Recurrent urothelial tumors following surgery for transitional cell carcinoma of the upper urinary tract

A retrospective analysis of 74 cases of transitional cell carcinoma of the renal pelvis and ureter treated at this institution over the past 30 years is presented. When nephrectomy alone or incomplete nephroureterectomy was performed, subsequent transitional cell carcinoma developed in 30% of the ureteral stumps. Subsequent bladder carcinoma occurred in 25% of the patients with primary upper urinary tract carcinoma. The type of initial surgery performed did not appear to influence this incidence of subsequent bladder tumors. Contralateral upper urinary tract carcinoma developed in only one patient. When nephroureterectomy is performed for carcinoma of the renal pelvis and ureter, a cuff of bladder that includes the ureteral orifice should be removed to obviate recurrent disease in the ureteral stump. Since single-incision nephroureterectomy did not include the intramural ureter in 50% of the cases in which it was performed, a second incision may be required for adequate exposure.     

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.     

Longitudinal ureteral split for retroperitoneal fibrosis with ureteral involvement

Idiopathic retroperitoneal fibrosis may rarely invade the ureteral wall, thereby rendering the attempt to perform classical ureterolysis futile. Possibilities for surgical correction include resection with end-to-end anastomosis, utilization of a spiral strip of ureter, small bowel substitution, iatrogenic nephroptosis or longitudinal incision of the involved ureter down to the mucosa. Two patients treated using the latter technique have been followed for 7 months and 132 months without recurrence of the obstructive process. The surgeon, when treating idiopathic retroperitoneal fibrosis, must be prepared to treat intrinsic ureteral involvement using the most appropriate surgical technique.     

Gunshot wounds to the ureter

Since our last review 17 more patients have been treated for ureteral gunshot injuries. In six cases the upper ureter, in two the middle, and in nine cases the lower ureter was involved. Associated visceral injuries were numerous with the small intestine the most commonly injured. In over 50% of the injuries to the lower ureter, the iliac vein was injured. In three patients the ureter was the only major structure involved. There was no hospital mortality. Optimal surgical repair done by generous resection, primary end-to-end anastomosis and stenting and drainage via a proximal ureteral T-tube gave excellent results and no longterm complications in a population subject to careful short and longterm followup. While an uncommon injury, the principles of effective repair are clear and must be applied in the face of serious associated disorders to continue these satisfactory results.     

Treatment of posterior skull base tumors

Treatment of ureteral stenosis has been attempted in many patients with transplanted kidneys. Treatment with the Acucise catheter system is a new approach for such patients. Published results of the approach in eight patients promise safety, effectiveness, and low perioperative morbidity. We report two cases of transplant ureteral stenosis treated with Acucise. One patient with stenosis of the pyeloureteral junction was treated successfully and has been free of recurrence for 9 months. The other patient had long-distance stenosis of the lower portion of the transplant ureter. Acucise incision was successful, but the patient had to undergo uretero-neocystostomy because of a ureteroperitoneal fistula. We use these cases to illustrate the disadvantages of endourological ureteral surgery as a standard therapeutic approach after renal transplantation. We suggest that Acucise is reliable when used in patients with uncomplicated short-distance ureteral stenosis; however, patients with long-distance stenosis or stenosis caused by heavily scarred periureteral tissue will not profit from it because of a higher complication rate.     

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.     

Uretero-external iliac artery fistula: a case report

We report a case of uretero-external iliac artery fistula. A 60-year-old female was referred to our hospital complaining of intermittent gross macrohematuria. She had undergone radical hysterectomy, radiation therapy and chemotherapy for advanced cervical cancer 2 years ago. The patient had a 7 Fr ureteral double-J stent for left hydronephrosis. Retrograde urography showed a filling defect (8 mm in diameter) of the left ureter. A contrast-enhanced computed tomographic scan showed left hydronephrosis and hydroureter but no evidence of fistula formation or extravasation. A pelvic arteriography revealed a pseudoaneurysm of the left external iliac artery at the crosspoint between the left ureter and the iliac artery. Surgical repair of the left uretero-external arterial fistula was successfully performed as well as left nephroureterectomy. The possibility of fistula formation between ureter and artery should be kept in mind in patients with long-term indwelling ureteral stents and history of radiation therapy.     

Transurethral incision in primary bladder neck obstruction

Sixty-one patients presenting primary obstruction of the neck of the urinary bladder are subjected to transurethral operative intervention and postoperative follow-up study in the period 1986 through 1990. The indications for performing transurethral incision of the bladder neck are established on the basis of subjective complaints against the background of data from uroflowmetry, miction cystourethrography and endoscopic study of the lower urinary ways. The obtained results point to an improvement of the subjective complaints in 74 per cent of the cases. In 78 per cent of the patients peak urinary flow exceeds 15 ml/sec. Repeated transurethral incision is necessitated in 8.1 per cent, and transurethral resection in the postoperative period is done in twelve patients (19.6 per cent). Postoperative strictures of the urethra are discovered in 8 patients (13.1 per cent), and retrograde ejaculation is documented in three patients (8.5 per cent) over the maximum observation term of 64 months. Postoperative hospitalization is average 3.2 days (range 2.7 to 5.9 days).     

In situ ESWL for ureteric calculi: the optimum treatment?

In situ ESWL for ureteric calculi is associated with good stone clearance rates but is it without significant morbidity? A review of 189 patients with single ureteric calculi (150 upper ureter, 39 lower ureter calculi) revealed an 89% stone clearance for upper ureteral calculi and 80% stone clearance for lower ureteral calculi. However 11% of patients with upper ureteral calculi and 20% of patients with lower ureteral calculi required additional intervention for complications or failed treatment. In situ ESWL may not be the optimum therapy for all ureteric calculi especially those in the lower ureter.     

Abdominoinguinal incision in adenocarcinoma of the sigmoid or cecum: report of two cases

PURPOSE: This study illustrates a technique allowing resection of a sigmoid adenocarcinoma with lateral fixation and a cecal adenocarcinoma with involvement of the psoas muscle and ureter. METHODS: The abdominoinguinal incision, an incision used in the resection of a sarcoma of the lower abdominal quadrants, was applied in the case of a sigmoid adenocarcinoma with posterolateral fixation and infiltration of the anterior abdominal wall and in a case of a cecal adenocarcinoma involving the right psoas muscle and ureter. RESULTS: In the first case, resection of the tumor mass en bloc with resection of the sigmoid and lower anterior abdominal wall muscles, including the inguinal ligament, was performed. Reconstruction of the muscular fascial defect was done with the rotation of a right rectus abdominis flap. The patient was well 12 months later. In the second case, the cecal carcinoma was resected en bloc with the right psoas and ureter; a right nephrectomy was also performed. This patient was well eight months later. CONCLUSIONS: The abdominoinguinal incision may provide the exposure needed to allow the resection of a sigmoid or a cecal adenocarcinoma with posterolateral fixation, often considered unresectable with conventional abdominal incisions.     

Recurrent basal cell carcinoma treated with cryosurgery

OBJECTIVE: Ureteral stenosis secondary to vasculitis is a rare disease. The etiology and treatment of this unusual cause of ureteral obstruction are discussed. METHODS/RESULTS: We report a case of ureteral obstruction secondary to Churg-Strauss vasculitis in a 45-year-old man. The patient was treated with prednisone and cyclophosphamide. Subsequently ureteral resection and reanastomosis were performed. CONCLUSIONS: Vasculitis of the ureter should be considered in patients with connective tissue disorders who present with ureteral dilatation. In some cases ureteral stenosis may require surgery in combination with steroid and/or immunosuppressive therapy.     

Fragmented platinum microcoils as embolization material. Preliminary evaluation in vivo

OBJECTIVES: To study the electromechanical activity of the normal ureter in 5 men and 4 women (mean age 39.4 +/- 10.8 years) scheduled for rectopexy due to rectal prolapse. The results of urinary tract investigations were normal. METHODS: During anesthesia for rectopexy, rectal mobilization necessitates ureteral exposure for protective reasons. One electrode was applied to each of the upper, middle, and lower third of the right ureter, and signals were registered for 30 minutes. Simultaneous recording of intraureteral pressure was performed. RESULTS: Slow waves, or pacesetter potentials (PPs), were recorded from the three electrodes. Identical readings for frequency, amplitude, and velocity of conduction were obtained from the three electrodes in the same ureter. Action potentials (APs) followed the PPs and were inconsistent and were associated with an intraureteral pressure increase (P < 0.001). No pressure elevation occurred with PPs. CONCLUSIONS: In contrast to PPs, APs seem to have a role in ureteral mechanical activity and might initiate ureteral peristalsis. The function of the PPs is unknown; they might pace the APs in terms of direction and frequency. The present study could characterize an electroureterographic pattern for the normal ureter. It is suggested that this pattern is changed in the various ureteral pathologic conditions and, thus, the electroureterogram be considered a useful investigative tool in ureteral disorders. However, the procedure in its present from is not applicable to clinical practice. Nevertheless, the present study might be of significance in explaining the mechanisms of ureteral motility and urinary bolus transport.     

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.     

Trace elements in egg contents and egg shells of slider turtles (Trachemys scripta) from the Savannah River Site

OBJECTIVES: Stricture of the vesico-urethral anastomosis is a well-known complication after radical prostatectomy. Dilatation, stricture incision or resection have been proposed for endoscopic treatment. METHODS: In a retrospective study of 340 patients with prostatic cancer who underwent a radical retropubic prostatectomy from 1988 until 1996, we looked at the incidence of anastomotic strictures. RESULTS: An anastomotic stricture was found in 24 cases (7%) requiring endoscopic treatment. Based on prospective X-ray studies, we were able to show that the site of stricture is located below the bladder neck musculature in most cases well above the distal urethral sphincter and pelvic floor. No continence problems were encountered following structure resection in a follow-up of 12-72 months determined by a questionnaire and pad test. CONCLUSION: The transurethral resection of anastomotic stricture allows for a rather generous tissue resection, which is preferable to incision or dilatation in our hands.     

Ureteral metastases from prostatic cancers. 2 cases. Review of the literature

The authors report two new observations of ureteral metastases from prostatic cancers and review the 17 already published cases. The relative rarity might well be only apparent, in relation with the delay in the exploration of the first observations. The diagnostic criteria are less clinical and radiological than anatomo-pathological, the metastases contrasting themselves with ureteral invasion by direct propagation. The anatomical status shows no predominance between tumoral or infiltrating forms, nor of any particular site on the ureter, while noting a relative frequence of bilateral involvement. The therapeutic approach is dependant upon these factors. The prognostic is reserved, at the cost of a segmental ureteral resection or a nephro-ureterectomy.     

Organ-preserving therapy in invasive bladder carcinoma]

With the aim of organ preservation, transurethral resection with subsequent radiotherapy (until 1985) or combined radio- and chemotherapy (since 1986) was undertaken as part of a prospective trial in 175 consecutive patients (137 men, 38 women; mean age 65 [31-90] years) with invasive bladder carcinoma, tumour stage T1-4 N0-3 M0. All patients had a transurethral resection, followed 2-6 weeks later by definitive radiotherapy at a dose of 50.4 Gy to the bladder in 28 fractions. 85 patients simultaneously with the radiotherapy received chemotherapy with cisplatin (25 mg/m2 daily) or carboplatin (65-75 mg/m2 daily) in the first and fifth weeks of radiotherapy. The 5-year survival rate for the whole group (including inoperable cases) was 50%. The survival rate as related to the T category was 53% for T1 (n = 26), 68% for T2 (n = 34), 45% for T3 (n = 94) and 22% for T4 (n = 17). 139 patients (79%) were left with a normally functioning bladder. Cystectomy was performed in 36 patients because of remaining tumour or recurrence after radiotherapy. Combined radio- and chemotherapy improved the histological remission rate, compared with an earlier control group with radiotherapy only, but it did not affect the survival rate. These data indicate that in advanced bladder carcinoma organ-preserving treatment with transurethral resection and definitive radiotherapy or combined radio- and chemotherapy can be successful.     

The early postoperative morbidity of transurethral resection of the prostate and of 4 minimally invasive treatment alternatives

PURPOSE: We compared the early postoperative morbidity of transurethral resection of the prostate to minimally invasive treatment alternatives with respect to the objective rate of complications and subjective morbidity assessed by a patient addressed diary-type questionnaire. MATERIALS AND METHODS: Parameters evaluated preoperatively were the International Prostate Symptom Score (I-PSS), free flow study, post-void residual, transrectal ultrasonography and a pressure-flow study. The patients underwent transurethral resection (28), transrectal high intensity focused ultrasound (20), visual laser ablation (15), transurethral needle ablation (15) and transurethral electrosurgical vaporization (17) of the prostate. On the day of hospital discharge the patients received the questionnaire and were asked to answer daily 7 questions concerning micturition status. After 6 weeks the questionnaire was returned and an I-PSS, uroflowmetry and post-void residual were obtained. RESULTS: Preoperatively, there was no statistically significant difference regarding the I-PSS, peak flow rate, prostate volume and degree of bladder outlet obstruction. After 6 weeks the peak flow rate improved most prominently after transurethral electrosurgical vaporization (+ 13.2 ml. per second), transurethral resection of the prostate (+ 12.3 ml. per second) and visual laser ablation (+ 11.1 ml. per second). The I-PSS decreased most significantly after transurethral resection (-14.1) and transurethral electrosurgical vaporization (-8.4). There was no difference regarding the rate of adverse events within the first 6 weeks postoperatively in the 5 treatment arms. Mean duration of catheter drainage plus or minus standard deviation was 3.7 +/- 1.2 days after transurethral resection of the prostate, 6.8 +/- 1.7 days after high intensity focused ultrasound, 7.8 +/- 1.5 days after visual laser ablation, 2.0 +/- 0.4 days after transurethral needle ablation and 3.3 +/- 0.8 days after transurethral electrosurgical vaporization. Analysis of the questionnaire revealed that the daytime frequency, degree of hematuria and incontinence were comparable for all 5 procedures within the first 6 weeks postoperatively. Postoperative dysuria was greatest after visual laser ablation and transurethral electrosurgical vaporization. Regarding the degree of nocturia, there was no improvement after visual laser ablation, while the remaining 4 procedures yielded a significant and comparable decrease. The most significant subjective improvement in uroflowmetry was reported after transurethral resection of the prostate and transurethral electrosurgical vaporization. Regarding the global quality of life question, the patients were generally more worried after visual laser ablation and transurethral needle ablation compared to the other 3 procedures. CONCLUSIONS: The overall morbidity of transurethral resection of the prostate within the first 6 weeks postoperatively is equivalent to that of the 4 minimally invasive treatment alternatives evaluated in our study. When comparing the 4 minimally invasive procedures, no dramatic differences were notable, although visual laser ablation seems to be associated with a greater degree of morbidity as assessed by this questionnaire.     

Ureteral obstruction due to primary localized amyloidosis

Localized amyloidosis of the ureter is a rare condition. There are only 27 cases reported. Because of the difficulty in differentiating between localized amyloidosis or other benign conditions and a malignant tumor many cases have led to nephroureterectomy. We report a case of a middle aged woman who had an almost complete obstruction of the right ureter caused by amyloidosis. Biopsies were taken via a ureteroscope prior to exploration of the ureter enabling the patient to be treated with local excision and ureteroneocystostomy instead of nephroureterectomy.     

Sequential transurethral surgery, multiple drug chemotherapy and radiation therapy for invasive bladder carcinoma: initial report

Forty-seven patients with muscle-invasive bladder cancer (T2-T4, Nx, M0) were treated by transurethral resection, followed by 3-4 cycles of combination chemotherapy (methotrexate 30 mg/m2 on days 1, 14; cis-platinum 100 mg/m2 on day 2; vinblastine 3 mg/m2 on days 1, 14; repeated every 21 days), and external beam irradiation (64-66 Gy to the bladder and 40 Gy to the pelvic lymphatics). Complete remission after trans urethral resection and chemotherapy was achieved in 24 out of 45 patients (53%). Cystectomy was performed in patients without complete response to transurethral resection and chemotherapy. The therapy was completed as planned in 45/47 patients. After transurethral resection, chemotherapy, and radiation therapy, biopsy proven complete response was achieved in 62% (28/45); Stage T2T3 in 67% (23/34), Stage T4 in 45% (5/11) of patients. Among 19 patients with positive biopsy findings after transurethral resection and chemotherapy, 14 underwent cystectomy. After follow-up of 4-55 months (median 23 months) 75% (34/45) are alive, 68% (31/45) have had their bladders preserved, and 53% (24/45) are free of the primary tumor. The actuarial survival of all 45 patients is 73%. Moderate nausea and vomiting during treatment were common; severe leukopenia and mucositis were observed in five patients. Late side effects such as miction disorders and diarrhea were predominantly mild. Although the observation period has been too short to allow a definitive evaluation of treatment results, we feel both from the point of bladder preservation and disease-free survival that the presented treatment approach is successful in a majority of T2T3 patients, whereas a large tumor size (T4) renders this treatment less effective.     

Ureteral triplication

A case of ureteral triplication is presented. There was reflux of the middle ureter, which did not end in the kidney, but rather ended blindly. There was atrophic pyelonephritis of the upper pole because of an obstructed ureter, and a normal lower caleceal system and ureter. There were three ureters but only two originated in the kidney and two entered the bladder, with only one ureter originating from the kidney entering the bladder normally. The refluxing ureter and the obstructed upper pole and ureter were removed.