(Purpose) In 1996, Japanese guidelines for the diagnosis of preclinical adrenal Cushing's syndrome were proposed. However, several patients with preclinical Cushing's syndrome (PCS) didn't clearly show that these diagnostic guidelines were universally applicable. The aim of the present study was to evaluate the validity of these diagnostic guidelines on the basis of our clinical experience.
(Patients and Methods) We performed adrenalectomy for adrenal incidentaloma in 16 patients with suspected PCS at our university hospital from 1990 through 2002. Eight patients met the Japanese criteria for the diagnosis of PCS (PC group) and 8 did not (dexamethasone [DXM] suppression group). Clinical characteristics and pathology profiles were compared between the groups.
(Results) No patients in the DXM suppression group showed responses of serum cortisol levels on a 1-mg overnight dexamethasone suppression test. Twenty-four-hour urinary levels of 17-hydroxycorticosteroids were significantly higher in the PC group than in the DXM suppression group. In all patients of both groups, adrenal scintigraphy showed marked accumulation of radioisotope in the adhesive, atrophic adrenal cortex. One patient of the DXM suppression group had severe adrenal symptoms after adrenalectomy. Several patients in the DMX suppression group showed clinical improvement after adrenalectomy, as well as did several patients in the PC group.
(Conclusion) Endocrine activity may have been higher in the PC group than in the DXM suppression group. However, because patients who failed a 1-mg DXM suppression test may in fact have autonomous cortisol secretion, adrenalectomy may still be indicated. Autonomous cortisol secretion might not be documented with the 1-mg overnight DXM suppression test; therefore, the results must be interpreted carefully.

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(Purpose) To analyze clinical manifestations and endocrinological aspects of the patients who visited our hospital to be examined for partial androgen deficiency in the aging male (PADAM).
(Materials and Methods) Two hundred forty-three patients were evaluated. History taking and questionnaires were employed for analysis of their symptoms. Serum total testosterone (T), free-T and other hormones were measured for evaluation of the androgen deficiency.
(Results) The chief complains of the patients were categorized as psychological symptoms, somatovegatative symptoms, and sexual symptoms, accounting for 51%, 36%, and 13%, respectively. A depressed mood, hot flashes and sweating and erectile dysfunction were dominant in these symptom categories, respectively. The prevalence of the psychological symptoms and somatovegatative symptoms was relatively high in the 30-50-year-old and 60-70-year-old groups, respectively.
The free-T, but not total-T, was significantly decreased with aging as measured by the RIA method. Twenty one percent of the patients showed a lower total-T level than the normal range (2.7-10.7ng/ml). The percentage of those with a total-T level lower than 2.0ng/dl, which is the criterion for T-replacement recommended by the American Association of Clinical Endocrinologists guidelines, was 9%. Eighty two percent and 30% of the patients had lower free-T levels than the normal range (15.2-43.5pg/ml) and that of men in their twenties in the Canadian data (9.3-26.5pg/ml). Depending on the criteria of androgen deficiency, not all patients had low total-T and free-T levels.
(Conclusion) Patients suspected of having PADAM present various clinical symptoms and endocrinological aspects.

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(Purpose) We describe our experience of sling removal performed after either the Vesica sling procedure (due to vaginal erosion or at the time of reoperation for recurrent stress incontinence) or the tension-free vaginal tape (TVT) procedure (due to persistent urinary retention).
(Materials and Methods) From May 1997 to December 2002, we performed 19 Vesica sling procedures and 66 TVT procedures for the treatment of urodynamic stress incontinence. In the former procedures, four patients (21%) developed vaginal erosion and underwent total or partial removal of sling material (Hemashield made from bovine-collagen-injected woven polyester). In another three patients, stress incontinence recurred 2-4 years after the Vesica sling procedure, and they underwent total sling removal and the TVT procedure. Before using the urethral pull-down process (UPDP) in TVT procedures, 2 out of 23 patients (8.7%) developed persistent urinary retention and underwent either sling release alone or partial sling removal concomitant with a second TVT procedure. After the introduction of the UPDP, no patient developed urinary retention.
(Results) Three patients in whom total sling removal was performed due to vaginal erosion after a Vesica sling procedure developed recurrent stress incontinence. One patient who underwent partial sling removal remained continent, but vaginal erosion recurred 2 years later. Patients who had total sling removal and TVT procedures due to recurrent stress incontinence after Vesica sling procedure became continent with an uneventful postoperative course. One patient who underwent transvaginal release of TVT tape (polypropylene mesh) due to urinary retention after the TVT procedure developed recurrent stress incontinence, and the other who underwent partial removal of TVT tape and a second TVT procedure had resolution of urinary retention without recurrence of stress incontinence.
(Conclusion) Prompt and total sling removal should be recommended for vaginal erosion after the Vesica sling procedure. In patients with urinary retention after the TVT procedure, partial removal of TVT tape and a second TVT procedure using the UPDP to prevent overtightness may be a preferable choice to attain both continence and resolution of urinary retention.

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(Objective) To determine the extent of drug-resistance among Enterococcus species we investigated in vitro experiments.
(Methods) Studies were carried out on pure cultured of enterococci isolated from 8, 575 urine specimens between 1990 and 2002. We had determined test strains to three kinds of species, which posses the urinary pathogenesis. Both an EF-agars and an ADH decarboxylase test performed the identification and speciation of the strains of enterococci. In vitro drug-susceptibility tests of enterococci were performed against the following antibiotics: ampicillin (ABPC), cefpirome (CPR), cefozopran (CZOP), imipenem/cilastatin (IPM/CS), minocycline (MINO), levofloxacin (LVFX), vancomycin (VCM), sulfamethoxazone/trimethoprim (ST), by employing the method for dilution antimicrobial susceptibility tests for bacteria that grow aerobically recommended by Japan Society of Chemotherapy. These drug-susceptibilities were shown susceptible, intermittent and resistant in according to National Committee for Clinical Laboratory Standards (M100-S12).
(Results) The most common species isolated was E. faecalis (84.4%), followed by E. faecium (9.9%) and E. avium (5.6%). In E. faecium and E. avium, the sensitivity to ABPC has tended to improve from 1999. This tendency inverse correlated to decreasing dosage of PCs. There was much difference of resistant rate to IPM/CS between each species, and no correlation to used dosage of CBPs. The rate of resistance to MINO did not change during this period. 60% of E. faecalis had sensitivity to LVFX and the rate did not change during this period. In E. faecium, whose resistant rate to LVFX was 90%, the sensitivity has been improved to over 25% from 2001. The improved tendency of E. faecium to LVFX had inverse proportion to decreasing dosage of NQs. With the exception of a little bit VRE (VCM resistant Enterococci), almost of them had sensitivity to VCM.
(Conclusion) The emergence of enterococci with alarming rates of resistance concomitantly to multi-drugs highlights the need for a more rational and restricted use of antimicrobials, in order to minimize the selection and spread of such strains. An early detection of these problem pathogens is also important for preventing any treatment failures.

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(Purpose) We performed contra-lateral testicular biopsies in 55 testicular tumor patients when high orchiectomy was performed. In these cases, two cases developed invasive testicular tumor later although the biopsies had not revealed testicular CIS. Then we re-examined the sensitivity of biopsies and judged if our results are contradictory against Skakkebaek's theory.
(Patients and Methods) The paraffin blocks of two cases who later developed testicular tumor were sliced again and re-examined by H/E staining and immunostaining with PLAP antibody (clone No. 8A9). The other 53 H/E samples were re-examined and the result of the contra-lateral testis was re-searched in the case that CIS was detected in the specimen.
(Results) CIS was detected in one of the two cases who later developed contra-lateral testicular tumor and another case among the other 53 cases. We could not reveal the result of the testis of case No. 3 because of the patient's disappearance. CIS existed 3.6% (2/55) and two cases were found to have been false negative.
(Conclusion) It is important for both urologists and pathologists to know well about testicular CIS and to perform biopsy according to Skakkebaek's guidance for raising the sensitivity to detect testicular CIS.

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(Background) Extraprostatic extension and positive surgical margin increase a risk of treatment failure after radical prostatectomy in patients with localized prostate cancer. We analized the location of extraprostatic extension and positive surgical margin in radical prostatectomy specimens.
(Materials and methods) In 104 radical prostatectomy cases the location of the extraprostatic extension (EPE) and/or positive surgical margin (PSM) were studied using step-sectioned specimens.
(Results) In 54 cases EPE and/or PSM were recognized. In 34 of 38 cases (89.5%) with EPE, the EPE was identified at lateral, posterolateral and/or posterior portions in base and/or middle of the prostate. Particularly, in 31 cases (81.6%) the EPE was found posterolaterally. Only in 5 of these 34 cases (14.7%) PSM resulted from the EPE. When 35 cases with PSM were evaluated, the PSM occurred apically in 22 (62.9%) and anteriorly in 11 (31.4%). Only in 4 cases (14.3%) PSM was caused by EPE of apical and/or anterior portions.
(Conclusions) The majority of EPE were observed at the posterolateral portion of the prostatic base and/or middle. However, PSM were frequently identified apically and/or anteriorly. These findings suggest that modifications of surgical technique of apical dissection might reduce the frequency of PSM.

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Interferon (IFN)-α has been widely used in systemic therapy for advanced renal cell carcinoma (RCC). IFN-α is represented by a large family of structurally related genes expressing at least 14 subtypes, each of which shows quantitatively distinct patterns of biological activities. Although those distinct patterns of biological activities of IFN-α subtypes against renal cancer cell lines have been demonstrated, there is no report that demonstrates the difference in each subtype-induced antitumor activity in patients with RCC. Herein, we present a unique case of advanced RCC that is resistant to interleukin-2 and IFN-α administration, and we describe its response to another IFN-α administration. The difference between the two IFN-α types lies in the distribution of the subtypes: this case, therefore, suggests that the difference in the subtype distribution may cause the different response of the RCC.
A 47 year-old male was diagnosed as left RCC with multiple lung metastases and underwent radical nephrectomy. The histological diagnosis was pT3b G2 clear cell carcinoma. He received intramuscular administration of 6×10⁶ units of natural human IFN-α (Sumiferon^®) three times a week following the operation. However, the lung metastases showed progression. Thereafter, he received intravenous administration of 1.4×10⁶ units of human interleukin-2 everyday. However, the lung metastases showed further progression and the hemoptysis, dyspnea, and chest pain deteriorated. Finally, he was given intramuscular administration of 5×10⁶ units of another natural human IFN-α (OIF^®) three times a week. After the OIF^® administration, his complaints subsided and a chest CT scan revealed reduced lung metastases and diminished pleural effusion. He had not received any anti-tumor agents other than IFN-α or interleukin-2 since the operation. However, although he remained free of hemoptysis, dyspnea, and chest pain after OIF^® administration, the lung metastases increased again and multiple brain metastases were also observed five months after the first OIF^® administration. He died of metastatic RCC one year after the operation.

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A 59-year-old man was admitted to our hospital with a left renal mass. A tumor was removed by radical nephrectomy and histological examination revealed renal cell carcinoma (pT2 N₀ V_1a). Two years later, CT scan showed multiple lung metastases. Despite treatment with recombinant IFN-α2b, 5-FU, and MMC, the disease showed slow progression. About three years after the start of combination therapy, cervical lymph node metastasis appeared. Administration of interleukin-2 (IL-2) was attempted. Intravenous IL-2 therapy was started at a low daily dose of 35×10⁴ JRU, and the daily dose was increased to 140×10⁴ JRU. Because of side effect, the dose was subsequentry decreased to 70×10⁴ JRU three times per week. After 31 weeks of IL-2 therapy, his multiple lung metastases and cervical lymph node metastasis disappeared. The patient's natural killer cell (NK) activity and Lymphokine activated killer cell (LAK) activity were low before IL-2 therapy, but both NK activity and LAK activity showed a marked increase after IL-2 therapy started. Therefore, the tumor response to IL-2 was suggested to depend on NK activity and LAK activity.

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A case of osteosarcoma in pelvic bone following radiation therapy for prostate cancer is reported. A 74-year-old patient was diagnosed with prostate cancer 10 years ago and started on the endocrine therapy with LH-RH agonist. He had no apparent distant metastasis, and received radiation therapy 8 years ago. He has complained of low back pain since several months ago. A high uptake on bone scintigram and osteolytic and osteoblastic damages on CT were noted in pubic bone and sacrum. The PSA level was less than 0.2ng/ml.
Pathohistological diagnosis by biopsy of the pubic bone was chondroblastic type osteosarcoma, showing an atypical cell proliferation with osteoid. Immunostaining for nonepithelial marker vimentin was positive. He underwent heavy ion radiation therapy for osteosarcoma at the National Institute of Radiological Sciences. Osteosarcoma is one of the rare delayed complications after radiation therapy and requires biopsy for correct diagnosis.

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Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant disorder characterized by an excess of extracolonic malignancies including those of the urinary tract. We report a case of metachronous bilateral ureteral cancer associated with HNPCC.
A 51-year-old man was referred to Nara National Hospital for further examination of left hydronephrosis on excretory urography performed on the periodical follow-up for colon cancer. Computed tomography shoed a mass in the left lower ureter and urine cytology was demonstrated class V. The operation was performed under the diagnosis of left ureteral cancer. The histopathological diagnosis was transitional cell carcinoma, grade2, pT1. After 4 months of the operation, he presented with gross hematuria. Retrograde pyelography demonstrated tumors in the right side (ureter and renal pelvis) and the histopathological diagnosis of the biopsy specimens revealed transitional cell carcinoma, grade 2. We performed 4 times of BCG instillation followed by laser ablation of the tumor.
The reported case was compatible for Japanese clinical criteria, group B for HNPCC.

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Renocolic fistulae caused by colonic diverticulitis are rare. We present a case of renocolic fistula caused by colonic diverticulitis associated with polycystic kidney.
A 51-year-old male with polycystic kidney on hemodyalisis presented with a lasting fever and left lower abdominal pain. Under the diagnosis of the infection of a cyst in a polycystic kidney, puncture of the cyst was performed. Nine hundred ml of turbid fluid, of which culture grew Bacteroides Fragilis, was discharged. Inflammation subsided after the puncture, but soon recurred. Moreover, pneumaturia was observed, and fecaloid fluid was drainaged. Barium enema demonstrated a fistula from the diverticulum of the descending colon into the punctured cyst. The patient underwent a nephrectomy combined with hemi-colectomy.

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A 63-years-old male with symptomatic benign prostatic enlargement (220ml as estimated by transrectal ultrasonography) was underwent transurethral holmium laser enucleation. Total operative time was 211 minutes and actual weight of tissue enucleated was 156 grams. There was no perioperative hyponatremia and a blood transfusion. The duration of catheterization was 3 days and the hospital stay was 5 days. Three months after treatment, the international prostate symptom score (IPSS) decreased from 19 preoperatively to 1. The quality of life (QOL) index decreased from 6 preoperatively to 1, whilst the maximum flow rate (Qmax) increased from 7ml/sec preoperatively to 58ml/sec.

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