PSVT) presented with a 63×39 mm, well-circumscribed retroperitoneal mass found by ultrasonography and abdominal computed tomography (CT). CT revealed a round, homogeneous tumor with calcification at the left renal hilum, and compressing the left adrenal and renal veins. Endocrinological examinations were within the normal range. Transabdominal laparoscopic excision of the retroperitoneal mass was planned because tumor malignancy could not be excluded by preoperative analyses. Histopathological examination proved that the tumor was a ganglioneuroma arising from the extra-adrenal retroperitoneum.

Complications of urologic laparoscopic surgery: a single institute experience of 1017 procedures.

PURPOSE: We evaluated complications of urologic laparoscopic surgery at our institution. PATIENTS AND METHODS: From December 1991 to January 2009, 1017 urologic laparoscopic surgical procedures were performed in Kansai Medical University, including 277 radical prostatectomies, 13 donor nephrectomies, 74 partial nephrectomies, 158 radical nephrectomies, 55 pyeloplasties, 97 nephrouretectomies, 54 simple nephrectomies, 128 adrenalectomies, 34 varicocelectomies, and 127 other procedures. Medical records of each procedure were retrospectively evaluated. The difficulty of each procedure was classified according to the European Scoring System (ESS). Intraoperative and postoperative complications were graded according to the Satava and Clavien classifications, respectively. RESULTS: Among the 1017 laparoscopic procedures, 148 complications occurred in 123 patients, resulting in a total complication rate of 14.6%. Conversion to open surgery occurred in 20 (1.9%) patients. Nephrouretectomy had the highest incidence of complications at 23.7%, which was significantly higher than that of other procedures classified as "difficult" group, according to the ESS (P < 0.05). Clavien grades I and II accounted for 73.8% of all the postoperative complications. We experienced one fatality that was caused by air embolism. CONCLUSION: We evaluated the complications of each procedure using the ESS for classification of technical difficulty. Based on the results of our retrospective study, nephrouretectomy should be upgraded as "very difficult" group according to the ESS. Appropriate grading by technical difficulty is beneficial for the prevention of complications from laparoscopic surgery.

[The persisting mesonephric duct with contralateral cryptorchism and ipsilateral renal aplasia: a case report].

A 30-year-old man with azoospermia underwent an examination for infertility. He had a history of right orchiopexy due to cryptorchism. Radiological examinations showed an absence of the left kidney and the left seminal vesicle. A testicular biopsy revealed normal spermatogenesis in the left testis, but no spermatogenesis in the right testis. The right vasograph demonstrated obstruction of the vas deferens at the inguinal region. The left vasograph showed that the left vas drained into a cystic lesion, which then drained into the bladder neck. The left ureter was connected to this cystic lesion. The final diagnosis was a persistent mesonephric duct which was open to the bladder neck. The pathogenesis of the persistent mesonephric duct combined with the ectopic opening of the ureter and the vas deferens is discussed. The patient was treated by testicular extraction of the testicular sperm, and intracytoplasmic sperm injection.

[Small cell carcinoma of the prostate: a case report].

A 76-year-old man had been treated with maximum androgen blockade therapy for a poorly-differentiated prostate adenocarcinoma (T3cN1M0, prostate specific antigen (PSA) 65 ng/ml, Gleason Score 4+5=9) since September 2002. By August 2003, his serum PSA levels were undetectable and the lymph node swelling had vanished. However, in December 2004, his serum PSA levels started rising gradually up to 0.66 ng/ml. Radiation therapy on the prostate was then performed (66 Gy). At that time, no metastasis was detected by computed tomography and bone scintigraphy. In August 2005, multiple bone metastases were detected. Immunohistochemical examination of a biopsy specimen from the bone lesion revealed a small cell carcinoma/neuroendocrine cell carcinoma. He died with undetectable PSA levels (less than 0.008 ng/ml) in December 2005. The autopsy showed multiple organ metastases including bone, liver, lungs and others. The immunohistochemical examination revealed pure small cell carcinoma in all metastatic lesions. A precise histological examination of the lungs using a 1 cm serial section could not reveal any tumors compatible with primary lung cancer. We concluded from the clinical history and autopsy findings that his initial poorly-differentiated adenocarcinoma of the prostate dedifferentiated into a pure small cell carcinoma with neuroendocrine differentiation.

[Priapism complicated by chronic myelogenous leukemia (CML); a case report].

A-29-year-old man visited our hospital with the complaint of a continuous rigid and painful erection which began two days before. We diagnosed ischemic type of priapism by aspiration of penile cavernosal blood analysis; an acidotic and hypoxic blood. The leukocyte count was 263,000/p, and chronic myelogenous leukomia (CML) was suspected. After the failure of conservative treatment, glans-cavernosal shunt (Winter procedure) was performed. The postoperative course was uneventful and the intercourse was possible at five months after the operation. CML was treated by administration of imatinib mesylate and no evidence of recurrence was observed.

[Bellini duct carcinoma of the kidney: a case report].

We report a case of Bellini duct carcinoma. A 65-year-old man visited our hospital because of an asymptomatic right renal mass directed by ultrasonography and computed tomography in an other hospital. His urine cytology was negative. The tumor showed a minimal enhancement in computed tomography. Under the preoperative diagnosis of an atypical right renal tumor, laparoscopic right radical nephrectomy was performed. The tumor is 50 mm in diameter and the surface was grayish-white in color. The histopathological diagnosis was low-grade Bellini duct carcinoma. Immunohistostaining revealed positive staining for UA-1 and EMA in the tumor tissue. No evidence of recurrence or metastasis was noted 36 months after surgery without any adjuvant therapy.

Colonic adenocarcinoma and stones in an Indiana pouch.

We report on a 63-year-old woman with adenocarcinoma and stones in an Indiana pouch. Adenocarcinoma of an Indiana pouch is extremely rare. To our knowledge, only four cases with adenocarcinoma in an Indiana pouch have been reported.

Autopsy case of primary choriocarcinoma of the urinary bladder.

Choriocarcinomas usually develop in the uterus and ovaries in the female, being extremely rare in the extragenital organs in the male. Extragenital choriocarcinomas in the male usually develop in the mediastinum or retroperitoneum. The frequency of choriocarcinoma in the urinary bladder is extremely low. The purpose of the present paper was to report an autopsy case of choriocarcinoma in the urinary bladder in the male. An 81-year-old male patient with macrohematuria was first diagnosed with transitional cell carcinoma (TCC). At autopsy a hemorrhagic necrotic tumor, which was found in the urinary bladder with metastatic lesions in the lungs, was diagnosed as choriocarcinoma microscopically. There was no evidence for choriocarcinoma derived from any other organs than the urinary bladder, although there were metastatic lesions in both lungs and the direct invasion into the prostate. From these findings it is concluded that the tumor was a primary choriocarcinoma in the urinary bladder in a male patient. Choriocarcinoma of the urinary bladder is very rare, but the prognosis is extremely poor in comparison with TCC even in the urinary bladder. Therefore, it is essential to clearly discriminate between choriocarcinomas and TCC.