Tatsu Ishii

Solitary psoas muscle metastasis after radical nephrectomy for renal cell carcinoma

Abstract Skeletal muscle is a very rare location for the metastasis of renal cell carcinoma (RCC) and only one case of solitary metastasis to the psoas muscle has been reported. We present a 63‐year‐old male patient with late recurrence (14 years) after left side radical nephrectomy for RCC. He first visited Chikushi Hospital, Fukuoka University, Japan in January 2000 for a postoperative follow‐up because he had shifted residence to the area. Follow‐up was by abdominal computed tomography (CT) and chest X‐ray. In December 2001, a CT scan showed a 1.5 cm enhanced mass in the right psoas muscle without any other metastasis. The mass was resected that month and histological study showed RCC metastasis.

URINARY LEVELS OF NUCLEAR MATRIX PROTEIN 22 IN PATIENTS WITH URINARY DIVERSION

OBJECTIVES To evaluate the influence of various types of urinary diversion on urinary nuclear matrix protein 22 (U-NMP22) levels. METHODS U-NMP22 values were determined for 38 urinary diversion patients without upper urinary tract cancer. The patients were divided into three groups: tubeless cutaneous ureterostomy (n = 12), ileal conduit (n = 15), and continent urinary reservoir (n = 11). The mean values and false-positive rates of U-NMP22 (cutoff value 12 U/mL) were compared among the three groups. RESULTS The mean +/- standard error U-NMP22 value for the ureterostomy, ileal conduit, and reservoir groups was 20.1 +/- 5.8 U/mL, 335.6 +/- 63.5 U/mL, and 671.8 +/- 220.4 U/mL, respectively (P = 0.0030). The false-positive rate of U-NMP22 for the ureterostomy, ileal conduit, and reservoir groups was 41.7%, 100%, and 100%, respectively. In the ureterostomy group, the exclusion of patients with pyuria improved the false-positive rate of U-NMP22 from 41.7% to 12.5%. CONCLUSIONS U-NMP22 levels may be useful in the diagnosis of upper urinary tract cancer in patients with a tubeless cutaneous ureterostomy. However, in patients with urinary diversion using a bowel segment, U-NMP22 has no diagnostic value because of the high U-NMP22 levels.

Treatment of Complicated Urinary Tract Infections with Ofloxacin following an Aminoglycoside

In order to reduce the dosage of aminoglycoside in the treatment of patients with complicated urinary tract infections (UTI) in outpatient clinics and to improve cost benefits, we tried both ofloxacin (OFX) treatment and a combination treatment with OFX and a single dose of aminoglycoside (isepamicin). Both groups showed the same cure rate on day 5, but the bacteriuria elimination rate on day 1 was slightly higher in the isepamicin-OFX group. The recurrence rate on days 7-14 did not differ between the groups. This aminoglycoside-OFX treatment did not show significantly higher effectiveness against complicated UTI but resulted in earlier elimination of bacteriuria. These results suggest that this combination therapy may be cost effective in treating complicated UTI, because of the shorter treatment period required.

Subcutaneous penectomy and phalloplasty using a testicle for invasive urethral carcinoma.

Invasive bulbomembranous urethral carcinoma appears highly aggressive and requires radical local excision to cure. The standard surgical therapy for this tumor includes en bloc resection of the penis, urethra, scrotum and pubic bone with radical cystoprostatectomy.1 However, recently it has become increasingly important to also consider quality of life.2,3 We report on a patient with invasive bulbous urethral carcinoma, who has been satisfied 5 years after surgery with the surgical and cosmetic results of the methods used for penis and bladder preservation.

Anticoagulant induced submucosal hemorrhage mimicking a renal pelvic tumor

A 73-year-old woman presented with gross hematuria and slight lumbago in June 1998. She had been on oral warfarin potassium for 4 years because of a permanent pacemaker implantation for the sick sinus syndrome. IVP revealed irregular right caliceal and pelvic defects, and narrowing of the infundibula. The left kidney was slightly hydronephrotic due to ureteropelvic junction stenosis. Abdominal computerized tomography (CT) showed thickening of the bilateral renal pelvic wall and the vestibule in the stomach with a slight homogeneous enhancement, which was considered suspiciously similar to bilateral renal pelvic and gastric tumors, or a malignant lymphoma (part A of figure). However, photogastroscopy did not reveal a stomach tumor. Repeat abdominal CT failed to show bilateral renal pelvic or gastric tumor. However, a hematoma was evident between the left gluteus medius and gluteus minimus (part B of figure). A thrombotest revealed less than 10% of normal value (normal during therapy 10% to 20%). We concluded that bilateral renal pelvic wall thickening was allowing hemorrhaging into the submucosa.

Barium Granuloma Involving Urinary Bladder

The first case of barium granuloma involving urinary bladder is reported. Surgical removal was the treatment of choice. Histological diagnosis was foreign body granuloma with xanthomatous inflammation. The foreign body was identified as barium by analytical electron microscopy.

TRANSRECTAL ULTRASOUND FINDINGS OF PELVIC ARTERIOVENOUS MALFORMATION

A 64-year-old man presented with a 1-month history of increasing bladder irritability and dysuria in December 1998. Digital rectal examination revealed an enlarged prostate with an irregular surface but without a pulsatile mass. There was no history of pelvic trauma or surgery. Serum prostate specific antigen (PSA) was 56.0 ng./ml. Transrectal ultrasound demonstrated a tubular and tortuous hypoechoic lesion along the left side of the prostate, which was suspicious for vascular abnormality (fig. 1). Systematic sextant prostate biopsy was performed under transrectal ultrasound guidance, avoiding the hypoechoic mass, and bleeding was minimal after the biopsy. A poorly differentiated adenocarcinoma was detected in all of the 6 biopsy specimens obtained. Pelvic CT demonstrated a large dilated and tortuous vascular system adjacent to the left side of the prostate (fig. 2). Digital subtraction angiography confirmed the presence of a large arteriovenous malformation in the left pelvis, fed by the left superior gluteal artery and draining into the left external iliac vein. During a 4-month period 6 courses of transarterial embolization of the left superior gluteal artery with metal coils were performed. Digital subtraction angiography showed a decrease in the size of the arteriovenous malformation.

Simple correction of ureteral stomal stenosis for cutaneous ureterostomy.

Cutaneous ureterostomy is a simple procedure to perform, but has some morbidity owing to stomal stenosis. We describe a new and simple technique applied to the stomal stenosis for cutaneous ureterostomy.

Clinical Investigation of Adrenal Incidentalomas in Japanese Patients of the Fukuoka Region with Updated Diagnostic Criteria for Sub-clinical Cushing's Syndrome

Objectives We retrospectively investigated the clinical and endocrinological characteristics of adrenal incidentalomas. Methods We studied 61 patients who had been diagnosed with adrenal incidentalomas and had undergone detailed clinical and endocrinological evaluations while hospitalized. We used common criteria to diagnose the functional tumors, but for sub-clinical Cushings syndrome, we used an updated set of diagnosis criteria: serum cortisol ≥1.8 μg/dL after a positive response to a 1-mg dexamethasone suppression test if the patient has a low morning adrenocorticotropic hormone (ACTH) level (<10 pg/mL) and a loss of the diurnal serum cortisol rhythm. Results Of the 61 patients, none (0%) had malignant tumors, 8 (13.1%) had pheochromocytoma, and 15 (24.6%) had primary aldosteronism; when diagnosed by our revised criteria, 13 (21.3%) had cortisol-secreting adenomas (Cushings syndrome and sub-clinical Cushings syndrome), and 25 (41.0%) had non-functional tumors. Compared with the non-functional tumor group, the primary aldosteronism group and the cortisol-secreting adenoma group were significantly younger and had significantly higher rates of hypokalemia, whereas the pheochromocytoma group had significantly larger tumors and a significantly lower body mass index. Conclusion Our study found a larger percentage of functional tumors among adrenal incidentalomas than past reports, partly because we used a lower serum cortisol level after a dexamethasone suppression test to diagnose sub-clinical Cushings syndrome and because all of the patients were hospitalized and could therefore receive more detailed examinations. Young patients with hypokalemia or lean patients with large adrenal tumors warrant particularly careful investigation.

Reduction of Blood Pressure Following After Renal Artery Adventitia Stripping During Total Nephroureterectomy: Potential Effect of Renal Sympathetic Denervation

Case series Patients: Male, 85 • Male, 89 Final Diagnosis: Essential hypertension Symptoms: High blood pressure Medication: Anti-hypertensive agents Clinical Procedure: Operation Specialty: Cardiology and Hypertension Objective: Unusual or unexpected effect of treatment Background: Catheter-based renal sympathetic denervation has been reported to be effective for treatment resistance hypertension in Australia and Europe. However, in the blinded SYMPLICITY HTN-3 trial, renal denervation did not achieve a significant decrease in blood pressure (BP) in comparison to sham controls. There have been various discussions on the factors that influenced this result. Case Reports: Two men on antihypertensive therapy underwent unilateral radical nephroureterectomy for cancer of the renal pelvis. When the renal artery adventitia was stripped and cauterized just before renal artery ligation, the measured BP of the 2 men increased after stripping adventitia and decreased gradually after cauterization of the renal artery. This was presumably due to removal of renal artery sympathetic nerves, similar to the mechanism of catheter-based renal sympathetic denervation, although anesthesia, fluid infusion, and/or mesenteric traction may have had an influence. Conclusions: A similar strategy involving thoracolumbar sympathectomy was reported about 50 years ago. The clinically significant blood pressure reduction in these patients suggests renal denervation is effective.