Renal arteriovenous fistula induced by extracorporeal shock wave lithotripsy treated by retroperitoneoscopic nephrectomy.

Renal arteriovenous fistula (AVF) is a rare but potentially severe and life-threatening entity. It can occur after various invasive renal interventions, including resection of a localized renal tumor, renal biopsy, percutaneous renal surgery, and even blunt injury of the kidney. The time of clinical presentation of a renal AVF is variable and may occur decades after the injury originally occurred. Here, we report a case of renal AVF induced by extracorporeal shock wave lithotripsy 11 years earlier in an asymptomatic 72-year-old woman. Given the patient's pre-existing hemodialysis dependence, retroperitoneoscopic nephrectomy was performed. On the basis of patient's clinical history, the location of the renal AVF, and the pathological diagnosis, we suggested that renal AVF was a late consequence of the injury to the intrarenal vessels induced by extracorporeal shock wave lithotripsy.

Extraperitoneal Rupture of a Bladder Diverticulum and the Role of Multidetector Computed Tomography Cystography.

Nontraumatic rupture of the bladder is less widely recognized than traumatic rupture, with a challenging early diagnosis due to high variability in clinical presentations. We report a case of extraperitoneal rupture of a bladder diverticulum in a patient with diabetes mellitus who presented with paralytic ileus. Despite conservative management, the patient developed sepsis requiring surgical treatment. Urinary tract infection and bladder outlet obstruction were considered to be potential mechanisms of the rupture. Multidetector computed tomography cystography should be used as the first-line modality when evaluating for a suspected bladder rupture, even in patients with nontraumatic bladder rupture.

Management of Ureterolithiasis in a Patient with Crossed Unfused Renal Ectopia.

Crossed renal ectopia is a rare congenital anomaly in which both kidneys are situated on one side and fused together in 85%-90% of cases. The management of urinary calculi in patients with crossed renal ectopia continues to pose challenges to urologists because the aberrant anatomy may make access and clearance of the calculi more difficult to accomplish. Here, we report a case of inferior crossed renal ectopia, without fusion, and a ureteral stone in which the patient was treated successfully by extracorporeal shock wave lithotripsy.

Laparoscopic Management of a Complex Adrenal Cyst.

Adrenal cysts are rare, and their clinical management remains controversial. We report a case involving an adrenal cyst with a complicated appearance on radiological studies. Unenhanced computed tomography revealed a unilocular, noncalcified, hypoattenuating mass with a thin wall in the left adrenal gland. The lesion gradually increased in size from 10 to 50 mm at two-year follow-up. On contrast-enhanced magnetic resonance imaging, a mural nodule with contrast enhancement was observed. The entire adrenal gland was excised en bloc via a lateral transperitoneal laparoscopic approach without violating the principles of surgical oncology. The pathological diagnosis was an adrenal pseudocyst. Laparoscopic adrenalectomy is a safe option for the treatment of complex adrenal cysts, while maintaining the benefits of minimal invasiveness.

Successful endovascular treatment using a covered stent for artery-ureteral fistula after surgery for abdominal aortic aneurysm.

Artery-ureteral fistula (AUF) is a rare condition but there is an increase in the number of reported cases. It is frequently difficult to treat. A 63-year-old male who had undergone a Dacron Y-graft placement for an infrarenal aortic aneurysm 3 years earlier, presented with hematuria. Contrast-enhanced computed tomography revealed a fistula located between the right common iliac artery and the right ureter at graft anastomosis. Endovascular treatment using a covered stent was performed successfully.

Inferior vena cava thrombosis associated with a distended ileal neobladder.

Venous stasis is generally accepted to be a predisposing factor for venous thrombosis. However, benign causes of inferior vena cava (IVC) obstruction with associated thrombus formation have not been well described. We herein present a case of IVC compression caused by a distended ileal neobladder measuring 2,000 mL in capacity that led to IVC thrombosis. Following transurethral drainage for six weeks and anticoagulation therapy with warfarin for six months, the thrombus completely disappeared. The patient was considered to have a hypercoagulable state resulting from an acute urinary tract infection, a condition that may be associated with an increased risk of thrombosis.

Conservative management of a delayed neovesicocutaneous fistula.

A neovesicocutaneous fistula is a rare complication after orthotopic bladder reconstruction, particularly in the late postoperative period. We report the case of a 59-year-old man who had undergone ileal neobladder construction 17 months previously. He presented with urinary retention concomitant with urinary tract infection due to a neovesicourethral anastomotic stricture. After a combination of transurethral catheter drainage and broad-spectrum antibiotic therapy for 3 weeks, the fistulous tract completely closed. Therefore, conservative treatment may be regarded as a valid option for a delayed neovesicocutaneous fistula.

Retroperitoneoscopic drainage of bilateral psoas abscesses under intraoperative laparoscopic ultrasound guidance.

Despite improved diagnostic modalities for psoas abscesses, the optimum management strategy is not uniform. A 67-year-old man presented with bilateral psoas abscesses secondary to L1-L2 pyogenic discitis. On contrast-enhanced CT, the largest of these abscesses measured 13 × 14 × 33 mm on the right. The patient developed sepsis caused by Klebsiella pneumonia. There were no signs of improvement after 3 weeks of systematic antibiotic administration. We performed surgical drainage of bilateral psoas abscesses by retroperitoneoscopy. Intraoperative laparoscopic ultrasound was useful to determine abscess location in the muscles prior to drainage and confirm no residual abscesses after drainage. The patient was afebrile 3 days later, and his clinical symptoms resolved. Retroperitoneoscopic drainage may represent a feasible minimally invasive therapeutic option for psoas abscess, and intraoperative laparoscopic ultrasound has the potential to increase the safety and efficacy of this surgical procedure.

Cough-induced internal oblique hematoma.

Violent or sustained cough can be associated with serious musculoskeletal complications. We report a case of a cough-induced internal oblique hematoma in an obese 73-year-old woman who was not receiving antithrombotic therapy. She had no history of trauma and presented with acute worsening pain in the right flank. She had been coughing continuously for the past month and had severe cough 2 days before the onset of pain. Ultrasonography revealed a hypoechoic mass in the right lateral abdominal wall. Unenhanced computed tomography of the abdomen showed a 7 cm × 7 cm × 4 cm hematoma in the right internal oblique muscle. The patient was managed conservatively without blood transfusion. Acute abdominal pain together with an abdominal painful mass, particularly in patients with cough, should alert physicians to the possibility of an abdominal wall hematoma.

Urinary frequency as a presentation of bulky malignant lymphoma in the pelvis.

Malignant lymphomas may originate from any area of the body and cause a variety of symptoms. However, a malignant lymphoma causing urinary symptoms is uncommon. We report a unique case of a 77-year-old woman who presented with a persistent pollakiuria. Radiographic imaging showed a large pelvic mass (13 × 13 × 11 cm) remarkably compressing and invading the bladder wall and accompanied with bilateral hydronephrosis. Urinary cytology revealed malignant lymphoma, and a final diagnosis of malignant lymphoma was made on the basis of transvaginal needle biopsy. Urinary cytology facilitated the definite diagnosis, following which we initiated a rapid and successful treatment with cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab.

The effectiveness of interferon-alpha subtypes alternation for metastasis from renal cell carcinoma.

Interferon-alpha (IFN-α) has been used in systemic treatment for metastatic renal cell carcinoma (mRCC). IFN-α has at least 14 subtypes, each of which has different biological activity. There have been reports that mRCC resistant to an IFN-α treatment responded to another IFN-α subtype. This study was performed to evaluate the effectiveness of alternation of different IFN-α subtypes for mRCC that did not respond to initial IFN-α treatment. In our department and associated institutions, alternating therapy of IFN-α was provided for 15 initial IFN-α refractory mRCC cases from June 2005 to September 2008. Among the 15 patients, the effects of alternating IFN-α therapy were as follows: complete response (CR), 0 cases; partial response (PR), 1 case; stable disease (SD), 3 cases; progressive disease (PD), 11 cases. The response rate (CR+PR) was 7% and disease control rate (CR+PR+SD) was 27%. No severe side effects were observed in any of these cases. The PR case is still in PR 21 months after alternating IFN-α therapy. Among the three SD cases, one has continued SD for 14 months and the other for 12 months. Alternating IFN-α therapy for mRCC can be attempted even if other cytokines are not effective.

Off-clamp laparoscopic partial nephrectomy for a fat-poor angiomyolipoma arising from the renal capsule: a case report.

Renal function can be significantly preserved after nephron-sparing surgery by decreasing the intraoperative ischemic duration or by performing off-clamp surgery. We report the case of a 56-year-old woman diagnosed with a minimal-fat angiomyolipoma arising from the renal capsule, which was successfully treated by retroperitoneoscopic partial nephrectomy without hilar clamping. Computed tomography revealed a 16 × 13 mm homogenous lenticular mass protruding from the lateral aspect of the left kidney. On both T1- and T2-weighted magnetic resonance images, the mass exhibited homogenous low-signal intensity and well-defined margins. Laparoscopic magnification indicated that the exophytic tumor was attached to the renal cortex by a small peduncle. The tumor was resected completely with negative surgical margin. The estimated glomerular filtration rate after surgery was nearly equal to that before surgery. Off-clamp laparoscopic partial nephrectomy is a feasible surgical option to prevent ischemic renal damage in select patients presenting with small, exophytic, and peripheral renal masses.

Cyst infection in unilateral renal cystic disease and the role of diffusion-weighted magnetic resonance imaging.

In multicystic renal diseases, cyst infection is a complex issue because of the absence of validated diagnostic methods. Unilateral renal cystic disease is a rare multicystic disease, believed to have an acquired maldevelopmental origin. Unilateral renal cystic disease is often confused with autosomal dominant polycystic kidney disease but has some distinguishing characteristics: unilateral localization, negative family history, and no progression to chronic renal failure. We describe a case of unilateral renal cystic disease with cyst infection that could be detected by diffusion-weighted magnetic resonance imaging, but not by conventional imaging techniques. Diffusion-weighted magnetic resonance imaging can be useful for detecting infected cysts, especially in multicystic renal diseases.

Management of a renal calculus larger than 4 cm in a patient with tuberous sclerosis complex-associated angiomyolipoma.

Renal calculi in patients with renal angiomyolipomas are difficult to treat because of the hemorrhagic potential of these tumors. We describe the case of a 65-year-old man having tuberous sclerosis complex-associated multifocal renal angiomyolipomas with a large renal calculus. The patient presented with left flank dullness and a previous history of spontaneous angiomyolipoma rupture. Intravenous pyelography revealed a 43 × 16 mm calculus in the pelvis and lower calyx of the left kidney. The calculus was successfully removed by retrograde flexible ureterorenoscopy and holmium-YAG lithotripsy. Flexible ureterorenoscopy is an effective, minimally invasive therapy for patients at high risk of renal hemorrhage.

Atlas of dihydrotestosterone actions on the transcriptome of prostate in vivo.

BACKGROUND: Using serial analysis of gene expression (SAGE), we studied the transcriptomic changes in vivo by dihydrotestosterone (DHT) treatment in mice to better understand androgen effects in the prostate. METHODS: Approximately 872,000 SAGE tags were isolated from intact and castrated (GDX) mice with and without DHT injection. RESULTS: GDX significantly altered 431 transcripts, including 110 transcripts restored by DHT, and 146 potentially new transcripts. Totally, 187 transcripts were significantly affected by DHT treatment, of which 124 were induced and 63 were repressed. Interestingly and consistent with the prostate's secretory role, DHT up-regulated the expression of many genes involved in various steps of protein metabolism such as synthesis, folding, and secretion. GDX modulated the expression of genes which induce cell apoptosis and inhibit cell proliferation through polyamine biosynthesis, retinoid X receptor actions as well as several signaling pathways and some related factors. These results clarify DHT effects on prostate transcriptome in the areas of protein metabolism, cell proliferation and apoptosis. In addition, we detected gene expression changes in metabolic pathways, cytoskeleton, immunity and endoplasmic reticulum stress. Furthermore, knockdown of S-adenosylmethionine decarboxylase 1 in LNCaP cells confirmed the importance of androgen-regulated genes (ARGs) in prostate cancer cell growth. CONCLUSION: Our data support the idea that ARGs are essential for the normal development of the prostate and can also be responsible for the pathogenesis of the prostate cancer.

Prostate-specific genes and their regulation by dihydrotestosterone.

BACKGROUND: Prostate is a well-known androgen-dependent tissue. METHODS: By sequencing 4,294,186 serial analysis of gene expression (SAGE) tags, we have investigated the transcriptomes of normal mouse prostate, liver, testis, lung, brain, femur, skin, adipose tissue, skeletal muscle, vagina, ovary, mammary gland, and uterus in order to identify the most abundant and tissue-specific transcripts in the prostate, as well as to target the androgen responsive transcripts specifically regulated in the prostate. Small interference RNA (siRNA) in LNCaP cells was applied to validate the roles of prostate-specific/enriched ARGs in the growth of human prostate cancer cells. RESULTS: The most abundant transcripts were involved in prostatic secretion, energy metabolism and immunity. Previously well-known prostate-specific transcripts, including many transcripts involved in prostatic secretion, polyamine biosynthesis and transport, and immunity were specific/enriched in the prostate. Only 22 transcripts among 114 androgen-regulated genes (ARGs) in the mouse prostate were modulated by dihydrotestosterone (DHT) in two or more tissues. The siRNA results showed that inhibition of HSPA5 and MAT2A gene expression repressed growth of human cancer LNCaP cells. CONCLUSIONS: The current study globally assessed the transcriptome of the prostate and revealed the most abundant and tissue-specific transcripts which are responsible for the unique functions of this organ. These prostate-specific ARGs might be used as targets to develop safe and effective gene-based therapy for the prevention and treatment of prostate cancer.

Seminal vesicle-rectal fistula with preceding right acute epididymitis.

A case of seminal vesicle-rectal fistula is reported. A 74-year-old Japanese man was admitted to our hospital due to repeated right scrotal swelling and high fever with pneumaturia. A diagnosis of the right acute epididymitis was made. Bilateral vesiculography showed contrast medium leakage to the rectum, and colonoscopy revealed ostium of the fistula in the anterior wall of the rectum. Symptoms were improved by extirpation of the right scrotal contents.

Expression of enzymes involved in estrogen metabolism in human prostate.

There is evidence that estrogens can directly modulate human prostate cell activity. It has also been shown that cultured human prostate cancer LNCaP can synthesize the active estrogen estradiol (E2). To elucidate the metabolism of estrogens in the human prostate, we have studied the expression of enzymes involved in the formation and inactivation of estrogens at the cellular level. 17beta-Hydroxysteroid dehydrogenase (17beta-HSD) types 1, 2, 4, 7, and 12, as well as aromatase mRNA and protein expressions, were studied in benign prostatic hyperplasia (BPH) specimens using in situ hybridization and immunohistochemistry. For 17beta-HSD type 4, only in situ hybridization studies were performed. Identical results were obtained with in situ hybridization and immunohistochemistry. All the enzymes studied were shown to be expressed in both epithelial and stromal cells, with the exception of 17beta-HSD types 4 and 7, which were detected only in the epithelial cells. On the basis of our previous results, showing that 3beta-HSD and 17beta-HSD type 5 are expressed in human prostate, and of the present data, it can be concluded that the human prostate expresses all the enzymes involved in the conversion of circulating dehydroepiandrosterone (DHEA) to E2. The local biosynthesis of E2 might be involved in the development and/or progression of prostate pathology such as BPH and prostate cancer through modulation of estrogen receptors, which are also expressed in epithelial and stromal cells.

[Bellini duct carcinoma: a case report].

A 53-year-old man was admitted to our hospital for the extensive examination and treatment of suspicioun of right renal pelvic tumor. Retrograde pyelography (RP), computed tomography (CT) and magnetic resonance imaging (MRI) showed a space-occupying lesion, about 2 cm in diameter, spread from the renal parenchyma to the renal pelvis. Right nephroureterectomy was performed because transitional cell carcinoma was suspected from the histopothology of the frozen section. The gross examination revealed a white tumor in the upper pole, protruding into the renal pelvis with hemorrhagic necrosis. Histological examination showed Bellini duct carcinoma of the papillary type. He received adjuvant combination chemotherapy with M-VAC (Methotrexate, vinblastine, doxorubicin, cisplatin). He has been alive without evidence of recurrence since the surgery.