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A 69-year-old man was admitted to our hospital with a chief complaint of lymphatic edema of left arm. He had a past history of transurethral resection of the bladder tumor 5 years ago, and pathological diagnosis was urothelial carcinoma with micropapillary variant, G3 = G2, pT1. CT scan revealed bladder tumor with invasion of the rectum, and multiple lymph nodes swelling in the axilla, retroperitoneum and pelvis (cT4bN3M1). The patient underwent biopsies of the bladder wall and the left axillary lymph nodes, and pathologic examination revealed micropapillary carcinoma. Five courses of gemcitabine plus cisplatin (GC therapy) were perfomed, and bladder tumor and lymph node metastases reduced remarkably, with serum CA19-9 level decreasing from 172,000 U/ml to 106 U/ml. However, the patient died from recurrence 23 months after the start of GC therapy.

The patient was a 77-year-old man who underwent radical cystectomy and ileal conduit urinary diversion due to bladder cancer in 1989. A stenosis of the right uretero-ileal anastomosis occurred in 1992, and of the left uretero-ileal anastomosis in 1999. These were treated with indwelling of a ureteral stent and percutaneous nephrostomy, respectively. He was admitted to our hospital for progressive renal dysfunction due to frequent pyelonephritis. We performed a reconstruction of the ileal conduit urinary diversion and after the removal of the bilateral ureteral stent he complained of nausea and general malaise. The laboratory data showed hyponatremia, hyperkalemia and azotemia, which were diagnosed as complication liked jejunal conduit syndrome. He was treated with hydration and salt supplementation. With regard to this case, we considered that a long ileal conduit close to the jejunum and renal dysfunction caused the complication liked jejunal conduit syndrome. Careful observation and follow-up laboratory examination should be performed if the patient has renal dysfunction and a long conduit near the jejunum is used for the ileal conduit.

Purpose: We investigated whether verapamil (VR), a known chemosensitizing agent of P-glycoprotein-mediated multidrug resistance, could enhance the preventative effect of doxorubicin (Adriamycin, ADM) on both intravesical recurrence and disease progression after transurethral resection (TUR) of superficial bladder cancer. Methods: The patients were randomized into two groups: one group received an intravesical instillation of ADM (30 mg) plus VR (15 mg) after TUR of superficial bladder cancer (19 times over 1 year), and the other group received ADM alone on the same treatment schedule. The nonrecurrence rate, the incidence of disease progression at the first recurrence and the side effects were compared over a median follow-up of 38.5 months. Results: Of the 226 patients registered, 157 were evaluable. No significant differences were observed in the patients' characteristics between the two groups. Although the incidence of disease progression at the first recurrence was not significantly different between the two groups, the ADM plus VR instillation group did show a significantly higher nonrecurrence rate than the ADM-only instillation group, and such significance persisted even when any possible bias was allowed for in a multivariate analysis. In terms of side effects, the incidence and severity of bladder irritation symptoms were not significantly different between the two groups. Conclusions: Intravesical instillation chemotherapy with ADM plus VR was found to have a significantly greater beneficial effect than with ADM alone for preventing recurrence after TUR of superficial bladder cancer.

Background Radical nephrectomy is the standard therapy for low-stage renal cell carcinoma. However, recurrence sometimes develops even in patients who are considered to have undergone a curative resection of the primary tumor. The purpose of this study was to evaluate the usefulness of UFT (a 1: 4 mixture of tegafur and uracil) adjuvant and the risk factors for recurrence in renal cell carcinoma. Methods A prospective randomized trial was conducted to compare the use of long-term oral UFT adjuvant with nonadjuvant therapy after a radical nephrectomy for Robson stage I or II renal cell carcinoma. A multivariate analysis was also performed to estimate the risk factors for recurrence. Results A total of 71 patients were entered into this study, and 66 were evaluable (33 for each group). There was no significant difference in patient characteristics between the 2 groups. The nonrecurrence rate at 5 years after a radical nephrectomy was 80.5% and 77.1% in the UFT adjuvant group and the nonadjuvant group, respectively, with a median follow-up of 112.9 months; the difference was not significant. The toxicity of UFT was generally mild and tolerable. The tumor grade was found to be an important factor influencing recurrence. Conclusion UFT cannot be universally recommended as an adjuvant therapy for radical nephrectomy in all patients with low-stage renal cell carcinoma.

We report the first case of angiosarcoma in the kidney occurring in a woman; the tumor was initially believed to be renal cell carcinoma. This malignant tumor was discovered in a patient with macrohematuria. The final diagnosis was confirmed by histologic and immunohistochemical findings. A review of the literature on this tumor is also included in the discussion.

The present study was designed to determine whether the administration of free radical scavengers, superoxide dismutase (SOD), catalase or dimethylsulfoxide (DMSO) is able to ameliorate ischemia/reperfusion injury in the canine kidney and also ascertain whether or not a relationship exists between oxygen free radicals and membrane-bound Na(+)-K(+)-ATPase activity. In 23 dogs, the vascular pedicle of the left kidney was clamped for 75 min at room temperature. The experimental animals received free radical scavengers for 30 min starting at 2 min prior to reperfusion. Renal tissue specimens were enzyme-histochemically examined regarding the activity of membrane-bound Na(+)-K(+)-ATPase, and a marked reduction just before reperfusion was revealed. The SOD- and the DMSO-treated groups showed a marked recovery of the membrane-bound Na(+)-K(+)-ATPase activity; however, the untreated and the catalase-treated groups still demonstrated a marked reduction 1 day after reperfusion. At the same time, widespread acute tubular necrosis in the cortex was observed in the untreated and catalase groups in comparison with the SOD and the DMSO groups. In addition, the SOD and the DMSO groups significantly preserved better renal function. Based on these findings, it was thus concluded that free radical scavengers ameliorate the recovery of depressed membrane-bound Na(+)-K(+)-ATPase activity and ischemia/reperfusion injury in the canine kidney.

A total of 29 patients with advanced renal cell carcinoma entered a pilot study of combination therapy with interferon alpha (IFN-alpha) and interferon gamma (IFN-gamma). IFN-alpha (HLBI: 3 x 10(6) IU, BALL 1:5 x 10(6) IU, IFN-alpha-2a: 9 x 10(6) IU or IFN-alpha-2b: 6 x 10(6) IU) was given intramuscularly every day and IFN-gamma (IFN-gamma-1a: 3 x 10(6) JRU) was given intravenously by drip infusion 3 times a week (every 2-3 days). The treatment was continued for 3 months as the induction therapy, and then the tumor response was evaluated. Of the 22 evaluable patients, 4 achieved a partial response (PR), 10 showed no change (NC), and in 8 the disease had progressed (PD) during the therapy. Thus, the overall response rate was 18.2% [95% confidence interval (CI) 2.1-34.3%]. A favorable response tended to be obtained in patients with good performance status or small pulmonary metastases, or in those who had no prior therapy with IFN-alpha, who received this treatment immediately subsequent to radical nephrectomy, or who received IFN-gamma as much as possible according to this regimen. Toxicity was evaluated in 28 patients: fever, general fatigue, anorexia, leukocytopenia and impaired liver function were frequently noted, and 3 patients were withdrawn from the study because of such adverse effects. In patients who had a PR or NC, the same dosage of IFN-alpha was continued to be given intramuscularly 2-3 times a week (every 2-4 days) as the maintenance therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

We clarified the risk of elevated creatine kinase (CK) and myoglobulinemia during incised muscle urological operations.We retrospectively reviewed 58 consecutive cases of radical nephrectomy with muscle incision and 89 consecutive radical prostatectomies or radical cystectomies without muscle incision. Operations with or without muscle incision were divided into 2 groups depending on operative time (200 minutes or less and 201 to 400). Increases in CK and myoglobin were compared between the 2 groups, and between muscle incision and no muscle incision at each operative time.CK and myoglobin were proportionally increased according to operative time in operations without muscle incision but not in muscle incision operations, in which high CK and myoglobin were seen even with short operative times. CK and myoglobin were more increased in muscle incision operations than in those without incision with significance at each operative time. However, maximum CK and myoglobin were 2,220 IU/L and 3,600 ng/ml, respectively, in muscle incision operations.Even with short operative times surgeries with muscle incision are associated with a marked increase in CK and myoglobulinemia. However, CK and myoglobin are not sufficiently high for rhabdomyolysis with acute renal failure to develop.

A prospective randomized trial was conducted to compare the prophylactic effect of intravesical installation of Adriamycin (ADM) plus verapamil (VR) with that of ADM alone for recurrence of superficial bladder cancer. A total of 226 patients were enrolled and randomized into 2 groups. Group A received intravesical instillation of ADM (30 mg/30 ml physiological saline) on 19 occasions during a 1-year period after transurethral resection, whereas group B received intravesical instillation of ADM (30 mg/24 ml physiological saline) plus VR (15 mg/6 ml saline) according to the same schedule used for group A. Evaluation was possible in 157 of the 226 registered patients (group A, 76; group B, 81). There was no significant difference in the patients' characteristics between the two groups, and there was no significant difference in the overall nonrecurrence rate determined over a 24-month follow-up period. However, group B showed a significantly higher nonrecurrence rate than did group A for tumors measuring less than 1 cm in diameter (P < 0.05) and for histological grade 2 tumors (P < 0.01) in spite of there being no significant difference in the other characteristics of each subgroup of patients. The incidence and severity of side effects were similar in both groups, and VR caused no significant systemic toxicity. Although further follow-up is necessary, these results suggest that intravesical instillation of ADM plus VR is clinically safe and may be more effective than instillation of ADM alone in preventing the postoperative recurrence of superficial bladder cancer (less than 1 cm in diameter, histological grade 2).

Bacillus Calmette-Guérin (BCG) immunotherapy is increasingly being accepted for management of some bladder transitional cell neoplastic lesions. Mild adverse reactions occur frequently. However, an unusual complication of tuberculous epididymitis is reported. A 64-year old man presented with bilateral epididymal mass. Four months earlier he had seven treatments with intravesical BCG instillation (Tokyo 172 strain) for a grade 2 transitional cell carcinoma in situ. Bilateral epididymectomy was performed. Microscopic examination of the epididymis revealed chronic inflammation and necrosis with granulomas and Langhans' giant cells. After the operation, there were no further complications.

Objectives. To evaluate the influence of various types of urinary diversion on urinary nuclear matrix protein 22 (U-NMP22) levels. Methods. U-NMP22 values were determined for 38 urinary diversion patients without upper urinary tract cancer. The patients were divided into three groups: tubeless cutaneous ureterostomy (n = 12), ileal conduit (n = 15), and continent urinary reservoir (n = 11). The mean values and false-positive rates of U-NMP22 (cutoff value 12 U/mL) were compared among the three groups. Results. The mean ± standard error U-NMP22 value for the ureterostomy, ileal conduit, and reservoir groups was 20.1 ± 5.8 U/mL, 335.6 ± 63.5 U/mL, and 671.8 ± 220.4 U/mL, respectively (P = 0.0030). The false-positive rate of U-NMP22 for the ureterostomy, ileal conduit, and reservoir groups was 41.7%, 100%, and 100%, respectively. In the ureterostomy group, the exclusion of patients with pyuria improved the false-positive rate of U-NMP22 from 41.7% to 12.5%. Conclusions. U-NMP22 levels may be useful in the diagnosis of upper urinary tract cancer in patients with a tubeless cutaneous ureterostomy. However, in patients with urinary diversion using a bowel segment, U-NMP22 has no diagnostic value because of the high U-NMP22 levels.

A series of 185 patients, 133 males and 52 females, were treated by ileal conduit urinary diversion in the past 17 years. The patients ranged in age from 7 months to 81 years with an average of 59 years. Diversions were performed for malignant diseases in 174 patients, 85% of whom underwent a simultaneous radical surgery. The follow-up covered the postoperative period from 4 months to 16 years 8 months with an average of 4 years 8 months. Six patients (3%) died within 1 month of operation, and 43 of a total of 58 mortal cases died of cancer thereafter. The survival rates of 143 patients with bladder cancer were 84% for 1 year, 72% for 3 years, 67% for 5 years, 62% for 10 years and 54% for 15 years. Early complications were noticed in 38% of the patients. Delayed wound healing due to local infection (20%) and intestinal obstruction (10%) were the two major complications in this period. Late complications were encountered in 51% of the patients. Mild peristomal dermatitis (22%) and gradually developing renal complications (22%) are two major problems in the standard ileal conduit urinary diversion. The latter was significantly more frequent in patients who underwent the operation between 1973 and 1981 than in those who had the surgery between 1982 and 1989. Postoperative hydronephrosis was observed in 15 (13%) of 117 patients who showed normal urograms preoperatively. Ileoureteral reflux was observed in 50% of the cases with nonobstructing conduits, while it increased up to 70% along with obstruction of the conduit.(ABSTRACT TRUNCATED AT 250 WORDS)

Cutaneous ureterostomy is a simple procedure to perform, but has some morbidity owing to stomal stenosis. We describe a new and simple technique applied to the stomal stenosis for cutaneous ureterostomy.

OBJECTIVE Retrospective analysis was carried out to evaluate the prognostic value of urothelial dysplasia with superficial bladder cancer. PATIENTS AND METHODS 62 patients with bladder cancer of pTa or pT1 who had been treated by transurethral resection (TUR-Bt), underwent random mucosal biopsies in the urinary bladder. The results of random biopsies were classified into 3 groups: negative group, dysplasia group and CIS group. The recurrence rate, progression rate and type of recurrences (true recurrence/new occurrence) were compared among the 3 groups. RESULTS The results of random biopsies were as follows; negative group was found in 42 (68%), dysplasia group in 17 (27%) and CIS group in 3 (5%). There were no significant difference in the characteristics of the patients among the 3 groups. The recurrence rates at 1, 2 and 5 years after TUR-Bt were 3%, 12% and 21%, respectively, for negative group, and 37%, 51% and 67%, respectively, for dysplasia group (p < 0.01). For CIS group, 2 of 3 cases (67%) recurrenced within 1 year after TUR-Bt. Non of negative group progressed to muscle invasion, whereas 57% of dysplasia group invaded bladder muscle after 6 years post operatively (p < 0.001). No significant relationship was observed between the absence or presence of concomitant dysplasia and the rate of true recurrence. Dysplasia group revealed a higher rate (47.1%) of new occurrence than negative group (2.4%) (p = 0.0001). CONCLUSION The presence or absence of concomitant dysplasia of superficial bladder cancer seems to be an important prognostic factor for future new ocurrence and progression after TUR-Bt.

Cutaneous ureterostomy is a minimally invasive urinary diversion procedure but postoperative stomal stenosis is a major problem. We describe a simple stomal reconstruction technique using a skin flap for the correction of deep ureteral stomal obstruction after cutaneous ureterostomy.

Skeletal muscle is a very rare location for the metastasis of renal cell carcinoma (RCC) and only one case of solitary metastasis to the psoas muscle has been reported. We present a 63-year-old male patient with late recurrence (14 years) after left side radical nephrectomy for RCC. He first visited Chikushi Hospital, Fukuoka University, Japan in January 2000 for a postoperative follow-up because he had shifted residence to the area. Follow-up was by abdominal computed tomography (CT) and chest X-ray. In December 2001, a CT scan showed a 1.5 cm enhanced mass in the right psoas muscle without any other metastasis. The mass was resected that month and histological study showed RCC metastasis.

Invasive bulbomembranous urethral carcinoma appears highly aggressive and requires radical local excision to cure. The standard surgical therapy for this tumor includes en bloc resection of the penis, urethra, scrotum and pubic bone with radical cystoprostatectomy.1 However, recently it has become increasingly important to also consider quality of life.2,3 We report on a patient with invasive bulbous urethral carcinoma, who has been satisfied 5 years after surgery with the surgical and cosmetic results of the methods used for penis and bladder preservation.

A 64-year-old man presented with a 1-month history of increasing bladder irritability and dysuria in December 1998. Digital rectal examination revealed an enlarged prostate with an irregular surface but without a pulsatile mass. There was no history of pelvic trauma or surgery. Serum prostate specific antigen (PSA) was 56.0 ng./ml. Transrectal ultrasound demonstrated a tubular and tortuous hypoechoic lesion along the left side of the prostate, which was suspicious for vascular abnormality (fig. 1). Systematic sextant prostate biopsy was performed under transrectal ultrasound guidance, avoiding the hypoechoic mass, and bleeding was minimal after the biopsy. A poorly differentiated adenocarcinoma was detected in all of the 6 biopsy specimens obtained. Pelvic CT demonstrated a large dilated and tortuous vascular system adjacent to the left side of the prostate (fig. 2). Digital subtraction angiography confirmed the presence of a large arteriovenous malformation in the left pelvis, fed by the left superior gluteal artery and draining into the left external iliac vein. During a 4-month period 6 courses of transarterial embolization of the left superior gluteal artery with metal coils were performed. Digital subtraction angiography showed a decrease in the size of the arteriovenous malformation.

A 73-year-old woman presented with gross hematuria and slight lumbago in June 1998. She had been on oral warfarin potassium for 4 years because of a permanent pacemaker implantation for the sick sinus syndrome. IVP revealed irregular right caliceal and pelvic defects, and narrowing of the infundibula. The left kidney was slightly hydronephrotic due to ureteropelvic junction stenosis. Abdominal computerized tomography (CT) showed thickening of the bilateral renal pelvic wall and the vestibule in the stomach with a slight homogeneous enhancement, which was considered suspiciously similar to bilateral renal pelvic and gastric tumors, or a malignant lymphoma (part A of figure). However, photogastroscopy did not reveal a stomach tumor. Repeat abdominal CT failed to show bilateral renal pelvic or gastric tumor. However, a hematoma was evident between the left gluteus medius and gluteus minimus (part B of figure). A thrombotest revealed less than 10% of normal value (normal during therapy 10% to 20%). We concluded that bilateral renal pelvic wall thickening was allowing hemorrhaging into the submucosa.

To prevent dermal invasion which causes gradual stomal stenosis in cutaneous ureterostomy, transplantation of autologous vaginal vestibular mucosa around the ureteral opening was examined in 9 female dogs. Results of a full-thickness graft to a full-thickness skin bed were hopeful. Though surface keratinization occurred, the thick graft survived well on the abdomen without obvious shrinkage, and the ureteral patency was maintained through the follow-up period with an average of 18 months. This method seemed to be applicable to clinical patients and to dog experiments as a model for separate renal function study.

To produce a chronic moderate hydronephrosis in dog, a method of partial ureteral occlusion using a specially designed polypropylene obturator was developed. In 11 of 14 dogs undergoing this procedure, excretory urography constantly revealed a moderate degree of hydronephrosis persisting for 7 weeks. Combination of this method in one ureter with the vaginal-cuff cutaneous ureterostomy, previously reported, in the contralateral ureter is a useful model for split renal function study of unilateral chronic hydronephrosis or obstructive nephropathy analogous to that of clinical case.

To protect ureteral stoma from necrosis and stenosis in cutaneous ureterostomy, an autograft of the entire vaginal wall to the canine abdomen was investigated. The patency of the ureteral stoma was well preserved for the observation period with an average of 9.4 months in 20 of 29 dogs. A combination of unilateral vaginal cuff cutaneous ureterostomy with bladder urine collection for the contralateral kidney is a useful experimental model for split renal function study. The value of this model has been shown by clearance study using the separate urine obtained from each kidney.

New procedures for tubeless cutaneous ureterostomy are described. The fundamental principles of the methods are 1) an everted ureteral nipple formation combined with a triangular skin flap as a permanent stoma and 2) a 2-stage operation to obtain a viable ureteral nipple against slough and retraction.