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Malignant ureteral obstruction often necessitates chronic urinary diversion and is associated with high rates of failure with traditional ureteral stents. We evaluated the outcomes of a metallic stent placed for malignant ureteral obstruction and determined the impact of risk factors previously associated with increased failure rates of traditional stents.Patients undergoing placement of the metallic Resonance® stent for malignant ureteral obstruction at an academic referral center were identified retrospectively. Stent failure was defined as unplanned stent exchange or nephrostomy tube placement for signs or symptoms of recurrent ureteral obstruction (recurrent hydroureteronephrosis or increasing creatinine). Predictors of time to stent failure were assessed using Cox regression.A total of 37 stents were placed in 25 patients with malignant ureteral obstruction. Of these stents 12 (35%) were identified to fail. Progressive hydroureteronephrosis and increasing creatinine were the most common signs of stent failure. Three failed stents had migrated distally and no stents required removal for recurrent infection. Patients with evidence of prostate cancer invading the bladder at stent placement were found to have a significantly increased risk of failure (HR 6.50, 95% CI 1.45-29.20, p = 0.015). Notably symptomatic subcapsular hematomas were identified in 3 patients after metallic stent placement.Failure rates with a metallic stent are similar to those historically observed with traditional polyurethane based stents in malignant ureteral obstruction. The invasion of prostate cancer in the bladder significantly increases the risk of failure. Patients should be counseled and observed for subcapsular hematoma formation with this device.

We ascertained the incidence and outcome of hydronephrosis related to abdominal or pelvic neoplasms and survival in pediatric patients.We retrospectively reviewed our institutional oncology database between January 1995 and November 2009. We reviewed the charts of all children with intra-abdominal (nonrenal) and pelvic neoplasms.Of the 366 patients whose charts were reviewed 66 (18%) had hydronephrosis at some point during treatment, including 12 with hydronephrosis that was not caused by the neoplasm and 1 who was lost to followup, leaving 53 with malignant obstruction. Of the remaining patients hydronephrosis resolved in 34 (64%) with treatment for the primary neoplasm alone while in 19 (36%) hydronephrosis persisted after primary oncological treatment. Univariate analysis revealed that patients with persistent hydronephrosis (p = 0.025), those with urological intervention (p = 0.05) and those with high stage disease (p0.001) had statistically significantly worse overall survival. On Cox multivariate analysis only disease stage remained statistically significant (p = 0.004).Analysis of this group revealed that pediatric nonrenal abdominal and pelvic tumors are associated with hydronephrosis in about 20% of cases. Approximately 60% of these cases resolved with treatment for the primary tumor alone while 13% required specific urological intervention for urinary tract involvement or compression. Patients with pediatric malignant ureteral obstruction had a 20% 5-year mortality rate. The main predictive factor was primary disease stage.

11C-choline was postulated to provide better diagnostic capabilities than other tracers used in positron emission tomography/computerized tomography for staging urothelial carcinoma. We compared the value of using 11C-choline with the well investigated 18F-FDG tracer in this setting.The study group included 20 consecutive patients with bladder cancer who underwent evaluation for local and metastatic disease using 11C-choline and 18F-FDG positron emission tomography/computerized tomography. Patients were treated with radical cystectomy with lymph node dissection, radiation therapy or chemotherapy independent of positron emission tomography/computerized tomography results. The histopathological findings (when available), followup positron emission tomography and radiological imaging served as the reference standard. Using the paired t test we compared the maximum standardized uptake and lesion-to-background ratio of the tracers. The positive predictive values were determined.A total of 51 lesions showed abnormal tracer activity. The positive predictive value for all detected lesions was 84.7% for 11C-choline positron emission tomography/computerized tomography and 90.7% for 18F-FDG positron emission tomography/computerized tomography. The corresponding positive predictive values for extravesical lesions were 79.4% and 88.2%, respectively. Discrepant findings between the tracers were noted at 11 sites. 18F-FDG positron emission tomography/computerized tomography correctly identified 4 extravesical metastases missed by choline positron emission tomography/computerized tomography in the absence of a contrary observation. Mean maximum standardized uptake and lesion-to-background ratio at extravesical sites were significantly higher for FDG.Within the limitations of a relatively small number of patients and partial histopathological analysis, 11C-choline positron emission tomography/computerized tomography appears to have no advantage compared to 18F-FDG positron emission tomography/computerized tomography in the detection of metastatic bladder cancer. 18F-FDG positron emission tomography/computerized tomography has a tendency toward greater accuracy.

Metal ureteral stents are a relatively new version of a device with a long history of relieving ureteral obstruction. Metal stents are effective for relieving ureteral obstruction but success regarding patient tolerability has been variable. We present our single institution experience with long-term metal ureteral stent placement.The charts of patients undergoing metal ureteral stent placement for chronic ureteral obstruction were reviewed. Data collected included patient age, gender, diagnosis/cause of obstruction, laterality, duration of indwelling metal stent, number of routine metal stent changes, complications and early discontinuations or stent changes.A total of 23 patients underwent placement of metal ureteral stents between February 2008 and September 2010. Bilateral stents were placed in 5 patients and 9 underwent a yearly metal stent exchange for a total of 42 ureteral units treated with metal ureteral stents. All metal stents were placed to relieve ureteral obstruction due to ureteral stricture, ureteropelvic junction obstruction, retroperitoneal fibrosis or extrinsic malignant obstruction. There were 3 metal stent failures in 2 patients with malignant ureteral obstruction. There were no complications, or early discontinuations or changes due to adverse symptoms, patient dissatisfaction, worsening renal function or progressive hydronephrosis.Metal ureteral stents are effective for benign and malignant ureteral obstruction in the absence of urolithiasis. Good tolerability and annual stent exchange make metal stents an appealing alternative for patients with chronic ureteral obstruction treated with indwelling ureteral stents.

Ureteral patency in malignant ureteral obstruction cases is a therapeutic challenge. We report our long-term experience with palliative treatment for extrinsic malignant ureteral obstruction with percutaneous placement of metal mesh stents.From January 1996 to December 2005, 90 patients with a mean age of 59 years (range 35 to 80) with ureteral obstruction due to extrinsic ureteral compression and/or encasement by primary or metastatic tumors, or retroperitoneal lymphadenopathy underwent implantation of self-expandable metal mesh stents. A total of 119 ureters were managed. Followup included urinalysis, blood biochemistry tests and transabdominal ultrasound or intravenous urography.The technical success rate of percutaneous antegrade insertion of ureteral self-expandable metal mesh stents was 100%. Renal biochemistry normalized and hydronephrosis gradually resolved 1 to 2 weeks after stent insertion. Median followup was 15 months (range 8 to 38). Hyperplastic reaction and/or encrustation, or tumor ingrowth developed in 45 stents. Secondary intervention, such as repeat balloon dilation and coaxial stenting, was done to improve patency. Migration was observed in 13 metal stents. The primary and secondary patency rates during followup were 51.2% and 62.1%, respectively. A double pigtail or external-internal stent was inserted in 45 cases in which secondary interventions did not ensure patency.Internal drainage of extrinsic malignant ureteral obstruction with metal mesh stents provides long-term decompression of the upper urinary tract in select cases. Certain problems limit the application of metal mesh stents in the ureter. Further studies are warranted to identify independent predictors of ureteral patency after the application of metal stents for malignant obstruction.

Urachal remnants are generally treated with the open method. We evaluated the role of laparoscopy for this anomaly in a consecutive series of 27 children treated during a 12-year period.A total of 27 children with a median age of 4.7 years presented with urachal remnants between 1993 and 2006. Two different laparoscopic approaches were used. In the first 9 children a 5 mm laparoscope was inserted at the umbilicus, with working trocars in the left and right upper abdominal wall. In the remaining patients the laparoscope was placed at the left lower abdominal wall, with working ports placed at the left lower and upper abdomen. The working ports were 2 mm trocars. The urachal remnants were ligated and excised by electrocautery, and the bladder-sided stump was ligated with 2 sutures. No drains were used. The specimen were exteriorized via the umbilicus.Median operative time was 35 minutes. There were no intraoperative or postoperative complications, and no recurrences. Cosmetic results were excellent.The laparoscopic approach for urachal remnants is safe, allows for better visualization of the anatomy and yields a cosmetic result that is superior to the open approach.

Purpose: We determined the need and sequence of retroperitoneal lymph node dissection and thoracotomy in patients with nonseminomatous testicular cancer, and with residual retroperitoneal and pulmonary masses after chemotherapy. Materials and Methods: We studied 159 patients undergoing retroperitoneal lymph node dissection and a thoracotomy following cisplatin based induction chemotherapy for metastatic testicular nonseminomatous germ cell tumor. Several well-known predictors for residual histology (necrosis, mature teratoma and cancer) were evaluated. Results: As expected, necrosis was found more often at retroperitoneal lymph node dissection if the primary tumor was negative for teratoma, the residual mass was small or the decrease in size was great. Contrary, neither residual mass size nor the decrease in size was predictive of the histological status of the residual lung lesion. Histological findings in the retroperitoneum and lung were strongly correlated, such that necrosis at retroperitoneal lymph node dissection was associated with an 89% probability of necrosis in the lung. Conclusions: Retroperitoneal lymph node dissection should be performed before thoracotomy is considered, since the histological status at dissection is a strong predictor of that at thoracotomy.

We compared chest computerized tomography (CT) to chest x-ray as chest staging modalities in testis cancer patients on the basis of abdominal CT findings. We identified 92 patients who presented with negative staging abdominal CT scans and 52 with abnormal abdominal CT scans. Of these patients 42 and 32, respectively, underwent a chest x-ray and chest CT concurrently as part of the initial staging evaluation. Dictated x-ray reports were used to compare study findings. Findings on chest x-ray and chest CT were considered concordant if both studies identified similar chest abnormalities. Findings were considered discordant if either study failed to identify an abnormality noted on the other test. Patient outcome during followup, response to therapy or chest pathology was used to discriminate benign from malignant radiological abnormalities. Radiographic chest abnormalities (chest x-ray and/or chest CT) were identified in 12 of the 42 patients with negative abdominal CT scans. Three of these 12 studies represented metastasis with the remainder being benign. Imaging results were concordant in all 3 patients with chest metastasis and 5 of 9 with benign chest disease. Chest x-ray identified abnormalities not observed on chest CT in 1 patient, with chest CT identifying abnormalities not observed on chest x-ray in 3. Radiographic chest abnormalities (chest x-ray and/or chest CT) were identified in 15 of 32 patients who had a positive abdominal CT. All chest lesions identified in these patients were believed to represent metastatic disease. Chest x-ray failed to identify abnormalities present on chest CT in 4 of the 15 patients. The use of chest CT as a staging modality in abdominal CT negative patients failed to increase diagnostic sensitivity relative to chest x-ray alone. However, in 32 patients with abnormal abdominal CT scans the use of chest x-ray alone would have missed intrathoracic metastatic disease in 4. These data suggest that chest x-ray may be the preferred initial chest staging study for testis cancer patients with negative abdominal CT, while chest CT is mandated in patients with abnormal abdominal CT.

Recurrence of teratoma or carcinoma in testis cancer patients found to have teratoma at post-chemotherapy retroperitoneal lymphadenectomy is well recognized. We report a case of an intra-abdominal desmoid tumor discovered 2 years following post-chemotherapy retroperitoneal lymphadenectomy in a testis cancer patient who had teratoma at the time of lymphadenectomy. To our knowledge this is the first case of an intra-abdominal desmoid tumor discovered in this setting. The characteristics and treatment considerations of this unusual tumor are described. Desmoid tumor should be included in the differential diagnosis of tumor recurrence in testis cancer patients previously subjected to post-chemotherapy retroperitoneal lymphadenectomy.

Urinary diversion among patients receiving prior radiation is common. Herein, we present our experience with ileal conduit (IC) diversion in patients with a history of prior abdominal and/or pelvic radiation therapy. We analyzed the charts of 177 patients who underwent IC urinary diversion between 1/1994 and 6/2000, and 36 patients were identified who had previously undergone radiation therapy. Decisions to proceed were based on surgeon preference as determined by intraoperative appearance and viability of the selected bowel segment. Chart review included serum studies, upper tract imaging studies, and complications related to diversion. Durability of diversion was determined by examining the interval between urinary diversion and the need for additional procedures. A total of 30 patients with at least 3 months follow-up were identified. Renal function remained stable in 86% (26/30) with a median follow-up of 21.5 months (range 3-63 months). Hydronephrosis was noted preoperatively in 4 patients (13%) who demonstrated stable upper tracts and serum creatinine in the post-operative period. Three patients (10%) developed unilateral hydronephrosis related to tumor recurrence, with one patient demonstrating a rise in baseline serum creatinine. Hydronephrosis was noted in 5 patients (16%) secondary to development of ureteroenteric stricture. Serum creatinine remained stable in 2 patients without intervention with 2 years follow-up. Intervention for obstruction was necessary in 3 patients at 22, 31, and 61 months following diversion. In one patient, an intraoperative decision to use the colon for urinary diversion was made secondary to appearance of small bowel. Minor complications were noted in 9 patients (30%), while 3 patients (10%) experienced major complications in the immediate post-operative period. Five patients (17%) experienced complications potentially related to the use of ileum for urinary diversion. The use of ileum for urinary diversion among patients with a history of radiation appears technically feasible and a viable treatment alternative. Our data support the use of ileum in the majority of patients as evidence by a low complication rate and a high rate of upper tract preservation. In addition, these data imply that a prior history of abdominal and/or pelvic radiation should not serve as the sole determining factor in the selection of bowel segment utilized during urinary diversion.

In vivo studies on human malignant tumors are limited because of a lack of suitable animal models. In this study, the usefulness of SCID (severe combined immunodeficiency) mice, deficient in functions of both T- and B-lymphocytes, was evaluated. Inbred SCID mice were kept in isolated cages and 2 × 10 7 cells of KU-7, an established bladder carcinoma cell line, were inoculated in the subcutaneous tissue of the flank region of six SCID mice. Athymic nude mice were inoculated by the same method and served as the controls. The KU-7 cells were taken within 14 days in the injected region in all six SCID mice, while in only five out of eight nude mice. Tumors subsequently formed at the site of inoculation in these mice were confirmed to be transitional cell carcinomas histologically and intra-abdominal metastases were noted in two SCID mice. We conclude that SCID mice provide an ideal in vivo model for experimental studies of human urologic malignant tumors.

Radiation nephritis is a process of necrosis, atrophy and sclerosis that follows exposure of the kidney to ionizing radiation. Experimental studies with electron microscopy demonstrate that this process begins as degeneration of the glomerular endothelium and the tubular epithelium, and their basement membranes, leading to collapse of these structures and the development of interstitial fibrosis. Rather late and complicating events are necrosis and thrombosis of arteries and arterioles, contributing to the destruction of the renal parenchyma. The process is the same with large doses (5,000 to 10,000 rads) and with medium doses (1,000 to 3,000 rads), the only differences being the extent and the speed with which the lesions develop and the frequency of arterial necrosis.

In the evaluation of the morbidity associated with ileal conduit urinary diversion in children, a retrospective analysis of the complications in 125 such children was done. When retroperitoneal Penrose drainage was used or when additional surgical procedures were performed, a significantly increased number of early postoperative complications were found. Conversely, when peristomal skin preconditioning was accomplished or when a single layer ureteroileal anastomosis was constructed, postoperative morbidity was markedly reduced. Ileal conduit urinary diversion remains the most satisfactory method of permanent urinary diversion in children.

Our experience in treating 13 patients with bladder tumors involving the abdominal wall is presented. A technique is described wherein part of the suprapubic abdominal wall is excised and the resultant defect is closed with ox fascia. Of the 9 patients treated surgically 8 have had no local recurrence but distant metastases have developed. Presently 2 patients are clinically free of disease, 18 and 22 months after abdominal wall excision. One of these 2 patients required a subsequent groin dissection and was then lost to followup.

Pathologic confirmation of soft tissue metastases is necessary for staging and followup of patientswith cancer of the prostate. Fine needle aspiration with cytologic evaluation is recommended over other biopsy procedures because it is safe, accurate and applicable to deep and superficial lesions. Small metastases, such as lymph nodes or skin nodules, remain in situ as useful tumor markers to follow the course of the disease and response to treatment.

The key to correct diagnosis of abdominal masses in children is awareness of all the possibilities. Three children with abdominal masses of uncommon urologic origin are described. The lesions were adrenal cortical carcinoma, a pancake pelvic kidney and a non-functioning hydronephrotic segment of a horseshoe kidney. Management of these patients is discussed and the literature is reviewed.

We report 2 cases of metastatic seminoma to emphasize the use of computed tomography in defining accurately the extent and volume of tumor before treatment. Computed tomography permits more direct visualization of the retroperitoneum, mesenteric and abdominal lymph nodes, and extra nodal extension of the tumor to other organ systems. Additionally, characteristic tissue densities are displayed (that is cyst and hemorrhage), which may serve as an index to the dynamics of tumor growth and change. Lymphography and venacavography are invasive studies and both share inherent limitations in imaging for seminoma. Cross-sectional imaging is more precise in describing treatment fields for radiation therapy. Results of treatment are monitored more confidently with computed tomography.

During an 8-year period 63 consecutive patients were treated for the first time for extensive metastatic nonseminomatous testicular cancer. Four patients did not respond sufficiently to chemotherapy to be considered surgical candidates, while 59 underwent surgical resection of retroperitoneal disease. Of these 59 patients 19 had concomitant wedge resection of associated pulmonary disease and 9 had a planned subsequent resection of residual pulmonary disease. Of the 63 patients 16 had stage B3 disease alone and 47 presented with pulmonary metastases associated with varying degrees of retroperitoneal disease. The most important determinant for survival was extent of pulmonary disease. Of 17 deaths 14 occurred among patients presenting with extensive pulmonary disease. Patients with minimal to moderate pulmonary disease have done well regardless of the extent of coexistent abdominal disease, 24 of 27 (89 per cent) remaining in sustained complete remission. Of 16 patients with massive palpable abdominal disease (B3) without coexistent pulmonary metastases 15 (94 per cent) survived free of tumor. The combination of extensive pulmonary and abdominal disease with or without liver involvement has a poor prognosis, with only 35 per cent of these patients remaining in sustained complete remission. Preoperative combination chemotherapy with platinum, vinblastine sulfate and bleomycin has improved survival free of tumor in this group compared to other combinations not including platinum (47 compared to 20 per cent) but the results in this selected group of patients are significantly worse than those seen for all other patients with lesser extent of disease. Tumor recurrence more than 9 months after achieving complete remission has not been noted during following to 10 years. A plea is made for cases of advanced disease (B3 and/or C) to be reported according to the extent of pulmonary disease as well as the associated abdominal disease, since analysis of these data reveals striking differences in patient survival, ranging from 100 to 35 per cent according to subgrouping.

An analysis of 62 palliative urinary diversions for malignant ureteral obstruction is presented. The average postoperative survival was 187 days. Cell type, duration of known disease, tumor grade and stage, renal function and previous therapy did not strongly influence survival. Renal function returned to normal in 64 per cent of the azotemic patients. Morbidity and mortality rates were high, largely because of underlying disease and adjuvant therapy. Nearly two-thirds of the patients left the hospital and this group subsequently spent 84 per cent of their remaining survival time at home. A criterion is presented for patient selection and suggestions are made for the selection of an operative procedure.

A huge abdominal mass developed 4 years after successful chemotherapy and laparotomy for stage III embryonal testicular cancer. Complete surgical extirpation proved that this lesion was a desmoid tumor of the abdominal wall and not a recurrent germ cell neoplasm. Fortunately, this mass was excised and not treated by aggressive chemotherapy.

A 3-year-old boy underwent an operation for a right undescended testis. A small, elastic, hard mass attached loosely to the spermatic cord was noted in the inguinal canal away from the testis and epididymis. Pathological examination of this mass revealed mesonephric remnant tissue.

A total of 7 boys 4 to 10 years old was evaluated for undescended testes. All patients had been seen previously by a pediatric urologist and diagnosed as having a retractile testis. In fact 4 boys had undergone surgical correction of a contralateral undescended testis at an earlier date at which time the testis in question could be manipulated into the scrotum. Another boy was examined under anesthesia and the operation was canceled because the testis could be brought into the scrotum. Subsequently, on followup evaluation 2 to 8 years later the ipsilateral testis could not be manipulated into the scrotum. Of the boys 6 then were treated with a short course of human chorionic gonadotropin. Four patients had a positive response but in 3 the testis was undescended again at examination 6 months later. Of the boys 6 ultimately underwent orchiopexy. Boys with highly retractile testes require periodic examination until puberty to ensure that those testes do not ascend secondarily.

The first case of endometriosis involving the abdominal wall and bladder secondary to hysterotomy is reported. The symptomatology, cystoscopic findings and treatment are discussed.

Although rarely reported, neuroblastoma in monozygotic siblings merits attention because study of its features may aid in elucidating mechanisms of tumorigenesis. We describe disseminated neuroblastoma in one of monozygotic triplets, including both documentation of monozygosity and long-term follow-up of the unaffected co-twins. Information from reports of monozygotic twins concordant and discordant for neuroblastoma reinforces the hypothesis that hereditary factors may be predominant in neuroblastoma diagnosed in infants, whereas nonheritable random mutational genetic events may be more important in neuroblastoma diagnosed after infancy.

Neuroblastoma is a common solid tumor of childhood. Maturation to a ganglioneuroma or regression has been reported to occur spontaneously or following minimal treatment. Malignant degeneration of such a ganglioneuroma is extremely rare. We present a report of a malignant tumor arising in a ganglioneuroma 19 years following abdominal radiation therapy for neuroblastoma.

We report a case of testicular ectopia, which represents the first instance of an ectopic testicle located cranial and lateral to the internal ring between the external and internal oblique musculature.

The use of total parenteral nutrition (TPN) in patients with advanced, untreatable cancer is controversial. Occasionally, however, damage to bowel by tumor, radiation, or surgery renders these patients unable to eat and TPN may be indicated to prevent premature death from starvation. We have used Home Parenteral Nutrition (HPN) to support three patients with advanced, untreatable abdominal cancer and inability to eat. Morbidity was minimal and survival times were 24, 6 and 1.5 months. Payment was covered by third party agencies. All patients and their families were gratified by the ability to return home with nutritional support. HPN can be used to support terminal cancer patients with bowel obstruction and may afford them longer survival. Ideally, patients considered for this should be well motivated, with good support systems, and with survival estimated to be at least months.

Lipoblastoma is a rare benign neoplasm of fetal-embryonal fat tissue with a 14% tendency to recur. It occurs almost exclusively in infants and children. To my knowledge, less than 100 cases, including children and adults, have been reported in the English literature. Two retroperitoneal and one case of mesenteric lipoblastoma, all presenting as a large palpable abdominal mass, are described. Our patients, aged 12 years, 7 months, and 11 months, were treated by total surgical excision of the tumors. They are alive and well 5, 4, and 3 years postoperative, respectively, with no evidence of recurrence and no indication for any adjunctive therapy. Pathologic evaluation was decisive for the best treatment and prognosis.

Polycythemia is rarely associated with pheochromocytoma. A patient with a 22-year history of malignant pheochromocytoma is presented in whom major complications developed as a result of long-standing polycythemia, apparently due to secretion of erythropoietin by the tumors. Despite attempts to reduce tumor burden by surgery, chemotherapy, and large doses of I-131-metaiodobenzylguanidine, polycythemia persisted. Extensive venous thrombosis developed requiring hospitalization and anticoagulation. Thus, polycythemia itself may be a cause of major morbidity in patients with pheochromocytoma, and prophylactic measures may be warranted. Review of the 130 patients with benign and malignant pheochromocytoma studied since the introduction of I-131-metaiodobenzylguanidine in 1980 revealed another six patients with hematocrits over 50 but only one had a hematocrit greater than 55 and required regular phlebotomy. In contrast, anemia (hematocrit less than 35) due to variety of causes was present in 18 cases.