Mei-Yu Jang

Risk Factors Survey for Extracorporeal Shockwave Lithotripsy-Induced Renal Hematoma

BACKGROUND AND PURPOSE Shockwave lithotripsy (SWL) is a widely used treatment for patients with renal and ureteral stones because of its noninvasive approach. Although minor complications occur in most patients, a relative severe complication, perirenal or subcapsular hematoma, may also occur. We evaluate the possible risk factors for perirenal hematoma after SWL. PATIENTS AND METHODS Between 2001 and 2011, a total of 10,887 SWL treatments were performed for urolithiasis. All SWL procedures were performed using a Siemens Lithostar multiline lithotripter at a frequency of 2/sec under intermittent fluoroscopic guidance. All these patients underwent outpatient treatment without general anesthesia, but pethidine was administered for pain control. Treatment episodes were retrospectively reviewed for medical history, patient age, sex, body mass index (BMI), mean arterial pressure at induction, location of stone, total number of shockwaves, and peak shockwave intensity. We also compared the hematoma group with the control group (no hematoma formation after SWL with matched age and sex) for various factors. RESULTS After 10,887 treatment episodes on a total of 6177 patients during this period, subcapsular or perirenal hematoma developed in 20 patients for a total incident rate of 0.32%. Eighteen patients had the symptom of flank pain, and 2 patients received a diagnosis accidentally without symptoms. Four patients received a blood transfusion because of low hemoglobulin concentration. All of them received conservative and supportive treatment without surgical exploration. Ten (50%) patients had a history of hypertension. Renal hematoma developed in 11 patients at the second or third SWL treatment. Hypertension, higher BMI, and larger stone size are predisposing risk factors (P=0.022, 0.026 and 0.026, respectively) for renal hematoma. CONCLUSIONS Renal hematoma is a rare (incidence rate, 0.32%) but possibly lethal complication. The most common symptoms of renal hematoma are severe flank pain and hematuria. A history of hypertension and higher BMI are important predisposing factors to perirenal hematoma.

Ketamine-induced ulcerative cystitis and bladder apoptosis involve oxidative stress mediated by mitochondria and the endoplasmic reticulum

Ketamine abusers develop severe lower urinary tract symptoms. The major aims of the present study were to elucidate ketamine-induced ulcerative cystitis and bladder apoptosis in association with oxidative stress mediated by mitochondria and the endoplasmic reticulum (ER). Sprague-Dawley rats were distributed into three different groups, which received normal saline or ketamine for a period of 14 or 28 days, respectively. Double-labeled immunofluorescence experiments were performed to investigate tight junction proteins for urothelial barrier functions. A TUNEL assay was performed to evaluate the distribution of apoptotic cells. Western blot analysis was carried out to examine the expressions of urothelial tight junction proteins, ER stress markers, and apoptosis-associated proteins. Antioxidant enzymes, including SOD and catalase, were investigated by real-time PCR and immunofluorescence experiments. Ketamine-treated rats were found to display bladder hyperactivity. This bladder dysfunction was accompanied by disruptions of epithelial cadherin- and tight junction-associated proteins as well as increases in the expressions of apoptosis-associated proteins, which displayed features of mitochondria-dependent apoptotic signals and ER stress markers. Meanwhile, expressions of mitochondria respiratory subunit enzymes were significantly increased in ketamine-treated bladders. Conversely, mRNA expressions of the antioxidant enzymes Mn-SOD (SOD2), Cu/Zn-SOD (SOD1), and catalase were decreased after 28 days of ketamine treatment. These results demonstrate that ketamine enhanced the generation of oxidative stress mediated by mitochondria- and ER-dependent pathways and consequently contributed to bladder apoptosis and urothelial lining defects. Such oxidative stress-enhanced bladder cell apoptosis and urothelial barrier defects are potential factors that may play a crucial role in bladder overactivity and ulceration.

Laparoscopic Bladder Diverticulectomy for Large Bladder Diverticulum: A Case Report

Bladder diverticula are herniations of the bladder mucosa through the bladder wall musculature. Acquired bladder diverticula are the result of outlet obstruction, mostly benign prostate enlargement, infections, or urethral stricture. Traditionally, bladder diverticulum was excised by the open method. However, the laparoscopic technique has been widely used to treat many urologic diseases, including bladder diverticulum. Laparoscopic diverticulectomy can be performed transperitoneally or extraperitoneally. We report our initial experience with laparoscopic transperitoneal diverticulectomy for a large bladder diverticulum caused by bladder outlet obstruction. The patient had satisfactory micturition and was discharged on the eighth postoperative day.

UNUSUAL GAS PATTERN IN EMPHYSEMATOUS CYSTITIS: A CASE REPORT

We present a case of emphysematous cystitis in a 43‐year‐old female. The gas pattern was unusual because there was only gas accumulation in the urinary bladder without bladder wall thickening or intramural gas formation. The differential diagnosis included postoperative states, enterovesical fistula, and iatrogenic instrumentation. The prognosis of emphysematous cystitis is good after early diagnosis and prompt treatment with appropriate antibiotics, blood glucose control, and adequate urinary drainage. The patient was discharged on hospital day 5 with one additional week of oral antibiotic therapy. She was quite well at the time of writing and her diabetes was controlled with an oral hypoglycemic agent.

Foreign Body Stone in the Urinary Bladder: A Case Report

Bladder calculi rarely form spontaneously and are usually a manifestation of an underlying pathologic condition of the lower urinary tract, including voiding dysfunction, urinary infection, obstruction, or foreign body retention. However, a ruptured Foley balloon‐induced bladder stone is an unusual complication of an indwelling Foley catheter. We report a case of spinal cord injury with paraplegia and bladder stone induced by a fragment of a ruptured Foley balloon. The bladder stone and the Foley balloon fragment were successfully removed by cystoscopy. The stone was composed of calcium oxalate and calcium phosphate. We report this unusual case to raise awareness that it is important to check the integrity of the Foley catheter after removal of the tube.

Cystitis Glandularis Mimics Bladder Cancer-Three Case Reports and Literature Review

Cystitis glandularis is an uncommon proliferative disorder of the mucus-producing glands within the mucosa and submucosa of urinary bladder epithelium. We report three cases with gross hematuria on first presentation. Both sonography and computer tomography revealing bladder tumor and transurethral resection was performed in all three cases. Cystitis glandularis was confirmed by pathology. Short-term follow-up of sonography and cystoscopy showed good results.

Primary small cell carcinoma of kidney after renal transplantation: a case report and literature review

Extrapulmonary small cell carcinoma (EPSCC) is a rare neoplasm comprising 2.5% to 5% of small cell carcinomas (SCCs). Bladder SCC is the most common site of genitourinary tract. Primary renal SCC is extremely rare. We report a case of primary SCC of the kidney which is rarely reported in the urinary tract and presents an aggressive clinical picture. A 59-year-old female visited a urologic clinic with complaint of persistent left flank soreness 10 years after undergoing renal transplantation. Abdominal computed tomography showed a left renal pelvis tumor. After the patient received left nephroureterectomy with bladder cuff resection, her pathology results showed SCC. After surgery, she received adjuvant systemic chemotherapy, and her recovery has been uneventful as of 8 months. Primary renal SCC presents with an advanced tumor stage and a short median survival period, therefore early intervention and close follow-up are recommended.

Lymphoepithelioma-like carcinoma of ureter—A rare case report and review of the literature

Lymphoepithelioma‐like carcinoma (LELC) is best known to occur in the nasopharynx. When LELC occurs in the urinary tract, this extremely rare neoplasm most commonly affects the bladder but has also been reported in the renal pelvis, ureter, prostate [1] , and urethra [2] . We present a case of LELC arising in the right proximal ureter of a 64‐year‐old male patient with hydronephrosis and nausea. Computed tomography demonstrated right ureter tumor. On biopsy, the patient was diagnosed with infiltrating urothelial carcinoma. An operation consisting of right nephroureterectomy and bladder cuff removal was carried out. The pathologic examination showed pure subtype of LELC, pT3N0. Unlike lymphoepithelioma in the nasopharynx, immunohistochemical analysis of this urinary LELC was negative for the Epstein–Barr virus. No disease progression was noted at 6 months’ follow‐up. Only eight previous cases of LELC involving the ureter have been reported, and a review of the available literature and a summary of ureter cases are presented here. This is the first report of a ureteral LELC case and third urothelial LELC cases [3] in Taiwan.

Transitional cell carcinoma of the renal pelvis with extension into the inferior vena cava: a report of two cases.

Of all primary malignant renal tumors, 10% to 15% originate from the renal pelvis, and 90% to 92% of these tumors are transitional cell carcinomas. Nonetheless, renal pelvis transitional cell carcinoma extending into the inferior vena cava is very rare. We report one confirmed case and one highly suspicious case of renal pelvis transitional cell carcinoma with a tumor thrombus in the inferior vena cava. Both of our patients died within 6 months of initial diagnosis, indicating the poor prognosis and advanced stage of transitional cell carcinoma with an inferior vena cava thrombus. Transitional cell carcinoma should be considered in patients with obstruction of the renal vein and the inferior vena cava.

Noncontrast computed tomography can predict the outcome of shockwave lithotripsy via accurate stone measurement and abdominal fat distribution determination.

Urolithiasis is a common disease of the urinary system. Extracorporeal shockwave lithotripsy (SWL) has become one of the standard treatments for renal and ureteral stones; however, the success rates range widely and failure of stone disintegration may cause additional outlay, alternative procedures, and even complications. We used the data available from noncontrast abdominal computed tomography (NCCT) to evaluate the impact of stone parameters and abdominal fat distribution on calculus‐free rates following SWL. We retrospectively reviewed 328 patients who had urinary stones and had undergone SWL from August 2012 to August 2013. All of them received pre‐SWL NCCT; 1 month after SWL, radiography was arranged to evaluate the condition of the fragments. These patients were classified into stone‐free group and residual stone group. Unenhanced computed tomography variables, including stone attenuation, abdominal fat area, and skin‐to‐stone distance (SSD) were analyzed. In all, 197 (60%) were classified as stone‐free and 132 (40%) as having residual stone. The mean ages were 49.35 ± 13.22 years and 55.32 ± 13.52 years, respectively. On univariate analysis, age, stone size, stone surface area, stone attenuation, SSD, total fat area (TFA), abdominal circumference, serum creatinine, and the severity of hydronephrosis revealed statistical significance between these two groups. From multivariate logistic regression analysis, the independent parameters impacting SWL outcomes were stone size, stone attenuation, TFA, and serum creatinine. [Adjusted odds ratios and (95% confidence intervals): 9.49 (3.72–24.20), 2.25 (1.22–4.14), 2.20 (1.10–4.40), and 2.89 (1.35–6.21) respectively, all p < 0.05]. In the present study, stone size, stone attenuation, TFA and serum creatinine were four independent predictors for stone‐free rates after SWL. These findings suggest that pretreatment NCCT may predict the outcomes after SWL. Consequently, we can use these predictors for selecting the optimal treatment for patients with urinary stones.