[A Case of Lymphorrhea after Radical Cystectomy Treated by Ultrasound-Guided Inguinal Intranodal Lymphangiography].

A 76-year-old woman was diagnosed with invasive bladder cancer and underwent cystectomy, bilateral external iliac, internal iliac and obturator lymph node dissection, and bilateral cutaneous ureterostomy. Pathological findings showed no lymph node metastasis ; however, the patient had lower abdominal pain and fever from the 14th postoperative day, and computed tomography (CT) revealed fluid retention in the pelvis. Retrograde pyelography showed no leakage from the urinary tract, and a drain was placed after percutaneous puncture of the pelvic cavity. There was copious drainage fluid and its nature and composition suggested lymphorrhea. Ultrasound-guided intranodal lymphangiography revealed contrast material leakage from the bilateral lymph node dissection sites. After lymphangiography, drainage from the drain decreased. Despite the drainage being minimal yet persistent, sclerotherapy was performed, the drain was removed and the patient was discharged. After discharge, there was leakage from the site of urethral extraction, and CT revealed recurrent lymph leakage. The patient was readmitted, and a second lymphangiography was performed. The leakage from the site of urethral extraction gradually decreased, and the patient was discharged on the 59th postoperative day. CT after discharge confirmed that the lymphorrhea had shrunk in size, and there has been no recurrence since then. Lymphangiography is a promising treatment option for lymphorrhea after pelvic surgery.

[A Case of IgG4-Associated Tubulointerstitial Nephritis Developing into End-Stage Renal Dysfunction Even after Release of Urinary Obstruction by Ureteral Stenting].

A 74-year-old woman was transported to an emergency room of a general hospital with sudden left flank pain. After examination, the pain was attributed to left hydronephrosis resulting from left retroperitoneal fibrosis (RF). The pain and renal function improved after left ureteral stenting. Four months after the transportation, she was referred to our hospital for further examination. Her renal function deteriorated again despite successful release of ureteral obstruction. Consequently, the left kidney developed end-stage renal dysfunction at 15 months after symptom onset. Pathological examination of the left dysfunctional kidney removed by laparoscopic surgery to avoid infectious pyelonephritis revealed numerous IgG4-positive plasma cells invading the renal parenchyma. The pathological findings suggested that the renal dysfunction was due to IgG4-related tubulointerstitial nephritis (IgG4-TIN) rather than ureteral obstruction. In the case of RF with decreased renal function, not only retroperitoneal lesion biopsy but also renal biopsy should be considered to diagnose IgG4-TIN and start steroid treatment if necessary.