Botryoid Wilms' tumor of the renal pelvis extending into the bladder

We report a case of botryoid Wilms' tumor that occupied the renal pelvis and extended into the bladder. A 3-year-old boy was referred to us with a chief complaint of gross hematuria and micturition pain. Computed tomography showed tumor occupying the right renal pelvis and ureter and extending into the bladder. Right radical nephroureterectomy was performed. The resected specimen showed a botryoid sarcoma-like appearance, occupied the right renal pelvis and ureter, and protruded into the bladder. Histologic findings showed typical triphasic Wilms' tumor. Botryoid Wilms' tumor has been reported in only 16 cases in the literature and in only 3 cases extended into the bladder.     

Simultaneous occurrence of renal cell and transitional cell carcinoma in the same kidney and ureter. A case report

An unusual case of 2 concurrent primary renal tumors within the same kidney is reported. A 70-year-old woman presented with gross hematuria when she was in the hospital for cerebral infarction. Excretory urography revealed a marked expansion of the right kidney with no renal function. CT scan showed a mass arising from the right kidney, the hydronephrotic right renal pelvis, and a mass in the lower right ureter. Selective renal angiogram showed marked neovascularity of the mass. There was an encasement of the intrarenal artery to the lower pole. Angiographic findings were highly suggestive of a renal cell carcinoma with a second neoplasm in the renal pelvis. Subsequently, the patient underwent right radical nephroureterectomy and partial cystectomy. Section of the removed specimen revealed a 4.0 X 3.8 cm solid tumor confined to the kidney in the upper pole and a transitional cell carcinoma arising from the renal pelvis. In addition, transitional cell carcinoma was present in the distal ureter.     

A case of primary ureteral carcinoma in the duplicated renal pelvis and ureter diagnosed by transurethral uretero-renoscopy

We present a case of primary ureteral carcinoma in the duplicated renal pelvis and ureter diagnosed by transurethral uretero-renoscopy. The case was of a 78-year-old man with the complaint of sudden asymptomatic macrohematuria. An excretory urogram strongly suggested the presence of duplication of the right collecting system, and cystoscopy revealed a gross hematuria from the right ureteral orifice. A retrograde ureteropyelogram revealed incomplete duplication of the right renal pelvis and ureter fused at about the ureter crossing over the iliac vessels, and a polyp-like filling defect in the lower segment of duplicated ureter at about 4 cm from the fusion of the ureters. Transurethral uretero-renoscopy was employed to investigate the filling defect, and a papillary tumor extended into the lower segment of duplicated ureter was revealed. Tumor was resected by a rigid operating instrument under transurethral uretero-renoscopy. The pathological diagnosis was grade I-transitional cell carcinoma of the ureter, so that right total nephroureterectomy with partial cystectomy was carried out subsequently. Surgical specimen after right total nephroureterectomy with partial cystectomy showed no other tumor in the pelvis or ureter macroscopically, and histopathological studies of surgical specimens were no evidence of malignancy. We believe that transurethral uretero-renoscopy significantly increases the diagnostic accuracy in determining the nature of upper urinary tract lesions, and this procedure is indispensable in the diagnosis of ureteral tumors. The present case was the 7th case of primary ureteral carcinoma in the duplicated renal pelvis and ureter in the Japanese literature.     

Case report of primary carcinoma in situ in upper urinary tract and review of the Japanese literature

A case of carcinoma in situ (CIS) in the right renal pelvis in a 71-year-old women is reported. The patient was admitted because of macroscopic hematuria. Drip infusion pyelography showed a filling defect (coagulum) in the right renal pelvis. Other abnormal findings were not made. Malignancy was suspected by cytology examination in both voiding urine and that obtained by catheter from the right pelvis. A right total nephroureterectomy was performed. Macroscopic abnormal findings were only of the coagulum in the renal pelvis. Pathologic examination showed CIS in the renal pelvis. We studied the features, pattern of recurrence, and prognosis of 19 cases of primary CIS in the upper urinary tract in the Japanese literature. A slight higher frequency was reported for women than for men. When the CIS was in the ureter, abnormal roentgenological findings, such as stenosis, filling defects, or a dilated ureter, were common (77%), contrary to expectation. But when the CIS was in the pelvis, such findings were rare. Urine cytology examination was positive in 95% of the patients. In four of the 19 patients, a recurrence was found. In all four patients, the first recurrence was in the bladder within 2 years of surgery. The kind of recurrent bladder tumors varied with the patients. The prognosis with recurrence was poor. If signs of recurrence were not recognized within 2 years of surgery, the prognosis was good.     

Renal matrix stones in an emphysematous pyelonephritis

A 74-year-old-woman was referred to our hospital for further examination. Her chief complaint had been a high-grade fever, but she was seen at our hospital without fever. Plain fi lm of kidney, ureter and bladder drip infusion pyelography and abdominal computed tomography (CT) showed a gas shadow surrounding calcifications in the right renal pelvis. We diagnosed right emphysematous pyelonephritis. Since changes in the CT findings were not remarkable for 2 weeks, we performed laparoscopic right nephrectomy, even though her condition had not worsened. The renal pelvis contained brownish and clayish matter. We report here this rare case of renal matrix stones.     

Pelvio-ureteral tumor 5 years after uretero-cutaneostomy

A 70-year-old woman visited our hospital with the chief complaint of intermittent gross hematuria from right ureterocutaneostoma. She had received total cystectomy and bilateral ureterocutaneostomy because of bladder tumor (transitional cell carcinoma, grade 3, stage T2) 5 years earlier. Urine cytology showed transitional cell carcinoma (TCC). The right retrograde pyelogram showed shadow defects of right pelvis and upper ureter, computed tomographic scan showed fatty density mass of right pelvis. Preoperative diagnosis was right pelvic and ureteral tumors. Right nephroureterectomy was performed on May 26, 1986. Histology revealed TCC, grade 3 on the pelvis and upper ureter. Cases of pelvio-ureteral tumors of ureterocutaneostomy were collected from the literature and reviewed.     

Two cases of squamous cell carcinoma of upper urinary tract with hypercalcemia

We report two cases of squamous cell carcinoma of upper urinary tract with hypercalcemia. Case 1; a 54 year old female with primary squamous cell carcinoma (SCC) of right ureter showed marked hypercalcemia and leukocytosis. High levels of serum parathyroid hormone-related peptide (PTHrP) and granulocyte colony stimulating factor (G-CSF) were detected. Although chemotherapy of cisplatin and 5-fluorouracil with radiotherapy was effective, thereafter recurrence was occurred in renal pelvis, and the patient died 17 months after the initiation of therapy. Case 2; a 54 year old male of primary SCC of right renal pelvis with local lymphadenopathy and anterior mediastinal metastases showed marked hypercalcemia. High levels of PTHrP were detected. Although the patient was administered UFT with palliative radiotherapy to the anterior mediastinum, he died 2 months after the initiation of therapy. To our knowledge, the case 1 is the third case that of the high levels of serum PTHrP and G-CSF simultaneously in squamous cell carcinoma of upper urinary tract.     

Mucin-producing cystadenoma (borderline malignancy) of the renal pelvis and ureter. A case report

The patient was a 63-year-old women who visited our hospital with the chief complaints of swelling, chills, fever and right lumbago. Fifteen years ago, she received surgical exploration for right renal stones at another department of urology. A large, soft and round kidney was palpable from the right upper quadrant of abdomen to the right lower abdomen. The parenchyma of the right kidney was thinned and inside the kidney there was a huge amount of yellowish mucin. The histological diagnosis was mucin-producing cyst-adenoma (borderline malignancy) of the renal pelvis and ureter. Mucin-producing cystadenoma of the renal pelvis and ureter origin was very rare, and only 4 similar cases to our patient were so far reported.     

Solitary contralateral renal pelvis metastasis 9 years after removal of renal adenocarcinoma.

Extremely rarely, renal cell carcinoma metastasizes to the contralateral renal pelvis or ureter. The present report concerns a case where a metastatic tumour was successfully removed from the left renal pelvis 9 years after right nephrectomy for the primary tumour.     

Malignant lymphoma of the ureter: a case report

We report a case of malignant lymphoma (ML) of the ureter. A 71-year-old man was admitted to our hospital with the chief complaint of macroscopic hematuria. IVP showed the dilation of left ureter and renal pelvis. Retrograde pyelography showed a 2cm filling defect in the right middle ureter. From the data given, a right ureteral tumor was suspected, and we performed tumor biopsy under an ureteral scope. Since it was diagnosed not as transitional cell carcinoma (TCC) of ureter but as ML with strong inflammation, partial ureterectomy and uretero-uretero anastomosis were done. Histological diagnosis was B cell follicular center lymphoma. Because Ga-scintigraphy revealed no evidence of other involement, it was diagnosed as ML originating from ureter. ML secondarily invading the urinary tract organs is commonly found, but ML originating from the urinary tract is rare. Especially, in regards to ML originating from ureter, only 16 cases have been reported in Japan.     

Simultaneous bilateral renal pelvic tumors: a case report]

A case of simultaneous bilateral renal pelvic tumors is reported. A 64-year-old man with the chief complaint of gross hematuria and left flank pain was admitted. Clinical investigations revealed a tumor in the right pelvis and ureter, and another tumor in the left renal pelvis. The right ureteral tumor had invaded the bladder. Right nephroureterectomy, total cystectomy, left partial pyelectomy and ureterocutaneostomy were performed. By pathological examination, right renal pelvic and ureteral tumors were non-papillary transitional cell carcinoma, grade 3, pT4, and the left renal pelvic tumor was papillary transitional cell carcinoma, grade 2, pT1. To our knowledge, this is the 16th case of simultaneous bilateral urothelial tumors of the upper urinary tract in Japan.     

A case of renal cell carcinoma metastasizing to the contralateral kidney and renal pelvis

Extremely rarely renal cell carcinoma metastasizes to the contralateral renal pelvis or ureter. A 42-year-old man had undergone left radical nephrectomy for renal cell carcinoma (pT1b, grade 2) in March, 2000. Fifteen months later, he complained of macroscopic hematuria. Computed tomographic scanning and retrograde pyelography showed a right renal pelvic tumor. Enucleation of pelvic tumor was performed and a parenchyma mass incidentally identified in the right kidney was also resected. Histopathological examination of each tumor revealed renal cell carcinoma identical to the primary tumors in the left kidney suggesting metastasis to renal pelvis and de novo tumor or metastasis in the right kidney.     

A case of aplastic inferior vena cava with right hypofunctional kidney

We report a rare case of anomalous inferior vena cava (IVC) in a 46-year-old woman hospitalized for the examination of right hypofunctional kidney. She had no history of trauma or pyelonephritis and there were no abnormalities in laboratory findings except serum creatinine value. Excretory urography showed no excretion of contrast medium from right kidney and retrograde pyelography revealed moderate hydronephrosis of right kidney but the obstruction of the ureter was not recognized. Abdominal computed tomographic scan showed a total trace of IVC and inferior venacavography demonstrated complete obstruction of the IVC from its origin with collateralization of upper lumber veins and vertebral veins. Surgical exploration was performed and demonstrated that IVC was a trace from the postrenal segment to hepatic segment. Two right renal veins were draining into the upper lumber vein and the right ureter was compressed slightly by lower renal vein, dilated ovarian vein and fibrotic connective tissue.     

Renal pelvis pressure flow relationship in pigs after transsections of the ureter

The relationship between pressure and flow of the multicalyceal renal pelvis of the pig was investigated in 10 units. The relationship was studied in the intact system and after three consecutive transsections of the ureter 3 cm proximal to the ureterovesical junction, at the lower pole of the kidney and as proximal on the renal pelvis as possible. The mean resting renal pelvic pressure changed from 7.3 to 8.8 cm H2O when a distal transsection was performed. The resting pressure after proximal transsection and pelvic transsection was 8.0 and 6.5 cm H2O respectively. During perfusion the intact system as well as the distal transsection showed a three-phased relationship. In the latter the phases showed a shift to the right and the renal pelvic pressure was significantly decreased at flow rates from 4-10 ml/ureter/min. Perfusion after proximal transsection and pelvic transsection caused only minor increases in the renal pelvic pressure approximating a linear relationship. The study confirms a three-phased relationship between pressure and flow in renal pelvis and a resistance to high flow rates depending on the length of the ureter.     

Modulation of smooth muscle activity by nitric oxide in the human upper urinary tract

The aim of the study was to ascertain whether nitric oxide (NO) might regulate motility in the human upper urinary tract. Smooth muscle activity in the human renal pelvis and proximal ureter was studiedin vitro in organ baths, and nitric oxide synthase (NOS) activity was studied by measurement of citrulline formation. NO, glyceryl trinitrate (GTN) and sodium nitroprusside (SNP) significantly reduced the frequency of spontaneous rhythmic contractions in renal pelvis and proximal ureter. Exogenously applied NO elicited relaxations in pre-contracted renal pelvis. Calciumdependent NOS activity was significant in the renal pelvis but undetectable in the ureter. Also, NOS activity was absent in hydronephrotic renal pelvis. NO, SNP and GTN inhibited smooth muscle activity in the human upper urinary tract. NOS activity was obtained in normal renal pelvis but not in hydronephrotic renal pelvis. Regulation of urinary tract NO concentrations might offer a strategy for treatment of renal colic and disturbances in upper urinary tract motility.     

Surgical management of incomplete duplex kidney with both upper and lower moieties ureteropelvic junction obstruction: a case report with modified reconstructive method

An incomplete duplex kidney combined with ureteropelvic junction obstruction is a rare entity, and the surgical management strategy is highly individualized according to the anatomic variability. Currently, there is no literature report of the specific reconstructive method for the condition when obstruction occurs in both the upper and lower units of the duplex kidney. In this case report, a 60-year-old female with a right solitary kidney was admitted to our hospital. The patient suffered intermittent right flank pain and had an occasionally palpable abdominal mass for seven years. Computed tomography and intravenous pyelography revealed an incomplete duplex kidney with obstruction in both the upper and lower units with a proximal confluence. A specially designed reconstructive method, including an ureteropyelostomy between the upper pole ureter and lower pole pelvis, plus a dismembered pyeloplasty between the lower pole pelvis and common ureter, was used, with no intra- or postoperative complications. The patient remained symptom free at the 6-month, 1-year and 2-year follow-ups. A diuretic renal scan showed better drainage, and ultrasound revealed no significant hydronephrosis. Thus, our specially modified reconstructive strategy could be a method of choice when addressing particular anatomies, such as incomplete duplex kidneys with ureteropelvic junction obstruction in both upper and lower poles when the obstruction is close to the confluence of the two ureters.     

Pyelovesicostomy as a form of urinary reconstruction in renal transplantation

The development of ureteral obstruction or ureteral fistula formation in the renal transplant recipient usually requires surgical repair. This involves reconnecting the donor ureter to either the recipient ureter (ureteroureterostomy) or bladder (ureteroneocystostomy), or creating an anastomosis between the renal pelvis and recipient native ureter (pyeloureterostomy). Occasionally, the donor or recipient ureter is absent, necrotic or diseased so that a ureteroureterostomy, ureteroneocystostomy or pyeloureteral anastomosis cannot be performed. In 8 such cases we have performed a direct anastomosis between the donor renal pelvis and recipient bladder (pyelovesicostomy) with a followup of between 2 months and 11 years. In all 8 patients there has been no deterioration in renal function attributed to obstruction at the anastomotic site or to the free reflux between the bladder and renal pelvis. Because of the excellent short-term and long-term results of pyelovesicostomy, this procedure should be considered as an excellent alternative to pyeloureterostomy, ureteroureterostomy and ureteroneocystostomy in the reconstruction of the upper urinary tract of the renal transplant patient.     

Immunohistochemical detection of neuronal plexuses and nerve cells within the upper urinary tract of pigs.

OBJECTIVE: To investigate the distribution and topography of nervous structures within the renal pelvis and upper part of the ureter of pigs, and thus help to determine the origin, propagation and mechanisms of the modulation of pelvi-ureteric peristalsis. MATERIALS AND METHODS: Whole-mount preparations of renal pelves from adult pigs were stained using a universal immunostaining method with streptavidin-alkaline phosphatase. Anti-neuron-specific enolase antibody and anti-neurofilament antibody were used as neuronal markers. RESULTS: The patterns of neuronal structures differed between the renal calyces, renal pelvis and upper ureter. In the calyx, there was one single dense nerve plexus; this network contained relatively thin nerve fibres running both circularly and longitudinally. In the wall of the renal pelvis and upper ureter there were two neuronal plexuses, one submucosal and another within the muscular layer; these nerve fibres were mainly orientated longitudinally. Some single nerve cells were also found at the pelvicalyceal border. CONCLUSIONS: These findings suggest a potent nervous system within the upper urinary tract of pigs that connects the renal calyces with the renal pelvis, pelvi-ureteric junction and ureter. The presence of these dense neuronal networks and nerve cells within the wall of the renal pelvis and ureter suggests that propagation, coordination and modulation of pelvi-ureteric peristalsis in pigs may arise through intrinsic nervous stimulation.     

Laparoskopische Nierenbeckenplastik bei komplizierter Doppelniere

Laparoscopic pyeloplasty has been established as an effective and minimally invasive technique for treating ureteropelvic junction obstruction. Only case reports are available describing the use of laparoscopic pyeloplasty in patients with duplicated collecting systems. We report the case of a patient presenting with a short stenotic connection between the hydronephrotic lower pole system and a solitary ureter coming from the upper pole. In this patient, a side-to-side anastomosis between the renal pelvis and the ureter was successfully performed. The present data demonstrate that laparoscopic pyeloplasty is an applicable tool even in patients with upper urinary tract anomalies such as duplicated collecting systems.     

A case of multiple urothelial tumors with chronic renal failure

We report a case of multiple urothelial tumors (left renal pelvis, ureter and bladder) with chronic renal failure in a 72-year-old man. The patient was admitted because of gross hematuria with increasing volume and intervals on September 14, 1985. Admission evaluation including excretory urography, retrograde pyelography, computed tomography and cystoscopy revealed multiple urothelial tumors in the left renal pelvis, ureter and bladder. Radical surgery, however, was postponed because of pneumothorax induced by an inadvertent insertion of the CVP catheter at operation. Subsequent respiratory disturbance persisted so that he was observed at the outpatient clinic following right ureterocutaneostomy. Gradual increase in anemia and decrease in renal function, however, prompted another admission. Gross hematuria necessitating frequent blood replacement could not be controlled by transurethral resection of bladder tumors. Therefore left nephroureterectomy with resection of bladder cuff was performed after internal arteriovenous shunt had been established, because favorable results regarding tumor resection were obtained from preoperative evaluations. He showed satisfactory recovery and was spared hemodialysis despite eventful postoperative course with transient decrease in renal function. The patient was discharged on 130th postoperative day and is now being followed up at the outpatient clinic. The relevant literature is also reviewed briefly.