[A case of ureteral disruption caused by a traffic accident].

Disruption of the ureter is very rarely caused by a blunt trauma, only 12 cases having been reported in Japan. A 20-year-old male suffered from a blunt abdominal trauma in a traffic accident. Although his urinalysis showed no abnormalities, a dull pain in the left flank region persisted for over a week after the injury. Under the suspicion of renal or ureteral injury, an excretory urogram (DIP) was conducted. The form of renal pelvis and calyces was almost normal on both sides, while extravasation of contrast medium was recognized around the lower pole of the left kidney. The retrograde pyelogram of the left side revealed that catheterization was possible up to 30 cm from the ureteral orifice, but the injected medium leaked into the retroperitoneal space making it impossible to visualize the left renal pelvis and calyces. An operation was performed under the diagnosis of left ureteral injury on the 19th day after trauma. The left ureter was completely disrupted 2 cm distally from the ureteropelvic junction. An end to end anastomosis of the ureter was done with 6-0 Dexon sutures. The DIP taken on the 25th day after the operation showed slight dilatation of the left pelvis and calyces. However, the renogram conducted 6 months after the operation demonstrated a normal pattern on both sides.

[Clinical studies on varicocele. (1). Findings on semen and testis].

The semen and testicular histology of 39 patients with varicocele on the left side, and who had high ligation of the internal spermatic vein at our Department between 1975 and 1981 was examined. The grade of varicocele was neither related to density nor motility of the sperm, nor to the score count of the left testis. In 40% of the patients, both density and motility of the sperm improved after the surgical treatment. In 80% of the patients, the left testis weighed less than the right testis. In most of the patients, the score count of both testes was lower than normal, and was found to decrease remarkably in testes weighing less than 10 g. In 30% of the patients, the score count of the left testis was lower than that of the right testis. A positive correlation was recognized between score count and testicular weight, and no correlation was found between the score count of the right testis and sperm density.

[Fracture of the penis: a report of four cases].

Four cases of fracture of the penis were treated surgically at our department between 1978 and 1982. No functional disorder has been observed in any case after the treatment. One hundred and ninety cases diagnosed as fracture of the penis reported in the Japanese literature were reviewed and their pathogenesis, diagnosis and therapy were discussed.

[Clinical value of testicular lymphangiography in diagnosis of retroperitoneal metastases].

Testicular lymphangiography was performed before retroperitoneal lymph node dissection in 20 patients with testicular tumor. The clinical value of testicular lymphangiography in the diagnosis of retroperitoneal metastases was evaluated retrospectively in comparison with the findings obtained by retroperitoneal lymph node dissection. In 12 patients who had no metastasis in the primary lymph nodes of the testis, testicular lymphangiography showed the lymph vessels to be diverged into 2 to 6 vessels (mean: 3.5) at the level between L2 and L4, and 4 to 10 lymph nodes (mean: 6.2) at the level between L1 and L4 were filled with contrast medium. On the other hand, in 8 patients who had metastases in the primary lymph nodes, several abnormal findings were observed in both lymph vessels and nodes, i.e., discontinuity, extravasation of contrast medium, dilatation, displacement and reflux to the distal side in the lymph vessels, and decrease in number (less than 2), non-visualization, filling defect, displacement and contrastfilling in the contralateral side in lymph nodes. Three to 5 of these abnormal findings were usually found in each case. The extravasation of contrast medium was not a finding specific to cases with lymph node metastases, because it was also found in a few cases without metastases. Testicular lymphangiography is a valuable method to detect primary lymph node metastases from testicular tumor. However, the combination of testicular and foot lymphangiography is imperative to demonstrate wide spread lymph node involvement in the retroperitoneum.

[A case of occult testicular tumor].

A 43-year-old male presented with a left supraclavicular mass as well as an upper abdominal mass. Biopsy of the supraclavicular mass revealed seminoma with components of both embryonal carcinoma and choriocarcinoma. Right orchiectomy was performed because physical examination showed that the left testis was normal but the right testis was slightly atrophic. The primary tumor which was approximately 1 cm in diameter was found in the right testis and histological examination revealed seminoma. When germ cell tumor is found in a region other than the gonads, either primary extragonadal germ cell tumor or occult testicular tumor is considered. To differentiate between the two, it is imperative to make careful histological exploration of the testes.

[Surveillance colonoscopy after ureterosigmoidostomy].

Twenty-two patients underwent surveillance colonoscopy for 2 to 54 months (average, 22 months) after ureterosigmoidostomy. The distance between site of ureterocolonic anastomosis and anal verge ranged from 13 to 30 cm (average, 18.3 cm) in right side and from 20 to 37 cm (average, 29.5 cm) in left side. The form of implanted site could be classified into 3 types which were flat, sessile and pedunculated types. Endoscopic biopsies performed on eleven polyp-like regions of ureterocolonic anastomosis revealed inflammation in 10 cases (90%) and adenoma without malignancy in one case (10%). The mucosa more than 5 cm away from implanted site showed findings of inflammation without constitutional abnormality in more than 60% of all patients. The periodical surveillance colonoscopy at intervals of approximately one year seemed to be useful for early detection of the tumors of the colon after ureterosigmoidostomy.

[Clinical study on ureterosigmoidostomy].

Clinical studies were made of 60 patients who had undergone ureterosigmoidostomy at our department. The 45 men and 15 women ranged from 35 to 73 years old, with a mean of 59.2 years. Ureterosigmoidanastomosis was performed using the modified Coffey II technique in this series. Bladder tumor was the reason for the operation in 55 cases, uterine cancer in 2, contracted bladder in 1, vesicovaginal fistula in 1 and urethral stricture in 1. In the excretory pyelogram one month after the operation, normal findings and slight hydronephrosis were observed in 37% and 63% of the patients, respectively. However, the pyelogram 6 months after the operation demonstrated normal findings in 61% of the patients, slight hydronephrosis in 34% and moderate hydronephrosis in 5%. None of them showed severe hydronephrosis. Slightly increased BUN level (less than 30 mg/dl) was seen in 15 out of 45 patients (32%) at one year after ureterosigmoidostomy. However, serum creatinine level was not above normal throughout the postoperative course. Although postoperative hyperchloremia was appreciably detected, it was easily managed by the administration of sodium bicarbonate. Serum sodium and potassium levels remained stationary. Of 35 patients observed for more than one year after operation, 11 patients (31%) had developed fever due probably to pyelonephritis, but sigmoidography failed to demonstrate any ureteral reflux. Either urinary or fecal fistula, a complication in the early postoperative period, occurred in 10 patients (17%). One of these patients died. Five patients were cured by conservative treatment. The remaining 4 patients underwent surgical treatment that was ureterocutaneostomy , nephrectomy, or colostomy.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of multiple urothelial tumors with chronic renal failure].

We report a case of multiple urothelial tumors (left renal pelvis, ureter and bladder) with chronic renal failure in a 72-year-old man. The patient was admitted because of gross hematuria with increasing volume and intervals on September 14, 1985. Admission evaluation including excretory urography, retrograde pyelography, computed tomography and cystoscopy revealed multiple urothelial tumors in the left renal pelvis, ureter and bladder. Radical surgery, however, was postponed because of pneumothorax induced by an inadvertent insertion of the CVP catheter at operation. Subsequent respiratory disturbance persisted so that he was observed at the outpatient clinic following right ureterocutaneostomy. Gradual increase in anemia and decrease in renal function, however, prompted another admission. Gross hematuria necessitating frequent blood replacement could not be controlled by transurethral resection of bladder tumors. Therefore left nephroureterectomy with resection of bladder cuff was performed after internal arteriovenous shunt had been established, because favorable results regarding tumor resection were obtained from preoperative evaluations. He showed satisfactory recovery and was spared hemodialysis despite eventful postoperative course with transient decrease in renal function. The patient was discharged on 130th postoperative day and is now being followed up at the outpatient clinic. The relevant literature is also reviewed briefly.

[Idiopathic calcinosis of the scrotum: a case report].

A 25-year-old man complained of painless, firm scrotal nodules which increased in number and size for the last 7 years. Physical examination was unremarkable except for many, firm painless nodules near the scrotal raphe. Preoperative diagnosis was multiple scrotal tumors of unknown etiology. Surgical excision was performed under epidural anesthesia. On microscopic examination, the nodules were located in the dermis and composed of calcified material which was positive with the von Kossa calcium stain. There were numerous foreign giant cells and dense fibrosis at the margins of the lesions. Idiopathic calcinosis of the scrotum was the final diagnosis. Although its etiology is unknown, the literature reviewed supported the view that the mast cell accumulation and its degranulation are related to idiopathic calcinosis of the scrotum.

[Artificial defect on myocardial SPECT image due to extra-cardiac MIBI accumulation].

If 99mTc-methoxy isobutylisonitrile (MIBI) myocardial scintigraphy was performed on the rest-stress protocol, MIBI accumulated in extra-cardiac area, gallbladder or liver, on rest image significantly. The purpose of this study was to evaluate whether extra-cardiac MIBI accumulation influences the quality of myocardial images. Rest-stress MIBI myocardial scintigraphy was performed in 90 patients. Fifteen patients showed defects on rest image in spite of normal findings on stress image. Before and after removing the area of extra-cardiac MIBI accumulation on projection images, SPECT was reconstructed in the 15 patients. Perfusion defect on rest image improved in 66% of patients (10/15) and 37% of total segments (33/89) by removing the area of extra-cardiac MIBI accumulation. Furthermore, it was 21% (4/19), 38% (11/29), 43% (16/37) and 50% (2/4) in anterior, septum, posterior and lateral segments respectively. Significant MIBI extra-cardiac accumulation, especially in the gallbladder, is one of the causes of artificial defects on rest image. Thus, reconstruction of SPECT after removing area of MIBI extra-cardiac accumulation will be an appropriate method to improve the quality of MIBI images.

[Detection of viability by percent thallium uptake with conventional thallium scintigraphy].

Thallium myocardial scintigraphy (TMS) is used for diagnosis of viability in infarcted myocardium before coronary revascularization. Underestimation of viability by TMS has been reported by many investigators. To evaluate viability precisely, thallium re-injection method or 24 hour delayed imaging is performed. However these techniques are not convenient and are difficult to perform in clinical practice. Percent Tl-uptake method was developed for predicting myocardial viability. To evaluate usefulness of this method, TMS was performed before and after PTCA in 23 patients with myocardial infarction. Left ventricle was divided into 3 layers, then each layer was divided into 4 segments (12 segments in total). Forth three segments showed recovery of perfusion on TMS after PTCA. Viability in infarcted myocardium is predicted by 1) redistribution (RD), 2) %Tl-uptake > or = 45% on the image immediately after exercise (TE), and 3) %Tl-uptake > or = 45% on delayed image (TD). Sensitivity was RD: 60%, TE: 90% and TD: 95% (p < 0.001 vs. RD). Specificity was RD: 74%, TE: 68%, and TD: 60% (NS). Predictive accuracy (PA) was RD: 69%, TE: 77%, TD: 73% (NS). Compared with RD, %Tl-uptake, either TE or TD, increased sensitivity with slightly improved PA, but decreased specificity slightly. Therefore %Tl-uptake would be a sensitive and useful predictor to find patients who are most likely to benefit from re-vascularization.

[University education in geriatrics--present status and future prospects of gerontology and geriatrics education in pathology].

The increase in the number and proportion of the elderly in Japan over the last 30 years has been faster than that in any other country. One of the measures we are compelled to take to deal with this drastic change in medicosocial circumstances is reform of the medical school curriculum. However, the necessary reforms are being implemented slowly and are still insufficient. We surveyed the present status of gerontology and geriatrics education in pathology, and the understanding, interest, and opinions on this matter among professors of pathology. Questionnaires were sent to 148 professors of pathology in 80 medical schools. Responses were received from 84 professors (57%) at 64 medical schools (80%). Of the 11 medical schools with a department of geriatrics 10(90%) included gerontology in the curriculum. In contrast, 43(80%) of the 53 remaining schools did not include gerontology in the curriculum, although education in geriatrics and gerontology has been given as part of pathology lectures in almost all medical schools. Many professors want to establish a department of geriatrics in their school, but feel it will be difficult because of lack of money and higher priority given to other fields. As other hindrances, most of the respondents noted the lack of money and higher priority given to other fields. As other hindrances, most of the respondents noted the lack of a good textbook of gerontology, ambiguity in the concept of the field, and the immaturity of gerontology as a science. Another major problem noted was uncertainty regarding the status of geriatrics as a clinical specialty. One professor mentioned that promotion of aging research would be the best way to solve these problems.

[University education in geriatrics. Present status and future plans of universities regarding the development of a program in geriatrics].

Because the number of people who reach an advanced age has been increasing at an unprecedented rate in Japan, geriatricians are expected to play a central role in health care for the elderly. However, only 16 out of 80 medical schools (20 percent) now have departments of geriatrics for undergraduate education. To develop undergraduate education in the field of geriatrics, a survey was sponsored by the Research Projects on Aging and Health (Health Science Research Grant the Ministry of Health and Welfare of Japan). A questionnaire regarding the present status and future plans of the university about a program in geriatrics, was sent to deans of medical faculties or vice-presidents of medical schools. The questionnaire included questions about current status and future plans regarding undergraduate geriatric education, the presence of a department or clinic of geriatrics, educational requirements in the field of geriatrics, opportunities for practice, institutions of practice, research on geriatrics, and other suggestions. The response rate was 93.7 percent (74/79). Departments or clinics of geriatrics had been established in 15 institutions (20.3 percent) and were planned in 18 (24.3 percent). Undergraduate education in geriatrics was considered necessary in 73 schools (98.7 percent) and indispensable as an obligatory subject in 56 (75.7 percent). Clinical practice was considered more important and effective than lectures in 50 schools (63.3 percent). Coordinated lectures on basic biomedical gerontology (such as mechanism of aging) and geriatric medicine for chronic degenerative diseases such as senile dementia were considered essential to the curriculum. In practicing geriatrics, experience in providing medical care to aged patients as well as social support and a welfare system for the aged is emphasized. Institutions, nursing homes, and geriatric hospitals outside medical schools be easily accessible. It was generally agreed that geriatrics should be taught in advanced classes. In conclusion, medical schools in Japan regard undergraduate education in geriatrics as necessary and agree on the optimal curriculum, but it is not universally implemented.

[University education in geriatrics. Opinions of teaching staff on undergraduate education in gerontology and geriatric medicine].

Undergraduate education in gerontology and geriatric medicine has become more important because of a progressive increase in the aged population. To assess curricula in geriatric medicine and to survey the opinions of teaching staffs as to the ideal curriculum, a questionnaire was sent to professors of gerontology and geriatric medicine at 14 medical schools. Responses were obtained from all 14 professors. In all medical schools, students are given lectures in the fifth or sixth year, or both. The total number of hours for the lectures varied from a few hours to 40 hours, and contents of the lectures varied between schools. Medical staffs pointed out that little time is allocated to geriatric medicine. They also emphasized the importance of bedside teaching.