肾移植术后并发双侧自体肾盂和输尿管移行细胞癌16例

目的 总结肾移植术后发生双侧自体肾盂、输尿管移行细胞癌的诊治经验.方法 回顾性分析16例肾移植术后发生双侧自体肾盂、输尿管移行细胞癌患者的资料.首次发现上尿路肿瘤的时间为移植后(56.2±33.0)个月.2例同时发现双侧上尿路肿瘤,其余14例双侧上尿路肿瘤先后发现的时间间隔为(8.6±6.7)个月.临床症状和检查阳性结果以血尿和自体肾积水为主.均行自体上尿路根治性切除术,术后行膀胱灌注化疗.结果 16例手术均成功.32次自体肾、输尿管的病理检查结果均为移行细胞癌,包括单纯肾盂肿瘤4次,单纯输尿管肿瘤9次,合并肾盂、输尿管肿瘤19次.23次肾盂肿瘤的分级为1级8例,2级11例,3级4例;28次输尿管肿瘤的分级为1级6例,2级10例,3级12例.术后随访(26.8±25.1)个月,1例出现肺部转移后死亡;1例发生腰背部软组织转移性移行细胞癌,局部切除;其他患者未发现肿瘤复发及转移.结论 肾移植后自体上尿路移行细胞癌的常见表现为血尿合并自体肾积水,该肿瘤侵袭性较强,对于膀胱及一侧自体上尿路同时存在移行细胞癌者,应行对侧自体肾上尿路预防性切除术.

Abstract：

Objective To investigate the clinical features of bilateral native pelvic and ureteral transitional cell carcinoma (TCC) in renal transplant patients. Methods A retrospective analysis was carried out on 16 patients with bilateral native pelvic and ureteral TCC after kidney transplantation.The mean time between transplantation and diagnosis of upper urinary TCC was 56. 2 ± 33. 0 months.Two patients were suffered from bilateral upper urinary TCC at the same time. The mean interval between 2 upper urinary tract operations of the remaining 14 cases was 8. 6 ± 6. 7 months. Hematuria and hydronephrosis of native kidneys were the main symptoms and targets in checkup. Intravesical chemotherapy was postoperatively given. Results All operations were performed successfully. All specimens obtained from the operations were pathologically diagnosed as TCC. The TCC location involved pure native pelvis (n = 4), pure native ureter (n = 9), and pelvis combined with ureter (n = 19). Pelvic TCC pathological grades included grade 1 in 8 cases, grade 2 in 11 cases, and grade 3 in 4 cases; Ureteral TCC grades included grade 1 in 6 cases, grade 2 in 10 cases, and grade 3 in 12 cases.Patients were followed up for 26. 8 ± 25. 1 months. One patient died of lung metastasis. (One case of lumbar soft tissue transfer was given local excision. The remaining patients had no recurrence and metastasis. Conclusion Renal transplant patients with hematuria and native renal hydronephrosis should be highly vigilant of the occurrence of upper urinary tract TCC. TCC after renal transplantation is invasive. Prophylactic contralateral nephroureterectomy should be performed on the recipients having TCC at the bladder and one side of native upper urinary tract.     

Peritoneal mesothelioma presented with bilateral hydronephrosis: a case report

We report a case of peritoneal mesothelioma presenting with bilateral hydronephrosis, which was difficult to be diagnosed. A 43-year-old woman was admitted to our hospital with acute renal failure. Ultrasonography revealed bilateral hydronephrosis. Retrograde pyelography revealed the stenosis of bilateral lower ureter. Pelvic magnetic resonance imaging demonstrated only a small mass lesion around the bilateral ureter. Other examinations showed no findings of malignancy. Under the diagnosis of retroperitoneal fibrosis, steroid therapy was performed. After 3 months, computed tomography (CT) revealed multiple abdominal masses. Percutaneous needle biopsy of tumor was performed. Pathological diagnosis was peritoneal mesothelioma. Chemotherapy based on the pleural mesothelioma was done but not effective, she died 9 months after the first medical examination.     

Bilateral herniation of renal pelves A complication of cutaneous pyelostomy

The first reported case of bilateral herniations of the renal pelves as a complication of cutaneous pyelostomy is presented. We describe a modification of the original surgical technique that may prevent herniation, based on fixation of the pelvis to the lumbodorsal fascia as well as the cut edge of the pelvis to the skin. In our patient the bilateral herniations were corrected by repairing the fascial defects and suturing of the pelvis to the fascia.     

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.     

Large pelvic schwannoma causing bilateral hydronephrosis

Schwannoma is a tumor originating from neural sheath schwann cells. We report here a case of benign retroperitoneal schwannoma that caused bilateral ureterohydronephrosis. The retroperitoneal localization in the present case is unusual. The tumor was 21 x 18 x 11 cm in dimension and reached from the prostate to the umbilical level. Even though the patient had bilateral hydronephrosis, the renal function tests results were in the normal range. Complete surgical excision was achieved by anterior laparotomy. Histological and immunohistochemical studies confirmed the diagnosis. At 6 months follow-up there was no evidence of recurrence and renal function test results were normal.     

Pressure volume relationships in human hydronephrosis

Pressure volume curves were obtained in 8 children with ureteropelvic junction obstruction prior to pyeloplasty after totally obstructing the ureteropelvic junction. All human renal pelves displayed a similar shape pressure volume curve. The human renal pelvis is able to accommodate to increasing volumes by maintaining a relatively low intrapelvic pressure Once its capacity is reached, pressures rise to pathologically high levels at a much faster rate. These findings suggest that hydronephrosis can be viewed as a compensatory mechanism which protects some kidneys from further overdistention, high intrapelvic pressures, and progressive renal deterioration by virtue of acquired changes in compliance, pelvic size, and renal function which limit the rate of pressure rise within the hydronephrotic kidney.     

One-session bilateral ureteroscopy: Is it safe in selected patients?

The aim of this study was to investigate the possibility to perform bilateral ureteroscopy in one session and to determine the procedure's indications and complication rate. Twenty-two patients underwent bilateral ureteroscopy in one session. Eighteen patients had bilateral lithiasis of the lower ureteral third, three patients had unexplained haematuria and one had unexplained bilateral hydronephrosis. The rigid ureteoroscope was used in cases with stones and the flexible one in cases with haematuria and hydronephrosis. Ureteral catheters were placed in all patients. The overall stone-free rate was 83.3%. The procedure failed to confirm a diagnosis in 2 patients with unexplained haematuria. Follow-up included IVU and retrograde cystogram 3 months after the procedure and a renal scan one year later. No major complication was observed. It is concluded that bilateral ureteroscopy in one session can be performed safely in selected patients. The method does not yield major complications and saves patients from a second procedure and a second anaesthesia.     

Sporadic bilateral synchronous multicentric papillary renal cell carcinoma masquerading as bilateral multifocal pyelonephritis

Pyelonephritis is defined as an inflammation of the kidney and renal pelvis. The diagnosis is usually clinical. Acute multifocal bacterial nephritis is a rare form of pyelonephritis that is more severe and sepsis is more common. We report a patient who presented with fever and right-sided abdominal pain associated with right flank tenderness, suggesting right acute pyelonephritis. Bilateral multifocal pyelonephritis was diagnosed on ultrasonography, radionuclide renal scintigraphy and computed tomography. However, owing to non-resolution of symptoms, a biopsy was performed, which showed bilateral papillary renal cell carcinoma (PRCC). PRCC is known to exhibit multicentricity. To our knowledge, a case of bilateral multicentric PRCC masquerading as bilateral multifocal pyelonephritis has not been reported in the English literature. This case highlights the need to be vigilant while treating patients with focal lesions of the kidney as an inflammatory condition lest a malignancy should be missed.     

肾盂鳞状细胞癌的诊断与治疗(附16例报告)

目的：探讨肾盂鳞状细胞癌的术前诊断及治疗效果。方法：回顾性分析16例肾盂鳞状细胞癌患者的诊断和治疗等临床资料。所有患者术前均行IVU检查，13例行B超检查，4例行CT和MRI检查；11例行根治性肾切除加局部淋巴结清扫术。结果：行IVU检查者仅提示4例有占位性变病，13例行B超检查者仅显示2例有占位性病变，4例行CT或MRI检查者均提示有肿瘤改变。近50％的患者术后1年内死亡。结论：术前诊断肾盂鳞状细胞癌的敏感方法为CT和MRI，其治疗方法首选根治性肾切除术，但预后差。     

Squamous cell carcinoma of the renal pelvis with giant hydronephrosis

We report a case of squamous cell carcinoma of renal pelvis associated with giant hydronephrosis. A 71-year-old woman presented to our hospital with a complaint of abdominal fullness due to the right giant hydronephrosis. Although the diagnosis of her hydronephrosis was made about 20 years ago at another hospital, it had been left untreated. Computed tomography showed the right hydronephrosis of 20 x 20 x 25 cm in diameter and no evidence of tumor or calculus in the right urinary tract. For relief of her complaint, right nephrectomy was performed. The fluid content was bloody and 4,200 ml in volume. Histological examination revealed a flat type squamous cell carcinoma of the renal pelvis. This is the 30th case of renal pelvic malignant tumor associated with giant hydronephrosis reported in Japan. The literature was reviewed and the management of giant hydronephrosis was discussed.     

Acute renal failure due to over-infusion in a child with bilateral obstruction of the pyeloureteral junction]

A 2-year-old boy was hospitalized with the chief complaint of oliguria and dyspnea. Bilateral hydronephrosis and obstruction of the pyeloureteral junction were detected by ultrasonography. Pulmonary edema was also found on chest radiographs. The clinical diagnosis was acute post renal failure due to bilateral pyeloureteral obstruction and pulmonary edema due to overtransfusion. After we performed bilateral percutaneous nephrostomy, the patient recovered from renal failure and pulmonary edema. Both nephrostomies were removed after we confirmed a non-obstructing pattern using the Whitaker test.     

Elastin content of the renal pelvis and ureter determines post-pyeloplasty recovery

PURPOSE: We evaluated the collagen-to-smooth muscle tissue matrix ratio and percentage of elastin in the renal pelvis, ureteropelvic junction (UPJ) and ureter, and compared these findings with the degree of obstruction, patient age and post-pyeloplasty renal recovery. MATERIALS AND METHODS: We analyzed histological sections from 75 patients with UPJ obstruction. Nine patients were excluded owing to bilateral UPJ obstruction and an improper specimen. We divided the specimen obtained from pyeloplasty into 3 parts, namely the renal pelvis above the obstruction, the obstructed UPJ portion and the ureter below the obstruction. To examine the collagen and smooth muscle, sections were stained using Masson's trichrome, and elastic van Giesson stain was used for elastin, smooth muscle and collagen. Collagen, smooth muscle and elastin populations were identified, and the tissue matrix ratio and percentage of elastin were calculated by color image analysis. RESULTS: In patients with lower ratios of collagen-to-smooth muscle in the UPJ proper hydronephrosis was more improved postoperatively (p = 0.049). In patients with a lower percentage of elastin in the renal pelvis, UPJ and ureter hydronephrosis was more improved postoperatively (p <0.0001). CONCLUSIONS: Because the UPJ portion was resected during pyeloplasty, the renal pelvis and the ureter remaining after pyeloplasty are likely to be related to improved hydronephrosis. A higher percentage of elastin in the renal pelvis and ureter contributes to inelasticity and low compliance, and results in a slower recovery from hydronephrosis after pyeloplasty.     

Case report: bilateral ureteral obstruction secondary to Aspergillus bezoar

Ureteral obstruction as a result of a primary aspergillus infection is rare. Early clinical suspicion in immunosuppressed patients is essential to diagnosis. We report a case of a 50-year-old diabetic woman presenting with acute renal failure, sepsis, and bilateral ureteral obstruction. Initial management included bilateral percutaneous nephrostomy tubes. Urine culture from both the left and right renal pelvis grew Aspergillus flavus. The left-sided obstruction resolved with antifungal therapy. However, her right ureteral obstruction persisted and was managed with ureteroscopy and removal of the fungal bezoar.     

Bilateral ectopic ureteroceles: report of a case

A case of bilateral ectopic ureteroceles with complete duplicated pelves and ureters occurring in a 9-year-old girl is reported. She complained of cloudy urine and urinary incontinence. IVU revealed bilateral complete duplicated collecting systems and hydronephrosis of upper poles of the kidney. Bilateral ureterovesiconeostomy by modified Politano-Leadbetter method was carried out. Her postoperative course was uneventful and hydronephrosis of upper poles on IVU at 1 year after discharge and urinary incontinence improved. The 11 reported cases with bilateral ectopic ureteroceles including our case are reviewed and some characteristics of this entry are discussed.     

Survival in second trimester oligohydramnios secondary to bilateral pelviureteral junction obstruction

The extent and onset of obstruction in hydronephrosis determine the varying degrees of renal impairment. Bilateral hydronephrosis, especially in combination with oligohydramnios, is considered a negative predictor for pregnancy outcome. We describe a case of bilateral pelviureteral junction obstruction causing severe oligohydramnios between 25 and 29 weeks of gestation. The prenatal and postnatal findings and treatment are demonstrated. In the presence of bilateral renal impairment and oligohydramnios, our patient had an unfavorable prognosis. The respiratory and renal function, however, were better than expected. We show how urinary tract reconstruction and neonatal intensive therapy can result in an acceptable outcome.     

Ureteropelvic junction obstruction in the newborn

Ureteropelvic junction (UPJ) obstruction is a common cause of hydronephrosis in infants. Newborns with severe obstruction often have marked improvement following correction; therefore early diagnosis and operation is important. From 1973 to 1983, 21 patients were operated on for UPJ obstruction diagnosed under 6 weeks of age. Six patients (29%) had antenatal ultrasonographic diagnosis. The remaining patients were diagnosed by IVP or radionuclide scan for palpable renal enlargment or for associated anomalies. Seventeen had unilateral and four had bilateral obstruction. Twenty-three pyeloplasties, one primary nephrectomy, and one cutaneous pyelostomy with subsequent nephrectomy were done. All pyeloplasties were dismembered, with tailoring of the renal pelvis. Postoperative renal function was followed with radionuclide scan or IVP. Postoperative complications included a single urinary tract infection in three patients and two bowel obstructions. One early postoperative death occurred in an infant with bilateral obstruction who developed congestive heart failure secondary to severe uncontrollable hypertension. There were two other unrelated late deaths. Documented functional improvement with minimal complications follow unilateral or simultaneous bilateral pyeloplasty in newborns with UPJ obstruction.     

A case of squamous cell carcinoma of the renal pelvis originating from a functional solitary kidney associated with renal stones

A 60-year-old man was hospitalized because of multiple bilateral renal stones and macrohematuria. The right kidney was not functioning, and the left kidney showed marked hydronephrosis. Left renal stones were treated by percutaneous nephrolithotomy. Several months later, squamous cell carcinoma of the treated renal pelvis was diagnosed. Although the patient was treated by chemotherapy and radiotherapy, he died of renal failure.     

Partial hydronephrosis in a patient with horseshoe kidney and bilateral duplication of the pelvis and ureter.

A case of the rare combination of horseshoe kidney, bilateral duplication of the pelvis and ureter, with stricture of one uretero-pelvic junction causing symptomatic hydronephrosis is reported. The patient was treated with resection as modum Anderson-Hynes. The embryology, symptomatology and treatment of such anomalies is discussed.     

A case of amyloidosis of the renal pelvis

We report a case of localized amyloidosis of the renal pelvis and upper ureter arising in a 74-year-old man who presented at our hospital with gross hematuria. The intravenous pyelogram showed right hydronephrosis and stenosis of right renal pelvis and upper ureter. The cystoscopy view was normal, but the right retrograde-ureteropyelogram showed a long irregular stricture of the renal pelvis. Ureteroscopy was performed and rubbing biopsy of edematous, bleeding lesion suggested class IIIb, transitional cell carcinoma. With the diagnosis of a right renal pelvic tumor, right nephroureterectomy was performed. The histology report stated "massive deposits of amyloids are seen in the segment of macroscopically abnormal renal pelvis". Amyloidosis of the renal pelvis is a rare entity and 12 cases were reported in the Japanese and English literature.     

Long-term followup of prenatally detected severe bilateral newborn hydronephrosis initially managed nonoperatively

PURPOSE: We determine the outcome of severe bilateral primary ureteropelvic junction type hydronephrosis detected prenatally and managed postnatally with an initially nonoperative protocol. MATERIALS AND METHODS: A total of 19 newborns (38 kidneys) with prenatally diagnosed primary grade 3 to 4 bilateral hydronephrosis were followed nonoperatively for a mean of 54 months (range 14 to 187). If urinary obstruction with evidence of renal deterioration (decreased differential function and/or progressive hydronephrosis) occurred pyeloplasty was performed. RESULTS: Pyeloplasty was required in 13 kidneys (35%) in 9 patients (bilateral 4, unilateral 5). Age at pyeloplasty ranged from 2 to 22 months (mean 6.5) in 12 patients and 64 months in 1. The remaining 25 kidneys were followed nonoperatively (bilateral 20, unilateral 5). At last followup the Society for Fetal Urology grade of hydronephrosis in kidneys followed nonoperatively was 0 to 2 in 21 and 3 in 4, compared to 0 to 2 in 9 and Society for Fetal Urology 3 in 4 kidneys treated with pyeloplasty. Mean followup required for the most severely hydronephrotic kidney to achieve maximum ultrasound improvement was 10 months (range 3 to 34) for kidneys followed nonoperatively and 14 months (4-31) for kidneys after pyeloplasty. Differential renal function was measured in each kidney pair and compared using the difference in percent function between the 2 kidneys. In the nonoperative group mean initial difference in percent function was 8% (range 6% to 20%) and mean final difference was 5% (2% to 8%). In the pyeloplasty group mean initial difference in percent function was 16% (range 8% to 30%) and mean final difference was 7% (2% to 16%). With close followup and prompt pyeloplasty renal function improved to greater than pre-deterioration levels in all kidneys. CONCLUSIONS: These data represent the natural history of severe bilateral newborn hydronephrosis. Renal dilatation and function improve with time in most kidneys. Close followup is required in the first 2 years of life to identify the subgroup (35%) of children with obstruction that requires prompt surgery. Such an approach prevented permanent loss of renal function. Nonoperative management with close followup during the first 2 years appears to be a safe and recommended approach for neonates with primary bilateral ureteropelvic junction type hydronephrosis.