Renal oncocytoma with bilateral synchronous renal cell carcinoma in a patient undergoing long-term hemodialysis

Abstract:   We report a case of bilateral synchronous renal cell carcinoma and renal oncocytoma in a 56-year-old male who had been treated with hemodialysis for 32 years. Because anemia gradually worsened, computed tomography and magnetic resonance imaging were carried out and revealed bilateral renal tumors within acquired cystic disease of the kidney. Bilateral nephrectomy was carried out, and the patient was diagnosed with multiple renal cell carcinomas and a single renal oncocytoma. To our knowledge, this is the first reported case of renal oncocytoma with synchronous renal cell carcinoma in a patient undergoing long-term hemodialysis.     

Successful management of metastatic urothelial carcinoma with gemcitabine and Paclitaxel chemotherapy in a hemodialysis patient

This is the first report of urothelial carcinoma (UC) in a hemodialysis (HD) patient treated with almost the same doses of gemcitabine and paclitaxel (GP) as those administered to patients with normal renal function. There have been some reports of UC treated with cisplatin-based chemotherapy in HD patients. However, there have only been a few reports of UC treated with GP in HD patients. Furthermore, to our knowledge, there has not been any report of UC in a HD patient treated with almost the same doses of GP as those in patients with normal renal function. Following cystectomy for bladder cancer, a 73-year-old woman undergoing HD developed lung metastasis and received combination chemotherapy with almost the same doses of GP as those in patients with normal renal function. After three cycles were completed, metastatic tumors disappeared and there has not been any recurrence or metastasis for 1 year to date. Furthermore, there were no grade 3 or 4 adverse effects during this treatment.     

Transitional cell carcinoma of ureteral stump after radical nephrectomy in a patient with a history of bladder carcinoma

Transitional cell carcinoma (TCC) of ureteral stump after radical nephrectomy is rare. Following nephrectomy patients with a prior history of bladder cancer must have their ureteral stumps evaluated. Furthermore, the presence of hematuria should alert the urologist to a possible TCC in the ureteral stump. We present a patient who developed TCC of the ureteral stump after radical nephrectomy.     

Simultaneous robot-assisted radical cystoprostatectomy and nephroureterectomy in a patient with multifocal invasive urothelial carcinoma and previous contralateral nephroureterectomy

We present a case of simultaneous robot-assisted radical cystoprostatectomy and nephroureterectomy with extended lymphadenectomy for multifocal invasive urothelial carcinoma in a patient with recurrent high-grade urothelial cancer and a previous right nephroureterectomy. The total urinary exenteration and extended lymphadenectomy was successfully performed with robot-assisted surgery in this unique case where the patient was rendered anephric at the end of the operation. We discuss the operative steps and the techniques performed to optimize the oncological results of robot-assisted surgery for invasive urothelial carcinoma, while attempting to preserve the renal function until the patient’s urinary system was totally exenterated.     

Successful resection of pheochromocytoma in a hemodialysis patient.

A 45-year-old woman with a pheochromocytoma who had been on regular hemodialysis for 4 years and underwent successful surgery is described. Careful preoperative management, including the use of prazosin and weight control, was carried out to prevent severe intraoperative and postoperative cardiovascular complications. Prazosin was given at an initial dose of 0.5 mg/day, and the dosage was increased to 20 mg/day prior to surgery. The increase in intravascular volume led to a gain of 3 kg in body weight. No deterioration of the cardiovascular or respiratory function was caused by these maneuvers, and surgery was performed without significant complications except for a rapid rise of blood pressure during tumor resection. To our knowledge, only one similar case report could be found in the English literature.     

EPO-producing gastric carcinoma in a hemodialysis patient

A case of erythrocytosis caused by gastric cancer that produced erythropoietin is described. To the authors’ knowledge, no case of erythropoietin-producing gastric cancer has been reported until now. A 73-year-old man with a 4-year history of maintenance hemodialysis for diabetic nephropathy required phlebotomy. Serum erythropoietin level was 181 mU/mL (181 IU/L). Gastroscopy results showed rough mucosa with hemorrhaging caused by gastric cancer. The patient underwent distal gastrectomy, and serum erythropoietin level decreased to 27.1 mU/mL (27.1 IU/L) by postoperative day 8. Existence of erythropoietin in the tumor tissue was confirmed immunohistochemically. The presence of severe acquired cystic disease of the kidney, renal cell carcinoma, and other malignant tumors should be investigated in hemodialysis patients displaying erythrocytosis.     

Metachronous bilateral ureteral cancer in patient with hereditaly nonpolyposis colorectal cancer

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

Total nephroureterectomy with ureteral intussusception and transurethral ureteral detachment and pull-through

We describe a technique for nephroureterectomy that includes ureteral intussusception and transurethral ureteral resection and our method for transurethral ureteral pull-through. These adjuncts permit total nephroureterectomy through a single skin incision and are appropriate in all cases except in patients with known high-grade transitional cell carcinoma of the renal pelvis or ureter. In 18 cases, these techniques have been shown to be reliable, safe, and rapid; in the 14 patients under observation for five years or longer, there have been no local recurrences of tumor.     

A case of bladder cancer with bilateral ureteral carcinoma in situ

A case of bladder cancer with bilateral ureteral carcinoma in situ (CIS) is presented. A 55-year-old male had gross hematuria and urinary retention. Cystoscopy revealed diffuse broad-based papillary tumors, which proved to be transitional cell carcinoma (G2) with CIS and submucosal invasion microscopically. Excretory urography showed normal upper urinary tracts except stasis of bilateral lower ureters. Neither lymph node swelling nor distant metastasis was found by computed tomography. Therefore the patient underwent total cystourethrectomy, pelvic lymph-adenectomy, and construction of an ileal conduit. Histological examination of the specimens demonstrated CIS on bilateral ureteral stumps on the renal side, which, however, was not continuous to that of the bladder. Much attention should be paid to upper urinary tracts for ureteral lesions before cystectomy in such bladder tumors and the proximal stump of the ureter should be examined using frozen section at the operation, but these were not sufficient in the present case in which skip lesions of the ureters were seen apart from the bladder.     

Quadriplegia after parathyroidectomy in a hemodialysis patient

We present a case of post-operative iatrogenic quadriplegia, which occurred after subtotal parathyroidectomy. This patient was on long-term hemodialysis for 7 years. The need of prolonged neck extension for this procedure was probably the main risk factor for the spinal cord injury. Systemic hypotension which contributed to the injury in this case, should be anticipated and promptly treated to prevent further damage. Spinal deformities associated with end-stage renal disease may make such patients more susceptible. Since appropriate precautions against potential neurologic damage can be undertaken, we suggest that evaluating carefully for the pre-existing spinal stenosis before a procedure requiring prominent and prolonged hyper-extension of the neck, especially in long-term hemodialysis patients is of paramount importance.     

Successful treatment of acute promyelocytic leukemia in a patient on hemodialysis

Acute promyelocytic leukemia (APL) has the best prognosis among acute leukemias, but there is little data about APL in patients on hemodialysis. A 64-year-old hemodialysis patient was successfully treated for APL by induction therapy with all-trans retinoic acid (ATRA), three courses of consolidation therapy with Ara-C, mitomycin?C (MIT), daunorubicin (DNR), and idarubicin (IDR), and maintenance therapy with ATRA. Complete remission has been maintained for 42?months in this patient. With dose modification, ATRA and chemotherapy may be safely given to patients on hemodialysis.     

Lithium acetate therapy in a maintenance hemodialysis patient

BACKGROUND/AIMS: Single cases of lithium carbonate dosing in hemodialysis patients have been published. We investigate the dose-serum level relationship after single and multiple lithium acetate dosing in a hemodialysis patient and review the literature. METHODS: Lithium acetate was administered orally over a period of 11 months in a patient with major depressive episodes after being placed on hemodialysis three times a week. The serum trough levels of lithium before and after hemodialysis were analyzed. The data were compared with those reported in the literature, and potential drug interactions and the importance of the residual renal function are discussed. RESULTS: No adverse events due to the lithium therapy were documented. Steady state levels of between 0.6 and 0.8 mmol/l of lithium acetate were achieved 17 days after initiating the therapy, using 24 mmol/l of lithium three times a week, in a patient with a residual diuresis of about 400 ml/day. In contrast, data reported in the literature implicate that only 9.6-14.4 mmol/l of lithium (450-600 mg of lithium carbonate) is sufficient to achieve adequate serum levels. CONCLUSIONS: The residual renal function can be important for lithium clearance. The creatinine clearance does not reflect this point.     

Ureteroneocystostomy for bilateral ureteral obstruction in carcinoma of prostate

“Fish-mouth” ureteroneocystostomy was successful in a patient with bilateral ureteral obstruction secondary to locally invasive adenocarcinoma of the prostate. The complications of permanent intubation are avoided and renal function is restored.