Target Molecule Expression Profiles in Metastatic Renal Cell Carcinoma: Development of Individual Targeted Therapy

The aim of this study is to analyze the level of target molecule expression in metastatic renal cell carcinoma (RCC) to determine whether there is a correlation between molecular marker expression and clinical response. Ten patients with metastatic RCC, who received receptor tyrosine kinase (RTK) targeted therapy after cytoreductive or radical nephrectomy, were included. The expression of target molecules relating to the RTK, mammalian target of rapamycin, hypoxia inducible factor, mitogen activated protein kinase, and adenosine monophosphate-activated protein kinase pathways were analyzed using real-time polymerase chain reaction and immunohistochemistry. We correlated the level of target molecule expression with clinical response, including efficacy and adverse events experience during RTK targeted therapy. All patients showed similar histological subtype and grade on pathological examination; however, the expression of RCC target molecules was very different among the patients. The expression of molecules related to the RTK pathway in RCC tissue as well as relative expression of molecules in RCC tissue compared to normal kidney tissue, were higher in patients who showed a good response to RTK targeted therapy compared to those that showed a poor response. Target molecule expression in normal kidney tissue was higher in patients who experienced high-grade adverse events than in patients who experienced low-grade events. Target molecule expression in metastatic RCC correlates with targeted therapy clinical response including efficacy and adverse events. Personalized target molecule expression profiles could be used to predict clinical response to different targeted therapies, thus helping optimization of targeted therapies for patients with metastatic RCC.

Urethroplasty Using Autologous Urethral Tissue-embedded Acellular Porcine Bladder Submucosa Matrix Grafts for the Management of Long-Segment Urethral Stricture in a Rabbit Model

We conducted this study to evaluate the combined effect of acellular bladder submucosa matrix (BSM) and autologous urethral tissue for the treatment of long segment urethral stricture in a rabbit model. To prepare the BSM, porcine bladder submucosa was processed, decellularized, configured into a sheet-like shape, and sterilized. Twenty rabbits were randomized to normal control, urethral stricture, urethroplasty using BSM only or BSM/autologous urethral tissue (n=5 per group). Retrograde urethrography was performed at 4, 8, and 12 weeks postoperatively, and the grafted specimens were harvested at week 12 to evaluate urethral reconstruction through histopathologic and immunohistochemical analysis. The mean urethral width of the control, stricture, BSM, and BSM/autologous urethral tissue groups at week 12 was 10.3+/-0.80, 3.8+/-1.35, 8.8+/-0.84, and 9.1+/-1.14 mm, respectively. The histopathologic study revealed that the BSM/autologous urethral tissue graft had a normal area of urethral lumen, compact muscular layers, complete epithelialization, and progressive infiltration by vessels in the regenerated urethra. In contrast, the BSM grafts revealed keratinized epithelium, abundant collagenized fibrous connective tissue, and were devoid of bundles of circular smooth muscle. Nontransected ventral onlay-augmented urethroplasty using an acellular BSM scaffold combined with an autologous urethral tissue graft represents a feasible procedure for urethral reconstruction.

Urethroplasty Using Autologous Urethral Tissue-embedded Acellular Porcine Bladder Submucosa Matrix Grafts for the Management of Long-Segment Urethral Stricture in a Rabbit Model

We conducted this study to evaluate the combined effect of acellular bladder submucosa matrix (BSM) and autologous urethral tissue for the treatment of long segment urethral stricture in a rabbit model. To prepare the BSM, porcine bladder submucosa was processed, decellularized, configured into a sheet-like shape, and sterilized. Twenty rabbits were randomized to normal control, urethral stricture, urethroplasty using BSM only or BSM/autologous urethral tissue (n=5 per group). Retrograde urethrography was performed at 4, 8, and 12 weeks postoperatively, and the grafted specimens were harvested at week 12 to evaluate urethral reconstruction through histopathologic and immunohistochemical analysis. The mean urethral width of the control, stricture, BSM, and BSM/autologous urethral tissue groups at week 12 was 10.3+/-0.80, 3.8+/-1.35, 8.8+/-0.84, and 9.1+/-1.14 mm, respectively. The histopathologic study revealed that the BSM/autologous urethral tissue graft had a normal area of urethral lumen, compact muscular layers, complete epithelialization, and progressive infiltration by vessels in the regenerated urethra. In contrast, the BSM grafts revealed keratinized epithelium, abundant collagenized fibrous connective tissue, and were devoid of bundles of circular smooth muscle. Nontransected ventral onlay-augmented urethroplasty using an acellular BSM scaffold combined with an autologous urethral tissue graft represents a feasible procedure for urethral reconstruction.

Two Different Surgical Approaches for Prostatic Stromal Sarcoma: Robot-Assisted Laparoscopic Radical Prostatectomy and Open Radical Cysto-Prostatectomy With Ileal Conduit

Stromal sarcoma of the prostate is very rare and shows rapid growth, which consequently is related to poor prognosis. Recently, we treated two cases of prostatic stromal sarcoma: one with robot-assisted laparoscopic radical prostatectomy and the other with open radical cysto-prostatectomy with an ileal conduit. To the best of our knowledge, this is the first case report of a prostatic stromal sarcoma managed by use of a robotic procedure. Here, we report of our experiences in the treatment of prostatic stromal sarcoma by use of two different methods.

Two Different Surgical Approaches for Prostatic Stromal Sarcoma: Robot-Assisted Laparoscopic Radical Prostatectomy and Open Radical Cysto-Prostatectomy With Ileal Conduit

Stromal sarcoma of the prostate is very rare and shows rapid growth, which consequently is related to poor prognosis. Recently, we treated two cases of prostatic stromal sarcoma: one with robot-assisted laparoscopic radical prostatectomy and the other with open radical cysto-prostatectomy with an ileal conduit. To the best of our knowledge, this is the first case report of a prostatic stromal sarcoma managed by use of a robotic procedure. Here, we report of our experiences in the treatment of prostatic stromal sarcoma by use of two different methods.

Human Amniotic Fluid Stem Cell-derived Muscle Progenitor Cell Therapy for Stress Urinary Incontinence

The most promising treatment for stress urinary incontinence can be a cell therapy. We suggest human amniotic fluid stem cells (hAFSCs) as an alternative cell source. We established the optimum in vitro protocol for the differentiation from hAFSCs into muscle progenitors. These progenitors were transplanted into the injured urethral sphincter and their therapeutic effect was analyzed. For the development of an efficient differentiation system in vitro, we examined a commercial medium, co-culture and conditioned medium (CM) systems. After being treated with CM, hAFSCs were effectively developed into a muscle lineage. The progenitors were integrated into the host urethral sphincter and the host cell differentiation was stimulated in vivo. Urodynamic analysis showed significant increase of leak point pressure and closing pressure. Immunohistochemistry revealed the regeneration of circular muscle mass with normal appearance. Molecular analysis observed the expression of a larger number of target markers. In the immunogenicity analysis, the progenitor group had a scant CD8 lymphocyte. In tumorigenicity, the progenitors showed no teratoma formation. These results suggest that hAFSCs can effectively be differentiated into muscle progenitors in CM and that the hAFSC-derived muscle progenitors are an accessible cell source for the regeneration of injured urethral sphincter.

Mucinous Adenocarcinoma in a Horseshoe Kidney

We report here on a case of mucinous adenocarcinoma that probably originated in the renal pelvis of a horseshoe kidney. A 61-year-old woman presented with a palpable mass in the left upper quadrant of the abdomen, and this mass had been present for several months. Computed tomography (CT) revealed a left renal pelvic tumor in the horseshoe kidney. Grossly, a 10x9x8 cm unilocular cystic mass filled with chocolate colored mucinous fluid was seen. A connection between the cystic mass and the renal pelvis was demonstrated on retrograde pyelography. Microscopically, the cyst contained anaplastic columnar mucosecretory epithelial cells. Some atypical cell clusters were freely floating in the mucinous lakes. The histopathological findings were consistent with mucinous adenocarcinoma. In addition, glandular metaplasia was noted in the cystic wall. Immunohistochemical assessment of the pelvic adenocarcinoma revealed the positive expressions of carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) and a weak positive expression of cytokeratin 7 (CK7).

Primary Neuroendocrine Carcinoma of the Urethra / 대한비뇨기과학회지

Primary neuroendocrine carcinomas are uncommon highly malignant tumors of the genitourinary tract, and they have a poor prognosis. We report here on a case of a primary neuroendocrine carcinoma of the urethra that developed after radical cystectomy and ileal conduit diversion for treating transitional cell carcinoma of the urinary bladder.

Efficacy and Safety of Uro-Vaxom Treatment for Patients with Recurrent Cystitis: An Open Multicenter Study / 대한비뇨기과학회지

PURPOSE: We wanted to investigate the efficacy and safety of the immunotherapeutic Uro-Vaxom for treating uncomplicated recurrent cystitis in female patients only. MATERIALS AND METHODS: Adult female patients were enrolled in this multicenter, open-label study if they had acute cystitis at the enrollment visit and positive results on urine culture (> or =10(3)CFU/ml). The patients were treated for 3 months with one capsule daily of Uro-Vaxom after antibiotic therapy, and they were observed for another 3 months. The primary efficacy criteria were the cystitis recurrence rates over 6 months, the distribution of cystitis and the proportion of patients with cystitis. RESULTS: A total of 50 patients were evaluated. During the 6-month trial, the number of cystitis recurrences was significantly reduced in comparison with the 6-month pretrial period (on the average 0.64 as compared to 3.0 recurrences, respectively p<0.001). The incidences of frequency, urgency and dysuria remained low until the end of the trial. Uro-Vaxom was well tolerated: side-effects were mentioned by 8% of the 50 patients, and there was no case leading to treatment withdrawal. CONCLUSIONS: Uro-Vaxom significantly reduced the incidence of cystitis during the 6 months of this study, including the 3 months of treatment. These results demonstrate that Uro-Vaxom is a valuable agent for prophylaxis of recurrent cystitis.

Prognostic Impact of Parenchymal Invasion Pattern and Adjuvant Chemotherapy in pT3 Transitional Cell Carcinoma of the Renal Pelvis / 대한비뇨기과학회지

PURPOSE: This study was designed to assess the prognosis of pT3 transitional cell carcinoma of the renal pelvis(renal pelvic tumor) according to the parenchymal invasion pattern and adjuvant chemotherapy. MATERIALS AND METHODS: A total of 48(34 males and 14 females) patients were surgically treated for a renal pelvic tumor. Of these 48 patients, the 27 pT3 renal pelvic tumor patients who had over one year follow-up period were enrolled. The patients were divided into two groups according to the invasion pattern(Group 1: renal parenchymal invasion, Group 2: peripelvic fat invasion). Among these 27 patients, 15 patients received adjuvant chemotherapy following surgery, whereas the other 12 patients did not. The prognostic factors, including age, gender, laterality, tumor grade, size, lympho-vascular invasion, lymph node involvement, the invasion pattern and adjuvant chemotherapy, were analyzed with respect to disease-free survival. RESULTS: There were seventeen patients in Group 1 and 10 patients in Group 2. The mean duration of follow up was 39.4 months. Age, gender, laterality, tumor grade, size, lympho-vascular invasion, invasion pattern and adjuvant chemotherapy had no significant impact on disease-free survival on both the univariate and multivariate analyses. Only lymph node involvement(p=0.028, hazard ratio=20.98) was a prognostic predictor in this study. However, the incidence of renal parenchymal invasion was higher for the high grade tumors than for the low grade tumors. CONCLUSIONS: The renal parenchymal invasion pattern and adjuvant chemotherapy had no significant impact on disease-free survival on both univariate and multivariate analyses for the patients with pT3 renal pelvic tumor. Further studies are necessary to clarify this result.

Enterogenous Cyst of the Testis

We present a rare case of an enterogenous cyst of the testis in a 21-year-old man. On ultrasonography, an ovoid hypoechoic solid mass (2x2x1.5 cm) was confined to the right testis. The left testis and bilateral epididymis were within normal limits. Grossly, the tumor was a unilocular cystic mass, without a solid component. Microscopically, the cystic mass was composed of mucin-secreting simple columnar epithelial lining cells, lamina propria and a well-differentiated muscularis propria. There was no evidence of any germ cell derivatives or neoplasia in the cystic mass and in the surrounding testicular parenchyma. Immunohistochemistry showed a positive reaction for cytokeratin and the epithelial membrane antigen in the epithelial lining; in addition, it was positive for smooth muscle actin in the well-differentiated muscularis propria.

Risk Factors for Subsequent Bladder Cancer Recurrence following Radical Surgery for Upper Urinary Tract Urothelial Cancer / 대한비뇨기과학회지

PURPOSE: The purpose of this study was to determine the clinical and pathological risk factors for subsequent bladder recurrence for the patients suffering with transitional cell carcinoma in the upper urinary tract (UUT-TCC) following radical surgery, and these factors should allow more accurate prediction of the disease outcome. MATERIALS AND METHODS: Between 1995 and 2004, a total of 71 patients underwent total nephroureterectomy for UUT-TCC. Patients with concomitant or previous bladder tumor or a follow-up period of less than 1 year were excluded in this study. Univarariate and multivariate analysis by Cox's proportional hazards model was used to determine the independent risk factors for intravesical tumor recurrence. RESULTS: Fifteen out of 71 patients (21.1%) experienced subsequent intravesical tumor recurrence during a mean follow-up period of 16.5 months (range: 3-28). On univariate analysis, tumor size, multiplicity, stage and grade were significantly correlated with subsequent intravesical tumor recurrence. On the multivariate analysis, tumor stage and multiplicity had a statistically significant impact on the risk of subsequent intravesical tumor recurrence. CONCLUSIONS: Tumor stage and multiplicity are important factors for subsequent intravesical tumor recurrence in the patients who suffer with UUT-TCC following surgery. Therefore, closer follow-up might necessary for patients with multiple foci and high stage UUT-TCC for the early detection of subsequent intravesical tumor recurrences.

The Use of Complementary and Alternative Medicine in Patients with a Urological Malignancy / 대한비뇨기과학회지

PURPOSE: The use of complementary and alternative medicine (CAM) is very common among patients with a urological malignancy. We assessed the prevalence and patterns of use of complementary therapies among patients with bladder, prostate and renal cancers. MATERIALS AND METHODS: Between May and July 2004, we conducted a survey to assess the use of CAM at 13 outpatient clinics in Korea. Seven hundred and eleven patients with bladder (269), prostate (300) or renal cancers (142) were selected to answer a self-administered questionnaire on CAM, which were then analyzed. RESULTS: Among 711 patients with urological malignancies, 279 (39.2%) had been treated with at least one type of CAM, in addition to conventional Western treatment. The cancer patients treated with radiation therapy or immunotherapy were more likely to employ CAM than those using other therapies. Age, gender, cancer type, occupations, religions, level of education and disease status (stable or progressive) were not associated with the prevalence of CAM. 44.3% of CAM users wanted to discuss CAM techniques with their doctors, but only 24.8% received an explanation of there use. CONCLUSIONS: CAM is used by a large number of patients with urological malignancies, particularly in those undergoing radiation therapy or immunotherapy. Urologists need to have an accurate knowledge and apprehension of CAM. The possible effects and side effects should be defined, with appropriate guidelines recommended for patients with a urological malignancy.

The Influence of Chlormadinone Acetate on the Total and Free Serum Prostate Specific Antigen Levels in Men with Benign Prostatic Hyperplasia / 대한비뇨기과학회지

PURPOSE: Chlormadinone acetate (CMA) therapy for benign prostatic hyperplasia (BPH) may lower the serum prostate specific antigen (PSA) level. However, little is known about the effect of CMA on the total or free serum PSA levels of PSA. Such information would be important since PSA testing is useful for prostate cancer screening. Thus, we prospectively studied the effect of CMA therapy on the total and free serum PSA levels. MATERIALS AND METHODS: The patients with lower urinary tract symptoms (LUTS) and BPH who were aged over 50 years were treated with 50mg CMA for 6 months. Men with a PSA level greater than 10ng/ml were excluded to reduce the likelihood of including cases of occult prostate cancer. Those with suspicious findings on the digital rectal examination and serum PSA testing were biopsied to rule out prostate cancer. alpha- blocking agents were permitted to treat the men with LUTS. Serum levels of the total and free PSA were measured at the study baseline and after approximately 3 and 6 months. The prostate volume (PV) was assessed by transrectal ultrasonography. RESULTS: The analysis included 170 patients with a mean age of 67.9 years, a baseline PV of 47.3ml and a baseline total PSA of 4.1ng/ml. The total PSA levels declined from 4.1ng/ml at baseline to 2.0ng/ml after 6 months of treatment (50.7% decrease, p<0.01). The mean percent free PSA (21% to 22% at baseline) was not significantly altered by CMA treatment. The PSA levels and PV at baseline did not affect the rate of decline of PSA. CONCLUSIONS: The total PSA serum levels decreased by an average of 50% during CMA therapy, but the percent free PSA did not change significantly. This information is potentially useful in the interpretation of the PSA data that's used for early detection of prostate cancer in the men receiving CMA.

Korean Nomogram for the Prediction of Recurrence-free Survival after Definitive Surgery for Renal Cell Carcinoma / 대한비뇨기과학회지

Purpose: This multiinstitutional study was to investigate the accuracy of the Kattan nomograms for the prediction of recurrence after definitive surgery for renal cell carcinoma (RCC) in Korean patients and develop a nomogram revised to complement the shortcomings. Materials and Methods: Clinical and pathological data of 1,866 patients with RCC who had been followed for at least 2 years after surgery in each participating institutes were reviewed as well as evidence of disease recurrence, defined to include local recurrence and distant metastasis. Accuracy of the Kattan nomograms' predictability in tumors 7cm or less was tested by calculating the area under the receiver-operating characteristics curve (AUC) and actuarial recurrence-free survival by Kaplan- Meier method. We used the Cox proportional hazard analysis to identify significant variables and develop prediction nomogram, and internally validated by bootstrapping method. Mean follow-up was 56.5 months (24-184). Results: Recurrence occurred in 12.5% of the patients and correlated with the pathological stage, with 4.3%, 7.9%, 15.0%, 22.6%, 38.4%, 58.3% for stages T1a, T1b, T2, T3a, T3b/c and T4, respectively (p<0.001). The AUC of the Kattan nomograms was 0.276. Factors significantly predictive of recurrence were T stage (p<0.0001), presentation (p=0.006), preoperative hemoglobin (p=0.023) and gender (p=0.032). Actuarial 60-month recurrence- free survival was 87.9% and using the prognostic factors, nomogram predicting 60-month recurrence-free survival was constructed. Conclusions: Korean nomogram complementing the preexisting nomograms for the prediction of recurrence-free survival after definitive surgery for RCC has been constructed, which may be useful in patient prognostication, counseling and follow-up planning.

Laparoscopic Radical Nephrectomy for T2 Renal Cell Carcinomas / 대한비뇨기과학회지

Purpose: A laparoscopic radical nephrectomy (LRN) has emerged as the standard care in appropriate candidates with stage T1 renal tumors (7cm or less). We extended our experience of LRN to stage T2 renal tumors (greater than 7cm), and compared the results with those of LRN for stage T1 renal tumors, as well as with those of an open radical nephrectomy (ORN) for stage T2 renal tumors. Materials and Methods: Between January 2001 and December 2004, a total of 67 patients, who underwent LRN for renal cell carcinomas, were retrospectively subdivided into the LRNT1 (n=48, tumor size7cm) groups. The surgical outcomes and perioperative morbidities were retrospectively evaluated. Also, the results of the LRNT2 group were compared with those of the open radical nephrectomy T2 group (ORNT2, n=29). Results: Compared with the LRNT1 group, the LRNT2 group only had larger tumors, but comparable operation time, blood loss, variation in the creatinine value (Cr), analgesics requirements, time to ambulate and diet, hospital stay and complication rates. The tumor sizes were similar in the two groups (p=0.260). However, the LRNT2 group had shorter operation time (p=0.039), lesser blood loss (p=0.044), Cr (p=0.027), analgesic requirements (p<0.001) and time to ambulation, diet and hospital stay (p<0.001, all). Conclusions: A LRN for stage T2 renal tumors is feasible and efficacious. The surgical outcomes were comparable with those of a LRN for stage T1 tumors, with the advantages of decreased blood loss and more rapid recovery over that of an ORN for comparable tumors greater than 7cm in size.

A case of metastatic malignant pheochromocytoma response to high dose 131I-MIBG treatment after surgery / 대한내과학회지

Approximately 10% of pheochromocytomas are malignant and its major criteria are tumor invasion of capsular blood vessel as well as metastatic invasion of other tissues. It is general rule that all resectable masses have to be removed surgically. However, there is no definite treatment modality about unresectable masses or microinvasive lesions. We experienced a case of 45 year-old male patient who was referred to our hospital for treatment of hypertension and headache. The plasma and urine catecholamine were increased above normal values and its metabolites also were increased. 131I-metaiodobenzylguanidine (MIBG) scan showed right adrenal mass and metastatic lesion of left iliac bone. This lesion was consistent with findings of the abdomen computed tomography (CT) and electron beam tomography (EBT) scan. We diagnosed this case as malignant pheochromocytoma. We removed primary tumor mass by wide excision and treated this patient with high dose 131I-MIBG. We report this case who shows good response to the high dose 131I-MIBG after surgery.

The Efficacy of Transcatheter Arterial Embolization in Renal Cell Carcinoma in Patients with a Poor Performance Status or at an Advanced Stage / 대한비뇨기과학회지

PURPOSE: To evaluate the efficacy of transcatheter arterial embolization (TAE) in patients with a renal cell carcinoma who were ineligible to undergo a nephrectomy due to their poor performance status and advanced stage. MATERIALS AND METHODS: The study included 42 patients ineligible for a nephrectomy due to their poor performance status and advanced stage. The patients were classified into three groups; 13 patients with TAE for poor performance status (group A-1), 15 patients with TAE for advanced stage (group A-2) and 14 patients without TAE (group B). Group A-1 was composed of patients with a low stage and poor performance status, but there were no significant differences in the clinical factors between groups A-2 and B. RESULTS: After TAE the tumor size became smaller in 19 cases, with the other 9 cases showing no response. TAE was more effective in group A-1 than A-2. The mean survivals of the three groups were 22 (A-1), 12.3 (A-2) and 4.8 months (B). In the A groups, 19 of the 28 patients were still alive, with a prolonged mean survival, which might due to the composition of group A-1, but group A-2 had a better mean survival than group B (p<0.001). Based on the above outcomes, those who underwent TAE had significantly better prognoses than those who did not. The adverse effects in the patients that underwent TAE included fever, back pain on the affected side, nausea and vomiting, but all the patients recovered from these adverse effects. CONCLUSIONS: TAE, with Ivalon, is a safe and effective treatment for the patients who are unable to undergo nephrectomy due to their poor performance status and advanced stage. TAE not only induces ablasion of the primary tumor, but also prolongs the survival.

A Multicenter Study of Antimicrobial Susceptibility of Uropathogens Causing Acute Uncomplicated Cystitis in Woman / 대한비뇨기과학회지

PURPOSE: Worldwide data shows that there is an increasing resistance among urinary tract pathogens to the first-line antimicrobial agents used in domestic areas. The objective of this study was to obtain data on the susceptibility patterns of the pathogens responsible for acute uncomplicated cystitis to currently used antimicrobial agents. MATERIALS AND METHODS: This study was carried out with the participation of fifteen hospitals in South Korea. A total of 239 isolates were obtained from female outpatients with acute uncomplicated cystitis. The antimicrobial susceptibilities to ampicillin, ampicillin/sulbactam, ciprofloxacin, gentamicin, trimethoprim/sulfamethoxazole(TMP/SMX) and tobramycin were determined by Vitek(R) antimicrobial susceptibility test systems. RESULTS: The most prevalent causative organism was Escherichia coli(79.9%), followed by coagulase negative Staphylococcus(4.2%), and a combination of other species of Enterobacteriaceae(8.2%). The mean rates of susceptibility were 35.5, 45.0, 85.7, 81.5, 62.1 and 85.3% to ampicillin, ampicillin/sulbactam, ciprofloxacin, gentamicin, TMP/ SMX and tobramycin, respectively. No significant differences were detected in the resistance rates between the results from 4 regional groups. CONCLUSIONS: The high prevalence of resistance to ampicillin, ampicillin/sulbactam, and TMP/SMX suggest these drugs would not provide adequate initial therapy, and therapies other than TMP/SMX may need to be considered. The relatively high prevalence of resistance to ciprofloxacin, compared with other countries, also requires on going surveillance to identify further changes among urinary tract isolates.

Retroperitoneal Tumor Surgery Using Extracorporeal Cardiopulmonary Bypass / 대한비뇨기과학회지

In recent years, cardiopulmonary bypass(CPB), a standard adjunct for open heart surgery, has been used more frequently to treat diseases that are not primarily of cardiac origin. We report one case of major left adrenal pheochromocytoma surgery and another of surgery for localized renal cell carcinoma with a tumor thrombus extending up the vena cava to the right atrium using adjunctive cardiopulmonary bypass.