[Case of far-advanced retroperitoneal extra-gonadal germ cell tumor responding to intensive treatment including multi-drug chemotherapy with peripheral blood stem cell transplantation and residual tumor removal].

A 37-year-old man with the chief complaints of lumbago and fever is presented. Laboratory data showed the extreme elevation of alfa feto-protein (AFP), human chorionic gonadotropin (hCG) and lactate dehydorgenase (LDH). Computed tomography (CT) scan revealed a huge retroperitoneal tumor with multiple pulmonary nodules as well as left supraclavicular and left axillary lymph nodes enlargement. Although he was suspected the testicular tumor with metastasis, he had no testicular abnormalities including tumor and microlithiasis. Therefore, he was diagnosed as a retroperitoneal extra-gonadal germ cell tumor, which had poor prognosis because of multiple metastasis and the tremendous increase of hCG. Although he was treated with three cycles of bleomycin, etoposide, and cisplatin (BEP), he achieved partial response and no normalization of tumor markers. After three cycles of BEP, he was treated with four cycles of paclitaxel and ifosfamide plus cisplatin (TIP) immediately. During chemotherapy, he was treated with his peripheral blood stem cell transplantation (PBSCT) as well. After the completion of two regimens' chemotherapies, all his tumor markers returned to be normal. However, retroperitoneal tumor, left supraclavicular and axillary lymphnodes still remained. He underwent three operations including retroperitoneal lymphnode dissection with nephrectomy, left supraclavicular and axillary lymphnodes removal, respectively. All specimens had no viable cells, histologically, The patient has been quite well and free of disease for 24 months. It is concluded that even if far-advanced germ cell tumor is discovered, a more promising prognosis could be expected with intensive and aggressive treatment such as our case.

[Prevalence of hydronephrosis and vesicoureteral reflux in pediatric urinary tract infection].

We studied 108 children diagnosed with urinary tract infection (UTI) to determine the frequency of hydronephrosis and vesicoureteral reflux (VUR). Fifty-two children (48.1%) had hydronephrosis (pyeloureteral junction obstruction: 27.8%) and 43 children (39.8%) had VUR (primary VUR: 36.1%). A renal scar was seen in 25.8% of the VUR cases. We recognized again that children with a history of UTI need to be examined promptly and thoroughly.

[A case of grade fever acute disseminated encephalomyelitis exhibiting urinary retention and high grade fever].

Acute disseminated encephalomyelitis is an acute inflammatory demyelinating disorder of the cenrtral nervous system and patients usually present with signs of meningitis, depressed levels of consciousness, disorientation and/or motor or sensory deficits, depending on the affected sites. We present an unusual case of acute disseminated encephalomyelitis with the chief complaint of high-grade fever and urinary retention instead of any signs of neurological disturbances. This is the 10th report of this kind of presentation in Japan.

[A pediatric case diagnosed as urachal cyst and vesicoureteral reflux by urinary tract infection: a case report].

A one-month-old girl was refereed to our department because of urinary tract infection. Ultrasonography showed grade III left hydronephrosis and cystic mass at the dome of the urinary bladder. Voiding cystourethrography revealed grade 4 vesicoureteral reflux associated with Hutch's diverticulum. In addition, magnetic resonance imaging revealed multiple cysts at the dome of the urinary bladder. The vesicoureteral reflux was repaired and the urachal cyst removed.

[A case of hypospadias with a dicentric Y chromosome].

An infant was referred to our department with complaint of abnormality of the external genitalia. Hypospadias and right inguinal hernia were detected and left testis was palpable, but right testis was not palpable. Chromosomal examination revealed 45, X/46, X, idic (Y) (q11.2). On ultrasonographic examination, uterus and ovary were not recognized. At one year of age, we performed operation of right inguinal hernia and right cryptorchism. During operation right spermatic cord and epididymis were detected, but right testis was not detected. At two years of age, urethroplasty was performed. After the operation closure of hypospadias fistulas was performed. Now the patient does not have fistulas and has good clinical progress.

Bilateral renal angiomyolipoma coexistent with pulmonary lymphangioleiomyomatosis and tuberous sclerosis.

A case of bilateral renal angiomyolipoma coexistent with pulmonary lymphangioleiomyomatosis and tuberous sclerosis was described, being in shock with massive hematuria. The left giant angiomyolipoma, filling the almost entire abdomen, was complicated with two large hump and moniliform aneurysms. This life-threatening hemorrhage was successfully treated by transcatheter arterial embolization; packing mechanically detachable coils into the aneurysms and embolization of trunk of the left renal artery. Lymphangioleiomyomatosis has been suggested to be an incomplete expression of tuberous sclerosis. Although coexisting renal and pulmonary involvement in tuberous sclerosis is rare, it is important to recognize lymphangioleiomyomatosis as a pulmonary involvement of angiomyolipoma with tuberous sclerosis.

[Comparison and outcome of prevalence of concurrent diseases in patients with urological malignant diseases].

We compared the prevalence of concurrent diseases (diabetes mellitus, hypertension, ischemic heart diseases and apoplexy) in patients with renal cell carcinoma, bladder carcinoma and prostatic carcinoma diagnosed in our department with that in all patients in our department analyzed using Mantel-Haenszel regression. In hypertension, there was a significantly high prevalence of patients with renal cell carcinoma (p < 0.05) in males and females, and prostatic carcinoma (p < 0.05). In diabetis mellitus, ischemic heart diseases and apoplexy, no apparent characteristic of prevalence was recognized. The close relationship between renal cell carcinoma, prostatic carcinoma and hypertension in this study corresponded with previous reports.

Asthenospermia in hay fever patients improved by stopping treatment with histamine H1 receptor antagonists.

We report two cases of asthenospermia, which appeared to be associated with exposure to histamine H1 receptor antagonists. A 44-year-old man and a 35-year-old man had continued the treatment with fexofenadine hydrochloride and cetirizine hydrochloride, respectively, under the diagnosis of hay fever. They and their wives had been examined as infertile couples. Infertility evaluations revealed no problems with their wives; the patients, however, were found to have a low sperm motility (<10%). On suspicion of adverse effects of the histamine H1 receptor antagonists, they stopped treatment with these drugs, which resulted in a complete reversal of spermatic dysfunction. Current information identifies the potential fertility hazards of histamine H1 receptor antagonists.

[Primary leiomyosarcoma of the spermatic cord with an unusually indolent clinical course].

A 33-year-old man referred to our hospital with a painful swelling of the left scrotal content which had gradually enlarged during the past 4 years. Physical examination revealed a hard, irregular, nontender mass of 5x4 cm in the left scrotum. The mass was fixed to the left epididymis and spermatic cord. Local excision was performed and histologcal examination revealed leiomyosarcoma originating from the spermatic cord. Distant metastases were not observed. Because of the reportedly high propensity for local recurrence, we performed radical orchiectomy and adjuvant radiation. The patient has been alive for 13 months with no evidence of disease.

[Inflammatory myofibroblastic tumor of the renal pelvis].

Inflammatory myofibroblastic tumor (IMT) of the genitourinary tract is rare and has been classified into separate groups based on their anatomical site and postulated aetiology. Herein, we present a case of IMT of the renal pelvis. A 44-year-old man presented with gross hematuria. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed a tumor of the left renal pelvis. Under the diagnosis of left renal pelvic tumor, he underwent left nephrectomy and ureterectomy. Microscopic examination revealed fascicular spindle cell proliferation in an oedematous myxoid background with an infiltrate of plasma cells. The spindle cells were strongly positive for smooth muscle actin (SMA) and vimentin, and negative for desmin and anaplastic lymphoma kinase (ALK). Diagnosis of the lesion was IMT of the renal pelvis.

[Metastatic tumor of spermatic cord with elevation of serum human chorionic gonadotropin beta-subunit].

A 62-year-old man was presented with a firm mass in right scrotum. Serum LDH and AFP were within normal range, but hCG-beta was elevated (2.3 ng/ml). Under the diagnosis of right testicular tumor, he underwent right radical orchiectomy. The specimen was a spermatic cord tumor with poorly differentiated adenocarcinoma. hCG-beta was still elevated postoperatively and gastric fiber revealed adenocarcinoma of the stomach. Histochemical staining for hCG-beta was positive in both tumor of the spermatic cord and stomach. Finally the tumor was diagnosed as metastatic tumor of spermatic cord from gastric cancer, causing the elevation of hCG-beta.

[A stage-dependent follow-up strategy after radical cystectomy for bladder carcinoma].

With the aim of developing stage-dependent follow-up strategy after radical cystectomy for bladder carcinoma, the records of 111 patients with bladder carcinoma who underwent radical cystectomy during the period between 1986 and 2003, were reviewed for the date and site of recurrence. Intrapelvic recurrence developed in 3 out of 56 patients with pT1> or =, 1 of 22 with pT2 and 6 out of 33 with pT3< or = at a median of 34 (range 32-58), 28, 8 (4-51) months, respectively. Extrapelvic recurrence developed in 20 patients with pT1> or =, 4 with pT2 and 14 with pT3< or = at a median of 43 (20-66), 15.5 (13-20), 8 (2-46) months, respectively. Recurrence developed earlier and more frequently in patients with pT3< or = and pT2 than those with pT1> or =. A stage-specific approach to tumor surveillance after radical cystectomy for bladder carcinoma, taking into consideration the risk of recurrence, represents a new approach for efficiently detecting recurrence and reducing medical costs. Our results offer the possibility of a new stage-specific approach to tumor surveillance after radical cystectomy for bladder carcinoma, for efficiently detecting recurrence and reducing medical costs, taking into consideration the risk of recurrence.

[A case of renal cell carcinoma associated with idiopathic thrombocytopenic purpura].

A 29-year-old woman was referred to another hospital with complaints of bruising and ecchymosis and thrombocytopenia (12,000/microl) was pointed out. After some examinations, the patient was diagnosed with idiopathic thrombocytopenic purpura and was started on steroid therapy. Then the patient consulted our hospital and computerized tomography revealed a left renal tumor 4 cm in diameter. Under the diagnosis of left renal neoplasm we performed left nephrectomy and splenectomy with preoperative high-dose intravenous gammaglobulin treatment. Pathological examination revealed clear cell carcinoma. After the operation, the platelet count increased gradually. We should consider bleeding tendency by thrombocytopenia and side effect of long-term steroid treatment when we perform operations on patients with idiopathic thrombocytopenic purpura.

[A case of spontaneous rupture of infectious renal cyst with difficulty in diagnosis].

A 27-year-old gravida was referred to an other hospital complaining of left lumbago and pyrexia, and she was diagnosed with acute pyelonephritis. Left lumbago increased and magnetic resonance imaging of abdomen demonstrated a low intensity area like hematoma around the left kidney. Then the patient was transported to our hospital under the diagnosis of high-risk graviditas. She was performed cesarean section. High-grade inflammation still continued after the operation and computerized tomography revealed the increase of high density area. We performed angiography of the left kidney for hemostasis, but the tumor in the left renal upper pole revealed hypovascularity. We started medication of imipenem/cilastatin sodium (IPM/CS). Inflammation and pyrexia did not improve until we changed antibiotics from IPM/CS to amikacin sulfate. Seven days after that high density area around the left kidney disappeared and a renal cyst was recognized by computerized tomography for the first time. Finally, the current case was diagnosed as spontaneous rupture of infectious renal cyst.

[Giant sarcomatoid carcinoma with spontaneous vesical rupture: a case report].

A 60-year-old woman has been on steroids under the diagnosis of polymyositis for 25 years. She was referred to our hospital complaining of asymptomatic macroscopic hematuria and lower abdominal pain. Physical examination revealed abdominal tenderness and rigidity. We suspected peritonitis because of free air image on the abdominal roentogenogram. The computed tomographic (CT) scan demonstrated an 8 cm solid mass in the bladder and defect of anterior wall of urinary bladder. Then we performed total cystectomy with cutaneous ureterostomy and partial resection of ileum as an emergency operation. Macroscopically, intra-peritoneal bladder rupture and severe adhesion of necrotic bladder dome wall to ileum were recognized and the tumor 8 cm in diameter existed in posterior wall of urinary bladder. Microscopic examination showed sarcomatoid carcinoma with spindle cell component and no invasion to ileum was recognized. Multiple lung, liver and bone metastasis appeared 6 months after the operation. She died of cancer 11 months after the operation.

[Vesicorectal fistula caused by pelvic metastasis of penile cancer: a case report].

A 65-year-old man was referred to our hospital complaining of glans induration. Tumor biopsy revealed squamous cell carcinoma. Although he was given radiation therapy and subcutaneous injection therapy of bleomycin, viable cancer cells remained. Then he was given combination chemotherapy of bleomycin and cisplatin, and paint therapy of bleomycin ointment. Local recurrence with a cauliflower-like tumor occurred five years after the chemotherapy. Then we performed total penectomy and reconstructive surgery of penis. Five years later, discharge of urine from anal appeared. Computerized tomography of pelvis demonstrated a mass 3 cm in diameter in the anterior portion of anal and cystogram demonstrated a vesicorectal fistula. We tried to perform fistulectomy, but foiled because of large fistula. Then we inserted a urethral catheter, which resulted in obstruction of fistula by its balloon, and we made a cystostomy for securing urinary tract. Pathological examination of tissue around the fistula revealed squamous cell carcinoma. His quality of life was improved, but his general condition became worse gradually and he died of cancer.

[A case of hypogonadotrophic hypogonadism causing lumbar stress fracture].

A 57-year-old man was referred to our hospital for further evaluation on hypogonadotrophic hypogonadism causing a stress fracture of the 4th lumbar vertebrae. Azoospermia had been pointed out at the age 30, but hormonal evaluation had not been performed. Physical examination revealed an eunuchoidal body proportion, a stretched phallus length of 4 cm and bilateral scrotal testes of 6 ml. Hormonal evaluation demonstrated a testosterone level of 13 ng/dl (normal, 320 to 1,030 ng/dl), a luteinizing hormone of 0.2 mU/ml (normal, 1.8 to 9.2 mU/ml) and a follicular stimulating hormone of 1.0 mU/ml (normal, 1.6 to 10.7 mU/ml). Results of a stress test of gonadotrophin-releasing hormone was a low delay type. Computerized tomography showed no abnormality in the hypothalamic-pituitary region. The patient was treated with the substitution therapy of androgen. The therapy was discontinued 6 months later because of severe nipple pain. We should perform hormonal evaluation and other examinations for male infertility.