Seung-Kwon Choi

A Rare Case of Upper Ureter Rupture: Ureteral Perforation Caused by Urinary Retention

Perforation of the ureter is a rare condition that causes a series of problems including retroperitoneal urinoma, urosepsis, abscess formation, infection, and subsequent renal impairment. There are causative factors that induce ureteric rupture, including malignancy, urinary calculi, idiopathic retroperitoneal fibrosis, recent iatrogenic manipulation, external trauma, degenerative kidney conditions, urography with external compression, and spontaneous causes. We report a rare case of ureteric rupture caused by urinary retention. The patient was treated with temporary percutaneous drainage and antibiotics. The present case illustrates that urinary retention can induce not only bladder rupture, but also ureteric rupture. It is thus of paramount importance to effectively manage patients with voiding problems.

Predictive Value of Preoperative Unenhanced Computed Tomography During Ureteroscopic Lithotripsy: A Single Institute's Experience

Purpose Ureteroscopic stone removal is frequently used to remove ureteral stones. Mucosal edema and bleeding are the two most important obstacles to a successful operation. This study analyzed relationships between unenhanced computed tomography (UECT) findings and ureteroscopic findings to determine whether ureteroscopic results could be predicted preoperatively by using UECT imaging. Materials and Methods From January 2009 to July 2011, 675 patients were diagnosed with ureteral stones through UECT. Among them, we retrospectively reviewed 92 cases of patients who underwent ureteroscopy (URS). We identified findings such as hydronephrosis, rim sign, periureteral fat stranding, and perinephric fat stranding on the UECT and then categorized these findings into four categories (none, mild, moderate, and severe) according to their severity. We also divided the URS findings of mucosal edema and bleeding into four categories (none, mild, moderate, and severe) and compared these findings with the UECT images. Results A total of 92 study patients were included in this study: 59 were male and 33 were female patients. According to the location of the stone, 31 cases were classified as upper ureteral stones, 15 were midureteral stones, and 46 were lower ureteral stones. Hydronephrosis identified with UECT was correlated with the mucosal edema severity observed during URS (p=0.004). The rim signs identified with UECT were proportional to the grade of mucosal edema (p=0.010). Conclusions Hydronephrosis and rim signs observed during UECT can be used as a predictive factor for intraoperative mucosal edema in patients undergoing URS.

Immunoglobulin G4-Related Systemic Sclerosing Disease: A Case Involving the Ureter and Kidney

Immunoglobulin (Ig) G4-related sclerosing disease is a newly defined clinicopathological entity characterized by lymphoplasmacytic infiltration of IgG4-positive plasma cells and varying degrees of fibrosis within affected tissues. Patients usually exhibit multisystem involvement and often respond well to steroid and immunosuppressive therapy. This report presents a case of IgG4-related sclerosing disease involving the ureter and kidney. We hope to bring IgG4-related sclerosing disease to the attention of urologists, because it is an uncommon disease that commonly responds to systemic corticosteroids.

Acute Idiopathic Scrotal Edema Caused by Epstein-Barr Virus.

Q1 first reported acute idiopathic scrotal edema (AISE) in 1956. No specific cause has been identified. Here, we discuss 2 cases of AISE caused by acute Epstein–Barr viral (EBV) infection. A 13-year-old male and a 6-year-old boy visited our hospital because of penile, scrotal and perineal swelling. Both of them reported no trauma to the perineal area and had never experienced an allergic reaction to any medications. Laboratory tests including urinalysis were normal. Penile and scrotal color Doppler ultrasonography (US) of the first case revealed diffuse swelling of the penile, scrotal and bilateral inguinal wall soft tissue with hypervascularity in addition to small nodules in both inguinal areas. Scrotal US of the 6-year-old boy showed multiple enlarged lymph nodes in the right inguinal area and diffuse soft tissue swelling of the scrotal and perineal wall. Serologic testing for cytomegalovirus and EBV were performed in both cases, which revealed the presence of immunoglobulin G (IgG) and immunoglobulin M (IgM) to the viral capsid antigen (VCA) of EBV, indicating recent EBV infection. Their symptoms disappeared spontaneously within a few days. The clinical manifestations of AISE include scrotal edema without tenderness. Penile, perineal and inguinal involvement occur in 20%, 42% and 67% of patients with AISE, respectively. It can be easily diagnosed with ultrasound examination. Edematous thickening and increased vascularity are characteristic of AISE. Enlargement and increased vascularity of the inguinal lymph nodes are commonly detected by US. There are many hypothesized etiologies; however, the cause of AISE has not been identified. EBV infection in young children is usually asymptomatic or resembles other febrile infections. The most common site of lymphadenopathy is the anterior and posterior cervical areas, and sometimes axillary and inguinal lymph nodes can be affected. Antibodies to the EBV nuclear antigen, the early antigen and the VCA are most useful for diagnosis. Acute EBV infection is characterized by rapid elevation of IgM and IgG antibody responses to VCA and a detectable IgG response to early antigen. Therefore, the IgMVCA test is the most specific serologic test for diagnosis of acute EBV infection. The clinical features of our cases were similar to those of testicular torsion or acute epididymitis. However, we were able to diagnose AISE by scrotal US without difficulty. We suspected an unusual infection as the cause of scrotal edema, and incidentally we found that IgM-VCA was elevated in both cases, confirming acute EBV infection. According to previous reports, acute EBV infection in childhood may cause inguinal lymphadenopathy, which is consistent with the clinical manifestations in our cases. Therefore, we suspect that acute EBV infection caused our patients’ acute scrotal and perineal edema. Based on our cases and previous reports about EBV, we suggest that acute EBV infection is the cause of AISE.

Spermatocytic Seminoma with Brain Metastasis.

Spermatocytic seminoma is a rare variant of testicular cancer. Patients with spermatocytic seminoma, who are commonly over 50 years of age at diagnosis, have clinicopathologic characteristics that are distinct from other testicular cancer patients. These patients typically present with a painless, palpable, slowly enlarging testicular mass without associated cryptorchidism. [1] Spermatocytic seminoma almost never shows metastatic spread unless complicated by sarcomatous transformation, and most patients who undergo orchiectomy require no further treatment. [2] In this report, we describe, to our knowledge, the first reported case of a spermatocytic seminoma with brain metastasis. A 77-year-old man presented with painless left scrotal swelling. He first noticed the swelling 6 years prior to presentation, and the swelling had been growing slowly. Physical examination revealed a non-tender, firm, and enlarged left testicular mass. Tumor markers, including alpha-fetoprotein and beta-human chorionic gonadotropin, were negative. Scrotal ultrasound and subsequent magnetic-resonance imaging revealed an enlarged left testis and epididymis with an infiltrative intratesticular mass displaying heterogeneous enhancement and diffusion restriction. Computed tomography of the abdomen, pelvis, and chest revealed no significant lymphadenopathy. We planned a left radical orchiectomy. The patient showed intermittent disorientation during his admission. After neurologic consultation, brain magnetic-resonance imaging was performed, which revealed multiple various solid lesions, with peritumoral edema, located in the left parietal lobe, right basal ganglia, and right cerebellum (Fig. 1). These findingswere indicative of multiple brainmetastases. There was no suspicious primary malignant lesion found in evaluating the patient other than the testicular cancer. As an initial procedure, the patient underwent a left radical orchiectomy as planned. Pathologic examination of the surgical specimen revealed spermatocytic seminoma with no sarcomatous transformation. Microscopically, it has been observed in a variety of cell morphology (nucleus-sized variation) from small lymphoid-like cells, medium-sized cells to large cells. The tumor involved the rete testis and epididymis without lymphovascular invasion, and it invaded into the tunica albuginea but not the tunica vaginalis. The patient was determined to have stage IIIc spermatocytic seminoma. The brain metastases were treated with external beam radiotherapy. The patient was reluctant to, and did not receive, chemotherapy, mainly due to his poor performance status. Nevertheless, the patient’s performance status had declined as of the last follow up. Spermatocytic seminoma is a rare variant of seminoma that behaves differently from other testicular cancers. In a previous population based study, the incidence of spermatocytic seminoma was 0.4 per million with a mean age at diagnosis of 53.5 years, representing 0.61 % of all testicular germ cell tumors and 1.1 % of entire seminoma. [1] Serum tumor markers are always negative in patients with spermatocytic seminoma, and there is no association with preexisting cryptorchidism or intraepithelial neoplasia. [3] Spermatocytic seminoma is typically an indolent neoplasm which has a less malignant biological behavior than other germ cell tumors. [2] Seung-Kwon Choi and Taegu Kim contributed equally to this work.

Hyperkalemic cardiac arrhythmia resulting from short‑term ingestion of potassium citrate for the management of ureter stones

is 5 g four times a day, which equates to 120 mmol of K/day. In Korea, the National Health Insurance Service insures the use of K citrate at recommended dose for patients after ESWL. Thus, we routinely consider treating patients with residual stones or fragments after ESWL with K citrate. Hyperkalemic cardiac arrhythmia caused by K citrate has been reported previously [2, 3]. In these reports, hyperkalemia has been diagnosed from 1 week to several months after the ingestion of K citrate, particularly in patients who took excessive doses of K citrate. In our case, the patient was treated with K citrate for the management of urolithiasis, a treatment that is widely used in urologic practice. Furthermore, life-threatening hyperkalemia developed 2 days after the ingestion of K citrate at a recommended dose. The risk of hyperkalemia following K citrate ingestion has been reported to be increased in elderly patients with impaired renal function. However, definitive dosage criteria and recommended K citrate doses for these patients are still lacking. Our data indicate that life-threatening hyperkalemic cardiac arrhythmia can develop in patients even if K citrate is ingested over only a short period; thus, careful monitoring of serum K levels is essential after the prescription of K citrate. In addition, appropriate dosage criteria and/or recommended doses of K citrate for high-risk patients should be established to prevent life-threatening adverse events. An 82-year-old female patient was transferred from a regional hospital to our emergency department for the management of obstructive uropathy. Computed tomography revealed multiple stones in the right renal pelvis and proximal ureter with ipsilateral hydronephrosis. An urgent percutaneous nephrostomy was performed to relieve the obstruction of right kidney. She was treated with meropenem for urinary tract infection. On day 16, she underwent extracorporeal shock wave lithotripsy (ESWL) targeted to right ureter stone. We prescribed potassium (K) citrate to effectively prevent stone recurrence and growth following ESWL. At this time, her serum levels of K, urea, and creatinine were 4.2, 7.1, and 150 μmol/L, respectively. On day 18, she complained of dizziness and nausea. Her systolic blood pressure and heart rate were 80 mmHg and 50 beats/ min, respectively. An urgent electrocardiogram revealed markedly widened QRS complexes with peaked T waves, loss of P waves, and right bundle branch blocks (Fig. 1). Her serum K level was >10.0 mmol/L. After treatment of hyperkalemia, her hemodynamic parameters were stable and electrocardiogram returned to baseline. The benefit of K citrate for urolithiasis has been demonstrated by the reduced rates of stone formation, and the clearance of pre-existing stones and residual fragments for patients taking K citrate [1]. Regarding K citrate powder for post-ESWL, the recommended dose

MP80-13 ROLE OF PREOPERATIVE MAGNETIC RESONANCE IMAGING IN PREDICTING THE EARLY RECOVERY OF URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVES: The predictive value of membranous urethral length (MUL) and shape of the prostatic apex (PA) for early recovery of urinary continence after radical prostatectomy (RP) were evaluated by preoperative magnetic resonance imaging (MRI). METHODS: Three-hundred three patients who underwent RP at our institute were prospectively analyzed. The MUL and shape of PA were measured by preoperative MRI. The urethral pressure profiles (UPP) were assessed preoperatively in all patients. The preand postoperative UPP were measured in a subgroup of 100 patients to assess the effect of change in UPP on early recovery of continence. Continence, defined pad-free state with no leakage of urine, was assessed at 3 months and 1 year after surgery. RESULTS: Of 303 patients, 213 patients (70.3%) initially achieved urinary continence 3moths after surgery, and a total of 251 (82.8%) patients achieved urinary continence 1 year after surgery. The MUL was longer in the continent group than in the incontinent group (11.2 mm vs. 12.4 mm, p1⁄40.001). Patients with the PA covering the membranous urethra on the anterior side (type 1 PA) showed worse urinary continence rates than those without (type 2 PA) (57.9% vs. 89.2%, p 12 mm and type 2 PA, showed a markedly increased probability of continence recovery compared to patients with a MUL 1⁄412 mm and type 1 PA (odds ratio 27.430, p<0.001). In all patients, the MUL (odds ratio 1.135, p1⁄40.016) and shape of the PA (odds ratio 5.621, p<0.001) were independent preoperative predictors of early continence recovery after RP. The inclusion of MUL and prostatic apical shape on MRI increased the predictive accuracy of the base model from 0.621 to 0.770 (p1⁄40.012). CONCLUSIONS: The MUL and shape of the PA on preoperative MRI significantly enhance the prediction of early continence recovery after RP. Maximal preservation of MUL is important during RP, especially for patients with a short MUL or a PA covering the membranous urethra on the anterior side.

MP67-11 DIABETES MELLITUS PROMOTES URETERAL SMOOTH MUSCLE CELL PROLIFERATION: A RESEARCH ON THE MECHANISM.

INTRODUCTION AND OBJECTIVES: The aim of our study was to evaluate the role of underlying diabetes mellitus (DM) that was proved to be a significant factor effecting on spontaneous stone expulsion by preceding research. We investigated the influence of DM on the ureter using a mouse-model system. METHODS: The mouse-model arm of this study used 20 15week-old mice, including 10 normal (control) mice and 10 DM mice. We measured the proximal, middle and distal ureteral smooth muscle thickness of each mouse and the differences among each ureteral section were analyzed. Mouse ureteral specimens were also analyzed via Western blotting to detect relative protein expressions. RESULTS: In the mouse model, we saw significant hyperproliferation of ureteral smooth muscle in DM mice compared to normal mice, which might provoke reduced peristalsis among DM mice. The ureteral smooth muscle of DM mice was obviously thicker than that of normalmice in all ureteral tissues: proximal (p1⁄40.040), mid (p1⁄40.010) and distal (p1⁄40.028). The expressions of P-ERK (p1⁄40.005), and P-JNK (p1⁄40.001) in the diabetic group had high expression levels compared to the normal group. High glucose also induced up-regulation of VEGF (p1⁄40.002) protein expression, and correlated PKC (p1⁄40.001) expression. CONCLUSIONS: One explanation for the higher risk of stonepassage failure among DM patient may be decreased ureteral peristalsis resulting in the hyperproliferation of ureteral smoothmuscle. JNKandERK pathways may play an important role in the pathologic manifestation.

Epigenetic inactivation of HOXA5 and MSH2 gene in clear cell renal cell carcinoma.

424 Background: The high-throughput method using microarray is easy and fast way to analyze the methylation status of hundreds of preselected genes and to screen them for signatures in methylation. The aim of our study is to detect hypermethylated genes and to analyze the association between methylation status and clinicopathological parameters of clear cell renal cell carcinoma. METHODS The genetic substrate included 62 cancer tissues and 62 matched adjacent normal kidney tissues. We adapted the GoldenGate genotyping assay to determine the methylation state of 1505 specific CpG sites in 807 genes. RESULTS We identified two genes (HOXA5 and MSH2) with β-value differences of more than 0.3 between cancer and normal tissues. High methylation group in HOXA5 had high Fuhrmans nuclear grade (P=0.041). Other data in HOXA5 and MSH2 were not significant with methylation status (P>0.05). Survival curve of high methylation group in HOXA5 was slightly lower than that of low methylation group. However, the statistical significances of overall survival in HOXA5 and MSH2 were low (P>0.05). CONCLUSIONS We report the hypermethylation of two genes in clear cell renal cell carcinoma. The data we obtained could provide the basis for a diagnostic test pathological assessment, or prognosis in clear cell renal cell carcinoma.

Postoperative adjuvant chemoradiation using oral capecitabine and 5-fluorouracil, cisplatin (FP) in completely resected locally advanced gastric cancer

4141 Background: Gastric cancer is the most common cancer in Korea. Adjuvant chemoradiation has become a standard of care in United States. We attempted to evaluate the efficacy and toxicity of FP before and after postoperative chemoradiation using oral capecitabine in locally advanced gastric cancer patients. METHODS Patients with gastric cancer staged IIIA to IV-M0 were treated with chemoradiation after curative resection with extensive (D2) lymph node dissection. Therapy consisted of one cycle of FP (5-FU 1000 mg/m2 continuous infusion on day 1-5, cisplatin 60 mg/m2 on day 1) followed by 4,500 cGY (180 cGy/day) to RT field with capecitabine (1,650 mg/m2/day throughout radiation). One month after completion of radiotherapy, patients received three additional cycles of chemotherapy. RESULTS Twenty-one patients were enrolled and twenty patients completed chemoradiation as planned. 17 patients were man, median age was 49 (range 31-62). The patients stage were IIIA(12), IIIB(6), and IV-M0(3). With a median follow-up of 14.2 months, two patients (9.5%) have relapsed, one in liver and the other in peritoneum. Grade 3/4 toxicity were neurtopenia 4 patients (19%), thrombocytopenia 1 patient (5%), fatigue 1 patient (5%), nausea/vomiting 1 patient (5%). There was no grade 3/4 hand foot syndrome, and no patient has developed febrile neutropenia. There has been no treatment related deaths. CONCLUSIONS These preliminary results suggest that postoperative regimen of FP and chemoradiation with capecitabine is a safe, well-tolerated in gastric cancer patients who have undergone a D2 dissection. Longer follow up and further studies are needed to evaluate efficacy. No significant financial relationships to disclose.