[Three cases of transitional cell carcinoma in bladder diverticulum treated by a bladder-preserving approach]

Three cases of transitional cell carcinoma (TCC) in the urinary bladder diverticulum were encountered during a period of 12 years and bladder preserving treatments were performed. Case 1: A 78-year-old man was admitted with a chief complaint of hematuria. Papillary tumors in the diverticulum of the right bladder wall were revealed (TCC, G3, T3N0M0). Intraarterial infusion chemotherapy was performed and complete remission was achieved. When a recurrent bladder tumor appeared 22 months later, transurethral resection was performed and there was no evidence of recurrence for 50 months. Case 2: A 60-year-old man was admitted with a chief complaint of gross hematuria. Cystoscopic examination revealed papillary tumors in a bladder diverticulum near the ureteral left orifice. Transurethral resection revealed TCC G2 and carcinoma in situ. Partial cystectomy, including the bladder diverticulum, and vesicoureteral neostomy was performed. The histological stage of the tumor was pTis and the wall of diverticulum possessed a thin muscle layer histopathologically. Twenty two months later, recurrence in the left bladder wall developed and transurethral resection and bladder instillation therapy were performed. For 21 months he had no evidence of recurrence. Case 3: A 59-year-old man was admitted with a chief complaint of hematuria. A solid tumor in the diverticulum of the bladder left wall was revealed. After 4 courses of intraarterial infusion chemotherapy, 41% remission was achieved and partial cystectomy was performed. Histopathological diagnosis was TCC G3, pT3b, INF-alpha, v (-), ly (-), and no muscle layer was found in the diverticulum. There was no evidence of recurrence 16 months after operation. By using the combination therapy, bladder preserving treatment is possible in the cases of bladder cancer arising in the diverticulum.

[A case of xanthogranulomatous pyelonephritis followed by computed tomographic scan]

Since it is difficult to differentiate xanthoglanulomatous pyelonephritis (XGP) from renal cancer, most cases of XGP are diagnosed after nephrectomy. We report a rare case of XGP followed by abdominal computed tomographic (CT) scan. A 65-year-old woman was admitted with high fever. Drip infusion pyelography showed a right renal stone but did not visualize the right kidney. A swollen right kidney was revealed on abdominal CT scan. Diabetes mellitus was detected by blood examinations and XGP was suspected. Conservative therapy with antibiotics was performed, the symptoms disappeared within 2 weeks and the right atrophic kidney was revealed on abdominal CT scan 12 months after onset. Histopathological findings on a renal biopsy specimen obtained 1.5 months after treatment were compatible with XGP. The diagnosis of XGP will become easier by using a combined approach including radiographic findings, physical finding and other data.

[Bilateral renal cell carcinoma of von Hippel-Lindau disease associated with von Willebrand disease: a case report]

A 42-year-old man diagnosed with von Willebrand disease 7 years earlier visited his home doctor with a chief complaint of gross hematuria. Abdominal ultrasonography showed bilateral renal tumors. He was referred to our hospital on June 15, 1993. His mother also had von Hippel-Lindau disease and was treated by hemodialysis after bilateral nephrectomy. The examination and imaging revealed bilateral renal cell carcinoma of von Hippel-Lindau disease associated with von Willebrand disease. Partial nephrectomy and enucleation for a small tumor on the right side and enucleations for five tumors on the left side were performed. Histological diagnosis of all tumors were renal cell carcinoma, clear cell subtype, grade 1 approximately 2. The patient has been well without local recurrence or distant metastasis for 16 months since the operation. This is the first case of bilateral renal cell carcinoma of von Hippel-Lindau disease associated with von Willebrand disease in Japan.

[Two cases of testicular tumor with brain metastasis]

During the last 8 years, 70 cases of testicular tumor were treated in our department. Of them 2 cases had brain metastasis. Case 1; A 37-year-old male was admitted with the chief complaint of cough. Retroperitoneal lymph node and lung metastases were discovered (stage IIIB, pT4aN1M1). Resected right testis was diagnosed as embryonal carcinoma, teratoma and STGC histopathologically. After 3 courses of PVB (cisplatinum, vincristine, bleomycin) chemotherapy right hemiplegia occurred and computerized tomographic (CT) scan revealed brain metastasis. His general condition degraded rapidly and he died of brain herniation 3 months after orchiectomy. Case 2; A 32-year-old male was admitted because of right testicular swelling and lung metastases (stage IIIB, pTiN0M1). Pathological examination revealed embryonal carcinoma, yolk sac tumor and teratoma. After 4 courses of chemotherapy with cisplatinum (CDDP), vincristine, methotrexate, peplomycin, and etoposide all lung metastases were disappeared. A few months later left hemiplegia by brain metastasis appeared suddenly. Four additional courses of high dose chemotherapy and resection of brain metastasis was performed. Complete remission continued for 13 months. The prognosis of testicular tumor with brain metastasis was very poor. During the last 8 years, 21 cases of testicular tumor with brain metastasis were reported in the Japanese literature. A follow-up study of prognosis in the literature was performed and discussed.

Newly developed ultrasonic aspirator and its application for endoscopic surgery

The authors have developed an ultrasonic aspirator to assist in urologic endoscopic surgery. It appeared that ultrasonic aspiration of bladder tumors was clinically efficient in transurethral surgery. Tumors 1 to 2 cm in diameter could be aspirated completely with this instrument alone. The application of the ultrasonic aspirator, which has also been designed with a coagulating function, to laparoscopic lymphadenectomy was evaluated. A special probe sheath was used to insulate it when using coagulation current. During operation, perivascular fatty tissue was removed safely with the aspirator. In the near future, the ultrasonic aspirator will be one of the most effective tools in laparoscopic surgery.

[Hyperbaric oxygen therapy in the successful treatment of two cases of radiation-induced hemorrhagic cystitis]

Hemorrhagic cystitis resulting from radiation to pelvic visceral malignant lesions often might be incurable and there have been established no definitive treatment. We experienced 2 cases with radiation-induced severe hemorrhagic cystitis refractory to conventional therapy. The treatment with hyperbaric oxygen to control hematuria was performed and obtained successful results. Gross hematuria was disappeared and cystoscopic figure was remarkably improved. No remarkable side-effect was observed in both patient. This experience suggested that hyperbaric oxygen could be considered the primary treatment for patient with radiation-induced hemorrhagic cystitis instead of usual treatment.

[Histological evaluation of enucleation for renal cell carcinoma using radical nephrectomy specimens]

Radical nephrectomy was performed in 30 cases of renal cell carcinoma in which CT scan and angiography findings had indicated the possible suitability of enucleation. The lesions were then enucleated from the operative specimens and assessed histologically to find the feasibility of tumor enucleation and to determine its indications. Histological investigation demonstrated that the tumor was completely surrounded by the pseudocapsule in only 17 cases, and even in such tumors the thickness of the pseudocapsule was not always regular and sometimes tumor invasion was seen in the pseudocapsule. It is therefore advisable to resect the tumor with no less than several mm of surrounding renal tissue when the pseudocapsule can not be clearly distinguished. Success of the enucleation was confirmed histologically in 22 out of 30 cases (73.3%). The factors related to failure of the enucleation were invasion throughout the renal capsule in 2, tumor exposure on the resected surface in 5, residual tumor in the tumor bed in 2 and venous invasion in 6 cases. Satellite tumors were not detected in any case. Favorable results were obtained in low grade, low stage tumors less than 6 cm in diameter and clearly distinct from normal renal tissue, therefore such cases were thought to be appropriate indications for enucleation. Although we selected the cases thought to be appropriate for enucleation by imaging techniques preoperatively, success was not obtained in all cases. Enucleation is a useful and recommendable operative technique for bilateral renal cell carcinoma or renal cell carcinoma in a solitary kidney.(ABSTRACT TRUNCATED AT 250 WORDS)

[Flare response on bone scintigraphy in metastatic prostate cancer]

Seventy-seven cases of prostate cancer were treated for 5 years at our department and all cases were followed by bone scintigraphy and tumor markers. Of these cases on case of flare response on bone scintigraphy was recognized. A 51-year-old man was hospitalized with chief complaint of lumbago. Serum PAP and gamma-Sm levels were 320 ng/ml and 15 ng/ml, respectively. Prostate biopsy revealed moderately differentiated adenocarcinoma. Bone scintigraphy and CT scan demonstrated multiple bone metastases and lymph nodes involvements. Treatment was started with diethylstilbestrol diphosphate (DES). At one month after the initiation of treatment tumor markers fell down to the normal level and lumbago was diminished, but only serum alkaline phosphatase was elevated and bone scintigraphy showed apparent progression of individual lesions (flare response). The treatment was not altered. At the times after 2, 8, 12 and 36 months successful treatment the bone imaging improved with reduced tracer uptake and no new lesions. The flare response is a healing reaction and is followed apparent improvement. In general, serial bone scintigrams accurately depict the activity of bone metastases in the patients of prostate cancer, but between 1 and 3 months after starting treatment the paradoxical "flare phenomenon" should be taken care.

[Outpatient ESWL in 500 kidneys]

Between March 1989 and January 1992, 600 cases (636 kidneys) with upper urinary tract stones were treated with ESWL, using a Lithostar. Of these, 78.6% were carried out in our outpatient service, and in the last two years approximately 90% of cases have been treated as outpatient. We evaluated first 500 kidneys, treated with ESWL as outpatient. There were 481 cases involving 500 kidneys (19 bilateral cases). The ages of the 367 men and 114 women ranged from 16 to 77 years. There were 227 kidney stones and 273 ureter stones. Most of the stones were less than 20 mm. The average number of sessions and shock waves for each patient were 1.4 times and 6,988 waves, respectively. While 74% of the patients could be treated in only one session, 9% of them needed 3 sessions or more. Auxiliary measures were needed in 23 cases (D-J stent insertion in 5 cases and ureteral catheterization in 18 cases) and 474 cases (94.8%) were treated by in-situ procedures. At 3 months after treatment, 470 cases were evaluated and the stone-free rates of kidney stones and ureter stones were 70.3% and 84.5%, respectively with an overall stone-free rate of 78.1%. With regard to complications, the rate of the clinic visit because of pain after treatment was observed in 4.6% and higher than 38 degrees C in 2.5%. However, no serious perioperative complications occurred. From these results, outpatient ESWL was considered to be safe and efficient without serious complications.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of testicular tumor with liver metastases maintaining complete remission for a long period]

A 20-year-old man was admitted with multiple lung, liver and retroperitoneal lymph node metastases from right testicular tumor. The serum hCG level was 170,000 mIu/ml. Orchiectomized right testis showed choriocarcinoma and teratoma pathologically. After 3 courses of chemotherapy of cisplatin, vinblastine and bleomycin, retroperitoneal lymph nodes were resected. Three courses of salvage chemotherapy of VP-16 (etoposide) were performed. The serum hCG level became normal and all metastases disappeared. For 37 months after operation there has been no recurrence of tumor. The 29 cases of testicular tumor with liver metastasis reported in the Japanese literatures during the last 7 years were discussed. The prognosis of testicular tumor with liver metastasis is very poor. However, adequate combination therapy might be effective for the far-advanced testicular tumor.

[Recurrence presenting as anuria at 16 years after partial nephrectomy for a pelvic tumor in a solitary kidney: a case report]

A 61-year-old male underwent right partial nephrectomy for a pelvic tumor of a solitary kidney at the former hospital on April 1975. Two years later he had a small bladder tumor and transurethral resection was performed. Since August 1985 he had been followed up in our hospital. On June 1986, the urine cytology showed class V, but neither cystoscopy nor drip infusion pyelography revealed the tumor. On January 1992, he consulted our department with macrohematuria and anuria. Serum creatinine and blood urea nitrogen level were 17.24 mg/ml and 84.1 mg/ml, respectively. Hemodialysis was administered. Retrograde pyelography revealed a defect of tumor at the pyeloureteral junction, and pyuria by ureteral catheterization showed class V cytology. Abdominal CT showed right hydronephrosis caused by the recurrence of pelvic tumor, and right nephrectomy was performed. The histopathological diagnosis was non-papillary transitional cell carcinoma, grade 3 > 2, pT3. He is in good condition with maintenance hemodialysis. In the Japanese literature there were 16 cases of pelvic tumor on the solitary or residual kidneys. In 12 of the 16 cases, kidney sparing treatment was tried and only our case has lived over 10 years. The indication of partial nephrectomy for pelvis tumor was discussed.

[Basic and clinical evaluation of the new kit for detection of serum prostate specific antigen (PSA)]

BALL-ELSA PSA is a monoclonal radioimmunometric assay kit for detection of serum prostate specific antigen (PSA) developed and generally used in Europe. Basic and clinical study of the kit was performed for evaluation of it's utility in Japanese patients. The sera from 56 patients with benign prostatic hyperplasia (BPH), 35 patients with prostate cancer (PCA) and 18 normal males were examined. Other kits such as EIKEN PSA and EIKEN PAP (prostatic acid phosphatase) were also evaluated in same sera. The results of the range in the measurement, within-assay error, between-assay error, dilution test, recovery test and others were well satisfied. In our clinical study, mean + 2SD of serum PSA values in normal males was 2.57 ng/ml. Serum PSA values determined by the two RIA kits, BALL-ELSA and EIKEN, showed a good correlation (r = 0.9909), but the BALL-ELSA PSA kit yielded values about 2.4 times higher than the EIKEN PSA kit on the same sample. We think that the difference might be largely due to differences in assigned PSA calibrators and diluents between the assay kits. Further investigations and discussions were expected on this point. In our study, the most suitable cut-off level for distinguishing PCA from BPH in BALL-ELSA PSA kit was 10.0 ng/ml.

[Simultaneous double malignant tumors on functional solitary kidney: a case report]

A case of simultaneous double cancer on functional solitary kidney is reported. A 72-year-old man was admitted to the Department of Internal Medicine with angina, hypertension and diabetes mellitus. After treatment involving percutaneous transluminal coronary angioplasty, he was sent to the Department of Urology to check the microhematuria. Cystoscopy showed normal interior of urinary bladder. Drip infusion pyelography and computed tomography demonstrated a tumor mass on the upper pole of the right kidney and atrophic left kidney. Preoperative diagnosis was right renal cell carcinoma. However, an additional pelvic tumor was found during surgery, and a partial nephrectomy was performed. Histologic examination confirmed the presence of 2 separate and distinct malignant entities: a renal cell carcinoma and a non-invasive transitional cell carcinoma. Postoperative recovery has been uneventful and without hemodialysis for 16 months. This is the 19th case of simultaneous occurrence of renal cell carcinoma and transitional cell carcinoma in the same kidney and the 1st case in the patient with a functional solitary kidney in the Japanese literature.

[Treatment of asynchronous bilateral renal cell carcinoma. On our experience of enucleation for two cases]

In patients with either bilateral renal malignancies or with carcinoma occurring in a solitary kidney, the principle of en bloc removal of the tumor-bearing kidney cannot be applied. Recently we have performed surgical enucleation in two cases of asynchronous bilateral renal cell carcinoma. Case 1. A 60-year-old woman was hospitalized with diagnosis of left renal tumor 10 years tumor 10 years after right nephrectomy for renal cell carcinoma. The tumor was enucleated while occluding the renal vessels. Pathological examination revealed that the tumor (a nodule of 35 g) was renal cell carcinoma of grade I and perfectly covered by pseudocapsule. Hemodialysis was not required. The patient has been well for more than 11 months postoperatively and Ccr is 65 ml/min. Case 2. A 62-year-old man with slight elevation of serum GOT and GPT level was examined by CT, which revealed a space occupying lesion in the left kidney. He had undergone nephrectomy for renal cell carcinoma of right kidney 11 years ago. Three nodules of 56 g, 6 g and 3 g were removed by in situ enucleation. They were renal cell carcinoma of grade II and there was no malignant penetration of the pseudocapsule pathologically. After surgery hemodialysis was required 10 times for 21 days. Renal function has been refined gradually and the patient is well with 47.3 ml/min of Ccr at 4 months postoperatively. Before this report of 2 cases there were 22 cases of asynchronous bilateral renal cell carcinoma in Japanese literature.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical experience of the newly developed ultrasound lithotripter]

At present, to perform percutaneous nephrolithotomy (PNL), the ultrasound lithotripter (US) is most widely used, permitting simultaneous breakup of a calculus and suction of fragments. Recently, we have used the OLYMPUS LUS (oscillation frequency 23 kHz, maximum amplitude 60 microns) in 24 cases of renal calculi (including 6 staghorn and 5 multiple), 4 cases of ureteral calculi and 2 cases of reno-ureteral calculi. Although the degree of breakability varied depending on the substance of the calculi, cystine calculi, generally deemed relatively hard, could also be fragmented. The calculi which were found in the ureter were all situated in the upper portion of the ureter. Direct access by the US probe was possible in 1 case, but in 5 other cases the electrohydraulic lithotripter (EHL) was applied first and larger fragments blasted back into the pelvis were broken up and suctioned with the US. Residual calculi were recognized in 4 cases of 6 staghorn calculi and 2 cases of 5 multiple calculi, all of which were found within calyces and were small enough to allow spontaneous passage. In all the other 24 cases, calculi were destructed and removed with the US. We consider that most renal and ureteral calculi can be broken up and suctioned with the US, virtually regardless of the kind of substance, as long as they are situated in the areas accessible by the US probe. The 60 micron amplitude hardly posed any risk of serious injury to the renal parenchyma, not to mention the pelvic mucosa.