[Tubeless cutaneous ureterostomy through a single stoma with new extraperitoneal ureteral route up to stoma].

Tubeless cutaneous ureterostomy through a single stoma has been said to be difficult to establish in patients with normal ureters or normal ureters combined with thick fatty abdominal wall, because of the poor blood supply at the end of the ureters. The technical improvements observed were as follows: 1) The peritoneal fold and the upward traction of the gonadal vessels decrease the ureteral tension and keep the blood supply to the ureters in the extraperitoneal approach. 2) The gonadal vessels and its surrounding tissue, covering the subcutaneous fatty tissue, help the ureteral adhesion at the anastomotic site. 3) Full diminution of the skin defect caused by flap formation, decreases the horizontal tension of the side-to-side anastomized ureters. Sixteen patients with normal ureters underwent this procedure. In a short-term (4-37 months) observation, 4 of the patients, including one with thick abdominal fat, showed unilateral hydronephrosis and 2 patients unilateral non-function kidney. The remaining 10 patients had no complications. Moreover, all the patients have kept their ureterostomies tubeless and their serum blood urea nitrogen and creatinine levels were within normal limits except for one patient. It is reasonably concluded that the new method will result in success clinically even in patients with normal ureters and thick abdominal fatty tissue.

[Prognosis in the cases with renal cell carcinoma according to clinical parameters].

BACKGROUND: The objects of this study is to evaluate the clinical prognostic factors in renal cell carcinoma. MATERIALS AND METHODS: During a 30-year period from January 1965 to December 1994, 1301 cases with renal cell carcinoma were treated at the Yokohama City University Hospital and its affiliated hospitals. In these cases, cause specific 679 cases from January 1965 to December 1990 were analyzed in a study undertaken to investigate long-term treatment results and clinical prognostic factors. RESULTS: 1. The cause specific 5-, 10-, 15-, and 20-year survival rates were 48.7%, 41.1%, 32.3%, and 26.5% respectively, indicating thus that a great number of cases had an ominous prognosis even 5 years or moreafter surgical treatment. 2. Among patients under 40 years of age (n = 29) none died more than 2 years after receiving operation, the prognosis for this particular group of cases being relatively good. 3. Female, incidentally detected cancer, small tumor size (< or = 4.0 cm), slow growing type and low stage were proven to be favourable prognostic factors in renal cell carcinoma. 4. The cause specific 5-year survival rate for the patients (n = 239) from 1965 to 1981 was 33.8%, while the rate for the patients (n = 440) from 1982 to 1990 was 56.5%. This improvement of survival rate was brought by the increase of the incidentally detected renal cell carcinoma. 5. In the incidentally detected renal cell carcinoma, the incidence of slow growing cases and the cases of less than 4.0 cm tumor size were higher than in the symptomatic renal cell carcinoma. 6. Multivariate analysis using Cox's proportional hazard model showed that stage was the most important prognostic factor. CONCLUSIONS: These results suggested that sex, age, symptom, tumor size, growing type, and stage were important prognostic factors in renal cell carcinoma.

[Subcapsular hematoma of the liver after extracorporeal shock wave lithotripsy].

We experienced a case of a hepatic subcapsular hematoma after extracorporeal shock wave lithotripsy (ESWL) for a right renal stone. To our knowledge this presentation is the second case in the Japanese literature. A 63-year-old female with a right renal stone received 2,800 shots of 14.0 kilo-volts shockwave with Sonolith 3,000. Preoperative examination of the blood disclosed no abnormalities in the coagulating system except slight reduction of platelet count and slight impairment of liver function. Postoperative routine ultrasound echograms revealed a hepatic subcapsular hematoma although she had no symptom. The size of the hematoma measured 11.0 x 5.0 cm in computed tomograms (CT). She was carefully observed without any treatments because the hematoma did not increase in size. CT scans 6 months after the ESWL treatment demonstrated neither hematoma nor masses in the liver. As a complication of ESWL for urolithiasis a hepatic subcapsular hematoma is very rare. We herein presented the case and discussed the complications of ESWL briefly in the literature.

Isolation of 1-Methylherbipoline Salts of Halisulfate-1 and of Suvanine as Serine Protease Inhibitors from a Marine Sponge, Coscinoderma mathewsi

Bioassay-guided isolation of serine protease inhibitors from a marine sponge, Coscinoderma mathewsi, has yielded 1-methylherbipoline salts of halisulfate-1 and of suvanine. Structures of these compounds were identified by spectroscopic analyses and literature data. Antithrombin and antitrypsin activity was determined.

Transarterial embolization and ablation of renal arteriovenous malformations: efficacy and damages in 30 patients with long-term followup.

PURPOSE: We evaluate the long-term efficacy and side effects of transarterial embolization and ablation for renal arteriovenous malformations. MATERIALS AND METHODS: A total of 30 patients with cirsoid arteriovenous malformations causing massive hematuria underwent 34 procedures of embolization or ablation. We confirmed the ratios of occluded arteriovenous malformation areas on angiograms and those of infarcted areas on computerized tomography. All patients were followed for 4.1 to 15.0 years (mean 8.0 +/- 2.8) after the initial procedures. RESULTS: Hematuria ceased in all patients after the initial procedures, including partial embolization or ablation of the arteriovenous malformations in 8. Massive hematuria recurred in 4 patients, who had undergone absorbable gelatin sponge (2), embolization, combined alcohol and subselective absorbable gelatin sponge embolization (1) and polyvinyl alcohol particles embolization (1). In these 4 cases total ablation of the arteriovenous malformations with alcohol was successful. In 29 patients, including aforementioned 4, no hematuria recurred after 5 years following total or partial ablation with alcohol. Large nontarget embolization with reflux of subselectively infused absorbable gelatin sponge caused a nonfunctioning kidney in 1 patient. The remaining 33 procedures caused 6.3 to 48.0% (mean 15.7 +/- 6.9%) areas of renal infarction. Polyvinyl alcohol embolization caused pulmonary embolism and renin dependent hypertension. CONCLUSIONS: Partial or total transarterial ablation of arteriovenous malformations with alcohol proved effective for long-term cessation of hematuria. However, this procedure as well as transarterial embolization has the potential risk of nontarget infarction.

[Nonoperative management of major blunt renal lacerations with urinary extravasation: report of two cases].

Two cases of major blunt renal trauma with urinary extravasation managed by conservative treatment are presented herein. The first case: A 13-year-old girl fell from a bicycle. A computed tomographic (CT) scan showed right renal laceration with retroperitoneal hematoma. Renal arteriography showed evidence of fresh arterial bleeding without visualization of the lower pole. She was treated conservatively with superselective arterial embolization of the lower pole. She developed no urinoma with normal renal function. Renal renin and blood pressures stayed within the normal range in follow up studies. The second case: A 12-year-old boy fell from a tree and hit his right flank. A CT scan showed fragmentation of right renal cortex with retroperitoneal hematoma. He was treated conservatively as his vital signs remained stable, no active arterial bleeding was found no renal arteriography and both renal pelvis and ureters were well visualized by intra venous pyelography. Retroperitoneal hematoma was absorbed without formation of urinoma. Renal function remained within normal limits in follow up studies.

[Comparative histological analysis of needle biopsy specimens, prostatectomized specimens and metastatic lymph nodes in prostatic adenocarcinoma--on the basis of the WHO histological classification].

The histological characteristics were comparatively analyzed among biopsy specimens, surgically removed prostates and metastatic lymph nodes obtained from 60 patients with prostatic adenocarcinoma treated by radical prostatectomy. According to the WHO-Mostifi's classification, the proportion of the 6 histologic components, large and/or small simple glands (LSG), micro-glands (MIC), cribriorm (CRB), fused glands (FUS), medullary/solid (MED) and columns-cords/trabecular (C-C), was determined semiquantitatively. LSG, MIC, and CRB are androgen-sensitive components, while FUS, MED and C-C are androgen-refractory components. The proportions of 5 histologic components excluding MIC were similar in the biopsy and prostate specimens. In 78.3% of the patients, the presence (or absence) of androgen-refactory components in the biopsy specimens coincided with that in the prostate specimens. However, the histologic except for the C-C component. Metastatic lymph nodes contained androgen-refactory components in all cases and tended to have more CRB and FUS and fewer LSG. The histology of the needle biopsy specimens may reflect that of the prostate glands, and may serve as a valuable parameter for determining therapeutic modalities. In addition, androgen-refactory components are frequently present in lymph node metastasis.

[Retroperitoneal malignant Schwannoma in the pelvis: a case report].

We report a case of malignant Schwannoma in the retroperitoneal space and discuss the clinical features briefly. A 77-year-old male visited our hospital in August, 1994 with the chief complaint of bloody stool. Digital rectal examination disclosed a large, elastic and soft mass in the prostatic region, presented identically by ultrasonography and computed tomography. Histological examination of the mass by transperineal biopsy revealed benign cellular Schwannoma. The patient underwent radical prostatectomy including the tumor because the tumor and the prostate could not be separated. Histological examination of this specimen also revealed benign Schwannoma with normal prostatic tissue. However, 2 months after the operation an abdominal CT scan revealed multiple metastasis in the liver, which was later diagnosed as malignant Schwannoma histologically. He is still alive with hepatic metastasis 15 months postoperatively.

[A case of asymptomatic extra-adrenal pheochromocytoma].

A 46-year-old female first presented to our clinic with a chief complaint of an abdominal mass. A computerized tomographic (CT) scan revealed a 6 cm retroperitoneal mass below the left kidney. Preoperative hormonal examinations showed elevation of catecholamines and vanillymandelic acid (VMA) in her 24-hour urine, although she had no hypertension. Therefore, the tumor was uneventfully removed and histologically diagnosed as pheochromocytoma. It is difficult to preoperatively diagnose normotensive extra-adrenal pheochromocytoma without any considerations of the possibilities. However, it may be hazardous to treat pheochromocytoma surgically without any preparations. In the present case, we emphasized the importance of preoperative accurate diagnosis of extra-adrenal pheochromocytoma and discussed briefly the clinical features in the literature.

Anatomic comparison of the ipsilateral and the contralateral testis in intravaginal torsion.

Sixteen cases of intravaginal testicular torsion were studied to compare the intrascrotal anatomy with that of the contralateral testis and to determine possible anatomic predisposition to testicular torsion. The anatomy of the contralateral testis was not always similar to that of the ipsilateral testis, and four of the contralateral testes were judged to be without risk of torsion.

[Extracorporeal shock wave lithotripsy for urinary calculi in an ileal reservoir following reconstruction of the urinary bladder].

A new method for reconstruction of the urinary bladder was introduced by Taguchi in 1977. It consisted of two components; making of pseudo-urethra and the reconstruction of urinary reservoir in the pelvis. The latter was made of the ileum and the peritoneum with temporary use of Japanese paper. This operative method was applied to a 28-year-old female patient when she had cystectomy and bilateral ureterostomy. Thereafter she had has no trouble for 13 years. However, her recent rentogenogram showed urinary tract calculi in the reservoir. Endoscopic treatment was not indicated because of the deformed reservoir and the inflexible pseudourethra. Thus, extracorporeal shock wave lithotripsy (ESWL) was applied to the case with successful results. We herrin reported the case and discussed the usefulness of ESWL for urinali calculi in the ileal reservoir.

[A case of middle ureteral tumor treated by end-to-end anastomosis following resection of 6.7 cm segment].

A 71-year-old male with a right ureteral tumor in the midportion and contracted kidney of the opposite side, due to complete vesicoureteral reflux, underwent end-to-end anastomosis after partial ureterectomy 6.7 cm in length. Our experience in this case led us to conclude that end-to-end anastomosis of the upper or mid-portion of the ureter was possible for the maximal 7.0 cm length of the ureteral loss, when the kidney could be fixed downward as much as possible.

[Clinical study on torsion of appendix in intrascrotal organ].

We reviewed 12 cases of torsion of appendix in the intrascrotal organ treated surgically and discussed its clinical features. An accurate diagnosis could be made in 5 of the 12 patients before operation because they had a palpable localized tender nodule at the affected area, but not in the other 7 patients because their whole scrotal contents had become swollen with time. The histological study on 6 patients with testicular swelling revealed their spermatogenesis intact. Therefore, we believe that torsion of the appendix in the intrascrotal organ has little influence on future fertility, and thus, correct preoperative diagnosis may diminish the necessity for surgical treatment.

[Ureteral polyp prolapsing from the external urethral meatus: report of a case].

We herein report a case of a ureteral polyp treated with transurethral resection (TUR) in a 41-year-old female with the chief complaint of urethral tumor. Cystoscopic findings revealed the tumor originating from the right ureteral orifice. However, intravenous pyelography showed no abnormalities. We resected the tumor transurethrally and the histological diagnosis was ureteral polyp. The postoperative course was uneventful without any signs of vesico-ureteral reflux or recurrence of the polyp. This is the first case of ureteral polyp prolapsing from the external urethral meatus in the Japanese literature.

A phase II study of prophylactic intravesical chemotherapy with 4'-epirubicin in recurrent superficial bladder cancer: comparison of 4'-epirubicin and adriamycin.

Since intravesical recurrence of superficial bladder cancer (Ta, T1) after transurethral resection (TUR) is frequent, adjuvant therapy to reduce the recurrence rate has been extensively investigated. Although intravesical chemotherapy has been employed for 30 years or more, neither the exact effect on the bladder epithelium nor the optimal dose and administration schedule has yet been clarified. In recent years, several derivatives of Adriamycin (ADR) have been developed, and 4'-epirubicin (FARM) is one of them. This drug has been shown to have antitumor effects almost equal to those of ADR and to produce less toxicity when given systemically as chemotherapy. In an attempt to clarify the effect of intravesical FARM in the prevention of recurrence of superficial bladder cancer, we conducted a prospective randomized trial to compare the effects of equal doses of FARM and ADR given by intravesical instillation after TUR in cases of highly recurrent superficial bladder cancer. A total of 73 patients with recurrent superficial bladder cancer were randomized to receive TUR and either 30 mg FARM or 30 mg ADR by intravesical instillation every 2-4 weeks for 1 year. The prophylactic effect on recurrence and the toxic effects of these drugs were investigated. The current results show that FARM provides efficacy almost equal to that of ADR in the prevention of recurrence in these patients. However, FARM also caused almost the same local toxic effects (bladder irritation, among others) as ADR. On the basis of these preliminary results, FARM is surmised to be one of the agents as beneficial as ADR in the prevention of recurrence of superficial bladder cancer.

[Detection of human papillomavirus DNA in condyloma acuminatum of the urethra: a case report].

A case in a 35-year-old male with recurrence of the condyloma acuminatum of the urethra is presented and the involvement of human papilloma virus (HPV) with this disease is mentioned. The HPV-DNA in the excised specimen was detected by the dot blot hybridization method with radiolabelled RNA probes, and the type of the DNA was investigated by the Southern blot hybridization method with biotinylated DNA probes, which could detect the HPV-DNA of types 6, 11, 16, 18, 31, 33 and 35. These analyses demonstrated the HPV-DNA of type 11 and another unidentified type in our case. From the literature with regard to the etiology of this disease considering the risk of malignancy, we also emphasize the necessity for close observation of the patients with condyloma acuminatum, clinically benign, which contains the so-called malignant type HPV-DNA.

[A case of intrascrotal hemangioma].

Intrascrotal hemangioma is rare. A case is presented and the literature is reviewed. A 35 year-old male with the complaint of a painless right scrotal mass underwent right high orchiectomy because the mass was hard and difficult to separate from the right testicle in scrotal exploration. Histologic study revealed that the tumor consisted of a venous hemangioma and the greater part of it was displaced by organized connective tissue. It is extremely rare for a case of intrascrotal hemangioma to require orchiectomy.

[A case of renal cell carcinoma similar to rhabdoid tumor of kidney in an adult; trial of radiation and chemotherapy].

We report a case of sarcomatoid renal cell carcinoma in a 30-year-old woman. The pathological findings indicated renal cell carcinoma (solid sarcomatoid and pleomorphic type) similar to malignant rhabdoid tumor of kidney (MRTK). We treated her with combination chemotherapy (vincristine, adriamycin, cyclophosphamide and actinomycin D) and local irradiation after nephrectomy. The number of bone metastatic foci increased and brain metastasis occurred. However, irradiation was effective on each focus. She died 8 months after the operation caused by brain metastasis. We conclude that sarcomatoid renal cancer is highly malignant and chemotherapy-resistant, but radiation may be partially effective.

[A case of retroperitoneal cavernous lymphangioma with the content of chylous fluid].

We report a case of retroperitoneal lymphangioma in a 26-year-old man whose chief complaint was lumbar discomfort. Ultrasonography revealed pararenal cyst on his left side. At the operation, we discovered a cystic tumor between peritoneum and Gerota's fascia. Pathological study indicated cavernous lymphangioma containing chylous fluid. There has been no recurrence for a year after the operation.

[Treatment of priapism by caverno-spongio-anastomosis].

We experienced two cases of priapism; one, idiopathic and low flow type, the other post-traumatic and high flow type. We tried caverno-spongio-anastomosis (CSA) as an operative treatment in both cases. Postoperative courses were uneventful. We suggest that CSA is a simple and reliable treatment of priapism.