Yasukazu Takase

Successful endovascular treatment using a covered stent for artery-ureteral fistula after surgery for abdominal aortic aneurysm

Artery-ureteral fistula (AUF) is a rare condition but there is an increase in the number of reported cases. It is frequently difficult to treat. A 63-year-old male who had undergone a Dacron Y-graft placement for an infrarenal aortic aneurysm 3 years earlier, presented with hematuria. Contrast-enhanced computed tomography revealed a fistula located between the right common iliac artery and the right ureter at graft anastomosis. Endovascular treatment using a covered stent was performed successfully.

Cough-induced internal oblique hematoma.

Violent or sustained cough can be associated with serious musculoskeletal complications. We report a case of a cough-induced internal oblique hematoma in an obese 73-year-old woman who was not receiving antithrombotic therapy. She had no history of trauma and presented with acute worsening pain in the right flank. She had been coughing continuously for the past month and had severe cough 2 days before the onset of pain. Ultrasonography revealed a hypoechoic mass in the right lateral abdominal wall. Unenhanced computed tomography of the abdomen showed a 7 cm × 7 cm × 4 cm hematoma in the right internal oblique muscle. The patient was managed conservatively without blood transfusion. Acute abdominal pain together with an abdominal painful mass, particularly in patients with cough, should alert physicians to the possibility of an abdominal wall hematoma.

Urinary frequency as a presentation of bulky malignant lymphoma in the pelvis.

Malignant lymphomas may originate from any area of the body and cause a variety of symptoms. However, a malignant lymphoma causing urinary symptoms is uncommon. We report a unique case of a 77-year-old woman who presented with a persistent pollakiuria. Radiographic imaging showed a large pelvic mass (13 × 13 × 11 cm) remarkably compressing and invading the bladder wall and accompanied with bilateral hydronephrosis. Urinary cytology revealed malignant lymphoma, and a final diagnosis of malignant lymphoma was made on the basis of transvaginal needle biopsy. Urinary cytology facilitated the definite diagnosis, following which we initiated a rapid and successful treatment with cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab.

Cyst infection in unilateral renal cystic disease and the role of diffusion-weighted magnetic resonance imaging.

In multicystic renal diseases, cyst infection is a complex issue because of the absence of validated diagnostic methods. Unilateral renal cystic disease is a rare multicystic disease, believed to have an acquired maldevelopmental origin. Unilateral renal cystic disease is often confused with autosomal dominant polycystic kidney disease but has some distinguishing characteristics: unilateral localization, negative family history, and no progression to chronic renal failure. We describe a case of unilateral renal cystic disease with cyst infection that could be detected by diffusion-weighted magnetic resonance imaging, but not by conventional imaging techniques. Diffusion-weighted magnetic resonance imaging can be useful for detecting infected cysts, especially in multicystic renal diseases.

Laparoscopic Management of a Complex Adrenal Cyst

Adrenal cysts are rare, and their clinical management remains controversial. We report a case involving an adrenal cyst with a complicated appearance on radiological studies. Unenhanced computed tomography revealed a unilocular, noncalcified, hypoattenuating mass with a thin wall in the left adrenal gland. The lesion gradually increased in size from 10 to 50 mm at two-year follow-up. On contrast-enhanced magnetic resonance imaging, a mural nodule with contrast enhancement was observed. The entire adrenal gland was excised en bloc via a lateral transperitoneal laparoscopic approach without violating the principles of surgical oncology. The pathological diagnosis was an adrenal pseudocyst. Laparoscopic adrenalectomy is a safe option for the treatment of complex adrenal cysts, while maintaining the benefits of minimal invasiveness.

Retroperitoneoscopic drainage of bilateral psoas abscesses under intraoperative laparoscopic ultrasound guidance

Despite improved diagnostic modalities for psoas abscesses, the optimum management strategy is not uniform. A 67‐year‐old man presented with bilateral psoas abscesses secondary to L1–L2 pyogenic discitis. On contrast‐enhanced CT, the largest of these abscesses measured 13 × 14 × 33 mm on the right. The patient developed sepsis caused by Klebsiella pneumonia. There were no signs of improvement after 3 weeks of systematic antibiotic administration. We performed surgical drainage of bilateral psoas abscesses by retroperitoneoscopy. Intraoperative laparoscopic ultrasound was useful to determine abscess location in the muscles prior to drainage and confirm no residual abscesses after drainage. The patient was afebrile 3 days later, and his clinical symptoms resolved. Retroperitoneoscopic drainage may represent a feasible minimally invasive therapeutic option for psoas abscess, and intraoperative laparoscopic ultrasound has the potential to increase the safety and efficacy of this surgical procedure.

Primary enteric-type tubulovillous adenocarcinoma arising in the renal pelvis: Letter to the Editor

To the Editor: In 1960, Hasebe et al. first demonstrated the clinicopathological features of an extremely rare case of primary mucinous adenocarcinoma arising in the renal pelvis. Following that, a substantial number of interesting case reports describing the pathological features of primary pelvic adenocarcinoma were published; however, within our thorough investigation, we found less than 100 cases reported in the English literature, with most cases reported from Asian countries. Indeed, it is well-known that transitional cell (urothelial) carcinoma accounts for up to 90% of epithelial-origin malignancies arising from the renal pelvis, whereas adenocarcinoma accounts for less than 1%. Pure adenocarcinomas of the renal pelvis are histopathologically classified as tubulovillous (71.5%), mucinous (21.5%), or papillary non-intestinal (7.0%). We herein report an extremely rare case of primary enteric-type tubulovillous adenocarcinoma arising in the markedly dilated left renal pelvis, presenting as hemorrhagic, necrotic and mucinous neoplasms, in a background of severe hydrocalycosis and hydroureter. The patient, who was a man in his early seventies with an unremarkable previous medical history, presented with gross hematuria, lumbago and back pain. CT revealed severe hydronephrosis in the left kidney, associated with two renal pelvic calculi and occupying heterogeneouslyenhanced multiple pelvic nodular lesions. However, there was no definite evidence of other tumor lesions of the neck, chest, or abdomen, including metastatic foci in the lymph nodes or other organs. The laboratory data, including the blood cell count, chemistry and tumor marker levels, were within the normal limits, with the exception of mildly elevated CRP (0.43mg/dL) and uric acid (8.1mg/dL) levels. A urinalysis revealed a low white blood cell count (1 to 4 cells per high-power field). Based on the clinical findings, the initial diagnosis by the urologists was renal pelvic urothelial carcinoma with hydronephrosis and pelvic calculi; but, the urine cytology did not suggest malignancy. However, since the possibility of malignancy could not be excluded, left nephrouretectomy was performed. On gross examination, the left kidney, measured 20 13 cm and weighed 877g. Its cut surface (Fig. 1a) showed an overtly cystically-dilated renal pelvis, filled with pelvic calculi, and papillary-projected huge mass lesions, measuring more than 5 to 7 cm in diameter, which appeared gray-whitish in color, accompanied by frequent hemorrhage, necrosis and mucin production. This hydrocalycotic and hydroureteric kidney showed a markedly thinned pre-existing renal parenchyma (Fig. 1a). Our thorough examination revealed no anomalous findings (i.e., horseshoe kidney). A microscopic examination of these tumors demonstrated a proliferation of atypical tall columnar epithelial cells, arranged predominantly in a papillary or villoglandular or fused tubular growth pattern with mucin production and focal stromal invasion (Fig. 1b). On a high-power view, these atypical cells showed enlarged hyperchromatic nuclei, prominent nucleoli and abundant eosinophilic to clear cytoplasm with characteristic brush borders (Fig. 1d). Intriguingly, in the adjacent noncancerous renal pelvic mucosa, we occasionally recognized glandular metaplasia with mild cellular atypia in the covering urothelial epithelium (Fig. 1d). In contrast, our thorough investigation revealed no apparent adenomatous components. The markedly atrophic pre-existing kidney contained a very small number of glomeruli and uriniferous tubules embedded in prominent fibrosis. Very few inflammatory cells were observed. Immunohistochemistry revealed that the abovementioned enteric-type adenocarcinoma cells were specifically positive for CK7, CK20, CDX2, b-catenin and MUC2, and focally positive for MUC5AC. As to the bcatenin, the immunoreactivity uniquely showed a membranous—but not nuclear—staining pattern (Fig. 1e). Based on all of these features, the final diagnosis was primary enteric-type tubulovillous adenocarcinoma arising in the left renal pelvis. We hypothesized that this was possibly induced by a long-term inflammatory reaction caused by the patients pelvic calculi and/or hydrocalycosis/hydroureter. To date, the patient has been followed for approximately 2 years since surgery, and remains well without any sign of recurrence. Figure 1F shows a schematic illustration of the primary pelvic adenocarcinoma observed in the present case, which involved and extended to the hydrocalycotic and hydroureteric kidney with pelvic calculi. Aggressive surgical treatment in the early stage of primary renal pelvic adenocarcinoma might be associated with a better prognosis, as this disease is associated with higher-grade (i.e., invasive characteristics) malignant tumors, with a reported overall survival rate of <50% within 2 years after surgery. It is therefore critical to establish an accurate pre-operative diagnosis based on urine cytology, the clinical utility of which has been generalized in the diagnosis of urinary tract tumors. However, there are few reports of the cytological findings of primary renal pelvic

Renal arteriovenous fistula induced by extracorporeal shock wave lithotripsy treated by retroperitoneoscopic nephrectomy: Renal AVF induced by ESWL

Renal arteriovenous fistula (AVF) is a rare but potentially severe and life‐threatening entity. It can occur after various invasive renal interventions, including resection of a localized renal tumor, renal biopsy, percutaneous renal surgery, and even blunt injury of the kidney. The time of clinical presentation of a renal AVF is variable and may occur decades after the injury originally occurred. Here, we report a case of renal AVF induced by extracorporeal shock wave lithotripsy 11 years earlier in an asymptomatic 72‐year‐old woman. Given the patients pre‐existing hemodialysis dependence, retroperitoneoscopic nephrectomy was performed. On the basis of patients clinical history, the location of the renal AVF, and the pathological diagnosis, we suggested that renal AVF was a late consequence of the injury to the intrarenal vessels induced by extracorporeal shock wave lithotripsy.

Extraperitoneal Rupture of a Bladder Diverticulum and the Role of Multidetector Computed Tomography Cystography

Nontraumatic rupture of the bladder is less widely recognized than traumatic rupture, with a challenging early diagnosis due to high variability in clinical presentations. We report a case of extraperitoneal rupture of a bladder diverticulum in a patient with diabetes mellitus who presented with paralytic ileus. Despite conservative management, the patient developed sepsis requiring surgical treatment. Urinary tract infection and bladder outlet obstruction were considered to be potential mechanisms of the rupture. Multidetector computed tomography cystography should be used as the first-line modality when evaluating for a suspected bladder rupture, even in patients with nontraumatic bladder rupture.

Management of Ureterolithiasis in a Patient with Crossed Unfused Renal Ectopia

Crossed renal ectopia is a rare congenital anomaly in which both kidneys are situated on one side and fused together in 85%–90% of cases. The management of urinary calculi in patients with crossed renal ectopia continues to pose challenges to urologists because the aberrant anatomy may make access and clearance of the calculi more difficult to accomplish. Here, we report a case of inferior crossed renal ectopia, without fusion, and a ureteral stone in which the patient was treated successfully by extracorporeal shock wave lithotripsy.