Leiomyosarcoma of the inferior vena cava extending into the right atrium. A rare differential diagnosis of a right atrial tumor with fatal outcome.

A 54-year-old female patient presented with a progressive and deteriorating dyspnea at the slightest exertion in particular during the past few days before presentation. Transthoracic echocardiography revealed a large space-occupying lesion in the right atrium extending into the inferior vena cava (IVC). Abdominal magnetic resonance aortography showed an elongated space-occupying lesion in the IVC with a significant portion of the tumor and almost completely filling the right atrium accompanied by an infiltration of the hepatic and renal veins. A pronounced tumor infiltration of the IVC at the level of the liver was confirmed intraoperatively and immunohistochemical analysis showed a moderate to poorly differentiated leiomyosarcoma. The extended tumor was successfully removed by a complex operation of the thorax and abdomen but the procedure was accompanied by severe bleeding. A few hours following the procedure the patient died due to a further episode of irreversible intra-abdominal hemorrhage.

Effects of artificial obstruction on the function of the upper urinary tract of Guinea pigs, rats and pigs.

PURPOSE: Four different experiments in animals were performed to evaluate the influence of pyelo-ureteral surgery on the function of the upper urinary tract. METHODS: Experiment I: In 17 female guinea pigs pyelo-ureteral anastomosis was performed microsurgically. Three months later, the ureteral peristalsis was investigated by measuring the intraureteral pressure and the in vitro activity of the renal pelvic and ureteric wall was analysed. Experiment II: 10 rats were used for microsurgical uretero-ureteral anastomosis. One month after surgery the pyelo-ureteral peristalsis was examined by videomicroscopy while simultaneously measuring the renal pelvic and intravesical pressure. Subsequently the kidneys were removed for histological examination. Experiment III: In 2 pigs unilateral pyeloplasty was performed. Using an implanted transmitter the intravesical and the renal pelvic pressures were recorded continuously over a time interval of 3 months. Five months after surgery the pyelo-ureteral peristalsis was investigated by pyelography. The kidneys were then removed for histological and biomechanical examinations. Experiment IV: A partial artificial obstruction was performed in 16 guinea pigs by implanting the ureter into the psoas muscle. Two to six months following surgery their upper urinary tracts were removed for analysis of in vitro activity as well as histological and immunohistochemical investigations of the ureter and renal pelvis. RESULTS: Experiment I: Ultrasound investigation showed in all cases a significant dilation of the renal pelvis. The ureteral contraction frequency distally was decreased in vivo as well as in vitro (p <0.05) compared with the controls. Experiment II: Videomicroscopic imaging showed in eight out of nine cases an interruption of the peristaltic wave below the anastomosis; the ureteral peristalsis was restored distally by ureteral contractions with a decreased frequency. Retroperistalsis was seen in the lower part of the ureter. The frequency of renal pelvic and ureteral contractions were decreased (p <0.05). Renal pelvic baseline pressure as well as contraction amplitude were irregularly changed. Histological examinations showed increased connective tissue within the renal pelvic wall in all cases. Experiment III: In both pigs an intermittent change in contraction frequency of the renal pelvis was found, associated with a changing contraction amplitude. Five months after surgery an interruption of the peristaltic wave was detected in both pigs. Histological examinations showed increased connective tissue within the renal pelvic wall. The stiffness of caliceal and pelvic tissue was lower following the pyeloplasty compared to the controls. Experiment IV: Following artificial partial ureteral obstruction in all guinea pigs the in vitro investigations showed an increased spontaneous activity of the upper urinary tract except in the proximal part of the ureter. Ureteral obstruction produced a change in contraction pattern of the proximal ureter and a decrease in contraction frequency of the distal ureter. Immunohistochemical investigations revealed rarefication and disorientation of nerve fibres within the proximal ureteric wall. CONCLUSIONS: Surgical interruption of the ureteral continuity and re-anastomosis cause a temporary disruption of the peristaltic wave at the anastomosis site. Ureteral peristalsis is restored by ureteral contractions associated with retroperistalsis as well as a decreased contraction frequency. Uretero-ureteral anastomosis in rats, pyelo-ureteral anastomosis in guinea pigs and pyeloplasty in pigs seem to influence the upper urinary tract similarly to a chronical functional obstruction, causing changes in pyelo-ureteral motility and spontaneous muscular activity of the renal pelvic and ureteral wall as well as biomechanical and histological characteristics.