[Emphysematous pyelonephritis complicated with diabetes mellitus: a case report].

A 46-year-old woman with diabetes mellitus was admitted to our hospital due to lower right abdominal pain. Urinalysis did not show marked pyuria. Abdominal computed tomography showed an abnormal gas shadow in the right renal parenchyma. A diagnosis was made of right emphysematous pyelonephritis. Despite aggressive supportive therapy, the patient's condition worsened. Therefore, right nephrectomy was performed. The next day her general condition was markedly improved. We reviewed 122 cases of emphysematous pyelonephritis including our case in the Japanese literature, and discussed its etiology, symptomatology, choice of treatment and prognosis.

[A clinical study on virilization of external genitalia in congenital adrenal hyperplasia].

PURPOSE: In the newborn female with congenital adrenal hyperplasia (CAH), there are variable degrees of clitoral enlargement and virilization of the urethra. In order to investigate the factors that cause these variations, the degree of musculinization of the external genitalia in 44 patients with CAH was studied retrospectively. PATIENTS AND METHODS: This study includes a total of 44 patients with CAH aged 2 months to 12 years and 11 months old who had consulted Nagoya City University Hospital from 1977 to 1994. The length of clitoris on the first consultation was compared with the age and its change was followed. Also, the relationship among the length of clitoris on the first consultation, the degree of urethral virilization, the clinical forms i.e. salt-losing or simple-virilization, and the glucocorticoid hormonal condition were investigated with each other. In 5 pairs of sisters, the length of clitoris on the first consultation was compared within each pairs, and also the degree of urethral virilization was compared. RESULTS: The clitoral length on the first consultation was significantly correlated with the age (y = 1.8 x + 1.8, r = 0.7, p < 0.0001). The mean clitoral length at birth calculated from these data was 18 mm, which is as large as that of adult female one, and the clitoral enlargement rate was 1.8 mm/yr. The correlation was not clear between the clitoral length and the degree of urethral virilization, the clinical forms, and the glucocorticoid hormonal condition, either. On the other hand, the degree of urethral virilization was comparable within clitoral length was not comparable within them. CONCLUSIONS: The urethral virilization was suggested to be determined by the internal hormonal environment during embryonal stage which was shared by the each pair of sisters. On the Other hand, the clitoral length was depend on the patient's age though the factor which determined the length was not apparent. These facts indicated that, not only the severely musculinizing cases, but also the new born female with mildly virilizing urethra should be followed strictly not to undergo the clitoral enlargement.

[Composite pheochromocytoma with ganglioneuroma in the adrenal gland: a case report].

A 67-year-old male demonstrated a right adrenal tumor at another hospital, and consulted our hospital for surgical treatment. Abdominal computed tomography revealed a 13 x 12 cm mass in the right adrenal region. Serum and urinary adrenaline levels were high, and the catecholamine levels in the blood sample of the selective adrenal vein were also high. The tumor was 1,325 g in weight and 13 x 9 x 18 cm in diameter. Pathological diagnosis was a mixed neuroendocrine-neural tumor. It was composed of pheochromocytoma and ganglioneuroma. This combination in the adrenal gland is rare. We reviewed 3 previously reported cases of composite pheochromocytoma with gangloineuroma in the adrenal gland in the Japanese literature, and this is considered to be the fourth case.

Malignant mesodermal mixed tumor of the ureter.

Malignant mesodermal mixed tumor comprised of epithelial and nonepithelial components is rarely encountered in the urological field. Only 6 cases of malignant mesodermal mixed tumor of the ureter have previously been reported in the literature. We recently encountered a 7th case of malignant mesodermal mixed tumor of the ureter and describe the case in detail. The etiology of malignant mesodermal mixed tumor is also discussed.

Results of closure of urethrocutaneous fistulas after hypospadias repair.

BACKGROUND: Urethrocutaneous fistulas are one of the major causes of morbidity after hypospadias repair. METHODS: During the last 2.5 years, 26 patients underwent repair of 41 urethrocutaneous fistulas. These fistulas were repaired by a 3-layered closure method, by using meticulous surgical techniques aided by optical magnification. In large fistulas, a dermal subcutaneous flap was created and brought over the surgically repaired urethral fistula. RESULTS: Twenty-four of the 26 patients with urethrocutaneous fistulas after hypospadias repair had fistula closure, with a 92% success rate. CONCLUSION: A high success rate was obtained with a multilayered closure using meticulous techniques to repair urethrocutaneous fistulas.

[A study of the indication for conservative surgery in adult hydronephrosis based on presurgery post-contrast computed tomography (CT) finding].

BACKGROUND AND OBJECT: The cases with adult hydronephrosis are usually performed either conservative surgery or nephrectomy according to the grade of residual renal function. The residual renal function of adult hydronephrosis are usually suspected with analysis of concentration and/or clearance of the renal urine content after percutaneous nephrostomy. However, percutaneous nephrostomy is invasive and risky. On the other hand, post-contrast computed tomography (CT) is non-invasive. We studied whether post-contrast CT is available for the assessment of residual renal function of adult hydronephrosis and also studied the indication for conservative surgery of adult hydronephrosis on post-contrast CT. MATERIALS AND METHODS: Conservative surgery or nephrectomy was performed in 14 patients with adult hydronephrosis in the duration from April, 1986 to March, 1995. All of 14 patients (14 kidneys) hydronephrosis were retrospectively studied of the character in the indication for conservative surgery by post-contrast CT before surgery. RESULTS: The indication for conservative surgery of adult hydronephrosis on post-contrast CT are (1) well enhanced renal parenchyma exist round the kidney, even if it is very thin, and (2) excretion of contrast medium to renal calyx are showed. CONCLUSION: It was concluded that post-contrast CT might be useful for the assessment of residual renal function of adult hydronephrosis.

Transinguinal laparoscopy for nonpalpable testis.

BACKGROUND: About 20% of all undescended testes are nonpalpable. Although surgical exploration was previously the method of choice for management, laparoscopy from the inferior edge of the umbilicus has been established as a useful method of examining a testis that is nonpalpable. However, conventional subumbilical laparoscopy is unnecessary when the testis or its remnant is located below the internal inguinal ring. We evaluated the efficacy of transinguinal laparoscopy after inguinal exploration performed for nonpalpable testis. METHODS: Twelve children with 14 nonpalpable testes (2 children had bilateral nonpalpable testes) were considered for a novel method of laparoscopy. We performed laparoscopy through the internal inguinal ring after opening the inguinal canal. RESULTS: Inguinal exploration revealed the testis or its remnant in 5 patients, and thus prevented unnecessary laparoscopy in these individuals. Transinguinal laparoscopy identified the anatomy in 7 patients. Four of the latter were found to have blind-ending vas deferens and spermatic vessels, while in 3 patients, the testes were located in the peritoneal cavity. CONCLUSION: Transinguinal laparoscopy may become the accepted method for managing nonpalpable testes, as inguinal exploration can eliminate the need for laparoscopy in some cases, and the visualization achieved with transinguinal laparoscopy is just as good as that with conventional laparoscopy.

Aromatase mRNA levels in benign prostatic hyperplasia and prostate cancer.

BACKGROUND: Estrogens are suspected to play a role in the pathogenesis of benign prostatic hyperplasia (BPH) and prostate cancer. In this study, the expression of aromatase messenger ribonucleic acid (mRNA) was determined, and these levels were quantitated, in human prostatic tissues to evaluate the role of estrogens in the pathogenesis of BPH and prostate cancer. METHODS: Prostatic tissues were obtained either by retropubic prostatectomy, radical prostatectomy, or radical cystectomy from patients with BPH, prostate cancer, and bladder cancer. The expression of aromatase mRNA in the prostatic tissues was studied by Southern blot analysis of the reverse transcription and polymerase chain reaction technique (RT-PCR) products. Aromatase mRNA levels were measured in human prostatic tissues by the RT-PCR using a fluorescent primer. RESULTS: Aromatase mRNA was identified in all specimens by Southern blot analysis of the RT-PCR products. The concentrations of aromatase mRNA (mean +/- SD) which were measured by fluorometric quantitation in 16 of 19 patients with BPH and in 3 of 4 patients with prostate cancer, were 1.81 +/- 3.02, and 0.84 +/- 0.27, x 10(-3) attomoles/micrograms of total RNA, respectively. CONCLUSIONS: These results demonstrate local formation of estrogen in the prostates of patients with BPH and prostate cancer. Controlled studies will be necessary to determine whether this may be a factor in the development of BPH and prostate cancer.

[One-stage urethroplasty with the modified OUPF IV for proximal hypospadias].

BACKGROUND: We previously performed one-stage urethroplasy with OUPF IV in 17 patients with proximal hypospadias and experienced meatal stenosis in 3 and meatal regression in 2. METHODS: Because these complications seemed to be caused by diminished vascularity, we modified the technique to preserve the vascularity to the peripheral site of the neourethra. The modified OUPF IV (Koyanagi) was used to treat 6 patients with proximal hypospadias during the last 3 months. RESULTS: Urethrocutaneous fistulas developed in 2 patients but meatal stenosis and meatal regression did not occur. CONCLUSION: We think this modification is suitable for severe proximal hypospadias.

Testosterone metabolism in primary cultures of epithelial cells and stroma from benign prostatic hyperplasia.

We studied the metabolism of testosterone in primary cultures of prostate epithelial cells and fibroblasts obtained from patients with benign prostatic hyperplasia (BPH). The conversion of 3H-testosterone in both cell cultures was predominantly to the oxidative pathway, with the formation of 3H-androstenedione increasing with cell number and time of incubation. Although we also detected some 5 alpha-reductase activity in these cells, the activity in the stroma component (0.00688 pmol/mg protein/min) was nonetheless insignificant when compared to the 5 alpha-reductase activity in the tissue of origin (0.0616 pmol/mg protein/min) and well below the 17 beta-hydroxysteroid dehydrogenase activity of the same cells (0.0518 pmol/mg protein/min). The aromatase activity in our cells was also measured by two separate techniques, but neither the deuterium procedure nor the production of oestrone from androgen precursors yielded any positive results, suggesting that under these experimental conditions there was no aromatase activity within the cells. The shift from the reductive to the oxidative pathways in these primary cell cultures was reminiscent of the androgen-metabolizing enzyme profiles seen in poorly differentiated prostate cancer. Whether this transition is an obligatory step in the development of hormone refractiveness remains to be elucidated.

Detection of sex-determining region in a male with chromosomal abnormality (46,X+mar) and hypospadias.

A 1-year-old boy was referred to us because of abnormal external genitalia; that is, his penis was kinked toward the perineal region. We diagnosed hypospadias. Chromosomal examination was performed on a sample of peripheral blood, the karyotype was 46,X+mar. Detailed karyotypic analysis revealed that the short arm of the marker chromosome originated on the ninth chromosome, but we could not determine whether the long arm was part of the Y chromosome, even with the use of quinacrine mustard. The sex-determining region of the Y was detected using the polymerase chain reaction method, which suggested that the long arm of the marker chromosome was delivered from the short arm of the Y chromosome.

[Radiological diagnosis of renal oncocytoma].

Eight patients (nine tumors) with histologically proven renal oncocytoma are presented. In all cases, differential diagnosis between renal oncocytoma and renal cell carcinoma could not be done on ultrasonography. On selective renal angiography, extended arteries surrounding the tumor margin was demonstrated in six of seven tumors without a spoke-wheel arterial supply. A sharp and smooth margin with capsule (lucent rim) could be found in five cases, and a spoke-wheel configuration of vessels could be seen in only two cases. A spoke-wheel pattern might be found with tumor growth. All tumors on computed tomography (CT scan) have a distinct margin, a smooth contour and a homogeneous appearance on contrast enhanced CT scan. The capsule and the presence of a central scar were clearly seen on T1 and T2 weighted images of magnetic resonance imaging (MRI). It is helpful to differentiate the oncocytoma from renal cell carcinoma. The modality of MRI may be useful in the preoperative diagnosis of oncocytoma.

Laparoscopic gonadectomy for testicular feminization syndrome.

Laparoscopic gonadectomy was performed on a patient with complete androgen insensitivity (testicular feminization syndrome). In the case presented here, although the gonads were free, the omentum which was adhering to the right inguinal ring, possibly as a result of previous inguinal hernia repair, obscured the right gonad. The left gonad was located behind the sigmoid colon. We present our laparoscopic experience in managing this case of testicular feminization syndrome.

[Pseudo-Bartter syndrome without hypopotassemia: a case with unilateral multicystic dysplastic kidney and congenital contralateral hyronephrosis].

A 2-month-old girl having a left multicystic dysplastic kidney with contralateral mild hydronephrosis is described. Furosemide was administered orally because of hyperpotassemia during the period between 1 month and 7 months of age. Peripheral plasma renin activity and plasma aldosterone activity increased at the age of 6 months, and ultimately reached the peak at 9 days after discontinuation of furosemide at the age of 7 months. Peripheral plasma renin activity and plasma aldosterone activity were normalized at the age of 11 months. Blood pressure during the whole period was normal. Contralateral hydronephrosis was improved gradually. The level of serum creatinine became normal at the age of 50 days. A case with a high level of plasma renin and aldosterone activity temporarily induced by furosemide was reported. Pathophysiology of pseudo-Bartter syndrome without hypopotassemia due to furosemide is discussed.

Detection and monitoring of simple renal cysts with computed tomography.

We retrospectively investigated the incidence of simple renal cysts in 1,288 healthy subjects, and monitored the growth and formation of such cysts in 39 subjects using abdominal computed tomography (CT). Simple renal cysts were detected in 138 (10.7%) of the 1,288 subjects. The incidence of simple renal cysts increased significantly with the subject's age (p < 0.001). We found that cyst size increased significantly with age and over time on serial CT studies (p < 0.001). Exoparenchymal cysts, comprising greater than 50% of extraparenchymal lesions, were significantly larger than endoparenchymal cysts (p < 0.001), and showed a greater tendency to increase in size over time.

[A case of adult giant hydronephrosis--a study of indication for kidney conservative operation].

A 40-year-old man with the complaint of right lower abdominal pain was admitted to our hospital. Urological examinations revealed right giant hydronephrosis and ureteropelvic junction (UPJ) obstruction caused by an aberrant artery. Radiography showed approximately 3,500 ml of fluid in the renal pelvis. Preliminary nephrostomy was performed and about 2,300 ml of fluid was removed. Enhanced computed tomography, angiography, radioisotope examination and pelvic urine analysis indicated that conservative operation in this case was possible and a pyeloplasty was performed. Two years after the operation the right renal function showed improvement with no complication of hypertension. Although nephrectomies have been performed in adult cases with giant hydronephrosis it is important to consider indication for conservative operations in those cases.

[Study of cell lines derived from benign hypertrophic prostate tissue].

Primary epithelial and fibroblast cells from benign hypertrophic prostate tissue were established. The prostate tissues were obtained by transurethral resection of the prostate or retropubic prostatectomy in patients with benign prostatic hypertrophy. Growth factors for cultured epithelial cells and fibroblasts were studied. The epithelial cells grew well in the WAJC-404 culture medium with insulin, epidermal growth factor and dexamethasone. Fibroblasts grew well in culture medium containing 10% fetal calf serum. The prostate tissue was stored at 4 degrees C for 7 days and no degenerative change in the stromal cells was seen during this period. Although epithelial cells did degenerate with the passage of time, epithelial cells cultured after storage for 4 days at 4 degrees C behaved similarly to those cultured immediately after being isolated. These primary cultures of epithelial cells and fibroblasts from hypertrophic prostate may be useful for various studies.

[A study of testicular tumor on magnetic resonance imaging].

Magnetic resonance imaging (MRI) was performed on 13 testes of 12 patients with testicular abnormalities. In all cases, scrotal palpation and initial clinical course had suggested malignant testicular tumors. The normal testes showed homogeneous intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images such as the appearance of the corpus cavernosum penis. Ten patients proved to have testicular tumors. In eight of them, the tumors showed homogeneous intermediate signal intensity on T1-weighted images, while in the other two, these images showed heterogeneous signal intensity. In four patients, tumors were of homogeneous low signal intensity on T2-weighted images, while in the other six, these images showed heterogeneous signal intensity. The rate of correspondence about local staging of testicular tumor between MRI and pathological diagnosis was 70 percent. In three patients whose testes were undoubtedly malignant according to clinical findings and examination data, MRI enabled us to diagnose one case of testicular atrophy. However, MRI suggested benign disease in the other two patients; nevertheless, surgery was performed as indicated by the other findings.

Administration and dosage of iohexol, a nonionic contrast medium, for dynamic renal computed tomography.

We investigated the optimal method of administering iohexol, which contains 300 mg iodine/ml (Omnipaque 300), a nonionic contrast medium, to maintain adequate renal contrast while reducing artifacts during dynamic CT scanning. In this study, 76 patients with renal disease received 10-50 ml of iohexol as follows: group I (14 patients), 20 ml injected as an intravenous bolus for 5 sec, followed by 30 ml intravenous drip infusion for 5 min; group II (18 patients), bolus of 20 ml injected for 5 sec; group III (13 patients), 20 ml diluted with sterile water (total volume 40 ml), and injected as a bolus for 8 sec; group IV (15 patients), 20 ml injection for 5 sec followed by intravenous drip infusion of 200 ml of Hartmann-Ringer's solution given at maximum speed; and group V (14 patients), 10 ml diluted with sterile water (total volume 20 ml) injected as a bolus for 5 sec. We found that corticomedullary differentiation was most distinct on the images obtained from group IV. We concluded that a lower concentration of iohexol (150 mg iodine/ml) given by intravenous fluid loading can provide superior CT images.

[Monotherapy with extracorporeal shock wave lithotripsy for renal and ureteral stones].

We performed extracorporeal shock wave lithotripsy (ESWL) as a monotherapy using the Medstone STS lithotripter on 288 patients with renal and ureteral stones between June, 1989 and June, 1991. We compared our results with previous reports on ESWL as used in combination therapy. Our cases consisted of 121 patients with renal stones and 167 patients with ureteral stones. A total of 437 sessions of lithotripsy were performed on 288 patients, for an average of 1.52 sessions of lithotripsy per patient. The percentage of stones measuring less than 4.0 mm in diameter that were fragmented was 94.3% for renal stones and 87.6% for ureteral stones. The stone-free rates 3 months after ESWL were 60.3% and 90.4%, respectively. Our results of the monotherapy with ESWL did not differ from those reported on ESWL as used in combination therapy, in terms of the rate of stone destruction and stone-free rates. We studied the other reports carefully and determined that ESWL monotherapy could have been performed in most those cases. We concluded that ESWL monotherapy is an excellent therapeutic method in the light of fewer complications and side effects compared with those from combination therapy, and the fact that the rate of recurrence for renal and ureteral stones is high makes ESWL monotherapy very useful because the procedure can be repeated.