Recurrent urinary retention due to clots caused by a congenital renal arteriovenous malformation that forms a complex vascular network: Report of two cases.

INTRODUCTION: Repeated urinary retention due to clots caused by congenital renal arteriovenous malformation is rare. CASE PRESENTATION: A 40-year-old woman (case 1) and a 66-year-old man (case 2) experienced recurrent urinary retention due to clots. Neither patient had a history of renal trauma nor was taking any medications. Contrast-enhanced abdominal computed tomography revealed a large hematoma in the renal pelvis and ureter with no masses, stones, or vascular lesions and only dilated blood vessels in the arterial phase in case 1. Angiography of the kidney in both patients revealed an arteriovenous malformation, and embolization of the arteries feeding the arteriovenous malformation was performed. Soon after embolization, hematuria disappeared completely with no recurrence for 5 years in case 1 and 2 years in case 2. CONCLUSION: Congenital renal arteriovenous malformation should be considered as a cause of recurrent clot retention, and angiographic embolization of the feeding arteries can be an effective treatment.

Effect of continual quality improvement of palliative care consultation teams by iterative, customer satisfaction survey-driven evaluation.

BACKGROUND: Current consensus recognizes the benefits of early intervention in palliative care consultation teams (PCCTs). As consultants, we should now attempt to improve the quality of our teams by utilizing a method mainly used in the business field. We aimed to investigate the effects of iterative evaluation of customer satisfaction surveys, filled by physicians and ward nurses in this study, for quality improvement of PCCTs. METHODS: In October 2019, the participants filled the first questionnaire survey about palliative care and PCCTs at a 678-bed hospital, and improvement areas were uncovered. Refinements were planned and implemented, and then reevaluated using the second questionnaire survey in March 2020. RESULTS: In addition to the characteristics of our clients evaluated from approximately 500 valid responses, the first survey showed that the response rate of the questionnaire, knowledge of palliative care and PCCTs, and publicity of the PCCT were recognized as issues needing attention. We planned to contrive ways to collect questionnaires, hold monthly workshops for palliative care, launch newsletters of palliative care, and go on client rounds. The second survey revealed improvements in the physicians' response rate (p = 0.02), the accuracy rate of application of PCCTs in Japan (p < 0.01), and ward nurses' confidence in opioid use (p = 0.04) and tendency toward easier accessibility to the PCCT (p = 0.07). CONCLUSION: Continual quality improvements through iterative, customer satisfaction survey-driven evaluation are a widely established practice in the business field. By using this appropriately, we could enable PCCTs to improve their quality.

[Usefulness of Fluorescent Urine Cytology in the Diagnosis of Urothelial Carcinoma].

Five-aminolevulinic acid, an amino acid that is metabolized in the cytoplasm to become protoporphyrin IX, is used in photodynamic diagnosis in various carcinomas because it accumulates in higher concentrations in tumor tissue than in normal tissue. 5-Aminolevulinic acid-induced fluorescent urine cytology is more sensitive than conventional urine cytology only in low grade urothelial carcinoma (UC), but it showed a tendency for higher sensitivity in high grade UC. To increase the number of patients and reconsider our previous findings, we compared the sensitivity and specificity of preoperative urine cytology and fluorescent urine cytology in 343 patients diagnosed as having UCs pathologically (215 bladder cancers, 128 upper tract UCs) and 197 non-cancer patients at Osaka Rosai Hospital from March 2013 to December 2019. The sensitivities of fluorescent urine cytology and conventional urine cytology were 81.1% and 63.3% (p<0.001), respectively, and specificities were 92.9% and 93.9% (p=0.84), respectively. The sensitivity of fluorescent urine cytology was superior to that of conventional urine cytology in both low grade UC (76.8% vs 41.1%, p<0.001) and high grade UC (83.1% vs 74.0%, p=0.023).

Complete remission of metastatic renal cell carcinoma to the bone with sunitinib.

Target agents such as tyrosine kinase inhibitors have improved renal cell carcinoma (RCC) patient outcomes. However, complete remission (CR) with target agents is rare. Furthermore, CR of bone metastasis is much less common. We report a case of CR in bone and lung metastatic RCC. Radical nephrectomy was performed first, and clear cell RCC was diagnosed. Thereafter, sunitinib was started, and bone and lung metastases resolved entirely after 8 months of treatment. Sunitinib therapy was discontinued after 2 years because of the adverse event of proteinuria. However, the patient has remained in CR for over 1 year after sunitinib cessation.

[Late Recurrence of Seminoma Diagnosed by Endoscopic Ultrasound-Guided Fine Needle Aspiration in a Retroperitoneal Lymph Node].

The patient was a 43-year-old man. At 30 years of age, he underwent high-inguinal orchiectomy for a right testicular tumor and was diagnosed with seminoma pT1N0M0. The patient had been followed without additional treatment and had dropped out 7 years after surgery. At 43 years of age, abdominal ultrasonography performed for screening revealed a swollen 4 cm-wide intra-abdominal lymph node, and he was referred to our department. Abdominal contrast-enhanced computed tomography (CT) showed a mass with a 5 cm-wide contrast effect that contacted the anterior surface of the inferior vena cava from the duodenum to the aortic bifurcation. Histological examination by trans-duodenal ultrasound-guided fineneedle aspiration suggested late recurrence of seminoma. After receiving three courses of BEP (bleomycin, etoposide, and platinum) therapy, the patient underwent laparoscopic lymphadenectomy. Pathological examination showed no residual tumor, and the patient was free of recurrence at 13 months after surgery.

High performance of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology.

OBJECTIVES: To investigate the efficacy of selective upper tract urinary cytology using extracorporeal 5-aminolevulinic acid for the diagnosis of upper urinary tract urothelial carcinoma. METHODS: We evaluated 104 patients who underwent radical nephroureterectomy and were diagnosed pathologically as having upper urinary tract urothelial carcinoma between March 2013 and May 2019 in Osaka Rosai Hospital. Preoperatively, we collected upper tract urinary cytology from both sides, and compared the sensitivity and specificity between conventional urine cytology and 5-aminolevulinic acid-induced fluorescent urine cytology. RESULTS: The sensitivity of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology was significantly higher than conventional cytology (90.4% vs 66.3%, P < 0.001), whereas the specificity was equally high (100% vs 98.2%, P = 1.0). In more detailed analysis, the sensitivity of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology was significantly higher than that of conventional cytology unrelated to patients' age (<76 years: 90.2% vs 68.6%, P = 0.013; ≥76 years: 90.6% vs 64.2%, P = 0.021), sex (male: 89.2% vs 67.5%, P = 0.001; female: 95.2% vs 61.9%, P = 0.02) or pT stage (pT1 or less: 91.4% vs 69.0%, P = 0.005; pT2 or more: 89.1% vs 63.0%, P = 0.006), tumor grade (high grade: 91.0% vs 70.5%, P = 0.002; low grade: 88.5% vs 53.8%, P = 0.013), and tended to be more efficacious for tumors that could not be detected by imaging techniques (83.3% vs 50.0%, P = 0.075). CONCLUSIONS: 5-Aminolevulinic acid-induced fluorescent selective upper tract urinary cytology is more sensitive than conventional cytology for the diagnosis of upper urinary tract urothelial carcinoma, regardless of pT stage and tumor grade.

Renal cell carcinoma in a horseshoe kidney treated with robot-assisted partial nephrectomy.

Horseshoe kidney is one of the most common congenital renal fusion anomalies and the incidence of renal cell carcinoma in horseshoe kidney is predicted to be approximately 5.2/100000 individuals. Because horseshoe kidney merges malformations and vascular changes, open surgery is the standard for treatment. There are no reports of robot-assisted partial nephrectomy (RAPN) for renal cell carcinoma in horseshoe kidney. We describe for the first time the safety and the utility of RAPN in a horseshoe kidney with renal cell carcinoma.

High diagnostic efficacy of 5-aminolevulinic acid-induced fluorescent urine cytology for urothelial carcinoma.

BACKGROUND: In general, urine cytology is often problematic because of its low sensitivity, especially for low-grade urothelial carcinoma (UC) in clinical practice. To improve the sensitivity, we focused on 5-aminolevulinic acid (5-ALA), because recent studies suggested that 5-ALA-induced urine cytology can be used for photodynamic diagnosis. In this study, we evaluated the diagnostic efficacy of 5-ALA-induced fluorescent urine cytology for UC. METHODS: We included in this study 318 patients comprising 158 non-cancer patients, 84 bladder tumor patients, and 76 upper urinary tract urothelial carcinoma (UUT-UC) patients treated in our institution from March 2013 to September 2018. Using the same voided urine sample, we compared sensitivity and specificity between conventional urine cytology and 5-ALA-induced fluorescent urine cytology. RESULTS: Overall, the sensitivity of 5-ALA-induced fluorescent urine cytology was significantly higher than that of conventional urine cytology (86.9% vs. 69.4%; p = 0.0002), and the specificity was equivalently high (96.2% vs. 95.6%; p = 1.0). In subgroup analysis, the high sensitivity of 5-ALA-induced fluorescent urine cytology was also detected regardless of age, sex, and tumor type. However, in terms of stage and grade, differences were only detected in patients with less than pTa stage (89.2% vs. 52.1%; p = 0.0001) and low-grade tumor (91.5% vs. 51.1%; p < 0.0001). CONCLUSIONS: 5-ALA-induced fluorescent urine cytology was significantly more effective for UC diagnosis when compared with the conventional cytology, especially in patients with low-stage and low-grade tumors. These findings indicate that 5-ALA-induced fluorescent urine cytology may potentially be a very useful tool for clinical use.

[CLINICAL STUDY OF INTEGRATED URINARY CARE TO SUPPORT SELF-RELIANCE AGAINST URINARY DYSFUNCTION WITH INVOLVEMENT BY UROLOGISTS].

(Purpose) We reviewed 207 patients with urinary dysfunction who were managed by voiding care team at Osaka Rosai Hospital between November 2016 and June 2018. (Materials & methods) The study involved 112, 32, 24, 19, 10, 7, and 3 patients in the Urology, Orthopedics, Surgery, Internal Medicine, Neurosurgery, and Otorhinolaryngology departments, respectively. The average age was 72.7 years, ranging from 27 to 94 years, and the patients were170 males and 37 females. The average body mass index was 23.3, ranging from 11.6 to 43.7. The degree of activity of daily life (ADL) was distributed from J (independent ADL) to C (bedridden), and consisted of 132 in J category, 23 in A, 28 in B, 24 in C. Forty-seven patients had diabetes mellitus (DM), 36 had a cranial nerve disease, 25 had a history of urinary retention, 17 had indwelling urethral catheters on admission, 53 had an emergency hospital admission, and 174 underwent ≥1 operations during admission. (Results & conclusions) Among the 112 patients treated in the Urology department, 60 underwent robot-assist radical prostatectomy (RARP), 36 transurethral resection of prostate (TUR-P) and Holmium laser enucleation of the prostate (HoLEP), and 16 other procedures. A total of 93% were indwelling urethral catheter free, and 92% were pad-free (≤1 pad per day) at 1 year. In contrast, only 66% of the 95 patients in other departments were indwelling urethral catheter free at 1 year and were indwelling urethral catheter-free within 100 days, except for only one patient. The self-reliant voiding rate, including patients who have their indwelling urethral catheter removed or managed clean intermittent self-catheterization, was 91% at 1 year. A univariate analysis indicated that an ADL of J, independent ambulation, self-care/undiapered, self-reliant voiding score ≤4 (on a scale from 0 to 10, with higher score indicating a poorer ADL), and a urinary function ≤4 (on a scale from 0 to 10, with a higher score indicating greater urinary dysfunction) were significantly associated with freedom from urethral catheter. A multivariate analysis with Cox's proportional hazard model revealed a urinary function of ≤4 to be an independent good prognosticator for being catheter-free. Furthermore, a univariate analysis indicated that ADL J, a scheduled hospital admission, ≥1 operations during admission, independent ambulation, self-care/independent portable toilet, self-care/undiapered, self-reliant voiding score (≤4), and a urinary function of ≤4 were significantly associated with the acquisition of self-reliant voiding. A multivariate analysis with Cox's proportional hazard model revealed a self-reliant voiding of ≤4 to be an independent good prognosticator for self-reliant voiding. (Conclusions) Achieving freedom from an indwelling urethral catheter and acquiring a self-reliant voiding function are suggested to be very important for integrated urinary care.

[Renal Pelvic Cancer with Delayed Diagnosis Due to Left Renal Injury : A Case Report].

We report a case of renal pelvic cancer found after left renal trauma. A 63-year-old man was admitted to our hospital because of gross hematuria after he had fallen down the stairs two days earlier. He had asymptomatic severe anemia (Hb : 3. 6 g/dl). Abdominal computed tomography (CT) scan revealed bilateral ureteropelvic stones, bilateral severe hydronephrosis and hematoma of the left upper renal pelvis. We diagnosed him with left renal pelvic hemorrhage by trauma, and transcatheter arterial embolization (TAE) was performed. After TAE, gross hematuria improved, but some hematuria continued to be noted. We suspected malignancy, and examined the patient with contrast-enhanced CT, transurethral resection and retrograde pyelography combined with urine cytology in the upper urinary tract, all with no evidence of malignancy. However, four months after the left renal injury, follow-up CT revealed multiple metastatic lesions. We performed a left nephrectomy, and the resulting pathological diagnosis was invasive urothelial carcinoma with squamous differentiation of the renal pelvis. We performed 7 courses of chemotherapy, but the multiple metastatic lesions progressed, and he died of the disease 19 months after the operation.

A Rare Case of Vascular Leiomyosarcoma Originating from a Branch Vessel of the External Iliac Vein.

Leiomyosarcoma arising from the external iliac vein is uncommon. This is a report of a 51-year-old Japanese man with venous leiomyosarcoma originating from a branch vessel of the left external iliac vein. The tumor was found during a medical examination, and the patient had no symptoms. Computed tomography showed a 72 × 49 mm mass adjacent to the left external iliac vein. The tumor was resected en-block along with ligation of the external iliac vein due to strong adhesion with the tumor. Histological examination showed venous leiomyosarcoma, and its origin was thought to be a branch vessel of the left external iliac vein. The patient has remained free from recurrence at 30 months after surgery.

Liposarcoma of the spermatic cord associated with scrotum lipoma: A case report and review of the literature.

Liposarcoma of the spermatic cord is a rare disease and often mistakenly diagnosed as inguinal hernia, hydrocele, and lipoma. We report the case of a 58-year-old man who presented with persistent discomfort and swelling on the left inguinal region. He was diagnosed with left scrotum lipoma when he was 12 years old. He underwent high orchiectomy and wide resection of the inguinal tumor. Histopathological examination revealed a well-differentiated liposarcoma of the spermatic cord with negative resection margin and scrotum lipoma. To our knowledge, this is the first report of liposarcoma of the spermatic cord with scrotum lipoma in English literature.

[A Case of Retroperitoneal Mature Teratoma with Combined Resection of Left Kidney].

A 37-year-old woman with the complaint of stomachache was referred to our hospital because a retroperitoneal tumor was detected in an ultrasound study at another hospital. Magnetic resonance imaging showed a poorly enhanced 14 cm tumor in the left retroperitoneal space suggesting a cyst that contained fat and showed calcification. Abdominal dynamic computed tomography revealed left renal vein stenosis and left ovarian vein dilation caused by tumor compression of the renal vein. The tumor was excised together with the left kidney because the renal vein was adhered to the tumor. The resected specimen weighed 1,300 g, and the histological diagnosis was mature teratoma. The patient has experienced no recurrence at eight months after surgery.

[A Case of Recurrent Renal Cancer in the Autografted Kidney, Treated with Percutaneous Cryoablation].

We report a case of recurrent renal cancer in the autografted kidney, treated with percutaneous cryoablation. A 59-year-old man who had bilateral renal tumors underwent radical left nephrectomy, ex vivo right partial nephrectomy and auto-transplantation at the right ileal fossa in our hospital 11 years ago. Histopathological examination showed clear cell renal cell carcinoma in bilateral kidneys (pT1bN0M0). He had been followed at another hospital without tumor recurrence for 11 years. In 2014, an enhanced CT scan revealed a renal tumor with a diameter of two centimeters in the autografted kidney, which was thought to be a recurrence of the initial renal cancer. He was referred to our hospital for further evaluation and treatment. He underwent percutaneous renal tumor biopsy, which confirmed renal cancer recurrence, followed by percutaneous cryoablation. Three months after cryoablation, an enhanced CT showed that the enhancement lesion in the autografted kidney had disappeared, and these findings were confirmed pathologically by absence of malignancy by a subsequent needle biopsy. The level of serum creatinine (sCr) was 1.16 md/dl immediately before cryoablation and 1.46 mg/dl at three months after cryoablation. Nine months after cryoablation, the patient had no reccurence and renal function was stable (sCr 1.43 mg/dl).

[A Subcutaneous Metastasis from Renal Pelvic Carcinoma Growing Rapidly after radical Nephrectomy : A Case Report].

A 78-year-old man was admitted to our department for a right renal mass detected by computed tomography which was accompanied by right hypochondriac pain. Dynamic computed tomography demonstrated a 7cm hypovascular right renal mass invading the liver. No metastatic disease was evident. Transabdominal nephrectomy and partial hepatectomy were performed under the diagnosis of right renal cell carcinoma in July 2014. Pathological examination revealed right renal pelvic carcinoma with liver invasion. After the operation, a subcutaneous nodule in the right forearm rapidly grew in one week. A needle biopsy revealed that it was a metastasis of the urothelial carcinoma. Additionally, lung metastases and lymph node swelling were detected. The patient received two courses of combination chemotherapy (gemcitabine, carboplatin) in August 2014. The subcutaneous metastasis was decreased, but it was not effective for other metastases. Two courses of another combination chemotherapy (methotrexate, vinblastine, epirubicin, calboplatin) were performed. It was effective for all metastatic lesions. During the third course, the patient developed melancholia and rejected additional therapy. He died in March 2015 due to disease progression.

[Etoposide and Carboplatin Effective for Treatment of Small Cell Carcinoma of Prostate : A Report of Two Cases].

Case 1 : A 76-year-old man consulted a physician because of pollakisuria, decline of urinary stream. A high level of serum prostate specific antigen (PSA) was detected and he came to our hospital. He was diagnosed to have prostate cancer, cT3aN0M1b, and was treated with combined androgen blockage (CAB). Two years and nine months later, postrenal failure appeared and serum level of neuron-specific enolase (NSE) was 162 ng/ml. We performed re-biopsy of prostate, and pathological examination indicated small cell carcinoma of the prostate. We treated him with combination chemotherapy comprised of etoposide and carboplatin, which was effective. Serum level of NSE was decreased and computed tomography showed reduction of the prostate volume and metastasis. Case 2 : An 84-year-old man was treated at a hospital with radiation therapy and CAB, because of prostate cancer. He came to our hospital with bladder tamponade. We performed transurethral coagulation and transurethral biopsy. Pathologically it proved to be small cell carcinoma of the prostate. The stage was cT4N1M1a, NSE and pro-gastrin-releasing peptide (Pro-GRP) levels were high. The same treatment given to him as in case 1, effectively decreased the metastasis and the level of serum NSE.

[A Case of Retroperitoneal Tumor in the Adrenal Area Turned Out to Be Schwannoma Mimicking an Adrenal Malignant Tumor].

A 76-year-old woman was found to have bilateral suprarenal tumors, 6.5 cm in diameter on the right side, and 2.4 cm in diameter on the left side, by ultrasonography, computed tomography, and magnetic resonance imaging. Strong accumulation of fluorodeoxyglucose in these tumors was found on positron emission tomography. Since it mimicked an adrenal malignant tumor, we performed right adrenalectomy. The pathological diagnosis of the removed mass was benign schwannoma, consistent of the Antoni type A. The left suprarenal tumor was not removed and she has been followed up for 18 months without any recurrence or tumor increase.

[Epithelioid Angiomyolipoma of the Kidney: A Case Report].

Herein we report a case of epithelioid angiomyolipoma of the kidney which is a rare subtype of angiomyolipoma. A 68-year-old man without a history of tuberous sclerosis complex (TSC) was referred to our department with a 40 × 84 mm left renal tumor incidentally detected by computed tomography. Computed tomography demonstrated a left renal heterogeneous mass which was enhanced at the early phase and washed out at the late phase. A tumor thrombus was seen extending into the main renal vein. No metastatic disease was evident. Thus, on the diagnosis of renal cell carcinoma, the patient underwent a left radical nephrectomy. Pathological examination showed that this tumor was composed predominantly of epithelioid cells, with a few blood vessels and adipose tissue and was diagnosed as epithelioid angiomyolipoma. He shows no disease progression for 6 months after the operation.