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.     

Renal pelvic tumor in chronic renal failure: report of a case

A 44-year-old female was admitted because of gross hematuria six years after beginning hemodialysis for chronic renal failure. There was a past history of hematuria one year before admission. Retrograde pyelography, computed tomographic scan and angiography had been performed, and a probable malignant tumor of left renal pelvis had been found in 1986. We recommended surgery at the time, but she refused treatment and was followed up. On June 22, 1987, the patient had a second attack of gross hematuria resulting in bladder tamponade, and hematuria from the left ureteric orifice was confirmed at cystoscopy. Ultrasound showed left obstructive nephropathy. Left nephrectomy was performed because of the presumptive diagnosis of malignant tumor. The histological diagnosis was transitional cell carcinoma of the left renal pelvis. Two courses of M-VAC (methotiexate, vinblastine, adriamycin and cisplatin) chemotherapy were accordingly given postoperatively. The incidence of renal pelvic tumor and its chemotherapy in patients with chronic renal failure are discussed.     

A clinical study on 34 cases of urothelial cancer of upper urinary tract

Thirty-four cases of tumor of the renal pelvis or ureter or both have been treated in our department during the past decade. The primary tumor was in the renal pelvis in 11 cases, in the ureter in 21 cases and in the ureter and renal pelvis in 2 cases, a co-existent tumor in the bladder was found in 4 cases. Seventeen patients had a tumor on the right side and 17 on the left side. The most frequent symptom was gross hematuria (70.6%) and flank pain was the presenting symptom in 7 cases (20.6%). On the intravenous pyelography, a filling defect in the renal pelvis or ureter (41.2%) and nonvisualization (53.0%) were frequent findings. Twenty-nine cases had undergone total nephroureterectomy with resection of a bladder cuff, 3 had simple nephrectomy and 2 had open biopsy alone. Postoperative radiation therapy was done in 1 case, chemotherapy in 10 cases, and 6 cases of them were treated by CAP therapy (cis-dichlorodiamine platinum, doxorubicin and cyclophosphamide). Actual and relative 5-year survival rates were 53.8% and 63.5%, and no significant difference was found in survival rate between the patients with renal pelvic tumors and those with ureteral tumors.     

肾盂输尿管癌肉瘤(附三例报告)

目的 总结肾盂输尿管癌肉瘤的临床及病理特点。方法 报告3例肾盂、输尿管癌肉瘤病例资料。3例均为女性，年龄分别为43、57、75岁。均以肉眼血尿或伴有腰痛就诊，经影像学检查诊断为肾盂输尿管肿瘤。结果 2例行患肾、输尿管全长切除和膀胱部分切除术，1例行姑息性肿瘤切除术。病理检查发现为同时存在癌与肉瘤成分。3例患者术后均未行放化疗，分别于术后8个月，14个月和2个月死于肿瘤转移。结论 此病临床罕见，预后极差，诊断依靠病理学检查，免疫组化对确诊有重要价值，病理诊断应与肉瘤样癌相鉴别。     

A case of Churg-Strauss syndrome which cheaf complain was gross hematuria

We report a case of Churg-Strauss syndrome complaining of gross hematuria. A 74-year-old man was admitted to our hospital for further examination of gross hematuria. Abdominal CT and retrograde pyelography revealed left renal pelvic tumor, and left nephrectomy was performed. There was no tumor, but submucous hemorrhage was seen in the renal pelvis. The histopathologic diagnosis was allergic granulomatous angitis. The administration of prednisolone was done, but he suddenly died of acute heart failure after 1 month postoperatively.     

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.     

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.     

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 carcinoma in situ of the renal pelvis

A case of carcinoma in situ of the renal pelvis in a 70-year-old female is reported. The patient was admitted with the complaints of macrohematuria and left back pain. Urine cytology, which was carried out three times using urine samples collected directly from the urinary bladder proved to be negative. Drip infusion pyelography (DIP) and retrograde pyelography (RP) disclosed stenosis of the left ureter at the level of L3-L4. Selective renal angiography revealed no abnormalities. Based on the DIP and RP findings, the diagnosis of tumor in the left ureter was made, and left total nephroureterectomy with partial cystectomy was performed. The removed kidney showed signs of mild hydronephrosis but no tumor was found macroscopically. The stenosed site of the ureter had scar-like tissue. Microscopic examination revealed that the stenosed ureter consisted of nonspecific granulation tissue but the mucosa of the renal pelvis showed grade III transitional epithelial cell carcinoma, At 24 months after operation, there is no evidence of tumor recurrence, and urine cytology is also negative.     

Ureteral polyp occurring as renal dysfunction with contralateral ureteral calculi: a case report

A 46-year-old man was admitted to our hospital complaining of macroscopic hematuria with dull pain in the right flank. Laboratory finding showed renal dysfunction and abdominal ultrasound sonograph revealed bilateral hydronephrosis (right > left). Retrograde pyelography showed left ureteral calculi and a filling defect in the middle portion of the right ureter. Renal function improved after bilateral single-J ureteral stent placement. Selective wash cytology of right renal pelvis was class II. Ureteroscopy demonstrated right ureteral obstruction with smooth-surfaced protruded tumor and cold cup biopsy was performed. Histopathological diagnosis was a fibroepithelial polyp but with no malignancy. In addition, left transurethral lithotripsy was performed under ureteroscopy. After the endoscopic examination, a double pigtail stent inserted into the right ureter. We performed conservative management by repeat urine cytologies and retrograde pyelography due to thrombocytopenia. The urine cytologies all proved negative and retrograde pyelography showed no abnormal changes. A ureteroscopic procedure is considered to be useful for the diagnosis of ureteral polyps. Transurethral resection of ureteral polyps with a ureteroscope is recommended for treatment.     

A case of transitional cell carcinoma presenting as rupture of a renal arteriovenous malformation

A 76-year-old man was seen at this hospital for the treatment of asymptomatic gross hematuria. Retrograde pyelography revealed a filling defect in the left lower calyx. The diagnosis was left renal pelvic carcinoma by urinary cytology. The patient underwent left nephrouretectomy with partial cystectomy. Hemosiderin accumulation on histological examination demonstrated an arteriovenous malformation in the left lower calyx. Transitional cell carcinoma was confirmed apart from the arteriovenous malformation, and no relation between the two was seen. These findings suggest the coexistence of a renal arteriovenous malformation with a renal pelvic and ureteral carcinoma. Hematuria was due probably to rupture of the renal arteriovenous malformation.     

Primary adenocarcinoma of the ureter: report of a case

The patient was a 66-year-old man who presented with asymptomatic hematuria. Left hydronephrosis was observed on drip infusion pyelography (DIP), and retrograde pyelography (RP) was performed because the image of the ureter was poor. On RP, stenosis was observed in the left ureter at the L5 vertebral level. The same findings were obtained by antegrade pyelography in combination with nephrostomy. A white-colored tumor was observed at the site ofstenosis by flexible pyeloscopy, and biopsy was performed. Adenocarcinoma was identified by histopathological examination. Total left renal nephroureterectomy was performed after its diagnosis as primary adenocarcinoma of the ureter (T2, NO, MO). To our knowledge, this is the 12th case reported in Japan.     

A case of renal pelvic carcinoma in situ]

A 72-year-old female visited our hospital with the complaint of macroscopic hematuria on Jan. 29, 1990. Cystoscopic examination revealed hematuria flowing out from the left ureteral orifice. A 1 cm mass was found in the left upper calyx by retrograde pyelography (RP). Urine cytology obtained by RP was class IIIb. Later, the mass was found in the left middle calyx by CT. Repeated RP revealed no mass and the wall of the left upper calyx was irregular. Washing cytology from the left renal pelvis was class V. Left total nephroureterectomy was performed on Feb. 2, 1990. Macroscopically, no tumor mass was apparent. Microscopically, transitional cell carcinoma in situ was widely spread from the left renal pelvis to the middle ureter. The preoperative upper calyceal mass was thought to have been a blood clot. At twelve months after the operation, there has been no evidence of tumor recurrence.     

Metastatic tumor of renal pelvis and ureter from prostatic cancer: a case report]

An 86-year-old man was admitted to our hospital with a complaint of gross hematuria. Urological examination revealed right hydronephrosis and poorly differentiated adenocarcinoma of the prostate with bone metastases. Abdominal computed tomographic scan and retrograde pyelography showed thickening of the ureteral wall with irregular stenosis in the right upper ureter. Right nephroureterectomy demonstrated diffuse lymphatic infiltration of PSA-positive cancer cells in the submucosa and muscle layer of the ureter as well as renal pelvis. This is the 6th reported case of metastatic ureteral tumor from prostate cancer in the Japanese literature.     

Spontaneous disappearance of multiple lung metastases after nephroureterectomy from sarcomatoid carcinoma of the renal pelvis: A case report

We report a case in which lung metastases disappeared spontaneously after nephroureterectomy from sarcomatoid carcinoma of the renal pelvis. A 58-year-old man presented with gross hematuria. Computed tomography (CT) revealed a left renal tumor and multiple lung metastases. Intravenous pyelography revealed a filling defect in the upper renal calyx. Urine cytology was positive. Left renal pelvic cancer was diagnosed and nephroureterectomy performed. The resected specimen was diagnosed pathologically as sarcomatoid carcinoma of the renal pelvis. Approximately 5 months later, CT revealed that the lung metastases had disappeared. There has been no evidence of disease for 46 months postoperatively.     

Bilateral multiple ureteral polyps causing intermittent hydronephrosis: a case report

We report an unusual case of bilateral ureteral polyps causing intermittent hydronephrosis, which developed extensively in the upper part of ureters. The patient was an 8-year-old male. He had several episodes of gross hematuria with right flank pain. Ultrasonography of the kidney showed mild bilateral hydronephrosis, while this finding was markedly aggravated in association with the onset of pain. Intravenous pyelogram and retrograde pyelogram revealed multiple filling defects in both upper parts of ureters. Since the diseased part of the ureter was wide (about 7 cm in length), a segmental resection of the right ureter with mobilization of the right kidney was performed, followed by end-to-end ureteral anastomosis. The pathological diagnosis was fibroepithelial polyps. Regarding the disease of contralateral ureter, no surgical treatment was performed because he had no clinical symptoms. Six years after the surgery, he again developed gross hematuria with left flank pain. Marked dilatation of the left renal pelvis was shown by ultrasonography, which suggested left intermittent hydronephrosis caused by ureteral polyps. He underwent a partial ureterectomy with mobilization of the left kidney for the left ureteral disease. No recurrence of polyps has been observed in the urinary tract since this surgery.     

A case of small cell carcinoma of the ureter

We report a case of primary undifferentiated small cell carcinoma of the ureter. A 62-year-old man showed gross hematuria. Retrograde pyelography and CT scan revealed a tumor in the left ureter. The light microscopic examination revealed small cell carcinoma and transitional cell carcinoma. To the best of our knowledge, this is the first report of a small cell carcinoma originating in the ureter in Japan.     

Inverted papilloma of the ureter

Two cases of ureteral inverted papilloma are reported. Case 1: A 48-year-old male had asymptomatic gross hematuria and filling defect of left middle ureter on intravenous pyelography. Segmental resection of ureter was performed. The specimen was a 1 cm polypoid lesion with histologic features resembling "multifocal bud-like proliferation", which was reported as the initial stage of the inverted urothelial tumor by Kunze et al. Case 2: A 64-year-old female with asymptomatic gross hematuria and complete obstruction of left middle ureter on ante- and retrograde pyelograms. Total nephroureterectomy was performed. A 4 cm lobulated and pedunculated lesion with histologic features of typical inverted urothelial papilloma was resected. Twenty-one cases of ureteral inverted papilloma in the literature, including our cases, are analyzed.     

Primary amyloidosis of renal pelvis with duplicate collecting system

A case of primary amyloidosis localized to the inferior renal pelvis of a kidney with a duplex collecting system is described. The onset of gross hematuria and mild flank pain necessitated investigations which yielded a clinical impression of tumor within the lower pelvis of a duplex collecting system. At laparotomy a grossly hemorrhagic-appearing mass in the lower pelvis was noted and a left ureteronephrectomy was undertaken. Histologic examination of the surgical specimen revealed amyloid deposition within the inferior pelvis, the corresponding distal portions of the papillae, and the most proximal ureter. Amyloid was not present elsewhere within either the renal parenchyma or the superior collecting system.     

Ureteral avulsion: a rare complication of ureteroscopy

A case of ureteral avulsion as a complication of ureteroscopy is presented. A 55-year-old woman was admitted to the hospital with the complaint of hematuria. The intravenous pyelography revealed a calculus measuring 16 x 12 mm located in the left upper ureter. Transurethral ureterolithotripsy was performed with 8 F rigid ureteroscopy. A safety guide wire was inserted and left ureteral olifice was dilated to 9 F. The ureteroscopy was smoothly introduced just under the stone. The stone was fragmentated with a pneumatic lithotripter. A part of the stone was pushed back to the renal pelvis, so the ureteroscope was passed to that stone and fragmentation was done as much as possible. The ureteroscopy was gently pulled out to the bladder, but the distal ureter was torn at the ureteral orifice and could be seen at the urethral orifice. Pelvis, upper ureter and middle ureter were intact, so open intervention for repair was not performed. A 6Fr double pigtail stent was placed over the safety guidewire. Cystscopy indicated a part of the distal ureter was protruded from the ureteral orifice. Eight weeks later, the protruded part of ureter was necrotic and calcified for ischemia. Transurethral resection of necrotic ureter was performed. Histologically, resected ureter changed necrotic tissue for ischema. Postoperatively intravenous pyelography did not reveal left hydronephrosis and cystoscopy indicated that the left ureteral orifice was almost normally repaired.