[A CASE OF METASTATIC BLADDER UROTHELIAL CARCINOMA WHOSE DISEASE WAS CONTROLLED FOR A RELATIVE LONG PERIOD BY MULTIDISCIPLINARY TREATMENT INCLUDING RADIATION TO A LUNG METASTASIS AND MULTIPLE COURSES OF CHEMOTHERAPY].

A 67-year-old woman complained of urinary frequency and gross hematuria. She was referred to our hospital with the diagnosis of bladder tumor. Transurethral resection of the bladder tumor (TURBT) was performed and pathological diagnosis was urothelial carcinoma (G2>G3) with muscular invasion. Because she hoped bladder preservation therapy, she received two courses of M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) therapy, one course of arterial infusion chemotherapy, and chemoradiotherapy with cisplatin. After those therapies she underwent 4 times of TURBT and two courses intravesical BCG therapy. However, solitary lung metastasis appeared 19 months after the initial TURBT. Multidisciplinary treatments including 25 courses of various multiagent chemotherapies, radiation therapy to the lung metastasis and surgical resection of a urethral recurrence were performed. Although a localized radiation pneumonitis was developed, the lung metastasis appeared to be controlled for 26 months after the radiation therapy to the lung. Bilateral ureteral and renal pelvic tumors appeared after the radiation therapy. Severe bleeding was occurred from renal pelvic tumors several times and she needed the hospital stay 2 times. Active bleeding stopped after the administration of chemotherapy each time. Although she died of occlusive jaundice due to the liver metastasis, she had been alive due to the multidisciplinary treatment for 67 months after lung metastasis appearance with relatively good performance status.

A Case of Pancreatic Side Effects Resulting from Sorafenib and Axitinib Treatment of Stage IV Renal Cell Carcinoma.

Tyrosine kinase inhibitors such as sorafenib and axitinib were developed to treat malignancies, including stage IV renal cell carcinoma. Recently, we experienced a patient with pancreatic side effects from both sorafenib and axitinib. We report this case and include a discussion of the literature.

Erythropoietin production in renal cell carcinoma and renal cysts in autosomal dominant polycystic kidney disease in a chronic dialysis patient with polycythemia: A case report.

In patients undergoing chronic hemodialysis (HD), erythropoietin (EPO) production from the kidney generally decreases and renal anemia develops. Patients without anemia, but with high serum EPO (sEPO) levels are rare among HD patients. The current study presents the case of a 67-year-old female HD patient with autosomal dominant polycystic kidney disease (ADPKD) and renal cell carcinoma (RCC), manifesting polycythemia with elevated sEPO levels. A radical nephrectomy was performed, which diminished the polycythemia, but the sEPO levels remained high. To determine the origin of the EPO production, immunohistochemistry was performed to detect EPO in the RCC and the renal cysts of the surgically resected kidney. In addition, the sEPO and EPO levels in a renal cyst were determined by enzyme immunoassay. EPO expression was demonstrated in RCC and cyst epithelial cells using immunohistochemistry, revealing extremely high EPO levels in the cyst fluid. Due to the remission of polycythemia following the nephrectomy, EPO production from the resected kidney appeared to have been the cause of the polycythemia. Positive EPO staining of the renal cysts in the resected polycystic kidney and sustained sEPO elevation following nephrectomy led to the hypothesis of EPO production in the renal cysts of the contralateral polycystic kidney. Although the postoperative EPO level was higher than the normal range, the hematocrit (Hct) level gradually decreased and recombinant human EPO was required again three months following the nephrectomy. Eight months after the nephrectomy, the Hct level was 30.2% with the use of rHuEPO. In conclusion, EPO production from RCC and renal cysts in ADPKD appeared to cause polycythemia in the HD patient.

Increased expression of α-actinin-4 is associated with unfavorable pathological features and invasiveness of bladder cancer.

In the present study, the association between clinicopathological parameters and α-actinin-4 (ACTN4) expression in bladder cancer specimens was evaluated, and the functional role of ACTN4 in bladder cancer cells was investigated. Immunohistochemistry using anti-ACTN4 antibody was performed in bladder cancer specimens (53 superficial and 42 muscle-invasive cases) from 95 patients who underwent radical cystectomy (n=46) or transurethral resection (TUR) only (n=49). We divided the levels of ACTN4 expression into 2 groups (low or high) by comparing the staining intensity in each specimen with that of the vascular endothelial cells in the same specimen, and we evaluated the correlations between these levels and pathological parameters, recurrence and prognosis. We also investigated the effects of ACTN4 suppression by siRNA on the invasive ability and proliferation of T24 and KU19-19 cells. High ACTN4 expression was significantly associated with higher tumor grade and higher pT stage. In patients with superficial bladder cancer treated only by TUR, the rate of intravesical recurrence did not differ significantly between patients with high ACTN4 expression and patients with low ACTN4 expression. In patients who had muscle­invasive tumors and underwent radical cystectomy, high ACTN4 expression was associated with neither recurrence nor poor prognosis. Nonetheless, high ACTN4 expression was shown by a large percentage (81%) of patients with muscle-invasive bladder cancer and by a small percentage (17%) of patients with superficial bladder cancer. Furthermore, the leading edges of the invasive bladder cancer showed increased ACTN4 expression. ACTN4 suppression significantly reduced the number of invading bladder cancer cells but unexpectedly increased the proliferation of bladder cancer cells. ACTN4 suppression increased the phosphorylation of ERKs but not AKT or STAT3, suggesting that the increased proliferation due to ACTN4 suppression was mediated in part by the ERK pathway. ACTN4 expression may suppress the proliferation of bladder cancer cells and may produce conditions which facilitate cancer cell invasion.

[Evaluation of clinical results in patients undergoing laparoscopic nephroureterectomy].

We evaluated the efficacy of laparoscopic radical nephroureterectomy (LNUx) by comparing the clinical results in 55 patients undergoing LNUx at the National Defense Medical College since 2001 with those in patients undergoing open radical nephroureterectomy (ONUx) there over the same period. LNUx was performed successfully in 54 of the patients, but one patient required conversion to ONUx. The mean operating time for LNUx was not significantly different from that for ONUx, and the mean estimated blood loss during LNUx was significantly lower than that during ONUx. Major complications occurring early in our laparoscopic series of cases were injury of the duodenum and bleeding from the inferior vena cava. Oncological outcomes were compared between LNUx (n＝50) and ONUx (n＝50) in patients with pathologically-confirmed urothelial carcinoma. The pT stage, histological grade, percentage of lymph node dissection and percentage of high grade hydronephrosis did not differ significantly between the two groups. Because the intravesical recurrence-free survival rates, extravesical recurrence-free survival rates, and disease specific survival rates were also similar in the two groups, we concluded that LNUx is an appropriate treatment for upper urinary tract urothelial carcinoma.

Modified posterior musculofascial plate reconstruction decreases the posterior vesicourethral angle and improves urinary continence recovery in patients undergoing laparoscopic radical prostatectomy.

The aim of this study was to evaluate the efficacy of our modified posterior musculofascial plate reconstruction (PMPR) procedure in laparoscopic radical prostatectomy (LRP). Prior to 2010, four operative procedures were used to expedite continence recovery: preserving the fascia covering the levator ani muscle, preserving the bladder neck, securing a functional urethral length by using a lateral-view dissection technique and suspending the vesicourethral anastomosis from the puboprostatic ligaments. Since February, 2010, a running suture between Denonvilliers' fascia (DF) and the median fibrous raphe (MFR, the fibrous tissue that lies immediately underneath the urethra) has also been used. In vesicourethral anastomosis, a double-armed running suture was performed. At the beginning of the anastomosis, the first stitches (at 1 and 11 o'clock positions on the bladder neck) were placed 1-2 cm dorsocephalad to the bladder neck (first through the seromuscular layer and then through the full thickness of the bladder neck). At the 5 and 7 o'clock positions of the urethra, the stitches were placed through the urethral mucosa as well as the the reconstructed musculofascial plate. The bladder shape was evaluated by postoperative cystography and the clinical results were compared between patients undergoing LRP without PMPR (group A) and those undergoing LRP with PMPR (group B). The cystograms demonstrated that the PMPR significantly shortened the vertical length of the bladder and significantly decreased the posterior vesicourethral angle. At 1, 3 and 6 months after LRP, the number of daily used pads was significantly lower in group B compared to that in group A and the time to achieve a pad-free status was significantly shorter in group B. Our modified PMPR procedure significantly improved the recovery of urinary continence following LRP and this improvement may be due in part to changes of the bladder shape.

Impact of increased erythropoietin receptor expression and elevated serum erythropoietin levels on clinicopathological features and prognosis in renal cell carcinoma.

Erythropoietin (EPO) expression and EPO receptor (EpoR) expression have been demonstrated in various malignant tumors. EPO-EpoR signaling can activate several downstream signal transduction pathways that enhance tumor aggressiveness. The present study was undertaken to evaluate the impact of overexpression of EpoR and elevated serum EPO (sEPO) levels on the clinicopathological features and prognosis of patients with renal cell carcinoma (RCC). EpoR expression was evaluated immunohistochemically in 56 patients. Tumors with a staining intensity greater than that of surrounding proximal tubules were defined as tumors with high EpoR expression. The association between EpoR expression levels and various clinicopathological factors was analyzed. sEPO levels were determined in 138 patients and its correlation to clinicopathological factors was also analyzed, and EpoR expression was determined in surgical specimens removed from 47 of those 138 patients. Patients with high EpoR expression and patients with sEPO elevation had clinicopathological features less favorable than those of other patients. Tumors demonstrating high EpoR expression had a significantly higher number of Ki-67-positive cells compared to those with low EpoR expression. Tumor assemblies in microvessels demonstrated high EpoR expression. Patients whose tumors demonstrated high EpoR expression and those with sEPO elevation had a significantly lower survival rate compared to other patients, and patients with both high EpoR expression and sEPO elevation had an extremely poor prognosis. Microvascular invasion was an independent factor associated with sEPO elevation, suggesting that EPO-EpoR signaling might be important in RCC metastasis. EPO-EpoR signaling may be involved in tumor growth and progression in RCC and the combination of EpoR expression and sEPO levels may effectively predict clinical outcome.

Prediction of biochemical recurrence after radical prostatectomy using peritumoral lymphatic vessel density in biopsy specimens in patients with localized prostate cancer.

INTRODUCTION: Lymphatic invasion has been associated with biochemical recurrence (BCR), and many patients with postoperative elevation of prostate-specific antigen (PSA) develop distant metastases within several years. We previously found peritumoral lymphatic vessel density (PTLD) in biopsy cores to be an independent predictor of lymphatic invasion in radical prostatectomy specimens, so we speculate that PTLD parameters in biopsy specimens could also be independent predictors of BCR after surgery. PATIENTS AND METHODS: We obtained positive biopsy cores from 110 patients who underwent radical prostatectomy at our institution. Biopsy cores were immunostained with the D2-40 monoclonal antibody, which specifically and selectively detects lymphatic endothelium. We evaluated differences between the BCR-free survival rates and used univariate and multivariate analyses to detect independent predictors of BCR. RESULTS: The results of a Cox proportional hazards model showed that lymphatic invasion in prostatectomy specimens was one of the independent postoperative prognostic factors for BCR (p = 0.0338). An additional model showed that one PTLD parameter, maximal PTLD, was among the independent preoperative predictors of lower BCR-free survival rates (p = 0.0200). CONCLUSIONS: Information about PTLD in prostate biopsy specimens could be helpful for selecting patients as radical prostatectomy candidates, and patients with high PTLD values should be carefully monitored after surgery.

Prognostic factors for upper urinary tract urothelial carcinoma after nephroureterectomy.

INTRODUCTION: The purpose of this study was to evaluate prognostic factors for patients with upper urinary tract urothelial carcinoma (UUT-UC) after nephroureterectomy and to seek a better way of finding more favorable clinical results for these patients. PATIENTS AND METHODS: We retrospectively reviewed the medical records of 121 UUT-UC patients who underwent a nephroureterectomy at our institution, and analyzed the prognostic significance of various clinicopathological parameters for progression-free and disease-specific survival rates by using univariate and multivariate analysis. RESULTS: A Cox proportional hazards model showed that extravesical tumor recurrence after surgery was an independent prognostic factor for disease-specific survival (p < 0.0001). An additional model showed that lymphovascular invasion (LVI) was one of the independent predictors of lower extravesical-recurrence-free survival rates (p = 0.0004). Our final finding was that pathological tumor stage and positive surgical margin were significantly associated with the presence of LVI (p < 0.0001 and p = 0.0029, respectively). CONCLUSIONS: We conclude that there is a high possibility of LVI in patients with large tumors. Our findings should be helpful in terms of determining whether or not to perform neoadjuvant chemotherapy for patients with large tumors, given the fact that we frequently find a severe reduction in renal function after nephroureterectomy.

Glucose-regulated protein 78 positivity as a predictor of poor survival in patients with renal cell carcinoma.

INTRODUCTION: Glucose-regulated protein 78 (GRP78), a chaperone for newly formed proteins during folding and glycosylation, is associated with resistance to apoptosis in some forms of cancer. We assessed GRP78 expression and its correlation with clinicopathological parameters and survival. PATIENTS AND METHODS: Immunohistochemistry was performed using formalin-fixed, paraffin-embedded specimens: 128 primary renal cell carcinoma (RCC) specimens (120 conventional and 8 other cell types) and 9 metastatic specimens. GRP78 positivity was determined based on intensity of staining and percentage of cells stained. Correlation of GRP78 positivity with clinicopathological parameters including patients' survival was evaluated. RESULTS: A statistically significant association was found between GRP78 positivity and higher tumor grade (G3; p <0.0001), advanced T stage (≥pT3; p = 0.0002), lymphovascular invasion (positive; p <0.0001), regional nodal involvement (≥N1; p = 0.0086), and distant metastases at presentation (M1; p = 0.001). Positivity of GRP78 expression was significantly associated with shorter disease-specific survival and shorter progression-free survival. Cox proportional hazard model showed that strong GRP78 positivity was an independent predictor of shortened progression-free survival in N0M0 RCC patients. CONCLUSIONS: There was a significant relationship between GRP78 expression levels and aggressiveness of RCC. Increased expression of GRP78 might be a useful parameter to predict shortened survival in patients with RCC.

[Clinical experience of 52 patients undergoing laparoscopic radical prostatectomy].

Perioperative results and oncological and functional results were evaluated for 52 patients who underwent laparoscopic radical prostatectomy (LRP). Median operative time was 341 minutes and median blood loss was 828 ml. The intraoperative complications were hemorrhage exceeding 3,000 ml (five cases), ureteral injury (two cases), and rectal injury (one case). The median day of catheter removal was postoperative day 7. Postoperative complications were temporal arrhythmia, mild hydronephrosis, port site hernia, urethral stricture, and a giant lymphocele. When surgical results were compared between the firsthalf cases and second-half cases who were operated on by a single surgeon, median operative time and intraoperative hemorrhage did not differ significantly between the two halves but the day of catheter removal after LRP was significantly earlier for the second-half group. The pathological stage was pT3 in 41.2% of the patients and the negative surgical margin rate was 62.7%. The 3-year PSA-failure-free survival rate was 64. 1%. Pad-free status (0-1 pad/day) was achieved in 84.4% of the patients. Erectile function was preserved in 58.3% of patients undergoing nerve-sparing LRP. Although the complication rate and the quality of operative procedures gradually improved, efforts to improve the oncological and functional outcomes of LRP must continue.

Impact of postoperative C-reactive protein level on recurrence and prognosis in patients with N0M0 clear cell renal cell carcinoma.

PURPOSE: Preoperative C-reactive protein is a strong predictor of recurrence and prognosis in patients with renal cell carcinoma while postoperative C-reactive protein reportedly predicts survival in patients with metastatic renal cell carcinoma. We evaluated the impact of postoperative C-reactive protein on recurrence and prognosis in patients with N0M0 clear cell renal cell carcinoma. MATERIALS AND METHODS: We defined increased preoperative C-reactive protein as 1 mg/dl or greater and postoperative C-reactive protein normalization as at least 1 postoperative measurement of less than 0.3 mg/dl. We reviewed the records of 263 patients with N0M0 clear cell renal cell carcinoma who underwent nephrectomy, and in whom preoperative and postoperative C-reactive protein values were available. We used multivariate analysis to identify independent factors predicting recurrence and prognosis. We also evaluated C-reactive protein at recurrence and its impact on survival. RESULTS: Increased preoperative C-reactive protein and nonnormalization of postoperative C-reactive protein were associated with worse clinicopathological factors. Postoperative C-reactive protein nonnormalization, increased preoperative C-reactive protein, microvascular invasion and histological tumor necrosis were independent predictors for recurrence. Risk stratification using these factors effectively predicted the possibility of recurrence. Anemia, thrombocytosis and postoperative C-reactive protein nonnormalization were independent predictors of overall survival. Postoperative followup revealed recurrence in 50 patients. The 3-year survival rate in patients with C-reactive protein 0.3 mg/dl or greater at recurrence was significantly lower than that in patients with less than 0.3 mg/dl at recurrence (47.3% vs 81.6%). CONCLUSIONS: Nonnormalization of postoperative C-reactive protein is a strong predictor of recurrence and prognosis. Patients with C-reactive protein 0.3 mg/dl or greater at recurrence might not survive as long as those with C-reactive protein less than 0.3 mg/dl at recurrence.

Anterior perirectal fat tissue thickness is a strong predictor of recurrence after high-intensity focused ultrasound for prostate cancer.

OBJECTIVE: To evaluate if and why obesity affects the clinical outcome in patients undergoing high-intensity focused ultrasound (HIFU) treatment for prostate cancer (CaP). METHODS: 115 patients who underwent HIFU treatment for localized CaP were categorized as obese, overweight or normal according to body mass index (BMI). The thickness of the anterior perirectal fat tissue (APFT) was measured by transrectal ultrasonography. Treatment was considered to have failed in the case of biochemical failure according to the Phoenix definition, positive follow-up biopsy or initiation of salvage therapy. Cox proportional hazards analyses were used to identify possible predictors for disease free survival (DFS), and an experimental fat tissue model was made to evaluate the ablation effect at the target tissue. RESULTS: According to the classification by the Western Pacific Regional Office of WHO, 43 patients were of normal weight, 24 were overweight and 48 were obese. The BMI groups did not differ in Gleason score, prostate-specific antigen level at diagnosis or clinical stage. There were, however, significant correlations between BMI and prostate-specific antigen nadir (P < 0.001), and BMI and APFT thickness (P < 0.01). Multivariate analyses showed that BMI fails to be an independent predictor of DFS when APFT (P < 0.0001) is included as a variable. CONCLUSIONS: Our results suggest that APFT thickness, for which obesity could be a useful surrogate, might represent the causative factor for poor clinical outcome after transrectal HIFU treatment for CaP.

[Oral mucosa graft urethroplasty for complicated urethral strictures].

OBJECTIVE: We evaluated the efficacy and outcome of one-stage oral mucosa graft urethroplasty, which is currently the procedure of choice for treating lengthy and complicated urethral strictures not amenable to excision and primary end-to-end anastomosis. PATIENTS AND METHODS: Seven patients 33 to 74 years old (mean age = 53.7) underwent one-stage oral mucosa graft urethroplasty for a stricture in either the bulbar urethra (four patients), penile urethra (two patients), or pan-anterior urethra (one patient). Three of the strictures were due to trauma, one was due to inflammation, and one was due to a failed hypospadia repair. The other two were iatrogenic. All patients had previously undergone either internal urethrotomy or repeated urethral dilation. Three patients received a tube graft, three received a ventral onlay, and one received a dorsal onlay. A free graft of oral mucosa was harvested from the inside of each patient's left cheek, and if necessary to obtain a sufficient length, the harvest was extended to include mucosa from the lower lip and the right cheek. The graft lengths ranged from 2.5 to 12 cm (mean = 4.6 cm). A urethral catheter was left in place for 3 weeks postoperatively. RESULTS: While no severe complications at the donor site were observed during follow-up periods ranging from 3 to 55 months (mean = 14 months), two patients who had received a tube graft developed distal anastomotic ring strictures that were managed by internal urethrotomy. The other five required no postoperative urological procedure even though one who had received a ventral onlay developed a penoscrotal fistula. CONCLUSION: Oral mucosa is an ideal urethral graft, and oral mucosa graft urethroplasty is an effective procedure for repairing complicated urethral strictures involving long portions of the urethra.

Adrenomedullin increases renal nitric oxide production and ameliorates renal injury in mice with unilateral ureteral obstruction.

PURPOSE: We evaluated the effects of adrenomedullin (Peptide Institute, Minoh-shi, Osaka, Japan) on mediators, including nitric oxide and transforming growth factor-beta, and parameters of renal injury in a murine unilateral ureteral obstruction model. MATERIALS AND METHODS: Three study groups of control, adrenomedullin treated and adrenomedullin plus L-NAME treated BALB/C mice, respectively, underwent left unilateral ureteral obstruction. A 24-hour urine sample was collected to measure urinary NO(2)/NO(3) 1 day before unilateral ureteral obstruction and kidneys were harvested on postoperative day 14. Tubulointerstitial damage markers were evaluated by immunohistochemistry. Tissue transforming growth factor-beta was determined by enzyme-linked immunosorbent assay. Endothelial and inducible nitric oxide synthase immunolocalization was also determined. RESULTS: Urinary NO(2)/NO(3) was significantly higher in the adrenomedullin group than in controls, confirming increased renal nitric oxide production. Immunohistochemistry showed increased endothelial nitric oxide synthase in vascular endothelial cells in the adrenomedullin group but tissue transforming growth factor-beta did not significantly differ in controls vs the adrenomedullin group. Interstitial collagen deposition and fibroblasts in the obstructed kidney were significantly decreased in the adrenomedullin group. The number of leukocytes and apoptotic cells in the obstructed kidney were significantly decreased by adrenomedullin. Renal injury amelioration resulting from adrenomedullin was blunted by the nitric oxide synthase inhibitor L-NAME. CONCLUSIONS: Adrenomedullin increased renal nitric oxide, and suppressed tubular apoptosis, interstitial fibrosis and inflammatory cell infiltration in mice with unilateral ureteral obstruction. The renoprotective peptide adrenomedullin may be useful for that condition.

Clinical impact of the presence of the worst nucleolar grade in renal cell carcinoma specimens.

OBJECTIVE: Renal cell carcinoma (RCC) with a high-nucleolar-grade component is considered to be an aggressive type of tumor. In the present study, we evaluated the impact of the presence of the worst-nucleolar-grade component and also tried to determine predictors for recurrence and prognosis in patients with the worst grade component. METHODS: We evaluated 314 patients with RCC. A three-graded system was used for nucleolar grading, the patients were classified into four groups according to the presence of the worst nucleolar grade (Grade 3) and the occupancy of each grade, and clinicopathological factors and clinical outcomes were compared. In patients of Grade 3 components (Groups 1 and 2), factors influencing on prognosis and recurrence were evaluated by multivariate analysis. RESULTS: There was no significant difference in clinicopathological factors between Group 1 (with Grade 3-dominant tumors) and Group 2 (with tumors in which Grade 1 or 2 was dominant and there were Grade 3 components). Neither did cause-specific survival or recurrence-free survival differ significantly between those two groups. In multivariate analysis, only distant metastasis was an independent predictor for prognosis in all patients with Grade 3 components. Moreover, an elevated C-reactive protein (CRP) level (>or=1 mg/dl) was the only independent predictor of recurrence in N0M0 patients. CONCLUSIONS: Regardless of dominancy, the presence of the worst grade component has a significant clinical impact in RCC patients. N0M0 patients whose RCC has worst-grade components but whose CRP levels are <1 are expected to have longer recurrence-free intervals and to survive longer than those whose CRP levels are higher.

A case of vesicocutaneous fistula to the thigh.

We report a case of vesicocutaneous fistula to the thigh that developed 7 years after an injury to the pelvis. A 34-year-old male patient was referred to our hospital because of a water-soluble yellow exudate from his left thigh. A urinary fistula was suggested by the results of an intravenous indigo carmine injection. Intravenous pyelography and computed tomography revealed the presence of a bladder deformation and a fistula originating at the ventral bladder wall and leading down to the left thigh. The patient underwent fistulectomy and partial cystectomy. To the best of our knowledge, no previous reports of vesicocutaneous fistula to the thigh have been published.

[Giant lymphocele arising after extraperitoneal laparoscopic radical prostatectomy].

A 68-year-old male visited our division with an elevation of PSA level. He underwent a needle biopsy of the prostate, and the histopathological diagnosis was poorly differentiated adenocarcinoma (Gleason score 4+3). The cancer was clinically diagnosed as T2aN0M0, and he underwent extraperitoneal laparoscopic radical prostatectomy and bilateral pelvic lymphadenectomy. Cystography 14 days after the operation still showed leakage at the vesico-urethral anastomosis and a dumbbell shaped bladder. A few days later, prominence of lower abdomen and a slight swelling of right leg presented with a high fever. Computed tomography revealed a giant lymphocele in the retroperitoneal space. We percutaneously punctured the lymphocele by using ultrasonography, inserted a pigtail catheter, and drained 1,000 ml of lymphatic fluid. After the puncture, sclerotherapy with minocycline was performed four times. Twenty days after the puncture, the lymphocele cavity was found to have shrunken and the pigtail catheter was removed. The lymphocele was diminished and did not recur thereafter.

Laparoscopic radical nephrectomy in ACDK-associated renal cell carcinoma accompanied by duplicated IVC: a case report.

A 59-year-old male patent who had undergone chronic dialysis for 13 years presented with gross hematuria. Radiological examinations showed a cystic renal tumor in the left kidney, multiple renal cysts due to acquired cystic disease of the kidney (ACDK), and a duplicated inferior vena cava (IVC). Although we suspected that the branches of the left IVC might be anormalous with regard to number and location, we could not obtain information about the left renal vein by 3-dimensional computed tomography because of the decreased blood flow in the end-stage kidney. Laparoscopic radical nephrectomy was performed using a transperitoneal approach. We first identified the left IVC and then exposed its surface widely so that we could identify the veins draining into it. We identified and divided two renal veins and also identified an adrenal vein and a gonadal vein draining directly into the left IVC. The enlarged kidney with multiple renal cysts was removed in a purely laparoscopic procedure.

[Adrenal metastasis of lung adenocarcinoma with unusual sites of lymph node metastasis and concomitant renal cell carcinoma: a case report].

A 58-year-old male presented to a clinic with general weakness. Right adrenal tumor was found by computed tomography and he was referred to our hospital. Imaging studies revealed right adrenal tumor (8 cm) with marked swelling of surrounding lymph nodes and synchronous left renal tumor (2 cm) that was weakly enhanced by contrast media. Needle biopsy of the left kidney proved to be clear cell type renal cell carcinoma (RCC) and the preoperative diagnosis was left RCC and right primary adrenal cancer with lymph node metastasis. We performed right adrenalectomy, lymph node dissection and left radical nephrectomy. Pathological findings of right adrenal tumor and lymph nodes were both metastatic adenocarcinoma, which was not consistent with RCC or adrenal-derived carcinoma. Then, we extensively reviewed preoperative radiological examinations and found a small lesion in the left upper lung. This lesion was attached to the mediastinal shadow and there was no obvious lymph node swelling around this lesion. According to pathological findings and an elevation of carcinoembryogenic antigen, the adrenal lesion was diagnosed as adrenal metastasis of lung adenocarcinoma.