[Congenital midureteral stricture with ectopic ureter: a case report]

A 7-year-old girl was hospitalized with urinary incontinence. Intravenous pyelography showed the dilatation of upper segment of the right kidney, in which slight radioisotopic accumulation was detected on renal scintigraphy with 99mTc-DMSA. On computerized tomographic (CT) scan, a cystic mass shadow occupied the retroperitoneal space. During surgery, the right kidney was found to be completely duplicated and the ectopic ureter opened in Vestibule vaginae accompanied with midureteral stricture. The ectopic ureter was incised above the strictural site and anastomosed with the ureter of the lower segment. Although approximately 700 cases of ectopic ureter have been reported in Japan, congenital midureteral stricture accompanying ectopic ureter is extremely rare.

Primary mucinous carcinoma of the renal pelvis

A case of primary mucinous carcinoma originating in the renal pelvis associated with renal lithiasis is reported. The left kidney removed was mostly occupied by mucinous carcinoma with areas of signet ring cell carcinoma. The epithelium covering the pelvis consisted of a single layer of columnar epithelium with scattered goblet cells and mucous glands. A series of careful examinations of the abdominal viscera failed to disclose any other primary lesion. The patient died with multiple peritoneal tumor disseminations eight months after the operation despite additional chemotherapy.

Determination of the phylogenetic relationships among Pacific salmonids by using short interspersed elements (SINEs) as temporal landmarks of evolution

Several subfamilies of the salmonid Hpa I short interspersed element (SINE) family were isolated from salmonid genomes and were sequenced. For each genomic locus that represented the subfamily, amplification by PCR of the orthologous loci in the 12 fish allowed us to determine the order of branching of the Pacific salmonid species. The deduced phylogeny suggests three evolutionary lines, namely, a line of chum salmon, pink salmon, and kokanee; a line of coho salmon and chinook salmon; and a line of steelhead trout. Our data also support a change in the phylogenetic assignment of steelhead trout from Salmo to Oncorhynchus. We present here an extensive phylogenetic tree constructed from an analysis of differential insertion of SINEs, and we propose that SINE insertion analysis is one of the best available methods for clarifying the order of divergence of closely related species.

[Hypothyroidism followed by interferon-alpha as adjuvant therapy of renal cell carcinoma: a case report]

A 58-year-old male patient was admitted to the hospital complaining of weight loss. Abdominal computerized tomographic (CT) scan disclosed a mass shadow in the left kidney. From the results of further examination, including drip infusion pyelography (DIP) and angiography, he was preoperatively diagnosed as having a left renal tumor. Left radical nephrectomy was performed on March 15, 1990. The lesion was histologically diagnosed as renal cell carcinoma (clear cell subtype, grade 2) confined by the renal capsule (stage I). No distant metastases were detected. Interferon-alpha was administered every other day as adjuvant chemotherapy. After the patient experienced muscle pain in his thighs and shoulders after exercise on February 11, 1991, the serum creatine phosphokinase (CPK) level progressively increased up to 2,329 U/l. On the basis of the results of various examinations reflecting thyroid gland function, he was diagnosed as having primary hypothyroidism due to Hashimoto's disease. Thyroid function improved after administration of triiodothyronine and thyroxine. Interferon has been reported to influence thyroid function, and, in this case, interferon-alpha therapy may have induced the primary hypothyroidism associated with Hashimoto's disease.

[A case of urinary bladder hernia]

A 77-year-old male visited our hospital complaining of swelling in the right scrotal and inguinal region, urinary urgency and difficulty of urination. Physical examination revealed an elastic soft mass in the right inguinal region toward the right scrotum. Rectal examination proved that the prostate was moderately enlarged. Cystogram and urethrography showed hernia of the bladder into the right scrotum and benign prostatic hyperplasia. Urodynamic studies demonstrated organic obstruction in the lower urinary tract. Transurethral resection of the prostate was done for benign prostatic hyperplasia. Later, surgical treatment for the bladder hernia was performed by replacing the bladder into the pelvic cavity and closing the hernial ring without resection of the bladder wall. The bladder hernia proved to be a para-peritoneal type. The postoperative course was uneventful. The previous reports of urinary bladder hernia are reviewed and the incidence, etiology, diagnosis the treatment are discussed.

[Malignant mesodermal mixed tumor of the bladder: report of a case]

A 59-year-old male took total cystourethrectomy on July, 1991, since the bladder tumor recurred 2 years and 4 months after transurethral resection. Six months after total cystourethrectomy, an abnormal mass shadow appeared on the right lower lung field. Metastatic lung tumor was strongly suspected from CT scan. Despite chemotherapy, the pulmonary lesion grew rapidly and the patient died. From the autopsy, metastatic lesions were found in the bilateral lung fields, skin (face, head and abdominal wall), pleura, bilateral kidneys, small intestine and lymph nodes (para-aortic and mesenteric). The primary bladder tumor contained histologically transitional cell carcinoma as the epithelial element and sarcomatous changes with osteoid formation as the non-epithelial elements. Thus, the primary lesion was diagnosed as a malignant mesodermal mixed tumor. However, all of the metastatic lesions showed only sarcomatous changes. Only 10 cases of malignant mesodermal mixed tumor of the bladder have been reported in Japan since Fujita's report. In general, total cystectomy is necessary for the treatment of this disease. It has a poor prognosis; 5 of the 10 patients died within one year after operation.

[Surgical treatment of impotence]

In recent years, several procedures have been successfully employed for the treatment of patients with impotence. Implantation of penile prosthesis is favored for organic impotence. Surgical revascularization of penile artery is attempted for arteriogenic impotence and surgery for producing a mechanical obstruction in the penile venous outflow for venous impotence. Here in, the current surgical procedures for the treatment of erectile dysfunction are reviewed and our experience on the treatment of venous impotence is described.

[Blind ending bifid ureter with stone in the blind branch: report of a case]

Blind ending bifid ureter is a rare anomaly in the urinary tract. This anomaly may result from failure of a premature branch of the ureteral bud to join with the metanephric blastema. A 21-year-old man was admitted with macroscopic hematuria and colic pain in the left flank region. Urinalysis demonstrated hematopyuria and excretory urography suggested bifid ending accessory ureter with a stone on the left side. Surgical exploration showed that the accessory ureter was bifurcated from the left ureter at about 5 mm from the bladder wall and ran parallel with the left ureter. Although dense adhesions to the surrounding tissue existed, the accessory ureter was resected at the site of the junction. It measured 3 cm in length and 1 cm in greatest diameter. The stone found at the tip of the accessory ureter was composed of calcium oxalate (24%) and calcium phosphate (76%). Histological examination revealed that the ureter had all layers of normal ureteral structure and no renal tissue was identified in the specimen resected. During a follow-up period of 22 months after the operation, he was free of urinary tract infection and abdominal pain. Of 77 cases with blind ending bifid ureter reported in the Japanese literature, a ureteral stone was found in the blind branch in only 5 cases.

[Adrenocortical carcinoma: report of a case]

A 24-year-old man visited our hospital complaining of hypertension and headache. Endocrinological findings revealed no abnormalities except for a slight decrease in serum adrenocorticotropic hormone (ACTH), a slight increase in urine 17-ketosteroid (17-KS), and a marked increase in serum pregnenolone. Computed tomography and magnetic resonance imaging revealed a 3 x 3 cm mass in the right adrenal area and I131-aldosterol scintigraphy demonstrated a high absorption of the isotope in the right adrenal area. Vena cavography suggested a 2 x 2 cm tumor thrombus originating in the right adrenal. Under the diagnosis of the right adrenocortical carcinoma, adrenalectomy and removal of the tumor thrombus were performed. Both serum pregnenolone and urine 17-KS returned to the normal level within a week after the operation and blood pressure was well controlled without any medication 3 months after the operation. Thus, the tumor seemed to be endocrinologically active.

[Studies on retroperitoneal lymph node dissection concerning postoperative ejaculatory function in patients with testicular cancer]

This study was done to explore the appropriate procedure of retroperitoneal lymph node dissection (RLND) to preserve ejaculatory function. The relation between postoperative ejaculatory function and area dissected at RLND was investigated in 47 patients with testicular cancer. The patients were divided into 5 groups according to the retroperitoneal area dissected. Group 1 (38 patients) underwent bilateral RLND, group 2 (3 patients) and 3 (2 patients) right unilateral RLND, and group 4 (2 patients) and 5 (2 patients) left unilateral RLND. The vertical limits of the dissected area were similar in all groups, namely renal pedicle and bifurcation of common iliac artery. The lateral limits were bilateral ureters in group 1, right border of aorta and right ureter in group 2, left border of aorta and left ureter in group 4, and vena cava and left ureter in group 5. Group 3 was similar to group 2, but the paraaortic region at the root of inferior mesenteric artery was also dissected. All patients in group 1 had dry ejaculation. Thirty patients in this group were examined for seminal emission and none of them could demonstrate seminal emission. Normal antegrade ejaculation was seen in group 2 and 4 patients, but retrograde ejaculation was recognized in group 3. Inability of seminal emission ws confirmed in group 5 patients. When consideration is given to the function of retroperitoneal sympathetic nerves, our results suggest that unilateral RLND without impairing superior hypogastric plexus should be adopted to preserve ejaculatory function.

Axoplasmic electrolyte contents measured by X-ray microanalysis in experimental uremic neuropathy

We investigated the mechanism of uremic neuropathy using experimental acute and chronic renal failure models in rats. After induction of renal failure, the motor nerve conduction velocity, axoplasmic electrolyte content, and cross-sectional area of myelinated fibers in the sciatic nerve were determined. The axoplasmic Na, K, Cl, and Ca contents were measured by electron probe X-ray microanalysis employing with sections from freshly freeze-dried sciatic nerves. The results obtained for both the acute and chronic renal failure models were similar. The sciatic motor nerve conduction velocity was significantly decreased in both cases as compared to that in the controls. The sciatic nerve axoplasmic Na content was significantly lower than that of the controls in both acute and chronic renal failure, and a significant reduction in the cross-sectional area of the myelinated fibers was observed in both renal failure models. These results suggest that impairment of the axonal membrane Na permeability and shrinkage of the myelinated fibers may play an important role in the decrease of motor nerve conduction velocity in uremic neuropathy.

[Malignant fibrous histiocytoma arising from the renal capsule: report of a case]

Malignant fibrous histiocytoma (MFH) is now considered the most common soft tissue sarcoma in adults, but MFH arising from the renal capsule is very rare. A 77-year-old woman was admitted with a painful mass in the left flank region on September 10, 1986. Preoperative diagnosis was hypovascular retroperitoneal tumor in contact with the upper pole of the right kidney. The tumor was removed together with the right kidney on December 18, 1986, and the specimen weighted 640 gm. Histological examination revealed storiform-pleomorphic malignant fibrous histiocytoma. No postoperative adjuvant therapy was carried out. Local recurrence of the disease was found about 9 months after the operation, and the patient died on February 23, 1988. Fifteen cases with MFH arising from the kidney reported in the Japanese literatures are reviewed, and the diagnosis, treatment, prognosis and tumor marker are discussed.

[Measurement of coefficient of variation of R-R interval in ECG for patients with impotence]

The coefficient of variation (CV = SD/mean x 100) of the R-R interval in electrocardiogram (ECG) was measured as an indication of parasympathetic nerve function in patients with impotence. Of 762 patients 104 (13.6%) had a CV value lower than 2.0. The factors which led to the low CV value were evident in 50 patients (48%), i.e. diabetes mellitus in 26, side effects by antiulcer, antidepressant or antihypertensive agent in 16, renal failure in 1, alcoholism in 2 and age over 70 years old in 4. The possible factors of the low CV value, such as neurogenic, thyroid, cardiovascular and endocrine disorders were found in 12 patients (11.5%). In the remaining 42 patients (40.4%), CV value was decreased by unknown factors. Measurement of CV of R-R interval in ECG was safe and useful as a screening test for patients with impotence to detect the dysfunction of the parasympathetic nerve system.

[Measurement of penile brachial index (PBI) in patients with impotence]

PBI was measured in 555 patients chosen at random from those who visited our impotence clinic between October 1984 and September 1986. Of 555 patients with impotence 29 (5.2%) showed a low PBI level of less than 0.6. On the basis of carefully taken history, risk factors causing the disturbance of penile blood flow were found in 13 (44.8%) of these 29 patients. They included diabetes mellitus, hypertension, surgery of pelvic organ, vertebral injury, vascular disorder of brain and gangliosympathectomy. Although penile angiography is necessary to make the definite diagnosis of vasculogenic impotence, hospitalization is usually required to perform the examination. Measurement of PBI is useful as a screening test to detect vasculogenic impotence at an outpatient clinic, because this examination is noninvasive and technically easy.

[A case of giant vesical calculus after ileocystostomy]

A 52-year-old female, who had undergone nephrectomy and ileocystostomy for right-renal tuberculosis and contracted bladder 19 years earlier was seen with anemia and metabolic acidosis. Radiographic findings demonstrated that the patient suffered from a giant vesical calculus. Cystolithotomy was performed and the removed calculus weighed 460 g. Of the 66 cases of giant vesical calculus weighing more than 200 g reported in our country only 7 were in females.

[Bilateral asynchronous renal pelvic tumors: a case report]

A 42-year-old male who had undergone the total nephroureterectomy for transitional cell carcinoma (Grade 3) in the left renal pelvis 5 years ago was seen with asymptomatic macroscopic hematuria. An evaluation of the clinical investigations revealed the right renal pelvic tumor. The right nephroureterectomy was performed and histological examination showed transitional cell carcinoma (Grade 2) of the renal pelvis. Postoperatively, the patient has been treated with intermittent maintenance hemodialysis. He is well and has no evidence of recurrence or metastasis 10 months after the surgery. The previous reports of bilateral renal pelvic tumors (28 cases) are reviewed and the incidence, age, interval between the first and second tumors, prognosis and management including postoperative hemodialysis are discussed.

[Congenital anterior urethral diverticulum: report of a case]

A case of congenital urethral diverticulum is reported. A 6-month-old male was admitted with difficulty to urinate and swelling of the base of penile shaft. Anterior urethral diverticulum was demonstrated by means of retrograde urethrography. A diverticulectomy combined with cystostomy was performed under the general anesthesia. Although the histological findings were insufficient to determine whether the urethral diverticulum was congenital or acquired, the former was strongly suspected judging from his clinical course. He developed urethrocutaneous fistula, one of the most common postoperative complication, on the 7th post-operative day. A complete cure of the fistula was achieved by the conservative treatment. We collected and analyzed 49 cases of congenital anterior urethral diverticulum of male children in Japan.

[Adult neuroblastoma of the adrenal with intraatrial tumor thrombus: report of a case]

A case of adult neuroblastoma of the right adrenal with tumor thrombus extending into the right atrium is reported. Because of right heart failure, the tumor thrombus in the right atrium was removed under the cardiopulmonary bypass. The histopathological examination of the tumor thrombus revealed neuroblastoma. Fourteen days after the first operation, the adrenal tumor, right kidney and tumor thrombus remaining in the vena cava were removed to prevent the recurrence of right heart failure. Two courses of chemotherapy and radiation were given postoperatively and the patient was doing well. Eight months after the second operation, however, the patient died of multiple metastases of the bone and liver.

[Retrograde nephrostomy for percutaneous nephrolithotomy]

Between June, 1985 and November, 1986, 25 patients at our institute underwent retrograde nephrostomy placement to provide percutaneous access to the kidney for percutaneous nephrolithotomy (PNL) of renal or upper ureteral calculi. Overall, retrograde nephrostomy was successfully completed through the desired calyx in 80% of the patients and calculi were successfully removed by the subsequent PNL. There were 5 failures primarily due to wrong indication and inexperience with the technique. The procedures had been done without significant complications in this series including unsuccessful cases. On the basis of our experiences, it is practically important for successful retrograde nephrostomy to fix the tip of the catheter firmly in the desired calyx until the puncture wire is advanced into the renal parenchyma. It is also important to aim the puncture wire at the skin in a favorable direction to avoid adjacent visceral penetration. Retrograde nephrostomy is a useful aid for percutaneous calculus removal particularly in patients with nondilated intrarenal collecting systems, because this new technique allows precise tract placement to the kidney required for efficient calculus manipulation with less risk than that associated with conventional percutaneous nephrostomy.

[Evaluation of immunosuppressive acid protein in genitourinary malignant diseases]

Clinical significance of serum immunosuppressive acid protein (IAP) was evaluated on the basis of experience on 55 patients with genitourinary malignant disease and 49 control patients. Although the measurement of serum level of IAP is not good enough to diagnose early stage of cancer, patients with 800 micrograms/ml or more of serum IAP can be suspected to have malignant diseases. With the exception of prostatic cancer, both mean serum level and positive rate of IAP were higher in patients with high stage of disease than in those with low stage. Furthermore, on an individual basis, serum level of IAP was elevated with the progress of malignant tumor and was reduced with effective treatment. Thus, serum IAP is considered as a valuable nonspecific tumor marker in monitoring clinical course of genitourinary malignant diseases except for cancer of the prostate. In patients with advanced prostatic cancer, no definite correlation was seen between serum IAP and stage of disease, histopathological finding or serum prostatic acid phosphatase.

Trisomy 11 in chronic myelomonocytic leukemia: report of two cases and review of the literature

Two cases of chronic myelomonocytic leukemia (CMMoL) with trisomy 11 as the sole chromosome abnormality are reported. A simple trisomy 11 also has been reported in 11 patients with myeloproliferative disorders, including CMMoL and acute nonlymphocytic leukemia (ANLL) in the literature. From data on these 13 patients, leukemia with trisomy 11 may be characterized by a nonlymphoid origin and myelomonocytic features. Patients with this abnormality were mostly elderly, and often had a preleukemic phase and a short survival. We propose that trisomy 11 and nonlymphocytic leukemia with myelomonocytic features may be a new association in human neoplasia.

[One stage reconstruction of penis with free forearm flap]

One stage reconstruction of the penis using free tissue transfer was performed on a 43-year-old man who had total penectomy for carcinoma of the penis. A free forearm tissue flap was used to reconstruct urethra and for external skin coverage and Jonas silver penile prosthesis was used as a stent. Nutrient vessels (one artery and two veins) were anastomosed with a lateral circumflex femoral artery and two branches of the saphenous veins respectively and the nerve of flap was anastomosed with the pudendal nerve. We believe that this method is functionally and cosmetrically acceptable for reconstructing the penis, although unfortunately extrusion of the prosthesis ensued 63 days after the operation in our case.