Relevance of concurrent hypercalcemia in ureteric sarcoidosis complicated with bladder urothelial carcinoma: a case report.

BACKGROUND: Sarcoidosis is a multisystem inflammatory disorder and can affect any organ; however, ureteric involvement is extremely rare with only four cases reported in the literature to date, all of which were diagnosed with surgical ureteral resection including a nephroureterectomy. This study reports the first case of ureteric sarcoidosis controlled with medical therapy where a differential diagnosis was performed based on the diagnostic clue of hypercalcemia. A definitive diagnosis was established without surgical resection of the ureter. CASE PRESENTATION: A 60-year-old man presented with anorexia and weight loss. Blood tests showed renal dysfunction and hypercalcemia. Computed tomography revealed left hydronephrosis associated with left lower ureteral wall thickening, which showed high signal intensity on diffusion-weighted magnetic resonance imaging. Similarly, we detected a bladder tumor on cystoscopy, and a 2-cm-long stenosis was revealed by retrograde ureterography; therefore, ureteral cancer was suspected. Meanwhile, considering the clinical implication of hypercalcemia, a differential diagnosis of sarcoidosis was established based on elevated levels of sarcoidosis markers. Fluorodeoxyglucose positron emission tomography showed fluorodeoxyglucose accumulation in the left lower ureter, skin, and muscles, suggestive of ureteric sarcoidosis with systemic sarcoid nodules. For a definitive diagnosis, transurethral resection of the bladder tumor and ureteroscopic biopsy were performed. Histopathological examination revealed ureteric sarcoidosis with bladder urothelial carcinoma. Following an oral administration of prednisolone, hypercalcemia instantly resolved, the renal function immediately improved, and the left ureteral lesion showed complete resolution with no recurrence. CONCLUSIONS: In this case, the co-occurrence of ureteral lesion with bladder tumor evoked a diagnosis of ureteral cancer. However, considering a case of ureteral lesion complicated with hypercalcemia, assessment for differential diagnosis was performed based on the calcium metabolism and sarcoidosis markers. In cases of suspected ureteric sarcoidosis from the assessment, pathological evaluation with ureteroscopic biopsy should be performed to avoid nephroureterectomy.

[A Case of Localized Amyloidosis of the Right Ureter Treated Effectively by Occulusive Dressing Technique Therapy Using Dimethyl Sulfoxide : Long-Term Follow-Up of Eight Years].

The patient was a 56-year-old female. She was referred to our department for further examination of right hydronephrosis in 2010. Computed tomography (CT) showed right hydronephrosis, and retrograde pyelography (RP) revealed stenosis of the right lower ureter. Urine cytology was negative. Transurethral biopsy of the right ureter was performed using ureteroscopic cup forceps and the histopathlogical diagnosis was ureteral amyloidosis. A whole-body search was performed, including rectal biopsy, but no evidence of amyloidosis was obtained. She was diagnosed with localized amyloidosis of the right ureter. A ureteral stent was indwelled and the patient was given occulusive dressing technique (ODT) therapy using dimethyl sulfoxide (DMSO) for 1 year. After ODT therapy, right hydronephrosis improved. After a 2-year followup, it worsened. ODT therapy was restarted and continued for 2 years. She consulted our department because of fever and right lumbago in April 2017 after a 4-month interruption of ODT therapy. CT revealed progression of the right hydronephrosis. A ureteral stent was indwelled and ODT therapy was restarted. The right hydronephrosis improved after 1 year. ODT therapy using DMSO was effective for localized ureteral amyloidosis, but periodic follow-up was necessary and ODT therapy was also effective when it recurred after the interruption of treatment.

[Possible Diagnosis of Segmental Ureteritis Due to an IgG4-Related Disease that Improved with Steroid Therapy].

A 70-year-old woman was referred to our department after being diagnosed with right hydronephrosis on the basis of computed tomography (CT). CT and magnetic resonance imaging results indicated circumferential wall thickening in the right middle ureter. A retrograde pyelogram revealed an approximately 20 mm stricture in the right middle ureter, and urine cytology results were pseudo-positive. Ureteroscopy was performed due to suspicion of a malignant tumor of the urinary tract, but no malignant lesions were found. Biopsy results showed only the pathology of nonspecific ureteritis, and a diagnosis could not be made even with immunostaining. The patient's blood IgG4 levels were high (317 mg/dl). Based on the diagnostic criteria, the patient was given a possible diagnosis of an IgG4-related disease and treated by the placement ofa ureteral stent and administration of steroid therapy. After starting treatment, blood IgG4 levels decreased and the imaging findings showed improvement. The ureteral stent was removed in the 12th week, and steroid administration was discontinued in the 14th week. No recurrence has since been noted.

Outcomes of Medical and Surgical Therapy for Entero-urinary Fistulas in Crohn's Disease.

BACKGROUND AND AIMS: The aims of this study were to evaluate the frequency of entero-urinary fistulas in a cohort of Crohn's disease (CD) patients and to analyse the outcomes of medical and surgical therapy. METHODS: This multicentre retrospective study included all CD patients with entero-urinary fistulas diagnosed by the presence of clinical symptoms and confirmed at surgery or by radiological or endoscopic techniques. We evaluated outcomes of medical and surgical therapy. We defined remission as absence of clinical symptoms with a radiological confirmation of fistula closure. Cox regression analysis was performed to evaluate factors predictive of achieving remission without need for surgery. RESULTS: Of 6081 CD patients screened, 97 had entero-urinary fistulas (frequency 1.6%). Seventy-five percent of fistulas occurred in men. After a median follow-up of 91 months, 96% of patients were in sustained remission. Thirty-three patients (35%) received anti-tumour necrosis factor (TNF) therapy. Of these, 45% achieved sustained remission (median follow-up 35 months) without needing surgery. More than 80% of patients required surgery, which induced remission (median follow-up 101 months) in 99% of them. Only the use of anti-TNF agents was associated with an increased rate of remission without need for surgery (hazard ratio 0.23, 95% confidence interval 0.12-0.44; p < 0.001). CONCLUSION: In this large cohort of CD patients, the frequency of entero-urinary fistulas was lower than previously described. More than 80% of patients required surgery, and in all but one of them surgery induced sustained remission. In a selected subgroup of patients, anti-TNF may induce long-term fistula remission and radiographic closure, making it possible to avoid surgery.

Decreased urinary glycosaminoglycan excretion following alfuzosin treatment on ureteral stent-related symptoms: a prospective, randomized, placebo-controlled study.

The objectives of the study were to evaluate changes in ureteral stent-related symptoms and urinary glycosaminoglycan (GAG) excretion after alfuzosin treatment, and to further investigate the relationship between stent-related symptoms and loss of urinary GAGs. Seventy consecutive patients scheduled for unilateral retrograde ureteroscopy with stent placement were recruited. Patients were randomly assigned to treatment with alfuzosin 10 mg/day or placebo for 3 weeks starting on the third postoperative day. The ureteral stent was removed when treatment stopped. International Prostate Symptom Score (IPSS), visual analog scale (VAS) score, and urinary GAG excretion were determined before treatment at 1, 2, and 3 weeks after treatment, and at 3 weeks after stent removal. Fifty-nine patients completed the study. IPSS, VAS score, and urinary GAG excretion were significantly lower in the alfuzosin group, compared with the placebo group, at 1, 2, and 3 weeks after treatment (P < 0.01). In both groups, IPSS, VAS score, and urinary GAG excretion were significantly lower at 3 weeks after stent removal compared with those before stent removal. No significant differences in IPSS, VAS score, or urinary GAG excretion were observed between the two groups at baseline and 3 weeks after stent removal (P > 0.05). Positive correlations were found between urinary GAG excretion (R(2) = 0.65, P < 0.001) and IPSS and between urinary GAG excretion and VAS score (R(2) = 0.33, P < 0.001). Stent placement contributes to loss of urinary GAGs. However, alfuzosin effectively reduces such loss and improves ureteral stent-related symptoms. Loss of urinary GAGs plays a role in these symptoms.

Ureteric vasculitis, an unusual presentation of polyarteritis nodosa: a case report.

A 22 year old female presented with vasculitic skin rash. She was incidentally found to be hypertensive and had proteinuria. Skin biopsy showed leuco-cytoclastic vasculitis. On Imaging, there was left hydronephrosis, hydroureter with bilateral multiple foci of ureteric stenosis and micro-aneurysms in relation to interlobar arteries of kidney. A diagnosis of classical Polyarteritis Nodosa (cPAN) with multi-level ureteric stenosis was made. She was treated with Glucocorticoids, Cyclophosphamide, following which Azathioprine was given.

[Ureteral endometriosis treated by hormonal therapy : a case report].

A 40-year-old woman visited our hospital with asymptomatic macroscopic hematuria. A nonpapillary ureteral tumor protruding from the left orifice was identified by cystoscopy. Computed tomography revealed left hydronephrosis due to the ureteral tumor. Transurethral resection for the ureteral tumor was performed and histopathological examination for the specimen revealed intrinsic type ureteral endometriosis. Administration of luteinizing hormone-releasing hormone agonist for 6 months markedly improved the hydronephrosis. The patient received hormonal therapy for 2 years in total. At present, there is no evidence of disease recurrence 6 months after the termination of hormonal therapy. To our knowledge, the present case was the 14th Japanese case with intrinsic type ureteral endometriosis reported in the literature.

[Effect of 3-oxypyridine and succinic acid derivatives on endometrial leucocyte infiltration and lipid peroxidation in recrudescence of inflammatory diseases of the uterus and its appendages].

The effect of domestic 3-oxypyridine and succinic acid derivatives (emoxipin, reamberin and mexidol) included in the complex treatment of recrudescence of inflammatory diseases of the uterus and its appendages, as manifested in endometrial leucocyte infiltration (ELI) compared to lipid peroxidation products concentration in blood serum, was assessed in a short-term, prospective placebo-controlled single-blind randomized trial. It has been found that two-week infusions of emoxipin (single dose, 150 mg), reamberin (single dose, 400 ml), and mexidol (single dose, 300 mg) favor a decrease in ELI and influence ambiguously on lipid peroxidation - antioxidant (LPA) system condition in blood serum of patients. It has been found that 3-oxypyridine derivative (emoxipin) decreases the intensity of ELI, but does not affect LPA system condition. Succinic acid derivative (reamberin) is inferior to emoxipin in the degree of decreasing ELI, but reduces the concentration of the antioxidant protein ceruloplasmin. Mexidol, being 3-oxipyridine and succinic acid derivative simultaneously, exceeds reamberin in decreasing ELI, increases concentration of blood antioxidant components (alpha-tocopherol and ceruloplasmin), and decreases the level of primary isopropanol-soluble products of lipid peroxidation.

First report of idiopathic segmental ureteritis successfully treated by steroid therapy.

We report a case of bilateral idiopathic segmental ureteritis in a 52-year-old woman. The diagnosis was established by imaging studies (magnetic resonance imaging/computed tomography scan), ureteroscopy and biopsies. The left side improved spontaneously, but the right ureteral stricture persisted after 3 months of ureteral stenting. Administration of prednisolone effectively relieved obstruction on the right side after 4 months. This is the first report of idiopathic segmental ureteritis successfully treated by steroid therapy, without invasive open procedures.

Solitary upper ureteral malakoplakia successfully diagnosed by ureteroscopic biopsy and treated conservatively.

Malakoplakia of the urinary tract is a granulomatous inflammatory disease due to bacterial infection and can usually be treated conservatively, whereas all of the past reported patients with solitary ureteral malakoplakia underwent surgical excision. We report a patient with solitary isolated upper ureteral malakoplakia that was successfully diagnosed by ureteroscopic biopsy. After conservative treatment with levofloxacin, bethanechol chloride and ascorbic acid, her right hydronephrosis and the lesion were reduced for more than six months.

[PDE5 inhibitors. A new option in the treatment of ureteral colic?]. / PDE-5-Inhibitoren. Ein neuer Therapieansatz in der Behandlung der Harnleiterkolik?

BACKGROUND: PDE5 inhibitors represent the gold standard in the medical therapy of erectile dysfunction (ED). Promising results have been published regarding further urological indications such as treatment of ureteral colic. The aim of the present study was to evaluate the functional effects of the PDE5 inhibitors sildenafil (SIL), vardenafil (VAR), and tadalafil (TAD) on tissue tension and cyclic nucleotide levels of human ureteral smooth muscle segments in vitro. METHODS: Relaxant responses of human ureteral smooth muscle were investigated in vitro using the organ bath technique. Cyclic nucleotides cAMP and cGMP were determined by specific radioimmunoassays. RESULTS: Relaxing effects of ureteral muscle tension were observed in the rank order VAR>SIL>TAD. While only VAR significantly elevated cGMP levels 3.3-fold over control, no increase for cAMP levels was observed. CONCLUSIONS: Our data provide evidence that cGMP is involved in the control of the normal function of the smooth musculature of the human ureter. Our findings suggest the potential of using selective inhibitors of PDE isoenzymes in the treatment of ureteral colic.

Ureteral endometriosis: diagnosis and management.

Ureteral endometriosis is a rare disease with only about 300 cases reported. The diagnosis is difficult. The symptoms are non-specific and the diagnosis is based on abdominal ultrasonography suspicion confirmed by intravenous pyelography. The management of ureteral endometriosis usually requires surgery. Hormone therapy should be offered to patients of childbearing age who desire to have children and have the disease in an early stage. Open or laparoscopic surgical treatment gives long-term favorable results.

[Malacoplakia in the ureter and bladder].

We report a case of malacoplakia in the ureter and bladder. A 78-year-old woman was admitted to our department for detailed examination of hydronephrosis. A small-fingertip-sized tumorous yellowish white lesion was detected by cytoscopy at a site that appeared to be the right side of the ureteral orifice. Transurethral resection was performed on the same site. Flat yellowish white protruding lesions were seen at two sites on the right ureter. Michaelis-Gutmann bodies were observed in biopsy specimens from both the bladder and ureter, and a diagnosis of malacoplakia was made. Ascorbic acid and bethanechol chloride were administered postoperatively. Endoscopy performed three months after the operation showed that the protruding lesions in the bladder and ureter had disappeared. Narrowing of the ureter or vesicoureteral reflux has not been seen to date.

CMV and BKV ureteritis: which prognosis for the renal graft?

This report describes two cases of ureteral stricture in renal graft recipients related to cytomegalovirus (CMV) and human polyoma BK virus (BKV) ureteritis with the same onset characterized by acute graft failure with no clinical signs of systemic viral infections. The histological analysis did not show other causes of graft impairment (i.e. drug toxicity and acute rejection). Ultrasound scan (US) revealed absent or mild hydronephrosis. The diuretic-MAG3 renal scan showed a urinary flow obstruction. The viral genomes were isolated from urine, peripheral blood and graft or ureteral tissues samples. A percutaneous nephrostomy confirmed the stricture, but it restored urine flow only in the graft affected by CMV ureteritis, the association with a specific antiviral therapy probably produced a stable restoration of graft function. In BKV ureteritis,the graft prognosis was poor; graft loss could be due to the progress of BKV nephropathy. A correct differential diagnosis of the etiologic agent responsible for the ureteritis is mandatory, because treatment and outcome of the infection are different.

[Partial ureterectomy in a case of intrinsic-type ureteral endometriosis].

We report a case of intrinsic-type ureteral endometriosis in a 28-year-old woman. She visited our hospital, complaining of lower abdominal pain. Drip infusion pyelography (DIP) showed left hydronephrosis, and left retrograde pyelography revealed a filling defect of the left pelvic ureter. Biopsy under ureteroscopy showed chronic ureteritis. It was difficult to exclude a malignant tumor, and we performed left partial ureterectomy and uretero-ureterostomy. The pathological examination showed endometrial tissue in the submucosal and muscle layer, and we diagnosed it as intrinsic-type ureteral endometriosis judging from the findings of the ureteroscopy and the operation. After the operation, drip infusion pyelography showed the improvement of the left hydronephrosis and ureteral passage, and the right ovarian endometriosis was found by gynecologists. She received hormonal therapy with the luteinizing hormone releasing hormone agonist for about half a year, but the right ovarian endometriosis remained unchanged. This is the ninth case in the Japanese literature reported as intrinsic-type ureteral endometriosis.

[Ureteral endometriosis: urological features]. / Endometriosi ureterale: aspetti urologici.

Endometriosis affects about 10-20% of premenopausal women but ureteral involvement is an infrequent event occurring only in 0.1-0.4% of cases. Clinical presentation and radiological aspects are non-specific so that preoperative diagnosis is difficult, requiring a high index of suspicion. Intravenous urography is mandatory in all patients with pelvic endometriosis. Between 1995 and 2001, 10 patients with severe endometriosis of the ureter were referred to our center. Bilateral involvement was present in 3 cases. 6 patients showed a significant involvement of other pelvic organs, with subsequent surgical treatment. 1 patient with bilateral ureteral endometriosis was treated by bilateral stenting and medical hormonal therapy, with good results. 2 patients underwent ureteral resection with primary reanastomosis; one of them showed an ureteral relapse 22 months after surgery, with the necessity of a second resection and ureteroneocystostomy. Ureteric resection and ureteroneocystostomy were initially performed in the other 7 patients, without evidence of recurrences in all cases (median follow-up 31 months). Hormonal therapy or hysteroadnexiectomy, when feasible, are necessary to reduce the risks of relapses. In our opinion, ureteral resection associated with ureteroneocystostomy gives the best chances to cure severe ureteral endometriosis.

[Localized amyloidosis of the ureter and bladder treated effectively by occlusive dressing technique therapy using dimethyl sulfoxide: a case report].

We report here the first case of localized amyloidosis of the ureter and bladder to be treated effectively by occlusive dressing technique therapy using dimethyl sulfoxide. The patient was a 48-year-old woman whose chief complaint was macrohematuria and right back pain. Ultrasound sonography demonstrated right hydronephrosis and an intravesical mass in the region of the right ureteral orifice. Retrograde pyelography revealed severe stricture of the right lower ureter. Cystoscopy demonstrated a yellow submucosal tumor around the right ureteral orifice. We suspected urinary tract amyloidosis, and transurethral biopsy and resection of the intravesical mass were performed under right ureteral stenting. Histopathological diagnosis was amyloidosis. There was no evidence of systemic amyloidosis. To treat residual amyloidosis of the ureter and bladder, we performed occlusive dressing technique therapy using dimethyl sulfoxide every day. After 6 months of therapy, the right hydronephrosis disappeared, and there was no evidence of a recurrence of amyloidosis. We concluded that this therapy was very effective and safe for urinary tract amyloidosis.

[Helium-neon laser radiation in the therapy of urinary bladder and ureteral tuberculosis]. / Gelii-neonovoe lazernoe izluchenie v terapii tuberkuleza mochevogo puzyria i mochetochnika.

The paper presents a comparative assessment of conventional therapy methods and the author's proposed treatment by using low-intensity helium-neon laser radiation in combination with endovesical submucous administration of tuberculostatics and glucocorticosteroids into the area of lesion in patients with tuberculosis of the bladder and intramural ureter.