[Two cases of lower abdominal tumors difficult to differentiate from urachal tumors].

CASE 1: A 28-year-old woman visited a local medical doctor, complaining of abdominal pain, urinary frequency and a sense of residual urine. Magnetic resonance imaging revealed a lower abdominal extraperitoneal tumor, approximately 5 cm in diameter, adjacent to the bladder dome. It was thought to be a urachal tumor, and she was referred to our hospital. A hard hen's egg-sized mass was palpable in the lower abdomen. Urinary analysis was normal. Cytological examination was also negative. Cystoscopy revealed redness in the bladder dome mucosa. Although the preoperative diagnosis was a urachal cancer, the pathological diagnosis on surgery was desmoids, and tumor excision was performed. No recurrence has been seen for 7 years postoperatively. CASE 2: A 71-year-old man complaining of swelling of the lower abdomen was referred to our department because he was suspected to have a urachal tumor, of about 15 cm in diameter, on computed tomography. A hard infant head-sized mass was palpable in the lower abdomen. Urinary analysis was normal. Cystoscopical examination showed a markedly compressed bladder dome, however, no abnormal findings were seen in the mucosa. Although the preoperative diagnosis was a urachal tumor, the intraoperative pathological diagnosis revealed no malignancy. The mass was connected to the bladder dome, and partial cystectomy was conducted. The final pathological diagnosis was a solitary fibrous tumor. No recurrence has been seen for 5 years postoperatively. Because a urachal tumor is highly malignant, radical cystectomy and urinary diversion might be planned preoperatively. However, care should be taken not to be too invasive, considering the possibility of a benign tumor.

Urinary tract infection associated with bacteremia caused by vancomycin-resistant enterococcus following continent urinary diversion.

Key Clinical Message: Even in a country where vancomycin-resistant enterococcus is rare, multidrug-resistant organism precautions are necessary when admitting patients with a history of medical exposure in other countries. On admission, screening is necessary and if infection is confirmed, a multidisciplinary approach involving different specialists is required. Abstract: The patient was a 49-year-old Japanese female living in the United States. Total pelvic exenteration for cervical carcinoma, Miami pouch formation, and ileostomy had been performed in the United States. She returned to Japan to undergo postoperative adjuvant chemotherapy. Fever and abdominal pain occurred 42 days after surgery. She consulted the fever outpatient clinic, and a diagnosis of urinary retention-associated acute renal failure and pyelonephritis was made. We detected vancomycin-resistant enterococcus on urine/blood culture 5 days after admission. Infection control measures were implemented, and the ward was closed for 3 days. We administered linezolid, which was effective for pyelonephritis and bacteremia.

[A case of adenocarcinoma arising in an ileal conduit].

We report a rare case of adenocarcinoma developing in an ileal conduit. A 78-year-old woman was referred complaining of abdominal pain. She had undergone radical cystectomy and ileal conduit formation for invasive bladder cancer 8 years previously. The pathological diagnosis was urothelial carcinoma, and distant metastasis was not found. She was lost to follow-up over 2 years postoperatively. Computed tomography at this time showed bilateral hydronephrosis. Metastasis was not revealed. Because renal failure progressed and gross hematuria developed, endoscopic examination through the stoma was performed. A mass adjacent to the ureteroileal anastomosis site was found. Biopsy led to a diagnosis of moderately differentiated adenocarcinoma. She died of renal failure 1.5 months after admission. To our knowledge, 9 cases of adenocarcinoma arising in an ileal conduit have previously been reported.

[A case of alpha-fetoprotein-producing female urethral adenocarcinoma].

We report a rare case of alpha-fetoprotein (AFP)-producing female urethral adenocarcinoma. A 52- year-old woman had urinary frequency. Ultrasonography showed a mass near the bladder. Therefore, she was referred to our hospital. Magnetic resonance imaging showed an approximately 4 cm mass at the urethra. Computed tomography did not show any lymphnode metastasis or distant metastasis. High serum levels of AFP were revealed. Carcinoembryonic antigen (CEA) and prostate specific antigen (PSA) were within the normal range. A transvaginal needle biopsy suggested adenocarcinoma. Radical cystourethrectomy and ileal conduit formation were performed. Histopathological diagnosis was adenocarcinoma. Immunohistochemical staining was positive for AFP and CEA, and negative for PSA. Serum AFP normalized immediately postoperatively. Adjuvant chemotherapy or radiotherapy was not performed. Eleven years postoperatively, the patient showed no evidence of tumor recurrence. To our knowledge, this is the first reported case of AFP producing female urethral adenocarcinoma.

Toxic epidermal necrolysis after the administration of enfortumab vedotin for urinary bladder urothelial carcinoma.

Introduction: Enfortumab vedotin is a novel drug for locally advanced or metastatic urothelial carcinoma, but it is associated with a high incidence of skin reactions (up to 47.0%). Case presentation: A 71-year-old male was administered enfortumab vedotin for bladder cancer associated with lymph node metastases. Slight erythema of the upper limbs appeared on Day 5. Erythema gradually worsened. On Day 8, second administration was performed. On Day 12, based on the extents of blisters, erosion, and epidermolysis, a diagnosis of toxic epidermal necrolysis was made. The patient died of multiple organ failure on Day 18. Conclusion: As serious cutaneous toxicity may appear early after the start of administration, it is important to consider the timing of the second administration of the initial course carefully. In cases of skin reaction, reduction or discontinuation should be considered.

Development of male breast cancer in a patient with prostate cancer during androgen deprivation therapy.

INTRODUCTION: Male breast cancer accounts for <1% of all breast cancer. We report a patient with prostate cancer during hormone therapy who developed breast cancer. CASE PRESENTATION: An 88-year-old male underwent androgen deprivation therapy for prostate cancer and developed an induration in the left breast 7 years after the start of treatment. After close examination, he was diagnosed with left breast cancer with lymph node metastasis. The prostate cancer was stable in a hormone-sensitive state. Left mastectomy was performed and the pathological diagnosis was invasive ductal carcinoma. DISCUSSION: In addition to our patient, seven patients who developed breast cancer during hormone therapy for prostate cancer were examined. Five of six patients had stage II or above, and four patients had lymph node metastases. Although local breast symptoms are frequently observed as adverse effects of hormone therapy, caution is warranted regarding male breast cancer.

Muscle invasive urinary bladder urothelial carcinoma presenting with secondary nephrotic symptoms.

INTRODUCTION: Nephrotic syndrome secondary to malignant disease accounts for approximately 10% of cases of nephrotic syndrome in adults. However, urothelial carcinoma of the bladder is a rare cancer, with only four cases reported to date. CASE PRESENTATION: A 76-year-old man presented with chief complaints of edema and anorexia. Laboratory examinations revealed hypoalbuminemia and marked proteinuria, and computed tomography demonstrated multiple bladder tumors. Transurethral resection of the bladder tumors was performed. The pathological diagnosis was urothelial carcinoma with muscular invasion. The patient underwent simple cystectomy and ileal conduit formation, and proteinuria disappeared after 4 weeks. However, urethral recurrence was noted, and he died 35 months after cystectomy. CONCLUSION: Five cases including ours were clinically reviewed. Nephrotic symptoms improved relatively rapidly after surgery in all cases. In contrast to the poor preoperative general condition, postoperative improvement can be expected, and surgical treatment should, therefore, be considered.

Severe necrosis of the glans penis associated with calciphylaxis treated by partial penectomy.

INTRODUCTION: Calciphylaxis is characterized by marked vascular calcification and painful skin ulcers, and it has a poor prognosis. CASE PRESENTATION: The patient was a 72-year-old male. He was referred for penile pain. He had a 4-year history of dialysis therapy under a diagnosis of diabetic nephropathy. Black and yellow necrosis was observed involving the entire glans, accompanying severe pain. Computed tomography revealed marked calcification involving the thoracoabdominal aorta to iliac arteries, the dorsal artery of the penis and the corpus cavernosum, leading to a diagnosis of calciphylaxis. Penile pain gradually exacerbated and partial penectomy was performed. After surgery, penile pain promptly subsided. Pathological examination confirmed marked calcification of the microvascular wall and narrowing of the lumen. CONCLUSION: We reviewed 15 Japanese patients with calciphylaxis who had undergone penile surgery. Surgical treatment was considered to be effective at relieving penile pain, but the prognosis remained poor.

Primary male urethral squamous cell carcinoma presenting with a genital abscess.

INTRODUCTION: Primary urethral cancer is a rare disease accounting for <1% of all urological cancer cases. We encountered a patient with urethral squamous cell carcinoma diagnosed during treatment of a genital abscess. CASE PRESENTATION: A 69-year-old male was referred to our hospital for recurrent urethritis and swelling of the scrotum. The genital skin was atrophic with a purulent discharge. A diagnosis of epididymitis-induced genital abscess was made, and conservative treatment was administered. However, local infection recurred and the infected tissue was resected 4 months after the first examination. The pathological diagnosis was squamous cell carcinoma. Subsequently, radical surgery was performed, but the patient died 17 months postoperatively. CONCLUSION: Four patients with primary urethral squamous cell carcinoma presenting as genital abscess have been reported. Careful examination is necessary while considering a malignant tumor as an underlying disease.

Patient with inguinal hernia containing the urinary bladder complicated by bladder stones.

INTRODUCTION: We encountered a patient in whom bladder inguinal hernia complicated by bladder stones was incidentally diagnosed. Bladder inguinal hernia containing stones in the prolapsed bladder is rare and only two cases have been reported. CASE PRESENTATION: The patient was an 82-year-old male in whom ascending colon cancer and inguinal hernia containing the urinary bladder were diagnosed based on abdominal computed tomography performed to examine anemia. The urinary bladder contained several small stones. Radical surgery for the hernia and lithotripsy of the urinary bladder were concomitantly performed with right colectomy. On stone analysis, the stones were found to be uric acid calculi. CONCLUSION: In the three patients with inguinal hernia containing the urinary bladder complicated by stones, including our patient, two-stage urination, organic lower urinary tract obstruction, and prolapse of the urinary bladder reaching the scrotum were noted in all patients.

Rat Bladders Augmented with a Novel Bovine Pericardium-Derived Biomaterial Reconstruct Functional Tissue Structures.

OBJECTIVES: To determine if rat bladders augmented with an acellular Japanese bovine pericardium-derived biomaterial (CardioDISC [CD]) could support bladder reconstruction, and increase bladder volume and compliance. METHODS: Female Sprague-Dawley rats were randomly divided into three groups (n = 5 each). After partial cystectomy, bladders were closed without augmentation (non-augmentation) or augmented with porcine small intestinal submucosa (SIS) or CD, both of which are acellular. At 1, 2, 4 and 8 weeks after surgery, bladder volume and compliance were measured. The bladders were then analyzed by immunohistochemistry for smooth muscle actin (SMA), urothelium uroplakin III (UPIII), and nerve fiber S100. RESULTS: At 4 weeks after augmentation, the SMA-positive cells from the host bladder tissues were present near the regions augmented with CD. In addition, S100-positive cells were present within the CD-augmented tissues. At 8 weeks after surgery, the CD-augmented tissues contained layered SMA-positive cells, urothelium uroplakin III -positive urothelium, and S100 fibers, similar to normal bladder tissue. The SIS-augmented bladders showed similar results. At 8 weeks after augmentation, the bladder volume of CD-augmented bladders was larger than that at 4 weeks, while the SIS-augmented bladders were the same as those at 4 weeks. The bladder volume of the non-augmented group did not increase. The bladder compliance of the CD-augmented bladders at 8 weeks was significantly higher than at earlier times. The bladder compliance of neither the non-augmented nor the SIS-augmented groups increased during the study period. CONCLUSION: Acellular bovine pericardium-derived material could be a suitable biomaterial for bladder augmentations.

Direct induction of layered tissues from mouse embryonic stem cells: potential for differentiation into urinary tract tissue.

The aim of this study was to induce organized layered tissues with characteristics of the urinary tract from embryonic stem (ES) cells alone. We seeded embryoid bodies (EBs) originating from mouse ES cells onto mono-layered collagen membranes and cultured them in four different media. Group 1 was grown in a mixed medium of keratinocyte serum-free medium (KSFM) and Medium 199, Group 2 in a mixed medium of KSFM and conditioned medium collected from 3T3 fibroblasts, Group 3 in an EB formation medium (control group), and Group 4 in KSFM only (control group). After 28 days, cultured tissues were transplanted into nude mice. Cultured tissues from Groups 1 and 2 formed four-layered structures comprising a stratified epithelium, a submucosal loose connective tissue layer, a smooth muscle cell layer identified immunohistochemically by alpha-smooth muscle actin, and a deep loose connective tissue layer identical to the adventitia. Immunohistochemistry showed that the epithelia were positive for cytokeratins. Tissues also expressed uroplakin as detected by reverse transcription/polymerase chain reaction. In contrast, specimens from Groups 3 and 4 demonstrated necrotic features. Uroplakin-positive (i.e., urothelium-like) cells developed only in Group 2 in the transplanted culture tissues in nude mice. In addition to inducing organized layered tissues from mouse ES cells directly in vitro, these findings demonstrate that tissues cultured in KSFM plus conditioned medium from 3T3 fibroblasts differentiate into luminal walls similar to those of urinary tract in vivo. These findings suggest a new approach to urinary tract regeneration.