Transitional cell carcinoma of the distal portion of ureter protruding into the sigmoid conduit six years after cystoprostatectomy

Bladder tumors develop after the diagnosis of upper urinary tract carcinoma in approximately 20% of cases, whereas the incidence of upper urinary tract tumor after the diagnosis of bladder cancer is low, approximately 2%. In a 64-year-old man who had undergone cystoprostatectomy treatment of bladder carcinoma 6 years previously, with the sigmoid conduit used for supravesicle diversion, a transitional cell carcinoma that developed in the conduit was not revealed with intravenous pyelography at regular follow-up intervals. The patient had only hematuria. After an obstructed left kidney, left ureteral stricture, and a filling defect in the conduit were observed radiologically and biopsy revealed a transitional cell carcinoma at the ureterosigmoid junction, the patient underwent left nephroureterectomy, partial resection of a third of the sigmoid conduit, and right ureteral reimplantation. The occurrence of upper urinary tract carcinoma after treatment of bladder cancer should be considered even in light of intravenous pyelography that shows no abnormality; and when such carcinomas occur in this situation, disease involving the conduit should be ruled out.     

Synchronous multifocal development of invasive transitional cell carcinoma of the urinary tract in a patient with renal failure receiving long-term hemodialysis: a case report

We report a case of transitional cell carcinoma in a patient with chronic renal failure receiving hemodialysis for 22 years. A 55-year-old man was admitted to our hospital. Under diagnosis of invasive bladder cancer and left renal pelvic tumor, removal of the whole urinary tract, e.g., bilateral nephroureterectomy and total cystourethrectomy was performed. Transitional cell carcinoma was found in bilateral renal pelvis, left ureter, bladder and prostate in the resected specimen. Thirteen months after the operation, multiple lung metastases and pathologic bone fracture of the 4th lumber vertebra were found. Chemotherapy (3 courses of modified CISCA, consisting of cisplatin, adriamycin and cyclophosphamide) was performed, but the died of systemic metastases of cancer and bleeding due to perforation of multiple gastric ulcers.     

Computed tomography for detection and staging of transitional cell carcinoma of the upper urinary tract

A total of 91 patients were treated for upper tract urothelial tumors between 1981 and 1991. Preoperative computed tomography (CT) scans and nephroureterectomy for treatment of transitional cell carcinoma were performed in 26 patients. At pathological examination, 28 tumors were diagnosed of which 19 were in the renal pelvis and 7 were in the ureter. Intravenous pyelogram, retrograde and antegrade pyelogram detected 26 of 28 tumors (93%). CT detected 24 of 28 tumors (86%). However, CT is still the best current method for staging of upper urinary tract urothelial tumors, although staging was correct in only 5 of 9 T3 and T4 tumors.     

Utility of the Bard BTA test in detecting upper urinary tract transitional cell carcinoma

OBJECTIVES: The Bard BTA test has been shown in early studies to be useful in diagnosing transitional cell carcinoma (TCC) of the bladder. However, the utility of this test has not been evaluated for TCC of the upper urinary tract. We therefore evaluated the clinical utility of the BTA test for upper urinary TCC. METHODS: We tested 71 specimens from the ureter and/or renal pelvis in 22 patients with a history or clinical suspicion for TCC and 9 patients with benign disorders. RESULTS: When compared to cytologic diagnoses, BTA had a sensitivity of 65%, a specificity of 40% (when correlated with clinical history), a false-positive rate of 33%, and a false-negative rate of 62%. The test had a positive predictive value of 83% and a negative predictive value of 32%. CONCLUSIONS: The BTA does not have any clinical value in detecting upper urinary tract TCC.     

A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy

PURPOSE: The optimal technique of excising the juxtavesical ureter and bladder cuff during laparoscopic nephroureterectomy is still evolving. We report on a novel transvesical needlescopic (2 mm. instrumentation) assisted technique of en bloc retrieval of the juxtavesical ureter and bladder cuff during laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma. MATERIALS AND METHODS: Retroperitoneal laparoscopic nephroureterectomy was performed in 8 patients using this technique. Two needlescopic ports (2 mm.) inserted suprapubically into the bladder were used in combination with a cystoscopically positioned Collins knife. RESULTS: Satisfactory circumferential detachment of the bladder cuff and en bloc mobilization of 3 to 4 cm. of the intact pelvic extravesical ureter were achieved transvesically in each case in a manner comparable to open surgery. CONCLUSIONS: This technique simulates established open surgical principles of treating the distal ureter during laparoscopic nephroureterectomy.     

Local staging with CT of tumors of the upper urothelium

OBJECTIVE: To evaluate the ability of computerized tomography (CT) to stage transitional cell carcinoma of the upper urinary tract. METHODS: 29 transitional cell carcinoma of the upper urinary tract submitted to nephroureterectomy were retrospectively evaluated. All 29 tumors had preoperative CT scans performed to stage the lesion. The pathological staging was compared to that of CT. RESULTS: 10 of the 29 tumors had CT evidence of tumor extension and 19 had localized noninvasive tumor on CT. Of the 10 patients with CT findings of tumor extension, 2 (20%) had superficial tumors and 8 (80%) had tumors that invaded into the adventitial fat, renal parenchyma or perirenal fat (pT3, pT4). Of the 19 patients with localized noninvasive tumor on CT, 13 (68%) had superficial tumors and 6 (32%) had pT3 or pT4 tumors. CT sensitivity for tumor invasion was 57% with a specificity of 87.5%. CONCLUSIONS: Our analysis shows that CT is of limited value in staging these tumors. When CT demonstrates direct tumor extension through the renal pelvic or ureteral wall, it is a sensitive indicator of high-stage tumor. However, the results obtained in low stage tumors must be viewed with caution.     

Disseminated intravascular coagulation: pathophysiology and principles of management

OBJECTIVE: To analyze the survival and the main prognostic factors in patients with transitional cell carcinoma of the upper urinary tract. METHODS: From 1983 to 1996, we treated 50 patients with transitional cell carcinoma of the upper urinary tract. Treatment was basically conservative except in those cases whose tumor stage or grade required a radical approach. Grading and staging were performed according to the 1992 TNM classification. Eighteen patients had died at one year mean follow-up., At the time the study was completed (June, 1997), 32 patients were alive with a mean follow-up of 4.9 years. Disease-free survival, overall and specific survival were analyzed according to sex, age, association with bladder tumors, localization, type of treatment, tumor size, number, histological grade and stage. RESULTS: The male-to-female ratio was 5:1. Patient mean age was 65.7 years. Association with bladder tumors was observed in 50%. Treatment was conservative in 40% and radical in 60%. The five- and ten-year disease-free survival rates were 69%, overall survival 61% and specific survival 71%. The univariate analysis showed the following to be unfavorable prognostic factors for survival: renal vs ureteral tumors, radical vs conservative treatment, high grade and stage tumors. The association of carcinoma in situ with other tumors of the upper urinary tract was also found to be an unfavorable factor for disease-free survival. The multivariate analysis associated T4 and G3 tumors with poor prognosis. CONCLUSIONS: Transitional cell carcinoma of the upper urinary tract was associated with bladder tumors in 50% of the cases. Low grade stage tumors demonstrated a high survival rate, therefore conservative treatment should be the first approach. High grade/ stage tumors were found to be unfavorable prognostic factors for survival.     

A case of asynchronous renal cell carcinoma and urothelial cancer of the urinary bladder and left ureter

A 49-year-old male with left renal cell carcinoma and urothelial cancer (bladder and residual left ureter), which asynchronously occurred, was reported. He had received radical nephrectomy due to renal cell carcinoma 12 years earlier. He was followed up by his local physician for 7 years postoperatively, during which time no metastatic lesion was detected. However, he presented with macroscopic hematuria on January 7, 1992, and a diagnosis of urinary bladder cancer was made at our hospital. Computerized tomography demonstrated a non-papillary, broad-based tumor on the left wall of the urinary bladder, which histologically was transitional cell carcinoma (grade 3). Radical cystectomy, ureterectomy of the left residual ureter and ileal conduit were performed. Histological examinations showed that the urinary bladder tumor was transitional cell carcinoma, grade 3, pT-3b, and CIS (transitional cell carcinoma, grade 3) was found in the residual left ureter. Chemotherapy containing cis-platinum was performed as an adjuvant therapy, but multiple lung metastatic lesions appeared 2 months postoperatively, the histology of which was transitional cell carcinoma, suggesting metastasis from the urothelial cancer. Chemotherapy was ineffective, and he died of the disease 9 months after the operation. If this patient had been under long-term follow-up, the urothelial cancer may have been resected completely by transurethral resection. Our report indicated the importance of examination of the urinary tract in patients with such cancers, as well as the necessity of long-term follow-up.     

One or two incisions for nephroureterectomy in transitional cell renal pelvis tumours

A retrospective study comprising 18 patients with transitional cell renal pelvis tumours (TCPT) was carried out to evaluate the results after two different surgical procedures for nephroureterectomy. The kidney was removed by a flank incision and the lower part of the ureter by either an incision in the lower part of the abdomen or intussusception of the ureter followed by transurethral resection of the ureteral orifice. Eight patients were subjected to nephroureterectomy by means of two incisions and another eight patients underwent a simple nephrectomy followed by ureteral intus-susception and transurethral resection. Two patients received other treatments. After nephroureterectomy with a separate incision for ureterectomy, the average hospital stay was 12 days, compared with 7.5 days in patients operated upon with only one abdominal incision. Recurrence of tumour or survival was not significantly different in the two groups.     

A case of invasive renal pelvic cancer: usefulness of auxiliary diagnosis using fluorescence in situ hybridization

A 65-year-old man, on whom transurethral resection had been performed twice for bladder cancer in the past, was admitted to our hospital for further Class V urinary cytology examination. A low density area of 1.5 cm in diameter in the left renal pelvis without enhancement was the only abnormal sign on computed tomographic (CT) imaging. Malignant cells were not detected by random biopsy of the urinary bladder. The retrograde pyelogram showed no filling defect on the left renal pelvis or ureter. The cytological diagnosis of the right split renal urine was Class III, and that of the left split renal urine was Class V. Fluorescence in situ hybridization (FISH) analysis, using specific probes for chromosome 8q21.3 and the centromere chromosome 11, was performed on cells from the bilateral split renal urine. Cells collected from the right split renal urine showed a normal disomic pattern, while those from the left split renal urine included an aneusomic pattern with polysomy. Left total nephroureterectomy was carried out. Histopathology proved invasive renal pelvic cancer. Thus FISH analysis may be useful for the localization of renal pelvic or ureteral cancers, which are difficult to diagnose.     

Complicated urinary tract infection: analysis of 179 patients

BACKGROUND: The aim of our study was to investigate the incidence, bacteriology, management and outcome of complicated urinary tract infections (UTIs) at the Veterans General Hospital-Taipei. METHODS: Between June, 1993, and July, 1994, medical records of 2,566 patients admitted to the Division of Urology, Veterans General Hospital-Taipei, were retrospectively reviewed. Of these patient, 1,322 had a diagnosis of benign prostatic hyperplasia (BPH), 607 were admitted for renal stones, 496 for ureteral stones, 75 for transitional cell carcinoma (TCC) of the urinary bladder, 47 for renal tumors and 19 for TCC of the ureter. Among all patients studied, 179 (6.98%) acquired a complicated UTI. Of these, 81 were admitted for BPH, 46 for renal stones, 42 for ureteral stones, five for TCC of the urinary bladder, three for renal tumors and two for TCC of the ureter. RESULTS: Of the 179 patients with complicated UTIs, 155 were men and 24 were women. The urine culture positive rate was 76.0% (136/179) and the most common bacteria were Escherichia coli, Proteus mirabilis and Pseudomonas aeruginosa. The principle mode of treatment included parenteral antibiotics and urinary diversion (percutaneous nephrostomy and Foley catheterization), when necessary. The infection control rate for these complicated UTIs was 96.3% for BPH, 95.5% for renal stone, 97.6% for ureteral stone, 80% for TCC of the urinary bladder, 100% for renal tumor and 100% for TCC of the ureter. Mortality due to complicated UTI was 3.9% (7/179). CONCLUSIONS: We concluded that the prognosis of complicated UTI is good if diagnosis and appropriate treatment are given promptly. Early drainage to relieve obstruction and intravenous antibiotics are initially necessary. Surgical intervention is required to resolve functional or structural abnormalities after the UTI has been controlled.     

A review of our first 100 cases of laparoscopic nephrectomy: defining risk factors for complications

OBJECTIVE: To present the complications from our first 100 cases of laparoscopic nephrectomy, a technically demanding procedure requiring lengthy experience, and to define the risk factors. PATIENTS AND METHODS: Indications for laparoscopic nephrectomy included patients requiring nephrectomy for benign pathology and those requiring nephroureterectomy for upper tract transitional cell carcinoma confined to the upper ureter and/or renal pelvis. All patients were operated on by one surgeon (D.A.T.) via a transperitoneal route and data on diagnosis, outcome and complications collected prospectively. RESULTS: The overall complication rate was 18%, of which 3% were major and 15% minor complications. Five cases were converted to open surgery electively. Complications and conversions were associated with a history of pyonephrosis, previous renal surgery, staghorn calculi, polycystic kidney disease, and xanthogranulomatous pyelonephritis. While there was no discernible decline in the decrease in complications with experience, operative duration decreased from a mean of 204 min for the first 20 cases to 108 min for the last 20. Complications and conversions were more closely associated with diagnosis than with the surgeon's experience. CONCLUSION: Laparoscopic nephrectomy and nephroureterectomy can be undertaken for a variety of indications with reasonable complication and conversion rates. Although inflammatory conditions increase the difficulty of these procedures, we feel that patients requiring nephrectomy for benign disease should be offered a trial of laparoscopic surgery.     

A case of ureteral tuberculosis appearing as a ureteral tumor

A 53-year-old female was admitted to our hospital after right hydronephrosis was found on the CT scan taken at another hospital. The urinary cytology and culture findings as well as the urinary culture for acid-fast bacilli results were all negative. At our hospital, CT scan revealed a thickening of the right ureteral wall, and right hydronephrosis. In spite of the fact that retrograde pyeloureterography showed a right ureteric obstruction at the ureterovesical junction, cystoscopic examination demonstrated a normal bladder. Since right lower tract carcinoma was suggested, we performed right nephroureterectomy with bladder cuff. Histopathological diagnosis, however, revealed renal and ureteral tuberculosis.     

Angiographic aspects of tumors of renal pelvis and ureter

Selective renal arteriography was done in 5 patients with transitional cell carcinoma of the renal pelvis and upper ureter. In 2 cases, the presence of tumor vessels was unequivocally diagnostic. In the remaining 3 cases, the arteriographic changes were not as prominent but were suggestive of neoplasm and were helpful in differentiating other causes of filling defects in the collecting system.     

Evidence for antiaggressive property of some calcium channel blockers

A retrospective study was carried out on 20 patients with transitional cell ureteral tumours (TCUT). Surgical exploration of the tumour was performed in 17 patients. Biopsies for frozen section were evaluated for decision concerning the extent of operative intervention. If radical excision of the tumour could be done, and if the ureteral defect could be bridged, a conservative procedure was chosen. Thus, segmental resection of the ureter and primary end-to-end closure of the ureter was performed in 5 patients and ureteroneocystostomy in 3 patients. In nine patients local tumour excision was not feasible and nephroureterectomy was done. The survival rate at 3 and 10 years after ureteral resection as well as after nephroureterectomy was the same, 66% and 16%, respectively. Local excision of non-invasive low-grade ureteral tumours could be safely performed in selected patients, based on local findings and frozen section at the time of surgery.     

Thermal effect on corneal incisions with different phacoemulsification ultrasonic tips

OBJECTIVES: To study the clinical effectiveness of the 200-microm holmium laser fiber for endoscopic management of upper urinary tract lesions. METHODS: From January 1997 to March 1998, we performed retrograde endoscopic treatment in 25 patients with urinary tract lesions using a 200-microm holmium laser fiber. Nineteen patients had 20 stones (16 ureteral, 3 lower calyx, and 1 middle calyx), 4 had bleeding lesions in the lower calyx, 1 had transitional cell carcinoma involving the renal pelvis and upper calyx, and 1 had a ureteral stricture associated with an impacted ureteral stone. We used a 7.5F flexible ureterorenoscope for renal and upper ureteral lesions, and a 6.9F rigid ureteroscope for mid and lower ureteral lesions. For treatment, we used a holmium:yttriumaluminum-garnet laser generator and a 200-microm flexible quartz fiber. RESULTS: All stones were successfully fragmented, including three lower caliceal stones. Lower caliceal bleeding spots were successfully cauterized for hemostasis in all 4 patients, and the pelvic tumor was successfully vaporized and ablated. In 1 patient, we had previously failed to treat a ureteral stricture with a 365-microm fiber because of inadequate visualization, but it was successfully incised using the 200-microm fiber. There were no significant complications such as ureteral obstruction or stenosis. CONCLUSIONS: The improved flexibility of the new 200-microm holmium laser fiber facilitates treatment of stones, tumors, strictures, and lesions in the lower calyx, where access is difficult when using the previously available 365-microm fiber.     

Ureteral injuries associated with gynecologic surgery: prevention and management

Gynecologic surgery is responsible for most of the ureteral injuries that occur. The "easy" operation--the "simple" abdominal hysterectomy--and not the technically difficult pelvic one, is responsible for most ureteral injuries. Total abdominal hysterectomy accounts for almost 50% of the genitourinary fistulas and perhaps 80-99% of all surgical ureteral injuries. This problem will persist until a most important surgical axiom is applied routinely during the accomplishment of all pelvic operations: With all dissections, the contiguous structures subject to injury must be exposed. This step not only will avoid injuries to the ureter but also will facilitate an equally important aspect, that is, urinary tract injuries must be recognized at the time of operation. With recognition and adequate repair, problems such as fistula formation and serious morbidity (and litigation) can be avoided almost entirely. Because the gnecologic surgeon frequently will find that urologic consultation is not available at the time of urinary tract injury, he or she must be aware of and familiar with the various ureteral reconstructive procedures that may be required. The gynecologic surgeon must devote time and study to the management of urinary tract injuries before their occurrence. All pelvic surgeons eventually will encounter ureteral problems. The methods of bladder mobilization and ureteroneocystostomy should be within the ability of all who operate within the pelvis. When extensive damage has occurred and a urologist is not available, the gynecologist who is unfamiliar with the more demanding techniques (that is, ureteroureterostomy, bladder flaps, ileal conduits) should avoid additonal damage to the urinary tract and accomplish a simple catheter ureterostomy, deffering the definitive repair for a urologist.     

In memoriam: Widukind Lenz, 1919-1995

To determine whether microsatellite instability is involved in the development of transitional cell carcinoma (TCC) of the urinary tract, a microsatellite instability assay was carried out using PCR with 9 microsatellite loci. Thirty-eight TCC samples (30 patients with bladder cancer, 5 with renal pelvic tumors and 3 with ureteral tumors) and 1 lymph node with metastasis were examined. Microsatellite instability was found in 8 of 38 tumors examined, and 3 showed alterations in more than 2 microsatellite loci. All 8 tumors were beyond grade 2 and stage pT2 advanced tumors. Stages pT1-2 and pT3-4 patients differed significantly. Microsatellite instability was greater in smokers than non-smokers, but the differences were not significant. Microsatellite instability in TCC of the urinary tract is rare in superficial tumors but more common in invasive tumors. Microsatellite alterations would thus appear to occur, and possibly be importantly involved, in the tumorigenesis of urinary tract TCC.     

Three cases of the nephrogenic adenoma of the bladder

Nephrogenic adenoma is a rare, benign tumor of the urinary tract. The origin of this tumor is supposed to be a metaplastic transformation of urothelium in response to stimulation such as recurrent urinary tract infections or surgical trauma. We experienced three cases of nephrogenic adenoma originating in the bladder. The first patient was a 29-year-old man with right vesicoureteral reflux (VUR). When Teflon injection for VUR was performed, a papillary tumor was found on the right wall of the bladder. Transurethral resection of the bladder tumor (TUR-Bt) was performed. The second patient was a 72-year-old woman who was suffering from chronic cystitis. Although she was treated with antibiotics for one year, the symptoms were not improved. Cystoscopy showed multiple papillary tumors at the retrotrigonum of the bladder and TUR-Bt was performed. The third patient was a 75-year-old man who had a history of the left pelvic and bilateral ureteral tumors. Left radical nephroureterectomy and right radical ureterectomy with an ileal graft replacement was performed. Three years later, cystoscopy demonstrated a papillary tumor at the retrotrigonum, which was resected transurethrally. Our cases are the 20th to 22nd cases of the nephrogenic adenoma of the bladder reported in the Japanese literature.     

Cytologic diagnosis of transitional cell carcinoma of the urinary bladder. Comparison with endoscopical and pathological findings on 538 cases

There were investigated 583 cases with tumors of the urinary bladder and 612 patients with non-malignant diseases of the urinary tract. Samples of voided urine were taken from all cases and direct smears fixed by drying were stained by rapid blue polychrome-tanin Dr?gan method Cytological results were compared with endoscopical and pathological findings. The overall rate of real positive results was 91.7% and false negative results were noticed in 8.3% of cases. A direct relationship between real positive results and histological "G" was found. Causes for false negative results were: tumor developed in a bladder diverticulum, calcified tumor, irradiated tumor, insufficient quantity of voided urine, chronic urinary infections and underestimation of cytological criteria of cellular malignancy. There were 9 false positive results in patients with nonmalignant diseases, due to lithiasis, chronic renal failure and chronic urinary infections. The cytological grade of differentiation was performed by the method purposed by Friedman and Ash, and concordance with the standard histological finding was 76.4%. Urine cytology is thought to be a useful method in the primary diagnosis and recurrences of transitional cell carcinoma of the urinary bladder, in all patients with hematuria, recurrent infections of the urinary tract and neglected lithiasis.