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Parapelvic cysts originate in the renal parenchyma and extend into the renal sinus. A series of 3 patients with symptomatic obstructing parapelvic cysts is described, 2 with acute presentations, and 1 with chronic symptoms. In 2 of the 3 cases, there was a significant delay in establishing a diagnosis. Although one individual was successfully managed by image-guided cyst aspiration, the second patient required repeated aspiration due to cyst re-accumulation. A high index of clinical suspicion and a combination of imaging modalities, including serial ultrasound, excretory-phase CT, and MAG3 renogram, are necessary to establish the diagnosis and monitor response to treatment., (© 2017 S. Karger AG, Basel.)

Objective: To determine the impact of earlier ureteral ligation (EUL) during hand-assisted retroperitoneoscopic nephroureterectomy (HARN) for primary renal pelvis urothelial cancer., Methods: We retrospectively reviewed 240 patients with upper urinary tract urothelial cancer who underwent HARN. Only patients with primary renal pelvis urothelial cancer and complete follow-up with a minimum of 1 year after HARN were enrolled into our study. We defined EUL as ligating the ureter prior to pneumoretroperitoneum and mobilizing the kidney during the surgery. Of these 61 patients, 31 (who composed the study group) underwent EUL, while 30 serving as controls were without ureteral ligation during the surgery. We analyzed intravesical recurrence utilizing log rank testing to assess the significance between the two groups., Results: Clinical parameters were similar between the two groups. The median follow-up after HARN was 39.7 months (range 12-96). There was no significant difference in the rate of intravesical recurrence and cancer-specific survival. However, patients without ligation of the ureter had shorter time to first bladder tumor recurrence (11.7 ± 9.1 months vs. 26.4 ± 19.1 months, p = 0.03)., Conclusion: EUL during HARN for primary renal urothelial cancer did not affect intravesical recurrence rate or cancer-specific survival., (Copyright © 2013 S. Karger AG, Basel.)

Objective: Our aim was to evaluate the biopsy quality of upper urinary tract urothelial transitional cell carcinoma with a new biopsy forceps (BIGopsy®, Cook Medical) compared to a classic biopsy forceps (Piranha®, Boston Scientific)., Patients and Methods: From December 2009 to December 2011, 20 patients with upper urinary tract urothelial transitional cell carcinoma underwent conservative treatment endoscopically. All lesions were evaluated and biopsied with 3 Fr cup forceps using both types of forceps (BIGopsy and Piranha). A single pathologist blindly analyzed the specimens in order to determine the optimal biopsy for each patient. Specimen histopathology results were graded; however, they were staged if the lamina propria was not invaded (T1) or if the tumor was detected at the lamina propria (T1+)., Results: Of the 20 upper urinary tract lesions, 12 (60%) were in the renal pelvis, 3 (15%) in the upper calyx, 1 (5%) in the middle calyx, 1 (5%) in the lower calyx, 1 (5%) in the upper third of the ureter and 2 (10%) in the middle third of the ureter. We did not detect T1 in all biopsies. One patient had no valid biopsies by both forceps. A diagnosis of urothelial carcinoma was made in 17 BIGopsy biopsies compared to 7 Piranha biopsies., Conclusion: Despite the limited number of cases, our study demonstrated the advantage of the new forceps (BIGopsy) in obtaining a valid biopsy of upper urinary tract urothelial tumors. Therefore, we recommend it in evaluating this pathology for optimal treatment., (© 2014 S. Karger AG, Basel.)

Benign tumors of the proximal ureter are very rare. Many of them could be confused with urothelial carcinoma and unnecessarily treated by nephrectomy. In this case, we present the treatment of a lymphangioma localized in the upper ureter, which is an example of benign tumor. During treatment percutaneous tumor resection, an organ-sparing approach, was employed., (Copyright © 2012 S. Karger AG, Basel.)

Aims: We investigated the patterns of failure and prognostic factors for locoregional control (LRC) in patients with upper urinary tract (UUT) transitional cell carcinoma (TCC) treated with radical surgery to evaluate the role of adjuvant radiotherapy., Materials and Methods: We retrospectively reviewed the medical records of 76 patients with TCC of the renal pelvis and ureter without distant metastasis who underwent curative-intent surgery. No locoregional or distant failure occurred in 19 patients with pTa-1 tumor, and we evaluated patterns of failure and prognostic factors in 57 patients with pT2 or more tumors. Adjuvant chemotherapy was applied in 25 patients., Results: Recurrences occurred in a total of 23 patients, and 20 of these experienced some kind of locoregional failure during follow-up. The overall crude and initial isolated locoregional recurrence rates were 35 and 28%, respectively. In pT2 patients, all 4 recurrences were isolated locoregional recurrences, and 3 of them were successfully salvaged with chemoradiotherapy. Patients with pT3-4 or who were positive for nodal disease (N+) had a lower rate of LRC and worse prognosis after recurrences. On multivariate analysis, incomplete surgery, venous invasion and squamous metaplasia were identified as independent prognostic factors for LRC., Conclusions: Initial loco-regional recurrence was commonly detected by routine computed tomography in locally advanced UUT-TCC. Incomplete surgery, venous invasion and squamous metaplasia were independently associated with poor LRC. Active postoperative adjuvant treatment such as concurrent chemoradiotherapy could be considered in pT3-4 or N+ patients with adverse risk factors., (Copyright © 2012 S. Karger AG, Basel.)

Plasmacytoid urothelial carcinoma of the bladder represents a rare and aggressive variant of urothelial carcinoma, which is usually diagnosed at an advanced pathologic stage. Until now, no reports exist on this rare tumor type in the upper urinary tract. Herein, we present the first report on the clinical course of a metastatic plasmacytoid urothelial carcinoma of the renal pelvis and show its unfavorable outcome despite multimodal therapy., (Copyright © 2012 S. Karger AG, Basel.)

Verrucous carcinoma (VC) is a rare variant of squamous cell carcinoma (SCC) with an extremely well-differentiated microscopic appearance. It is able to show extensive local invasion, but practically never metastasizes. VCs mostly occur in the oral cavity, larynx, nasal cavity, esophagus, vulva, vagina, anorectal region, penis and skin. VCs sometimes coexist with conventional SCCs, and in these instances they are associated with a higher recurrence rate than pure VCs. The occurrence of VC in the renal pelvis is very rare and to date only 4 cases have been reported. We report here a case of VC with a focus of conventional SCC in the renal pelvis. The patient showed fistula formation by residual tumor in the follow-up period., (Copyright © 2011 S. Karger AG, Basel.)

Primary adenocarcinoma of the renal pelvis is rarely reported in the literature. Here we present a case of primary mucinous adenocarcinoma of the renal pelvis with elevated serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels. A 56-year-old woman was referred to our center with intermittent fever and left-sided back pain for 1 month. Computed tomography showed bilateral nephrolithiasis, mild right hydronephrosis and left pyonephrosis accompanied with ambiguous soft tissues. A radionucleorenogram showed that the glomerular filtration rate of the left and right kidney was 0 and 79 ml/min, respectively. Left nephrectomy was performed without lymph node dissection. Histopathology revealed mucinous adenocarcinoma and elevated serum CEA and CA19-9 levels were found. She died of multiorgan metastasis after 5 months. A review of the literature is also reported., (Copyright © 2011 S. Karger AG, Basel.)

Objectives: The aim of this experimental study was to assess the possibility of decreasing the size of the ureteral stents used after an endopyelotomy. To this end, an experimental study was performed which compared a ureteral double-J wire stent versus a standard 7F ureteral stent after endopyelotomy., Methods: Twenty healthy female pigs were randomly divided into 2 groups: group I (double pigtail ureteral stent 7F) and group II (lumenless ureteral double-J wire stent, Zebrastent™, 0.035 inches in diameter). Percutaneous, endoluminal ultrasonographic and fluoroscopic studies were analyzed during the 3 different phases of the study. The first phase included premodel documentation of normal urinary tracts and laparoscopic ureteropelvic junction (UPJ) obstruction induction. During the second phase, 6 weeks later, diagnosis and endopyelotomy were carried out. Sixteen weeks after the obstruction treatment, follow-up imaging studies and postmortem evaluations of all animals were performed., Results: After the sonographic and fluoroscopic assessments, we determined the success rate for each group: 80% for group I and 90% for group II. No significant statistical differences were evident in the evolution of the diameter of the UPJ between groups. Better healing of the UPJ and a lower level of retroperitoneal repercussions were seen in group II., Conclusions: The ureteral double-J wire stent (Zebrastent) has been shown to be highly effective after endopyelotomy. This means that it is possible to reduce the size of ureteral stents after endopyelotomy with the advantages that this entails. Double-J ureteral stents probably act as a scaffold rather than a mold., (Copyright © 2010 S. Karger AG, Basel.)

Background: Obstructive uropathy is argued to involve an ischemia-type tissue injury. Further, hypoxia-inducible factor 1 alpha (HIF-1 alpha) constitutes a nuclear transcription factor normally upregulated under hypoxic conditions. We hypothesized that HIF-1 alpha is expressed in the hydronephrotic renal pelvis, as a result of tissue hypoxia., Patients and Methods: Renal pelvis tissue specimens were obtained from 2 patient groups. Group 1 (controls, n = 10) consisted of patients who underwent nephrectomy due to nonobstructive renal malignancy. Group 2 (n = 18) consisted of patients who underwent open procedures due to intractable hydronephrosis, not amenable to conservative measures. HIF-1 alpha detection was conducted via immunohistochemical techniques, while histological alterations in both groups were also recorded., Results: Smooth muscle hypertrophy and urothelial hyperplasia were major findings in group 2. HIF-1 alpha-positive cells (fibroblasts and occasionally macrophages), mainly localized in the stroma, were also found to a greater extent in group 2 (p = 0.0066)., Conclusion: We conclude that HIF-1 alpha is mainly expressed in stroma fibroblasts of the hydronephrotic renal pelvis, implying the presence of significant tissue hypoxia at the dilated upper urinary tract., ((c) 2009 S. Karger AG, Basel.)

Introduction: The association between staghorn calculus of the kidney long-standing and urothelial tumors of the renal pelvis is well documented. We describe 3 patients with urothelial cancer in a kidney who underwent percutaneous nephrolithotomy (PCNL)., Patients and Methods: Retrospective analysis of our series of more than 500 PCNLs revealed 3 patients in whom urothelial cancer of the renal pelvis was diagnosed during or following percutaneous stone removal. Preoperative assessment included IVP, renal sonography and renal scan using DTPA in all 3 patients, and CT in 2 patients. Imaging did not raise the suspicion of a neoplastic lesion., Results: All patients had a long history of urolithiasis and urinary infections. No patient was diagnosed preoperatively. One patient was diagnosed postoperatively, when a CT demonstrated a renal lesion. The second patient underwent simple nephrectomy due to a non-functioning kidney, and the tumor was found on pathological analysis. In the third patient, biopsies were taken from a suspicious-looking tissue in the renal pelvis during the PCNL session. All patients had transitional cell carcinoma: 1 associated with sarcomatoid features and 1 with squamous carcinoma. They all died from metastatic disease 2-19 months after the diagnosis of urothelial cancer., Conclusions: The preoperative diagnosis of urothelial cancer in patients with staghorn stones is difficult due to the existing stone and inflammation. Since the prognosis of urothelial cancer is extremely poor, biopsies of the renal pelvis, obtained directly through the nephroscope during the PCNL session, may be the only key for early diagnosis and treatment. A high index of suspicion should be raised when patients suffering from infected staghorn calculi are encountered, and such intraoperative biopsies should be considered., (2005 S. Karger AG, Basel)

Introduction: Patients with ureteropelvic junction obstruction occasionally remain undiagnosed until adulthood. There are no objective criteria to predict the results of pyeloplasty in adult patients. We have evaluated the results of pyeloplasty in adult patients and investigated whether these results are correlated with the histopathology of the surgical specimen., Materials and Methods: Histological sections from 26 patients with ureteropelvic junction obstruction were analyzed. Their mean age was 25.1 years. Diethylenetriamine-pentaacetic acid scans were used to determine the degree of renal obstruction and postoperative healing. Improvement in diuretic renography was defined as a greater than 20% decrease in the half-time of the preoperative value. To examine smooth muscle and collagen tissue, sections were stained using Masson's trichrome. Smooth muscle ratio was identified by color image analysis., Results: 18 patients (69.2%) fulfilled the criteria of healing. Patients with an improved scan had a mean smooth muscle percent (SMP) of 1.85+/-0.87 while subjects with no significant change in their diuretic scans had a mean SMP of 0.36+/-0.03 (p=0.001). There was a strong correlation between the SMP and the improvement., Conclusions: Adult pyeloplasty was found successful in about 70% of the cases. The SMP of the renal pelvis seems to be helpful in predicting the surgical outcome., (copyright 2004 S. Karger AG, Basel)

The occurrence of mucinous metaplasia of the renal pelvis in the absence of an associated malignancy is quite uncommon. We report a case of mucinous metaplasia of the renal pelvic epithelium without an associated squamous metaplasia in a 40-year-old male with history of recurrent left renal calculi and urinary tract infections since the age of 10 years., (Copyright 2004 S. Karger AG, Basel)

A primary low-grade lymphoma of mucosa-associated lymphoid tissue arising from the renal pelvis is extremely rare. We present a 77-year-old man with this disease which was difficult to diagnose preoperatively., (Copyright 2002 S. Karger AG, Basel)

Fifty-three patients with invasive transitional cell carcinoma of the renal pelvis and ureter were studied for p53 protein overexpression by immunohistochemistry. Overexpression of p53 protein was observed in 19 patients (35.8%). There was a significant correlation between overexpression of p53 protein and histologic grade (p < 0.01). However, there was no correlation found between p53 immunoreactivity and pathologic stage. By univariate survival analysis, a significant difference in cumulative survival was observed between stage pT2 and stage pT3 or pT4 tumors (p < 0.05). The difference in survival between patients with p53-positive and negative tumors did not reach statistical significance (0.05 < p < 0.01). Multivariate analysis revealed that pathologic stage had an independent prognostic value (p < 0.05). The independent prognostic value of p53 protein overexpression did not quite reach statistical significance (p = 0.07). p53 protein nuclear overexpression appears to be a relatively weak prognostic indicator for patients with invasive transitional cell carcinoma of the renal pelvis and ureter.

To investigate the pathogenicity of the hyphal form of Candida in pyelonephritis a Candida albicans strain, assuming only the yeast form but not the hyphal form when induced by ultraviolet mutagenesis, and a revertant strain from this mutant strain showing bimorphism were compared in a rat experimental model with regard to the incidence of ascending Candida pyelonephritis and the grade of inflammation. To increase the frequency of pyelonephritis unilateral incomplete ureteral stenosis was created. The revertant strain assuming the hyphal form showed a significantly (p < 0.01) higher frequency of pyelonephritis as compared with the mutant strain not assuming this form, and the grade of inflammation was also higher in the revertant strain group. Also, higher renal tissue and serum levels of both lipid peroxide and superoxide dismutase, which are related to marked renal oxidant injury, tended to be correlated with the degree of neutrophil infiltration in the acute phase. These findings suggest that the hyphal form plays an important role in the development of C. albicans pyelonephritis and also that the oxygen radicals from neutrophils appearing at the sites of inflammation play a major part in the further extension of inflammatory lesions.

In unilateral kidney disease, it has been suggested that the ipsilateral state could be estimated by measuring contralateral kidney size; thus, a contralateral increase should reflect an ipsilateral impairment and vice versa. This could easily be performed using ultrasound. In our experiments with partial obstruction of one ureter (created in 1- to 3-day-old rats), a consistent and stable contralateral kidney hypertrophy occurred. However, after unobstruction, the hypertrophy persisted for at least a 6-week observation period, despite the disappearance of hydronephrosis and presence of a normal weight of the ipsilateral kidney. This would undeniably hamper the diagnostic utility of kidney size determination. To find out whether or not the hypertrophy ever disappears, we have performed studies after 6, 9 and 15 weeks. (1) The weight of the unobstructed kidney was found normal except after 15 weeks. The microstructure was normal except for some minor changes. (2) The contralateral kidney was significantly heavier than controls at all checkpoints (+10, +13 and +6%). No significant regression occurred over the observation period. (3) Furthermore, the weights of both kidneys were interrelated, but the slopes were positive; thus, the contralateral hypertrophy was not greater the lesser the ipsilateral kidney weight. The reasons for the persistence of contralateral hypertrophy are discussed. The present findings do not support the idea of documenting improvement by measuring contralateral kidney size. However, repeat studies in the same individual may prove to be more sensitive and are therefore recommended until further notice.

Benign tumors in the renal pelvis are unique and rarely reported. We report a case of a benign polyp in the renal pelvis. A 68-year-old woman presented with a mass in the right renal sinus and underwent right nephrectomy. Histological investigations of the tumor revealed a polypoid angiofibromatous lesion of the renal pelvis which was benign in nature. Final pathological diagnosis was a benign fibroepithelial polyp.

Xanthogranulomatous pyelonephritis (XPN) is an uncommon, but not rare, type of bacterial infection of the kidneys. Malignancies originating within the renal pelvis are uncommon. We report a case of XPN associated with a transitional cell carcinoma (TCC) of the renal pelvis in a 70-year-old woman. The pathogenesis of carcinoma of the renal pelvis in the presence of XPN is related to obstruction, chronic inflammation, and mechanical irritation caused by calculi. In the case reported here, obstruction was due to a concomitant TCC of the ureter without the presence of calculi. A review of the twelve published case reports of XPN with TCC of the renal pelvis, including the present case, showed that the frequency of this association is 3.3%, the average age at presentation is 65.3 (range 49-78) years, and that the male:female ratio is 2:1. Moreover, 25% of the patients had TCC of the ureter and 8.3% TCC of the bladder. The combination of XPN, TCC of the renal pelvis, and lithiasis occurred in 33.3% of the cases. XPN must be treated by nephrectomy not only because it is a destructive inflammatory process leading to complete loss of renal function, but also because the kidney may be harboring a malignant tumor.

Extremely rarely renal cell carcinoma metastasizes to the contralateral renal pelvis or ureter. The present report concerns a case where a metastatic tumor could be successfully removed from the left renal pelvis 3 years after right nephrectomy for the primary tumor. A review of the literature revealed this to be only the fourth such case documented.

Two rare cases of urothelial tumor with high serum carcinoembryonic antigen (CEA) and TA-4 levels are presented. One is a case of lymph node metastasis due to bladder tumor: pathological diagnosis revealed mucoepidermoid carcinoma. The other is a case of left renal pelvic tumor: pathological diagnosis revealed transitional cell carcinoma with glandular and squamous differentiation. The serum CEA and TA-4 levels, high before surgery, decreased after surgery.

Histological investigation of ureteropelvic junction (UPJ) specimens of 21 patients with congenital hydronephrosis revealed in 7 instances pathological changes, which might be responsible for the obstruction. In 15 cases a significant increase of collagenous tissue within the UPJ, along with a relative deficiency of monocytes was noted. Each of the smooth muscle fibers was surrounded by fibrous tissue, which caused interruption of the "nexus" function and therefore loss of muscle contractions. The inability of normal muscle contractions within the UPJ might be a contributing factor to the pathogenesis of congenital hydronephrosis.

A 75-year-old woman with transitional cell carcinoma of the renal pelvis was revealed to have sarcoid granulomas within the kidney as well as in the renal pedicle lymph nodes. Furthermore, noncaseating granulomas had been found in the pelvic lymph nodes in a histological study following previous total cystectomy for bladder cancer. The association of sarcoidosis with genitourinary malignancies is briefly discussed.