Extensive bilateral renal pelvis, ureter and bladder leukoplakia

We are presenting a case of leukoplakia spread to the bilateral renal pelvis, ureter and bladder in a 52-year-old woman. We believe this case is important because it involves leukoplakia that is more extensive than in any cases previously cited in the literature. No other possible etiologic cause except a heavy smoking habit was defined. Conservative follow-up was preferred to aggressive surgery.     

The length and collapsibility of the ureter play roles in the augmented reflection of intraabdominal pressure into the renal pelvis

Background/purpose

Flow of a fluid through a collapsible tube is under the influence of various factors including the external compressing pressure. The intraabdominal pressure (IAP) should influence the flow through the ureter. Therefore, an experimental study was planned to investigate the effects of ureteral length and external compressing pressure onto the intrapelvic pressure (IPP) in rabbits.

Methods

Nineteen adult rabbits were used for the experiment. Under general anesthesia, an intraperitoneal and an intrapelvic catheter were placed to measure IAP and IPP. A urethral catheter was placed for bladder decompression. After this standard preparation, a ureteric stent was placed in the ureter in group 1 (n = 7). Distal or proximal ureter transection was performed in group 2 (n = 6) and group 3 (n = 6), respectively. Basal pressure measurements have been recorded. Then the pressures were recorded every 5 minutes, and IAP was increased gradually for 4 cm of water pressure in each subsequent 30-minute period. All analyses were performed for a standard IAP interval (5 to 25 cm H₂O).

Results

IAP did not differ between groups (P = .08). IPP values were significantly higher than the corresponding IAP values in each group (P = .0001). IPP showed significant difference between IAP values of groups (P = .0001). IPP was significantly increased in group 2 when compared with group 1 and group 3 (P = .0001; P = .0001), but no difference was encountered between groups 1 and 3 (P = .1). There has been a strong relationship between IPP and IAP values in all groups. The Rsq values were 0.912, 0.783, and 0.943 for group 1, group 2, and group 3, respectively (P < .0001). Mathematic relations between IPP and IAP also were analyzed. The relations were IPP = 3.9 + 1.10 × IAP, IPP = 10.3 + 1.10 × IAP, and IPP = 3.3 + 1.12 × IAP for groups 1, 2, and 3, respectively.

Conclusions

Renal pelvis pressure responds with augmented increases to increments in IAP in urinary tracts with different ureteric lengths. Increase in IPP is more pronounced in longer ureters possibly owing to increased resistance to flow. Prevention of ureteric wall collapse reverses the augmented increase in IPP responses. Therefore, both the length and collapsibility of the ureter play a detrimental role in the generation of augmented IPP responses to increments in IAP. The magnitude of IPP as a response to increments in IAP can be estimated by using mathematical relations between IPP and IAP. Increases in IAP may simulate proximal ureteric obstruction and may take part in the pathogenesis of hydronephrosis.     

Squamous cell carcinoma of the renal pelvis and ureter: incidence, symptoms, treatment and outcome

PURPOSE: Squamous cell carcinomas of the renal pelvis and ureter are rare. We report a large series of patients and compare it to patients with urothelial carcinoma. MATERIALS AND METHODS: The initial material was comprised of 808 patients with renal pelvis or ureteral cancer. A review of the histopathological material and clinical records was performed. RESULTS: Only 2 (4%) of 65 patients with squamous cell carcinoma had stage pTa/pT1/pT2 tumors compared to 460 (62%) of 743 patients with urothelial carcinoma. Median survival was much shorter for surgically treated patients with squamous cell carcinoma compared to those with urothelial carcinoma (7 vs 50 months). However, there was no significant difference in the disease specific 5-year survival rate between patients with squamous cell carcinoma and urothelial carcinoma in the same disease stage. Vascular invasion, microscopic solid tumor pattern and large tumor size had negative prognostic significance in multivariate analyses. Histopathological tumor type (squamous cell carcinoma or urothelial carcinoma) had no prognostic significance. CONCLUSIONS: The prognosis for squamous cell carcinoma is poor, but stage for stage the prognosis is not different between patients with urothelial carcinoma and squamous cell carcinoma of the renal pelvis and ureter. It can be presumed that high stage squamous cell carcinoma and urothelial carcinoma become symptomatic first at a time when the tumors already are large, deeply invasive and most often incurable. New treatment modalities are urgently needed to improve the poor prognosis in patients with advanced stage squamous cell carcinoma and urothelial carcinoma of the upper urinary tract.     

Transitional cell carcinoma of the renal pelvis and ureter: Outcome and patterns of relapse in patients treated with postoperative radiation

We assessed the records of 101 patients with locally advanced transitional cell carcinoma (TCC) of the renal pelvis and ureter treated with postoperative radiation therapy to determine outcome and patterns of failure. Locally advanced disease (i.e., T3–4N0 or N+ disease) was identified in 65 patients. Postoperative radiation was used to treat 86 patients, with a median dose of 35 Gy in 20 fractions over 4 weeks to the tumor bed and regional lymph nodes. There were 15 patients with no residual disease who were offered no further therapy. No patient received postoperative chemotherapy. Prognostic factors were examined using univariate and multivariate analysis, and the patterns of failure were identified after postoperative irradiation. Median follow-up was 9.3 years, during which 76 deaths occurred. The 5-year overall survival was 43% and 10-year survival was 23%. A multivariate analysis identified T3 category, lymph node involvement, and age at diagnosis as significant prognostic factors for survival. Tumor grade was a significant prognostic factor on univariate analysis but not on multivariate analysis. Failure analysis showed that only 36% of patients with locally advanced disease remained relapse free. For this group of patients, distant metastases developed in 53%, and locoregional failured occurred in 35% despite postoperative irradiation. Locoregional failure occurred in 95% of patients with nodal involvement who received postoperative radiation, and 77% of those developed distant relapse. This leads us to conclude that patients with resected locally advanced (T3, T4N0, N+) TCC of the upper urinary tracts have a high risk of relapse and death from disease despite postoperative radiotherapy. Because the main feature of the disease is early distant failure, post-operative chemotherapy is required to improve the outcome for this group of patients.     

Micropapillary carcinoma of the renal pelvis and ureter

PURPOSE: MPC located in the upper urinary tract is rare with only 2 cases reported to date. We report clinical and histopathological data on 26 patients to increase the knowledge of this rare entity. MATERIALS AND METHODS: A clinical and histopathological review was performed in 943 patients with a neoplasm in the renal pelvis or ureter, diagnosed between 1971 and 1998. We identified 26 patients with MPC. No patients were alive at the end of the study. RESULTS: Of the patients 11 had greater than 50% MPC and 15 had focal MPC (at least 10%). The incidence was 2.8%. Median patient age at diagnosis was 69 years (range 54 to 88) and the male-to-female ratio was 17:9. All except 4 patients had stage T3 disease or higher. Carcinoma in situ was identified in 64% of cases and vascular invasion was present in 81%. A total of 20 patients (77%) died of disease and only 7 survived longer than 5 years. CONCLUSIONS: The prognosis is poor since most patients with MPC of the renal pelvis and ureter initially present with advanced disease. Stage for stage the prognosis is not different from that in nonMPC urothelial cell carcinoma. Surgery is curative in less advanced cases. However, radiotherapy and systemic chemotherapy appear to be ineffective.     

Apoptotic cell death and Smad4 expression in transitional cell carcinoma of the renal pelvis and ureter

PURPOSE: To investigate the frequency of apoptosis and the expression of Smad4 protein as well as their roles in transitional cell carcinoma (TCC) of the renal pelvis and ureter. METHODS: Apoptosis was detected by using terminal deoxynucleotidyl transferase (TdT)-mediated dUTP-biotin nick end labeling (TUNEL) technique in 34 formalin-fixed and paraffin-embedded specimens of renal pelvic and ureteral TCC. The expression of Smad4 was immunohistochemically studied. RESULTS: The incidence of apoptosis ranged from 1.10 to 3.75% with a median of 2.50% in TCC of the renal pelvis and ureter. The incidence of apoptosis was noted to be closely related to histologic grade but not to pathologic stage of the cancer. The expression of Smad4 was detected in six of 34 cases (17.6%). Regarding subcellular distribution, Smad4 protein was localized both in cytoplasm and nucleus of the cancer cells. In comparing the incidence of apoptosis with the expression of Smad4, no significant associations were seen between them. The expression of Smad4 was not related to the tumor grade nor stage of the cancer. CONCLUSIONS: The present study demonstrated close association of the incidence of apoptosis with the tumor grade of TCC of the renal pelvis and ureter. Significance of Smad4 expression was not noted in the study. It suggests that apoptotic cell death may play an important role in the tumor progression of renal pelvic and ureteral TCC.     

Renal pyelic fusion with crossed solitary ureter: Case report and review of literature

Renal fusion anomalies are detected incidentally on imaging, with horseshoe kidney being the most common followed by crossed renal ectopia. We report a rare congenital anomaly of renal pyelic fusion with a solitary ureter. Both the renal units were in the normal position and location. This rare anomaly was associated with lumbar vertebral defects, neurogenic bladder, vesico‐ureteric reflux, upper tract dilatation and recurrent urinary tract infections.     

Cystic hamartoma of the renal pelvis

Cystic hamartoma of the renal pelvis is a rare benign tumor in the same category as mixed epithelial and stromal tumors. We present a 33-year-old woman with a solid and cystic intrarenal tumor extending into the renal pelvis. She underwent radical nephrectomy and ureterectomy under the diagnosis of renal tumor or renal pelvic tumor. Histopathologically, the tumor was composed of a biphasic proliferation of epithelial and mesenchymal elements. We believe the present case is best classified as a cystic hamartoma of the renal pelvis in the category of mixed epithelial and stromal tumors because of the coexistence of hamartomatous lesions, such as the proliferation of adipose cells and well to poorly differentiated fibromuscular lesions.     

Transitional cell carcinomas of the renal pelvis and the ureter: comparative demographic characteristics, pathological grade and stage and 5-year survival in a Taiwanese population

OBJECTIVE

To compare the predictive value for 5‐year survival of demographic characteristics, pathological grade and stage between upper tract urothelial carcinoma (UTUC) of the renal pelvis (RPUC) and ureter (UUC) in a Taiwanese population.

PATIENTS AND METHODS

In this study (1986–98) we analysed 141 patients with UTUC, including 71 with RPUC and 70 with UUC (median age 59 years; median follow‐up 54 months, sd 2.5). Prognostic indicators were examined by univariate and multivariate logistic regression analyses.

RESULTS

A significant percentage of patients had tumour on the right side and a high proportion of those with UUC were women. Gross haematuria and hypertension were the most common symptoms of RPUC. The sensitivity of intravenous pyelography in diagnosing RPUC and UUC was 49% (34/69) and 36% (25/70), respectively. However, in patients assessed by retrograde pyelography the diagnostic sensitivity was 85% (60/71) for RPUC and 89% (55/62) for UUC. The incidence of tumour recurrence after nephroureterectomy with bladder cuff excision was significantly higher in those with UUC (13%) than RPUC (3.6%). Distant metastasis was detected in 37 of 141 (26%) patients, the most common sites being bone (46%), lung (22%), liver (14%) and colon (8%). Univariate logistic regression analysis showed significant differences in the prognosis for high‐grade and high‐stage tumours. The prognosis was particularly poor in patients aged >60 years. According to the multivariate logistic regression analysis, tumour stage and grade were the best outcome predictors for RPUC, but stage and age were the best outcome predictors for UUC.

CONCLUSION

UUC is more common in women and has a more aggressive clinical outcome than RPUC after nephroureterectomy with bladder cuff incision. Tumour stage and grade are the best predictors of survival in patients with RPUC. Also, in patients with UUC the prognosis is poor in older patients and those with advanced stages of cancer.     

Incidence and survival of patients with carcinoma of the ureter and renal pelvis in the USA, 1973–2005

Study Type – Prognosis (retrospective cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Upper‐tract urothelial carcinoma (UTUC) is a relatively uncommon urological malignancy with survival and outcomes data largely determined from single‐centre series which can be limited by relatively small case numbers. Through review of a large population based cohort, this study provides valuable information regarding epidemiological and survival patterns for over 13,000 patients with UTUC diagnosed over the past three decades.

OBJECTIVE

? To evaluate epidemiological and survival patterns of upper‐tract urothelial carcinoma (UTUC) over the past 30 years through a review of a large, population‐based database.

PATIENTS AND METHODS

? Data from the Surveillance, Epidemiology and End Results (SEER) database from 1973 to 2005 were reviewed in 10‐year increments to evaluate disease trends. ? Univariate and multivariate survival analyses identified prognostic variables for outcomes.

RESULTS

? In total, 13 800 SEER‐registered cases of UTUC were included. The overall incidence of UTUC increased from 1.88 to 2.06 cases per 100 000 person‐years during the period studied, with an associated increase in ureteral disease (0.69 to 0.91) and a decrease in renal pelvic cancers (1.19 to 1.15). ? The proportion of in situ tumours increased from 7.2% to 31.0% (P < 0.001), whereas local tumours declined from 50.4% to 23.6% (P < 0.001). ? There was no change in the proportion of patients presenting with distant disease. ? In multivariate analysis, increasing patient age (P < 0.001), male gender (P < 0.001), black non‐Hispanic race (P < 0.001), bilateral UTUC (P= 0.001) and regional/distant disease (P < 0.001) were all associated with poorer survival outcomes.

CONCLUSIONS

? The incidence of UTUC has slowly risen over the past 30 years. ? Increased use of bladder cancer surveillance regimens and improved abdominal cross‐sectional imaging may contribute to the observed stage migration towards more in situ lesions. ? Although pathological disease characteristics impact cancer outcomes, certain sociodemographic factors also appear to portend worse prognosis.     

Predictive value of renal histological changes for postoperative renal function improvement in children with congenital ureteropelvic junction stenosis

BACKGROUND: The aim of this study was to evaluate the relationship between renal function, as measured by diuretic radionuclide renography, and the outcome of pyeloplasty. A study was designed to evaluate renal parenchymal biopsy specimens derived from children undergoing corrective surgery for ureteropelvic junction (UPJ) stenosis, and compare these to preoperative and postoperative renal function status. METHODS: Thirty-five children with congenital unilateral UPJ stenosis were evaluated. In addition to all conventional diagnostic procedures for UPJ stenosis, differential renal functional (DRF) activity was assessed in each of these children by obtaining 99mTc diethylenetriaminepentaacetic acid renogram curves. All children underwent dismembered pyeloplasty, and follow-up renogram evaluation was conducted 6 and 12 months after surgical repair. Biopsy specimens from renal cortical regions obtained during the surgical correction of UPJ stenosis were evaluated, and changes in renal histology were graded from I to V according to their severity. Spearman's correlation test was used to compare the histological evaluation results and the basal, 6- and 12-month follow-up DRF findings. A Wilcoxon paired test was used to evaluate statistical differences between values. RESULTS: The findings showed a positive correlation between the severity of histological changes and DRF activity. All kidneys (22) with a DRF activity value of < 40% preoperatively demonstrated at least grade III changes when biopsy specimens were examined. Of children with a DRF activity value > 40% (13), only three showed severe histological changes. Histological grades were correlated between basal (r = -0.4; P = 0.019), 6-month (r = 0.54; P = 0.002) and 12-month (r = 0.54; P = 0.02) findings. In the Wilcoxon paired test, there was a statistically significant difference between basal and 6-month values (P < 0.05), and also between basal and 12-month values (P < 0.01). There was no statistically significant difference between 6- and 12-month values (P > 0.20). CONCLUSION: Comparative evaluation of postoperative renal function with DRF activity and renal parenchymal histological alterations revealed a close correlation in terms of renal function improvement potential following reconstructive surgery in children with UPJ stenosis.     

Roles of p53 and MDM2 in tumor proliferation and determination of the prognosis of transitional cell carcinoma of the renal pelvis and ureter

BACKGROUND: The significance of p53 overexpression for the prognosis of transitional cell carcinoma (TCC) of the renal pelvis and ureter remains controversial. Simultaneous evaluation of p53 and MDM2 may enable better prediction of tumor proliferation and patient prognosis than that obtained with evaluation of p53 alone. METHODS: Immunohistochemical detection of p53 protein, MDM2 protein and Ki-67 antigen as proliferation markers was performed for tissue samples obtained from 74 patients with TCC of the renal pelvis and ureter. The correlations of p53/MDM2 overexpression with conventional pathological features, Ki-67 labelling index (LI) and patient survival were studied. RESULTS: Overexpression of p53 was related to progression of each of the pathological features examined (grade, stage, type of infiltration, vascular invasion and lymphatic invasion) and Ki-67 LI was significantly higher with high p53 expression than with low p53 expression. However, overexpression of MDM2 was related to neither disease progression nor Ki-67 LI. Survival analyses were performed for 66 patients. Univariate analysis showed p53 to be a useful prognostic indicator, but in a multivariate analysis only type of infiltration and Ki-67 LI were independent survival markers, while p53 was not. Overexpression of MDM2 was unrelated to patient survival, and the combination of p53 and MDM2 for survival indication was found not to be useful. CONCLUSIONS: Overexpression of p53 is related to disease progression, increased tumor proliferation and patient survival for TCC of the renal pelvis and ureter, but the independent prognostic value of p53 did not reach statistical significance. Combined analysis of MDM2 with p53 cannot be recommended for examination of the malignant potential of TCC of the renal pelvis and ureter.     

Tumours of the ureter and renal pelvis treated with resection and renal autotransplantation: a study with up to 20 years of follow-up

OBJECTIVE: To report long-term follow-up data from patients treated with resection of urothelial neoplasms of the upper urinary tract combined with autotransplantation of the kidney. PATIENTS AND METHODS: In a clinical and histopathological review of 23 patients who had 25 autotransplantations, they were followed for 7-20 years or until death. Nine patients had either a solitary kidney or bilateral renal pelvic tumours (group A) and 14 had a normal contralateral kidney (group B). RESULTS: Seven operations were unsuccessful, ending in nephrectomy. Of the nine patients in group A two with high-grade renal pelvic tumours survived with no dialysis and recurrences for 127 and 238 months, respectively. Three patients required haemodialysis 0-3 times weekly for 27, 85 and 108 months, respectively. Three patients with low-grade disease developed invasive recurrences in the autotransplanted kidney after 16, 27 and 90 months, respectively, and later died from the disease. One patient died in an accident after 14 months. Of the 14 patients in group B, one developed a deeply invasive recurrence in the autotransplanted kidney after 86 months, despite frequent controls. CONCLUSIONS: In patients with a normal contralateral kidney resection and renal autotransplantation is not indicated and might even be harmful, compared to standard nephroureterectomy. The operation might be beneficial in patients with solitary kidneys but other treatments should first be considered, including open or endoscopic resection, and nephroureterectomy and haemodialysis.     

肾盂输尿管肿瘤的CT诊断及其在术前分期中的意义

报告１６例肾盂输尿管肿瘤的ＣＴ诊断经验。与术后病理对照肾盂肿瘤１３例诊断准确度９２．３％，输尿管肿瘤３例，确诊２例，误诊１例。ＣＴ分期与病理对照准确度８５．７％。术前ＣＴ检查不便有助于对盂尿管肿瘤做出正确的诊断，而且ＣＴ术前分期有助于选择治疗方案和评价预后。     

Response of the renal pelvis and ureter to distension of the contralateral renal pelvis and ureter: identification of the reno-renal pelvic reflex

For the study of the relationship of the pelviureteric system of one kidney to that of the contralateral one, bilateral cutaneous ureterostomy was performed in 14 dogs. The renal pelvis (RP) and ureter (U) of one side were distended separately with a balloon filled with saline in increments of 1 and 0.25 ml, respectively, and the pressure response of the contralateral RP and U was recorded. The test was repeated after anesthetization of the RP and U. RP distension with 1 ml of saline effected a pressure rise (P < 0.05) in the ipsilateral RP but no pressure response in the ipsilateral U or the contralateral RP or U (P > 0.05). RP distension with 2, 3, and 4 ml of saline induced a significant pressure rise in the ipsi- and contralateral RP but not in the ureters. Ureteric distension produced a pressure elevation (P < 0.05) on the ipsilateral U but had no effect on the contralateral U (P > 0.05) or on either of the renal pelves (P > 0.05). Distension of the anesthetized RP or U effected no pressure response in any of the ipsi- or contralateral RPs or Us. In conclusion, distension of the RP with large volumes led to an increase in pressure in the contralateral RP but not in the U. A reflex relationship is postulated to exist between the two renal pelves and to be mediated through a reflex we call the reno-renal pelvic reflex. It seems that this reflex acts to allow either of the kidneys to share an extra load of the other one by increasing the contractile activity of the RP, thus assumedly assisting the regulation of urine flow.     

Ligation of the native ureter in renal transplantation.

PURPOSE: Native ureteral ligation may be required in renal transplantation when ureteroureterostomy is performed. Native nephrectomy has been done to avoid the complication of hydronephrosis after native ureteral ligation. We reviewed the records of renal transplant recipients who underwent native ureteral ligation to determine the incidence of post-ligation symptoms and need for native nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed 1,275 renal transplants performed from January 1986 through September 1999, including 278 cases (22%) of native ureteral ligation. The majority of patients had anuria or oligouria before transplantation, although 3 were not dialysis dependent. Followup was 1 to 140 months. Charts were reviewed for flank pain, infection and the need for native nephrectomy. RESULTS: Six of 278 patients (2.2%) required native nephrectomy 7 to 82 months after transplantation with flank pain as the indication in all. The cause of renal failure was polycystic disease in 3 of the 6 cases, unknown in 2 and diabetes in 1. The patient with diabetes had papillary necrosis and bleeding in the nephrectomized kidney. None of the 278 patients had infection and early post-ligation flank pain developed in only 1 (0.4%). CONCLUSIONS: The native ureter may be safely ligated during renal transplantation. Late nephrectomy may be required in a small percent of cases, most commonly in those of polycystic disease. The need for nephrectomy is most often related to the original renal disease.