The usefulness of power Doppler ultrasonography for diagnosing prostate cancer: histological correlation of each biopsy site

OBJECTIVE

To correlate the findings of power Doppler ultrasonography (PDUS) of the prostate with those of site-specific transrectal ultrasonography (TRUS)-guided biopsy.

PATIENTS AND METHODS

The study comprised 28 patients referred to our institution for TRUS-guided prostate biopsy because of an elevated PSA level and/or abnormal digital rectal examination. PDUS findings were graded 0, 1 or 2; grades 0-1 were considered as negative and grade 2 as positive. The blood volume of each biopsy site was also determined using the mean number (MN) value that represents the average vascularity in a 5-mm square sample. PDUS values were correlated with the histological findings of 147 biopsies with 19 focal lesions.

RESULTS

Grade 2 was assigned to 19 sites, grade 1 to 52 sites, and grade 0 to 76 sites. Fourteen of the 19 PDUS findings of grade 2 sites revealed carcinoma and five were grade 1. Ten of 35 TRUS-positive sites were carcinomas, three benign prostatic hyperplasia (BPH) and 22 normal. The MN value for prostatic carcinoma was 4.33, for BPH 11.7 and for normal tissue 4.7. The overall sensitivity of PDUS was 74%, the specificity 96% and the positive predictive value 74%.

CONCLUSIONS

Because TRUS alone cannot detect all cancers, PDUS should be used routinely in all patients undergoing TRUS-guided biopsy, to improve the diagnostic yield of prostate cancer.

Loss of regulation of circulating 1,25-dihydroxyvitamin D with paradoxically decreased serum phosphate levels in individuals with recurrent kidney stones

A low serum phosphate concentration is characteristic in individuals in whom kidney stones form, this being related to serum 1,25-dihydroxyvitamin D, parathyroid hormone and urinary phosphate excretion. In order to determine whether these parameters are related to recurrence of stone formation, they were analyzed in single and recurrent stone formers as well as controls. An inverse correlation between serum levels of phosphate and 1,25-dihydroxyvitamin D was observed in control subjects, indicating that a drop in serum phosphate results in upregulated circulating 1,25-dihydroxyvitamin D level in controls. While the circulating low phosphate level upregulated the 1,25-dihydroxyvitamin D level in single stone formers, the elevation was less than expected from the drop in serum phosphate in recurrent stone formers. The results thus suggest that loss of upregulation of 1,25-dihydroxyvitamin D by serum levels of phosphate might be important for stone formation. The possibility of deregulation of 1,25-dihydroxyvitamin D to maintain physiological requirements in stone formers and prevent further nephrolithiasis therefore warrants attention.

Paravesical granuloma after inguinal herniorrhaphy. Case report and review of the literature

Paravesical granuloma after herniorrhaphy is an unusual complication due to infected suture material and often mimics bladder or urachal malignancy. We present 3 cases of this disease and reviewed 21 previously reported cases. Our patients underwent hernial repair 2-7 years before examination and presented urinary symptoms. They were treated with antibiotics and underwent exploration of the inguinal wound infection but the symptoms did not resolve. En bloc excision and partial cystectomy were performed and resulted in complete resolution of the symptoms. It is important to consider paravesical granuloma in patients who had undergone herniorrhaphy in the differential diagnosis of bladder or urachal tumors.

[A case of female paraurethral cyst diagnosed as epithelial inclusion cyst]

The patient was a 36-year-old woman with a chief complaint of pain of the urethral meatus. A cyst existed just below the urethral meatus. The paraurethral cyst was removed completely. Histologically, the cyst was lined by stratified squamous epithelium. According to the criteria proposed by Das, paraurethral cysts are classified into 4 groups: epithelial inclusion cysts, Müllarian cysts, Gärtner duct cysts, Skene duct cysts. In this case, the cyst seemed to be an epithelial inclusion cyst. In the Japanese literature, paraurethral cysts have been incompletely classified from an etiological perspective. Differential diagnoses based on the histological findings of the cysts may be important to determine the etiology.

[Cyclophosphamide-induced renal pelvic tumor--a case report]

We report a case of transitional cell carcinoma in the left renal pelvis, which occurred in a 24-year-old man. He had been treated with cyclophosphamide (CPM) for a period of 27 months for retroperitoneal rhabdomyosarcoma diagnosed at the age of 10. At first 1.2 g CPM had been given twice intravenously for 3 months, followed by oral administration of 41 g CPM for 23 months. Drip infusion pyelography revealed a filling defect in the left renal pelvis. A left renal pelvic tumor was strongly suspected on computerized tomography and magnetic resonance imaging. Left nephroureterectomy was then performed. Histological diagnosis of the left renal pelvic tumor was transitional cell carcinoma, grade 2, pT1N0M0. No recurrence was defected 17 months later. This case seems to be the second case of cyclophosphamide-induced upper urothelial carcinoma reported in Japan.

Measurement of protein C inhibitor in seminal plasma is useful for detecting agenesis of seminal vesicles or the vas deferens

Protein C inhibitor (PCI), a plasma serine protease inhibitor of activated protein C, is present at high concentrations in the seminal plasma of normal subjects and is decreased in some infertile patients. We measured the concentrations of PCI, prostate-specific antigen, and fructose in the seminal plasma of infertile patients (n = 125) and of normal subjects (n = 13). We also measured time-dependent changes in the concentrations of PCI and fructose in seminal plasma after ejaculation. A weak correlation was found between the levels of PCI and fructose (r = 0.268, P = 0.016). The PCI level in seminal plasma of patients with seminal vesicle and/or vasal agenesis was significantly lower (P < .01) than in normal subjects. The level of fructose in seminal plasma decreased in vitro in a time-dependent manner after ejaculation, whereas the concentration of PCI was stable at 48 hours after ejaculation. These data suggest that PCI in seminal plasma, as well as fructose, may become one of the markers for agenesis of seminal vesicles and/or the vas deferens.

Prognostic significance of Ki-67 expression in advanced prostate cancers in relation to disease progression after androgen ablation

OBJECTIVE

This study was performed to examine the expressions of Ki-67 antigen, bcl-2 and p53 oncoprotein and to assess their capacity to predict the short-term response to the initial endocrine treatment and disease progression in prostate cancer.

METHODS

Formalin-fixed and paraffin-embedded tumor tissues from a total of 73 patients with untreated prostate cancers were collected by transrectal ultrasound-guided biopsy. All patients with stage C or D prostate cancers had received continuous endocrine treatment. Ki-67 antigen, p53 and bcl-2 oncoprotein were detected by immunohistochemical methods.

RESULTS

Short-term response to initial endocrine therapy judged at 3 months showed a significant correlation with Ki-67 labeling index (LI) and bcl-2 expression. Multivariate analysis showed that only a high Ki-67 LI was an independent potential predictor of prostate-specific antigen failure or the appearance of new metastasis.

CONCLUSIONS

The findings suggested that the Ki-67 LI was the most useful parameter to predict disease progression after the initial endocrine treatment. Additional studies must be performed to evaluate the prognostic significance of both cell proliferation and apoptosis in detail.

Distinguishing patients with senile dementia of Alzheimer type and normal elderly subjects utilizing xenon CT-CBF and multivariate analysis

Local cerebral blood flow (LCBF) was measured in 17 patients with senile dementia of Alzheimer type (SDAT) and 17 normal controls, utilizing stable xenon computed tomography (Xe CT-CBF). In patients with SDAT, LCBF values were decreased in the cerebral cortex and subcortical structures including the thalamus, basal ganglia and white matter of both hemispheres. Linear discriminant function analysis of LCBF values separated patients with SDAT from normal elderly subjects, with an error of 8.8%. Variables helpful in distinguishing SDAT patients from normal subjects were LCBF values for the frontal and temporal cortex. Multiple regression equation for predicting cognitive performance scores from LCBF values showed the best correlations with LCBF values for the frontal and occipital cortex and thalamus. Xe CT-CBF measurements provide useful information concerning diagnosis and brain function in patients with SDAT.

A new staging criterion for bladder carcinoma using gadolinium-enhanced magnetic resonance imaging with an endorectal surface coil: a comparison with ultrasonography

OBJECTIVE

To evaluate the accuracy of a new staging criterion, submucosal linear enhancement (SLE) on gadolinium-diethylenetriamine-pentaacetic acid-enhanced T1-weighted magnetic resonance imaging (MRI) using an endorectal surface coil (endorectal enhanced MRI), and to compare the accuracy of this method with that of transurethral ultrasonography (TUUS).

PATIENTS AND METHODS

The study included 71 patients with bladder tumours (63 men and eight women, mean age 65.5 years, range 31-85). The SLE coincided with abundant submucosal vascular beds, as reported in a previous study. When the SLE beneath the tumour maintained continuity, the tumour was diagnosed as superficial (</= T1), but if the SLE was interrupted by the tumour, the disease was considered invasive (>/= T2a). Superficial muscle invasion (less than half the muscle layer) and deep muscle invasion (more than half the muscle layer) were classified as T2a and T2b, respectively. When the tumour formed an extravesical mass, the tumour was classified as T3b.

RESULTS

The staging accuracy for bladder tumours using SLE on endorectal-enhanced MRI or TUUS was 83% and 60%, respectively (P < 0.01). Using the SLE, muscle invasion of bladder tumour was diagnosed with an accuracy of 87%, a sensitivity of 91% and a specificity of 87%; this was significantly better than with TUUS (P < 0.01).

CONCLUSION

The criterion of SLE on Gd-DTPA enhanced T1-weighted MRI using an endorectal surface coil is useful for staging bladder tumour, and the staging accuracy is significantly better than with TUUS.

[A case of renal capsular leiomyoma]

A 50-year-old woman was admitted for the treatment of retroperitoneal tumor. Enhanced comtuted tomography showed a low density mass between the left kidney and psoas muscle. Magnetic resonance imaging revealed a high intensity and homogeneous mass on T1-weighted sequence, and a low intensity and heterogeneous mass on T2-weighted sequence. Surgical exploration revealed that the tumor was adherent to the left kidney and en bloc excision of the tumor and the left kidney was performed. Histopathological diagnosis was leiomyoma originating from the renal capsule.

[A case of emphysematous pyelonephritis with emphysematous cystitis]

A 74-year-old woman with diabetes mellitus had a high fever, and was treated with antibiotics and insulin in another hospital. She was referred to our department, because CT scan showed the right hydronephrosis and the abnormal gas shadow in the right renal calyces. Ureteral catheterization was performed on the right side and cloudy urine was drained. Urine culture yielded E. coli. Since submucosal emphysematous changes were demonstrated in the bladder mucosa by cystoscopy, she was diagnosed with emphysematous pyelonephritis with emphysematous cystitis associated with diabetes mellitus. Administration of antibiotics and insulin and the ureteral catheter drainage improved her condition immediately. Abnormal gas shadow on CT scan and submucosal emphysema on cystoscopy disappeared. We reviewed 110 cases of emphysematous pyelonephritis and 23 cases of emphysematous cystitis including our case in Japan, and report their clinical characteristics.

Significance of vitamin D receptor gene polymorphism for prostate cancer risk in Japanese

Vitamin D receptor gene (VDR) polymorphisms have been reported to be related to prostate cancer risk in the USA. We analyzed the distribution of TaqI RFLP and poly(A) of VDR in 100 prostate cancer patients and 202 urological controls. Among the control, 79.2% were homozygous (TT) for the absence of a TaqI RFLP, while 17.8% were heterozygous (Tt) and 3.0% homozygous (tt) for its presence. The distribution was almost the same in the cancer group; 80% were homozygous TT, 18% heterozygous Tt, and 2.0% homozygous tt. Polymorphism of poly(A) sizes was categorized as a long allele (> or = 18 As) and a short allele (< 18 As). The distribution did not vary between the cancer and control groups; 80, 79.2% were LL, 18, 17.8% LS and 2.0, 3.0% SS, respectively. These results showed no significant association of two VDR polymorphisms with prostate cancer risk, however a different distribution of VDR polymorphisms between Japanese and non-Japanese men.

[The progress in diagnostic imaging for staging of bladder and prostate cancer: endorectal magnetic resonance imaging and magnetization transfer contrast]

We retrospectively studied the staging accuracy of endorectal magnetic resonance imaging (MRI) in comparison with transrectal ultrasound examination (TRUS) for 71 localized bladder cancers and 19 localized prostate cancers (PC) radically resected. The accuracy of clinical staging for bladder cancer in endorectal MRI and TRUS was 85.9% and 69.2%, respectively. The presence or absence of the continuity of submucosal enhancement on T2-weighted MRI images could be useful for the staging of bladder cancer. The accuracy of the seminal vesicular invasion for prostate cancer in endorectal MRI and TRUS was 95% and 63%, respectively. To determine whether magnetization transfer contrast (MTC) provides additional information in the diagnosis of prostate cancer, the magnetization transfer ratios (MTRs) were calculated in 22 patients with PC, 5 with benign prostatic hyperplasia (BPH) and 4 controls. The mean MTR in the peripheral zone of the normal prostate (8.0% +/- 3.4 [standard deviation]) showed a statistically significant decrease relative to that in the inner zone of the normal prostate (27.4% +/- 3.4, p < 0.01), BPH (25.5% +/- 3.7, p < 0.01), pre-treatment PC (30.6% +/- 5.9, p < 0.01), and PC after hormonal therapy (20.3% +/- 6.3, p < 0.01). The mean MTR in pre-treatment PC was significantly higher than that in BPH, or in PC after hormonal therapy (p < 0.01). MTC was considered to be useful for conspicuity of prostate cancer lesion.

Progression-linked overexpression of c-Met in prostatic intraepithelial neoplasia and latent as well as clinical prostate cancers

The c-met proto-oncogene encoding the receptor for the hepatocyte growth factor is expressed in several cancers. In the present study, c-met protein (c-Met) was detected in eight of 22 (36%) cases of prostatic intraepithelial neoplasia (PIN), five of 15 (33%) latent and 17 of 21 (81%) clinical prostate cancers, including seven metastatic lesions, using an immunohistochemical method. All seven (100%) metastatic lesions investigated demonstrated strong staining, and a correlation between c-Met expression and histology was observed. These results suggest a significant relationship between c-Met expression and progression of prostate neoplasms, including latent cancers.

[A case of valve-like structure in ureter associated with pyonephrosis due to Salmonella infection]

A 7-year-old boy had a fever of 39 degrees C. Abdominal computed tomography (CT) revealed marked left hydronephrosis with hydroureter. Percutaneous nephrostomy was performed. Salmonella infanitis was detected from the drainage urine. Cystourethrography after nephrostomy showed bilateral vesicoureteral reflex (VUR). On the left side, ureteropelvic junction (UPJ) stenosis was found. Left fistelography showed hydronephrosis, but the ureter was not visualized. A mechanism like a valve at the left UPJ was suggested; the bladder urine was able to ascend to the pelvis but not to be drained from the pelvis. The left renal function was not expected to recover from the findings of renal scintigram and CT. Left nephroureterectomy and right anti-VUR operation were performed. The extirpated renal and ureteral specimens revealed a nonpapillary tumorous structure like a valve at the left UPJ. The histological examination of the valve-like structure revealed the presence of two muscle layers without an adventitia folded at the UPJ.

N-acetyltransferase 1 genetic polymorphism influences the risk of prostate cancer development

The potential involvement of N-acetyltransferase 1 (NAT1) genetic polymorphisms in prostate cancer (PCa) patients was analyzed in 101 patients with PCa and 97 controls with no incidental malignancy. Identification of NAT1*10, the variant allele associated with the rapid acetylator phenotype was by allele-specific polymerase chain reaction (PCR). When the NAT1*10 heterozygote and other genotypes without NAT1*10 allele were considered as low risk genotypes, NAT1*10/NAT1*10 had a significantly higher risk of PCa (OR = 2.4, 95% CI; 1.0-5.6). If our preliminary results can be confirmed in a larger population, it may be a useful marker for PCa risk.

[The clinical usefulness of high-dose intravenous immunoglobulin therapy for chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy]

To explore the optimum dose of intravenous immunoglobulin (i.v.Ig) for treating patients with chronic inflammatory demyelinating polyrneuropathy and multifocal motor neuropathy, we compared the usefulness of i.v.Ig among 3 treatment doses. Fifty-nine patients were randomly divided into three treatment dosage groups: 20 patients for Group I using 50 mg/kg/day x 5 days, 19 patients Group II using 200 mg/kg/day x 5 days, and 20 patients Group III using 400 mg/kg/day x 5 days. We assessed clinically and electrophysiologically the effectiveness of the treatment at 5 weeks after the initial infusion. For patients in Group I and II who had not improved (or worsened) with the first treatment, we gave a one-step larger dose in the second treatment (i.e. 200 mg/kg/day x 5 days for those who had been given 50 mg/kg/day x 5 days, 400 mg/kg/day x 5 days for those who had been given 200 mg/kg/day x 5 days) after more than 9 weeks. We found that 15% of the patients in Group I, 21% in Group II and 60% in Group III improved dose-dependently with the first intravenous immunoglobulin treatment. Seven (47%) of 16 patients in Group I and 4 (40%) of 11 patients in Group II improved after the second treatment with larger doses. Adverse reactions including chill sensation, fever, skin eruption and increase in blood GOT and GPT levels were transient and mild. One patient in Group III developed left hemiparesis showing the small infarction in the right thalamus during the course of the treatment, but the symptom was mild. In conclusion, the high-dose intravenous immunoglobulin therapy (400 mg/kg/day x 5 days) is useful for treating patients with CIDP and MMN, although care must be taken of the risk of causing cerebral infarctions.

[Preoperative balloon occluded arterial infusion chemotherapy for locally invasive bladder cancer--accurate staging for bladder preservation]

The possibility of bladder preservation by preoperative balloon occluded arterial infusion (BOAI) chemotherapy was studied in 111 patients with locally invasive bladder cancer. BOAI was performed by blocking the blood flow of the internal iliac artery and by performing intra-arterial infusion of adriamycin (50 mg/body) and cisplatin (100 mg/body). Before BOAI the clinical diagnosis was T2 in 36, T3a in 29, T3b in 27, T4 in 11 and after BOAI it was T0 in 1, T1 in 27, T2 in 25, T3a in 20, T3b in 20, and T4 in 10. Down staging was observed on diagnostic images in 46.6%. Thirty patients (27.0%) received transurethral resection of bladder tumor (TUR-Bt) and their bladder could be preserved. The 5-year cancer-specific survival rate was 100% in pT0 (n = 9), 97.5% in pT1 (n = 47), 79.9% in pT2 (n = 21), 80.0% in pT3a (n = 6), 39.9% in pT3b (n = 18) and 51.9% in pT4 cases (n = 9). For the bladder preservation, accurate staging diagnosis is required. Since 1992, endorectal magnetic resonance imaging (MRI) has been used in addition to imaging diagnosis for improving the accuracy of staging diagnosis. The accuracies of staging diagnosis with and without endorectal MRI were 62.5% and 44.0%, respectively. BOAI as a neoadjuvant chemotherapy has the possibility of bladder-preserving therapy in locally invasive bladder cancer. Also, the endorectal MRI can improve the accuracy of staging diagnosis, which is important for the bladder preservation.

Interferon-alpha and 5-fluorouracil therapy in patients with metastatic renal cell cancer: an open multicenter trial. The Japanese Study Group Against Renal Cancer

OBJECTIVES

Recent clinical trials have implied the cytotoxic and antiproliferative effects of combining 5-fluorouracil and interferon-alpha in the treatment of metastatic renal cell cancer. We therefore conducted an open multicenter trial to test the efficacy of such a combination on this cancer.

METHODS

Human lymphoblastoid interferon (3 MIU per patient) was administered subcutaneously three times weekly for 12 weeks, while 5-fluorouracil was administered (600 mg/m2/day) as a continuous infusion for the first 5 days, followed by an intravenous bolus infusion of 600 mg/m2 once a week from the 3rd week until the 12th week.

RESULTS

Of the 63 patients entered into the trial, 55 were eligible and evaluable for systemic toxicities, and 53 were evaluable for their response. All patients had undergone a prior nephrectomy, and their European Cooperative Oncology Group (ECOG) performance status ranged from 0 to 3 (median 0). Three complete and eight partial responses were induced, with an overall response rate of 20.0%. The median time to progression and the median survival time were 11 and 33 months, respectively. World Health Organization grade 3 toxicities were observed in 8 patients; however, no grade 4 toxicities or toxicity-related deaths were noted.

CONCLUSIONS

Combination therapy of interferon-alpha plus 5-fluorouracil at the above-described dosage and schedule produced no better responses than interferon monotherapies. Prolongation of survival could be attributable to the fair performance status of the patients. This regimen has limited value for the treatment of patients with advanced renal cell cancer.

[Abscess of corpus cavernosum: a case report]

A 72-year-old man was admitted to our hospital complaining of a penile mass. The local biopsy indicated an abscess formation in the corpus cavernosum. In spite of antibiotic treatment, the abscess cavity ruptured to the dorsal skin and the urethra. After cystostomy formation, dorso-caverno-urethral fistula was closed by conservative therapies. Although the patient was followed up with antibiotics on an outpatient basis, necrotic changes in the right foot were noticed and he was diagnosed with arteriosclerosis obliterance in the right lower leg. Therefore, he was referred to an orthopedic clinic for amputation of his right lower leg with cystostomy catheter. This is the 7th case reported in Japan.

Cytochrome P4501A1 and glutathione S-transferase M1 genotypes as risk factors for prostate cancer in Japan

BACKGROUND

The p53 mutation spectrum of prostate cancers developing in Japan indicates a role for environmental factors. This suggests there might be differences in susceptibility due to genetic polymorphisms in metabolic activation enzyme genes. We analyzed genetic polymorphisms of the xenobiotic-metabolizing enzymes, CYP1A1 and GSTM1.

METHOD

Genotyping of CYP1A1 and GSTM1 was investigated by using allele-specific PCR in 115 prostate cancer (PCa) patients and 204 control patients.

RESULTS

The CYP1A1 Val/Val genotype significantly increased the risk for PCa (OR = 2.6; 95% CI = 1.11-6.25) and the Ile/Val genotype showed a similar tendency (OR = 1.4; CI = 0.86-2.29). Individuals with the GSTM1 (0/0) genotype demonstrated a slightly increased risk (OR = 1.3; CI = 0.82-2.04). The combination of the CYP1A1 Val allele and GSTM1 (0/0) genotype was associated with a higher risk (OR = 2.3; CI = 1.18-4.48) than the CYP1A1 Val allele alone. When cases were analyzed by age at initial diagnosis, the relative risks with both the CYP1A1 Val allele and the GSTM1 (0/0) genotype were higher in the young group than in the old group (CYP1A1; OR = 1.7, CI = 0.89-3.17: GSTM1; OR = 1.6, CI = 0.84-2.99). The frequency of the GSTM1 (0/0) genotype was also higher in patients with advanced stage disease. In stage D, the OR was 1.7 with a CI of 0.93-3.17 and in stages A and B, the OR was 0.8 with a CI of 0.40-1.62.

CONCLUSIONS

These results suggest that CYP1A1 and GSTM1 polymorphisms are linked to a propensity for PCa development.

Allelic loss and microsatellite instability in prostate cancers in Japan

A series of 25 primary prostate cancers in Japanese were screened for loss of heterozygosity and microsatellite instability using twelve microsatellite markers containing APC, DCC, TP53, BRCA1, and BRCA2. Frequent loss of heterozygosity was observed for D8S201 (48%), LPL (48%), and DCC (26%). In contrast, the incidence did not exceed 15% at BRCA1 and BRCA2 loci. Microsatellite instability was observed in 28% of stage B, C, and D cancers. These data suggest that microsatellite instability and loss of unidentified genes on chromosome 8p may be involved in carcinogenesis of the prostate; however, BRCA1 and BRCA2 may not be largely involved in the development of prostate cancer in the Japanese population.

Early experience of minimally invasive valve surgery

In this paper we report on our early results of minimally invasive cardiac valve surgery. A series of 6 consecutive patients with valvular disease underwent valve repair and valve replacement via a right parasternal incision; aortic valve replacement 3, mitral valve replacement 1, mitral valve repair 2. There were no intraoperative complications requiring median sternotomy. Five patients had no blood transfusion. There was only one postoperative event; this patient had a sudden massive bleeding from the chest tube after extubation of the endotracheal tube, an immediate re-suture of the aortotomy was performed. The reoperative course was uneventful. Minimally invasive cardiac surgery for aortic and mital valves is an excellent option for most patients affected by isolated valvular disease.

[Extracorporeal shock wave lithotripsy in patients with coagulopathies: report of three cases]

We describe our experience with extracorporeal shock wave lithotripsy (ESWL) in three patients with coagulation disorders (one case of hemophilia A, and two cases of thromboasthenia). We successfully performed ESWL using factor VIII or transfusion of platelets without any severe hemorrhagic complications, such as perirenal and subcapsural hematomas. We consider that adequate supplement of coagulation factor or platelets may lower the risk of hemorrhagic complications in coagulopathic patients who undergo ESWL.