Spontaneous rupture of pyelocaliceal diverticulum

One rare case of spontaneous rupture of pyelocaliceal diverticulum is reported in a 31-year-old Japanese man presented with a severe left flank pain. Intravenous pyelography and computerized tomography demonstrated extravasation of contrast medium from his diverticulum which contained numerous calculi. As a possible cause of spontaneous rupture of pyelocaliceal diverticulum in this case, we suggest that the paper-thin parenchyma covering the diverticulum was not strong enough to tolerate the minimum elevation of intrapelvic pressure due to the obstruction of delivered stones.

[Extramammary Paget's disease with a large mass in male genitalia: a case report]

A 57-year-old Japanese man presented with a mass 3 cm in diameter at the root of the penis. The patient had noticed the mass growing for 5 years, but had no pain or itching. Histological examination revealed it to be invasive Paget's disease, and the mass was resected along with skin of normal appearance within 3 cm around it. Regional lymph node metastasis was also revealed in the operation, and irradiation at the pelvic and inguinal region was done. Extramammary Paget's disease with a large mass is relatively rare, and invasive extramammary Paget's disease has a poor prognosis.

[A study on bacteria within stones in urolithiasis]

The bacteria in 37 stones obtained from 37 patients with urinary stone diseases, that is, 11 renal stones (containing 2 staghorn calculi), 21 ureteral stones, 4 bladder stones and 1 urethral stone, were studied, according to the Nemoy & Stamey's method. The stones were collected by partial nephrectomy (1 case), nephrolithotomy (1 case), pyelolithotomy (1 case), percutaneous nephrolithotripsy (PNL) (6 cases), 12 ureterolithotomies, transurethral ureterolithotripsy (2 cases), cystolithotripsies (4 cases) and spontaneous deliveries (10 cases). According to a stone analysis by infrared spectrophotometer revealed 30 were noninfection stones (81.1%) and 7 infection stones (18.9%). Of these 37 stones, 5 stones (13.5% of 11 stones) had bacteria within them. These stones consisted of 4 infection stones (57.1% of all infection stones) and 1 noninfection stone (3.3% of all noninfection stones). Out of 4 patients having bacteria within their stones, urine culture of whom were carried out before stones were collected, only one patient (25%) had the same species of bacterium (E. coli) both within the stone and in urine. The E. coli within the stone and that in urine, however, showed quite different reactions to some antibiotics. The fact that all organisms within stones cannot be detected by urine culture before collecting stones of the patients in our present study, suggests that patients undergoing endourological surgery, such as extracorporeal shock wave lithotripsy and PNL, may have a risk of complications, such as severe urinary tract infection and urosepsis, if the possibility of the presence of organisms within stones is not taken into consideration.

[Mixed gonadal dysgenesis with plasty in males]

A 13-year-old Korean boy is reported here as a case of mixed gonadal dysgenesis. The patient presented with perineal hypospadia. He had scrotal testis, epididymis, vas deferens on right side, and abdominal streak gonad, Fallopian tube on left side. He had also uterus and vagina. His chromosome was 46XY type. Among 59 reported cases in Japan, 12 had undergone plasty into male. All of them had hypospadia. In 51 cases, 17 had testes in scrotum. None of them had a testicular tumor. So we decided to do plasty in male, and to follow up his testis quite carefully.

[A case of adrenal myelolipoma]

A case of adrenal myelolipoma is presented. The patient was a 61-year-old woman who complained of lumbago this time. A tumor of the left adrenal gland, however, had been found by computed tomography 4 years earlier. Judging from the CT, the size of this tumor had not changed at all, although the density of the mass on admission had reduced, compared with that of 4 years earlier. Laboratory examinations of adrenal function was normal. Left adrenalectomy was performed. Histologically, this tumor consisted of adipose and some hematopoietic tissue. We reviewed 43 cases of adrenal myelolipoma resected surgically in Japan.

[Hydronephrosis caused by Crohn's disease: a case report--review of 41 cases with urinary tract complication reported in Japan]

A 34 year-old man, who had been under care with diagnosis of Crohn's disease in the department of gastroenterology of our hospital since 1983, was referred to our urological clinic on May 21, 1987, because of right hydronephrosis found on ultrasonography. He did not complain of any urological symptoms. He underwent further roentgenographic examinations and a diagnosis of hydronephrosis complicated with Crohn's disease was made. On surgery of July 30, resection of ileocecal lesion, end-to-end ileocolostomy, right ureterolysis were performed. He is now visiting our clinic without recurrence of hydronephrosis up to present (7 months). In addition, we reviewed the 41 cases of urological disorders complicated with Crohn's disease in the literature reported in Japan. The cases were of vesicoenteric fistula including pericystitis (33 cases), hydronephrosis (10 cases), urolithiasis (2 cases) and ureterocolonic fistula (1 case). The patients were from 10 to 57 years (27.2 years in average) old. Sex distribution was uneven, 39 of patients were men and 2 were women. Urologic surgery was performed in almost all of the cases except for the patient with urolithiasis. All the patients having vesicoenteric fistula had urological complaints but the patients with hydronephrosis were relatively free from urological complaints. Thus, Crohn's disease has been recognized as an important gastrointestinal disease for urologists, and we will emphasize that periodical abdominal ultrasonography and urography for the patients with this disease should be necessary for checking up other complications such as hydronephrosis.

[Adrenal tumors discovered incidentally on ultrasonography: three case reports]

A series of three adrenal tumors is reported. They were discovered incidentally on ultrasonography for screening. One case was a benign pheochromocytoma and the others were non-functioning adrenocortical adenomas. They were hypoechoic on ultrasonography and were 4.5 x 3.5 x 4.0, 3.0 x 2.5 x 2.5 and 3.5 x 2.5 x 2.0 cm. Non-functioning adrenal tumors of a diameter smaller than 3.0 cm generally tended not to require surgery. Ultrasonography is useful for screening and evaluating patients with an adrenal mass without surgery as well as is computed tomographic scan.

[Localized amyloidosis of urinary bladder: a case report]

A case of localized amyloidosis of the urinary bladder is reported. A 82-year-old woman visited our hospital with the chief complaint of miction pain and residual urine sensation. Cystoscopic examination revealed a broad-based and nonpapillary tumor without bleeding on the right lateral wall. A transurethral biopsy of this tumor was performed. A histopathological examination with H.E. and Congo red stains demonstrated amyloid deposition in the submucosal layers of the vesical wall. Rectal biopsy and other findings suggested no deposition of amyloid in other organs. On the basis of these findings, we made a diagnosis of localized amyloidosis of the urinary bladder. To the best of our knowledge, the present case is the 23rd of localized amyloidosis of urinary bladder in Japan. The patient was asymptomatic after biopsy. We discuss the clinical features and management of this disease.

[A case of papillary cystadenoma of epididymis]

We present a case of papillary cystadenoma of the right epididymis in a 52-year-old man. He visited our hospital complaining of painless mass in his right scrotum. This painless hard mass was palpable at the head of his right epididymis and was 1 cm in diameter. Right epididymectomy was performed. A histological examination revealed epithelial proliferation of ectatic efferent ducts and microcysts filled with papillary processes, and a diagnosis of papillary cystadenoma of the right epididymis was made. In Japan, our present case is the 12th of papillary cystadenoma of epididymis. We chiefly reviewed the clinical aspects of this disease, especially the relationship between this disease and von Hippel-Lindau's disease.

[Congenital unilateral multicystic kidney in an adult]

Congenital unilateral multicystic kidney is relatively rare in adult (16% in adult, and 84% in children). Most of the adult cases are asymptomatic, and should be followed up conservatively, but nephrectomy was performed in many cases reported in Japan, because it was difficult to distinguish those cases from renal tuberculosis. Here we present one adult case, and discuss its clinical findings, diagnosis, treatment, etiology and embryology.

[Dissolution therapy of struvite calculi with solution G]

In 6 patients (9 kidneys) irrigation with Solution G in the renal pelvis was performed for the dissolution of their infectious stones. Staghorn calculi larger than 30 mm in diameter were observed in all patients. In two kidneys all stones were dissolved and the rest were dissolved into small fragments that constituted no problem in those kidneys. Irrigation was done with no major side effects or complications. The dissolution of infectious stones with Solution G is another possible treatment that could be first chosen among percutaneous nephrolithotripsy, extracorporeal shock wave lithotripsy and other treatments.

[Lipogranuloma with marked eosinophile infiltration in male genitalia]

A characteristic lipogranuloma in the male genitalia is presented. Histopathological examination revealed a granuloma resembling sclerosing lipogranuloma with marked eosinophile infiltration. Only 11 cases with such a histopathological feature have been reported. Including this case all cases have similar localization, shape and clinical course. The genesis of these granulomas is discussed.

[Giant vesical diverticulum: a case report]

A case of giant vesical diverticulum is reported. A 31-year-old man was admitted with intermittent self-catheterization for 6 months duration due to urinary retention. A cystogram demonstrated a giant solitary diverticulum extended left-posteriorly, which compressed the bladder outlet and caused obstruction. On cystoscopy, the neck of the diverticulum was seen postero-lateral to left ureteral orifice. There was no vesical trabeculation, but slight obstruction of the bladder neck was suspected secondary to intermittent self-catheterization. A diverticulectomy was carried out by combined approach without ureterocystoneostomy. The patient had no difficulty in voiding after the operation.

[A case of renal angiomyolipoma treated by partial nephrectomy--the management of renal angiomyolipoma from the conservative point of view]

A 25-year-old female was admitted for further investigation of the right renal mass, which was noted during evaluation for hepatitis. She had no personal or family history of stigmas of tuberous sclerosis. On physical examination, a movable hard smooth mass of fist size was palpable in the right abdomen. Drip infusion pyelography revealed an elevation of right kidney. Ultrasonography revealed that the abdominal mass had a high amplitude echo area. On CT the mass was heterogeneous with irregular margin and had regions of low attenuation value, suspicious of a tumor with high fat content. An angiogram of the right renal artery revealed a hypervascular tumor showing multiple saccular aneurysms, and absence of arteriovenous shunting. Based on the aforementioned findings, the mass was diagnosed as renal angiomyolipoma. Partial right nephrectomy was performed through an extraperitoneal approach. Pathological diagnosis was a renal angiomyolipoma. Convalescence was uneventful, and the remaining parenchyma of right kidney was working well on drip infusion pyelography three months after operation. The management of renal angiomyolipoma from the conservative point of view is also discussed.

Complete duplication of male urethra. Two case reports

Complete urethral duplication is a rare anomaly in boys. About 60 cases have been reported in the literature, of which approximately one-third were managed with a surgical procedure of total excision of the accessory urethra. Another third were managed by partial excision, and the rest were managed conservatively. Here 2 cases are presented, and the surgical treatment is discussed.

[Pheochromocytoma: review of 22 patients and 23 operations]

Twenty-two cases of pheochromocytoma encountered at our department between 1965 and 1986 are reviewed. Eighteen of the patients were adults (26 to 62 years old) and 4 were children (9 to 13 years old). Thirteen were males and 9 were females. In a total of 23 operative procedures, 31 tumors were resected excluding lymph node metastasis. The preoperative accuracy of the diagnostic methods for locating the tumor was as follows. KUB and intravenous pyelography with tomography in 12 of 31 tumors (39%), aortography and/or selective arteriography in 21 of 27 (78%), selective venous sampling for catecholamine level in 4 of 4 (100%), computed tomography in 10 of 10 (100%), ultrasonography in 4 of 6 (67%), and iodine-131 metaiodobenzylguanidine scintigraphy in 4 of 6 (67%) tumors. The tumors resected were cases, as followings, a single unilateral adrenal tumor in 14 (right 6, left 8), bilateral adrenal tumors, bilateral adrenal plus extraadrenal tumors and unilateral adrenal plus extraadrenal in each, one case and extraadrenal tumor in six cases (single 5, multiple 1). Either lumbar or thoracolumbar surgery methods were adapted in 9 of 14 cases with single adrenal and one of 5 with single extraadrenal tumors, and in the remaining 13 cases transperitoneal methods were selected. One patient died on the 6th day after operation from gastrointestinal bleeding. Thus the surgical mortality rate in our series was 4.4%. Of the 3 patients with malignant pheochromocytoma, two (9 and 13 years old) are alive each 192 and 67 months after operation. The former is in a tumor-free condition, however in the latter multiple bone metastasis was detected 37 months after operation. The third patient (29 years old) died 62 months after operation from metastatic hemorrhagic tumors in the liver.

Extra-adrenal pheochromocytoma manifesting renovascular hypertension

A case with extra-adrenal pheochromocytoma, which was found by chance in the course of renovascular hypertension, is reported. The tumor was on the stenotic portion of the right renal artery. The results of examinations for pheochromocytoma were not conclusive, that is, inconsistent elevation of plasma catecholamines and urinary catecholamine excretion, equivocal results of pharmacological tests for pheochromocytoma, and negative results in [131I]metaiodobenzylguanidine scintigraphy. The stenosis of the right renal artery disappeared, the blood pressure was normalized by surgical resection of the tumor, and the extra-adrenal pheochromocytoma was finally diagnosed by pathohistological findings. Renovascular hypertension appeared to be the primary cause of this hypertension, judging from the significant decrease in blood pressure induced by an angiotensin II analog and a renal vein renin ratio of 7.3. Even in the case of obvious renovascular hypertension, the possibility of this unusual coexistence with pheochromocytoma should be considered.

[Percutaneous nephrolithotripsy: a report of 50 cases]

Fifty patients with renal (33 patients), renal and ureteral (4 patients) and ureteral (13 patients) stones were treated by percutaneous nephrolithotripsy (PNL) between November 15, 1984 and December 14, 1985. Complete stone removal was achieved in 39 cases (78%). Four of the 11 cases of incomplete stone removal were among the first 5 cases we treated. We have not experienced any severe complications in our 50 cases. The cause of the unsuccessful attempts, complications and other factors of PNL are briefly discussed.

Lysis of autologous tumor cells by peripheral blood lymphocytes treated with interleukin 2 in patients with renal cell carcinoma

Peripheral blood lymphocytes derived from patients with renal cell carcinoma were stimulated with interleukin 2 and tested in a 4-hour 51chromium-release cytotoxicity assay against autologous cultured tumor and myeloid K562 cells. Of 23 patients autologous tumor lysis of more than 0 per cent was observed in 20 (range 5.3 to 82.8 per cent) and more than 10 per cent lysis was noted in 16. Since no significant correlation between the degree of cytotoxicity and the pathological findings of tumor stage, grade, cell type or lymphocyte infiltration in the tumor was found, it was impossible to predict from the pathological findings which tumor could be lysed by peripheral blood lymphocytes treated with interleukin 2. Comparison of natural killer cell activity against K562 of freshly prepared peripheral blood lymphocytes to that of interleukin 2-treated lymphocytes revealed significant augmentation from 23.6 +/- 9.7 to 65.2 +/- 29.1 per cent. From the kinetics study the lysis of autologous tumor cells was detectable on day 2 of interleukin 2 exposure and the peak activity was observed on day 5. A similar trend was noted in regard to K562 cell lysis. Measurements of peripheral blood lymphocyte subsets with monoclonal antibodies and argon ion laser flow cytometry resulted in a significant decrease of cells positive for OKT 4 (helper/inducer) and a significant increase of cells positive for OKT 8 (suppressor/cytotoxic) and Leu 7 (natural killer) by interleukin 2 treatment. A cold target cell inhibition test was performed in 2 patients with unlabeled autologous tumor and K562 cells as cold inhibitors. In 1 patient unlabeled K562 completely inhibited the tumor lysis but in 1 complete inhibition by autologous tumor and incomplete blockade by K562 were found. From this observation we concluded that peripheral blood lymphocytes treated with interleukin 2 lysed not only autologous tumor cells but also K562. Our results demonstrate that adoptive immunotherapy with peripheral blood lymphocytes activated by interleukin 2 in patients with renal cell carcinoma could be appropriate as a therapeutic procedure.

[Surgical management of primary aldosteronism--progress in localization studies and operative treatment]

Primary aldosteronism due to an adrenocortical adenoma is commonly known as surgically correctable hypertension. Forty-three cases of primary aldosteronism were treated operatively at our Department between 1960 and 1985. Forty of them were operatively, found to have aldosteronoma with a mean size of 1.88 cm and weight of 2.67 g. The patients average age was 39.4 years old and the male to female ratio was 1 to 3. Adrenal phlebography, selective adrenal venous sampling, adrenal scintigraphy, CT and echography were used to preoperatively locate the tumor, and their diagnostic value was 83, 78, 76, 87 and 60%, respectively. Unilateral adrenalectomy or unilateral partial adrenalectomy was performed extraperitoneally with lumbar oblique incision in 32 of the 43 operated patients. Since the application of the preoperative diagnosing studies above mentioned, tumor localization has been clearly demonstrated in about 90% of the patients and the unilateral extraperitoneal approach is proved as a safe operative method with minimal blood loss of less than 200 ml and performed within two hours. Unilateral adrenalectomy by the flank approach has now become the operation of choice for the treatment of an aldosterone-producing adrenal adenoma.

Renal arteriovenous fistula associated with a huge renal vein dilatation

We report a case of an aneurysmal type of renal arteriovenous fistula with a huge spherically dilated renal vein. Although the findings on routine computerized tomography made us strongly suspect renal cell carcinoma associated with a hilar lymph node metastasis, we were able to diagnose the arteriovenous fistula by means of a dynamic computerized tomography scan. On the basis of the roentgenographic findings, partial nephrectomy was performed successfully.

[Clinical experience of enoxacin in the treatment of nongonococcal urethritis]

Enoxacin (ENX) is a new derivative of pyridonecarboxylic acid and has a broad spectrum antibacterial activity. In this study, the effects of ENX on nongonococcal urethritis (NGU) were examined in 20 patients. ENX was administered orally 3 times a day at a daily dose of 600 mg for 2-23 days. Before treatment, Chlamydia trachomatis was isolated from urethral epithelium in 5 of the 20 patients. Of the 18 patients evaluated in this clinical trial, 15 (83%) responded well, and ENX was effective in 3 of the 5 Chlamydia positive cases and in 12 of the 13 Chlamydia-negative patients. As adverse reactions, headache was observed in one case and numbness of limbs in another case. No abnormality induced by ENX was recognized in laboratory findings. It is concluded that ENX is a useful drug in the treatment of patients with NGU, particularly in whom Chlamydia trachomatis is not isolated.

Role of magnesium in the growth of calcium oxalate monohydrate and calcium oxalate dihydrate crystals

Since about 85% of synthesized calcium oxalate dihydrate (COD) crystals proved not to have changed into calcium oxalate monohydrate (COM) crystals at 30 min of incubation time at 37 degrees C when our evaluation method of the COD-to-COM ratio was being used, we made a comparative study of the inhibitory effects of magnesium, one of the well-known inhibitors of calcium oxalate stone formation, on the growth of seeded COM and COD crystals. The results demonstrated that magnesium in identical concentrations might have stronger inhibitory effects on the growth of COM crystals than on that of COD crystals and suggested that these different effects of magnesium on the growth of COM and COD crystals might arise not only from the difference between the specific surface areas of COM and COD crystals, but also from that between the direct inhibitory effects of magnesium on these two types of calcium oxalate crystal growth.

Retroperitoneal schwannoma

A case of retroperitoneal benign schwannoma is presented; in addition, 133 cases of retroperitoneal schwannoma reported in Japanese literature are studied. In our series 66 per cent of the cases were found to be cystic. Therefore, the cystic change may be one of the preoperative features of schwannomas, because other types of retroperitoneal tumor do not frequently form cysts. Furthermore, the necessity of postoperative electron microscopy for accurate histologic diagnosis is discussed.