Zdeněk Chudáček

Extensively Cystic Renal Neoplasms in Adults (Bosniak Classification II or III) – Possible “Common” Histological Diagnoses: Multilocular Cystic Renal Cell Carcinoma, Cystic Nephroma, and Mixed Epithelial and Stromal Tumor of the Kidney

Objective(s): To give an algorithm for resolution of extensively cystic renal neoplasms, preoperatively classified in the Bosniak classification as a category II and III. Methods: From 1991 to 6/2004, 701 patients with 727 renal tumours were surgically treated at our hospital. Extensively cystic tumours were found in 10 cases. Extensively cystic tumours were defined as multicystic tumours without any solid nodules visible neither on CT, nor grossly in the specimen at operation (the Bosniak classification type II or III). Results: Seven multilocular cystic renal cell carcinomas, three mixed epithelial and stromal tumour of the kidney and one cystic nephroma were diagnosed on histology. Conclusion(s): Extensively cystic renal tumours classified as the Bosniak type II or III correspond histologically to the entities mentioned above (multilocular cystic renal cell carcinoma, cystic nephroma, mixed epithelial and stromal tumour of the kidney). These entities cannot be distinguished one from another on preoperative imaging studies. A preoperative biopsy and intra-operative frozen-section analysis do not lead to a correct diagnosis in many cases. Fortunately, the operative strategy is the same for all these tumours. In such cases, the nephron sparing surgery is indicated, whenever technically feasible, as almost all extensively cystic renal tumours have a good prognosis.

Gastric lipoma presenting as upper gastrointestinal obstruction

Abstract: A 61-year-old man presented with an upper gastrointestinal obstruction caused by a submucosal gastric lipoma in the prepyloric area. The diagnosis was made coincidentally during his admission for another disease. Gastric resection was performed because of a large lipoma combined with florid gastric ulcers. The frequency of gastric lipoma, its differential diagnosis, means of diagnosis, and treatment are discussed.

Rupture of papillary renal cell carcinoma.

Ojective: Typical signs of papillary renal cell carcinoma (PRCC) are extensive necroses of the tumorous mass, which can modify the clinical appearance of PRCC. These necroses can imitate cysts on radiological examinations (ultrasonography and CT). The tumours are fragile and vulnerable to spontaneous rupture or rupture following minimal trauma (i.e. they act as a locus minoris resistentiae). Material and Methods: A total of 650 patients with a total of 671 renal tumours were surgically treated at our hospital between January 1991 and December 2003. Results: In 16 cases bilateral tumours were found (in all cases RCC) and in five cases two types of tumour were identified in one kidney [all were a combination of conventional RCC (CRCC) and PRCC]. Altogether, 621 tumours (92.5%) were diagnosed as RCCs. Of these, CRCC was found in 563 cases (90.7%), PRCC in 36 (5.8%), chromophobe RCC in 14 (2.3%) and unclassified RCC in 7 (1.1%). All cases of ruptured PRCC were included in our study. Interestingly, only PRCCs ruptured in this series. Rupture was described in three cases of PRCC (8.3%): it was spontaneous in two cases and resulted from a traffic accident in the third. Conclusions: The extensive necrosis regularly found in PRCC can cause rupture of the tumour followed by retroperitoneal bleeding. Rupture affected <10% of our cases of PRCC. CT findings are usually not characteristic and can mimic a simple haematoma of unknown origin. Similarly, the perioperative finding is unclear in most cases. The final correct diagnosis of the renal tumour is frequently established only by the pathologist.

Laparoscopic urinary bladder diverticulectomy combined with photoselective vaporisation of the prostate

Introduction Pseudodiverticulum of the urinary bladder is mostly a complication of subvesical obstruction (SO). The gold standard of treatment was open diverticulectomy with adenectomy. A more contemporary resolution is endoscopic, in two steps: the first transurethral resection of the prostate (TURP), the second laparoscopic diverticulectomy (LD). Aim To present a one-session procedure – photoselective vaporisation of the prostate (PVP) with LD. Material and methods From 1/2011 to 6/2014, 14 LDs were performed: 1 LD only, 1 with laparoscopic radical prostatectomy, 12 combined with treatment of benign prostatic hyperplasia (BPH), 4 cases of TURP and LD in the second period. In 8 cases, PVP and LD in one session were combined. These 8 cases are presented. 3D CT cystography was used as a gold standard for assessment of diverticulum. Results The mean age was 66.5 ±5.5 (57.3–75.1) years, the mean size of the diverticulum 61.8 ±22.1 (26–90) mm. The procedure starts in the lithotomy position. It includes PVP and stenting of the ureter(s). Changing of position and laparoscopy follows: four ports, transperitoneal extravesical approach. Photoselective vaporisation of the prostate was performed using the Green Light Laser HPS (1x) or XPS with cooled fibre MoXy (7x). The mean delivered energy in PVP was 205.1 ±106.4 (120–458) kJ. The mean time of operation was 165.0 ±48.5 (90–255) min. No postoperative complications were observed. One patient underwent TUR incision after 1 year for sclerosis of the bladder neck. Conclusions Pseudodiverticulum of the urinary bladder (with or without SO) is a relatively rare disease. One session of PVP (Green Light Laser XPS, MoXy fibre) and laparoscopic (transperitoneal extravesical) diverticulectomy is the preferred method for treatment of subvesical obstruction due to BPH and bladder diverticulum at our institution.

MiT translocation renal cell carcinomas: two subgroups of tumours with translocations involving 6p21 [t (6; 11)] and Xp11.2 [t (X;1 or X or 17)]

IntroductionMiT translocation renal cell carcinomas (TRCC) predominantly occur in younger patients with only 25% of patients being over 40 years. TRCC contains two main subgroups with translocations involving 6p21 or Xp11.2. Herein we present 10 cases.MaterialsEight cases were treated at main author’s institution (identified among 1653 (0.48%) cases of kidney tumours in adults). Two cases were retrieved from the Pilsen (CZ) Tumour Registry.ResultsSix cases were type Xp11.2 and four 6p21; 7 female, 3 male patients; Xp11.2 4:2, 6p21 3:1. The mean age 49 years (range: 21–80), 5 patients (50%) over 40 years. The mean age of the group with Xp11.2 TRCCs was 55 (median 51) and 6p21 41 (32) years. One female with a 6p21 tumour (24 years) underwent nephrectomy at 4 months of pregnancy. Stage (UICC, 7th ed. 2009) was 5xI, 3xIII, 2xIV. The mean size of tumour was 80 (40–165) mm. The mean follow-up was 33.2 (1–92) months. In patients with 6p21 tumours, one (25%) died after 3 months due to widely metastatic disease. In patients with Xp11.2 tumours, 3 (50%) succumbed due to metastatic disease (range 1–8 months). Three patients with Xp11.2 are alive at 7, 52 and 92 months of follow-up, were diagnosed at early stage (T1a).ConclusionTRCCs were more common in females. Patient with 6p21 tumours were younger than those with Xp11.2. Both types have definitive malignant potential Type Xp11.2 seems to be a more aggressive neoplasm than 6p21. The case with metastatic 6p21 tumour is the 4th case described in the English literature.

Laparoscopic adrenalectomy for metachronous ipsilateral metastasis following nephrectomy for renal cell carcinoma

Introduction Although laparoscopic adrenalectomy (LA) is considered as a gold standard approach for adrenalectomy, there are minimal data describing options and outcomes of LA after previous ipsilateral nephrectomy (PIN). Aim To describe our results in a group of patients who underwent LA after PIN. Material and methods From August 2004 to October 2012 we performed at our institution 88 LA. Of this amount we performed 5 LA for metachronous metastasis of renal cell carcinoma (RCC) after PIN. This group was compared to a group without previous nephrectomy. Results The group comprised 4 men (80%) and 1 woman (20%); the mean age at the time of surgery was 66.8 ±8.5 (range: 60-77) years; the mean period between nephrectomy and adrenalectomy was 5.2 (range: 1.5-14) years; the operating time was longer in patients after PIN for 7 min; the mean blood loss was higher by 22 ml; duration of hospitalization was shorter by 1.3 days, paradoxically, compared with patients without PIN. There was no need for conversion to open surgery and we did not observe any other complications. Conclusions Laparoscopic adrenalectomy for metastasis of RCC after PIN is a technically feasible method in selected patients and it is associated with no significant differences in perioperative data in comparison with the group without prior nephrectomy. The patients benefit from minimally invasive surgery. The performance has required an experienced laparoscopic surgeon.

Morphological Characterization of Papillary Renal Cell Carcinoma Type 1, the Efficiency of Its Surgical Treatment.

Aim: Papillary renal cell carcinoma type 1 (pRCC1) represents the second most common type of malignant renal epithelial tumour. The origin of its characteristic appearance, its growth mechanism, and the long-term efficiency of its surgical treatment remain uncertain. Our aim was to determine typical characteristics of surgically treated pRCC1. Methods: pRCC1 was verified in 83 of 1,629 (5.1%) kidney tumours surgically treated in the period of January 2007-January 2016. The clinical and radiological characteristics, type of surgery, histopathology results and follow up data were recorded. Spearman correlation, Kruskal-Wallis analysis of variance, Fishers exact, and chi-square test were used to analyse appropriate variables. The overall survival rate was evaluated using the Gehan-Wilcoxon test and the Cox proportional hazards model. Results: The mean tumour size was 52.0 mm (15-180); 98.8% of the tumours showed a spherical shape and in 82.1%, exophytic growth was observed. Partial nephrectomy was performed in 80.7%. A majority (81.9%) were classified as pT1. Tumours, 89.2% of them, belonged to Fuhrman grade 1 or 2. The mean follow-up was 46.8 months. The overall survival was associated with pT category (p ≤ 0.0001). Conclusions: Typical signs of pRCC1 are a spherical shape, exophytic growth and low Fuhrmans grade. More than three-fourths of pRCC1 could be treated by the nephron-sparing surgery.