Ex Vivo Partial Nephrectomy and Autotransplantation for Complex and Multifocal Renal Cell Carcinoma at a Single Institution: A Case Series.

Renal autotransplantation is a rare surgical procedure designed to preserve renal function in patients with complex urinary system diseases or highly complex renal tumors. Between 2012 and 2023, four patients underwent ex vivo partial nephrectomy (PN) and autotransplantation for complex renal tumors at our hospital. Two patients had bilateral multifocal renal tumors, including von Hippel Lindau (VHL) disease and hybrid oncocytic chromophobe tumor (HOCT). The remaining two patients had highly complex renal tumors with Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score of 12, one of whom had a solitary kidney. None of the patients experienced any postoperative surgical complications. Pathologically, nine of the excised tumors had negative surgical margins, except for one of the four tumors on HOCT. Postoperative renal function decreased at one month compared to preoperative renal function (P = 0.01); however, there was no significant difference at three months (P = 0.07). None of the patients had a local recurrence or metastasis at the latest follow-up.Ex vivo PN and autotransplantation are feasible and reasonable treatment methods for highly complex and multifocal renal tumors regarding safety, local tumor control, and preservation of renal function.

Evaluation of the Influence of a History of Childhood Nocturnal Enuresis on Nighttime Urinary Frequency and the Causes of Nocturia in Adults.

OBJECTIVE: To examine whether a history of nocturnal enuresis affects nighttime urinary frequency and to evaluate nocturia etiologies in adults. MATERIALS AND METHODS: A total of 143 participants with at least one episode of nocturia per night were included in this study. The self-reported questionnaire collected data on demographic characteristics, medical history, history of nocturnal enuresis in elementary school, lower urinary tract symptoms, and frequency-volume charts. RESULTS: A history of nocturnal enuresis was observed in 52.4% of participants. However, night-time urinary frequency was significantly lower in participants with a history of nocturnal enuresis in elementary school than in those without such history. On multivariate analysis, a history of nocturnal enuresis was also negatively associated with nighttime urinary frequency (P <.01). There was a collinearity effect between age and nighttime urinary frequency. A history of nocturnal enuresis did not affect the presence of nocturnal polyuria or overactive bladder in participants. However, sleep disturbances were fewer in participants with a history of nocturnal enuresis (odds ratio 0.404). CONCLUSION: A history of nocturnal enuresis might be negatively associated with nighttime urinary frequency due to fewer sleep disturbances. Further, progression of nocturia may depend on conditions, such as age and acquired diseases.

Early occlusion control of the intrapericardial inferior vena cava under femoral-femoral extracorporeal circulation using a technique to prevent pulmonary embolism during nephrectomy for renal cell carcinoma with tumor thrombus: two case reports.

BACKGROUND: Renal cell carcinoma with tumor thrombus extension into the inferior vena cava occurs in approximately 5% of cases. Despite such situations, an aggressive surgical approach is recommended. However, intraoperative prevention of pulmonary embolism by a fragmended tumor thrombus is necessary. To prevent pulmonary embolism, placement of a temporary suprarenal filter has been attempted, however, the precise placement of a temporary filter between the level of the hepatic vein and right atrium is not always easy because of its migration, tilting, and strut fracture. Here we report a method for early occlusion control of the intrapericardial inferior vena cava to prevent pulmonary embolism during nephrectomy in level II or III renal cell carcinoma tumor thrombus. CASE PRESENTATION: Our first case was a 37-year-old Japanese man with left renal cell carcinoma extending into the inferior vena cava below the main hepatic vein (level II) and our second was a 75-year-old Japanese man with right renal cell carcinoma extending into the retrohepatic inferior vena cava at the main hepatic vein (level III). En block resection of the kidney and the tumor thrombus was performed with the aid of partial extracorporeal circulation; the postoperative course of both patients was uneventful. CONCLUSION: Control of intrapericardial inferior vena cava is a feasible method to prevent pulmonary embolism.

[A case of renal salt wasting syndrome progressing to severe hyponatremia after gemcitabine-cisplatin chemotherapy].

Renal impairment with a decreased glomerular filtration rate is a classical nephrotoxicity associated with cisplatin (CDDP). Renal salt wasting syndrome (RSWS), which is characterized by water and salt wasting, is a rare nephrotoxicity associated with CDDP. This syndrome shares many similarities with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Thus, it is important to differentiate between RSWS and SIADH because the treatment of one affects the pathogenesis of the other. Here, we report a case of RSWS after chemotherapy with CDDP. A 72-year-old man with bladder urothelial carcinoma (cT2N0M0) was admitted to our hospital for the first cycle of neoadjuvant chemotherapy with CDDP and gemcitabine. He was administered intravenous fluids on day 2 before chemotherapy. Five days later, he developed nausea, dysorexia, delirium, hyponatremia (serum sodium level 115 mEq/l), and renal dysfunction. Thus, we administered a normal saline infusion. Over the next 6 days, his serum sodium level increased to 137 mEq/l, and we stopped normal saline infusion. Three days after discontinuation of saline infusion, his serum sodium level again decreased to 128 mEq/l, and the next day, his systolic blood pressure dropped gradually between 70 and 80 mmHg. Therefore, we resumed the normal saline infusion, and after 3 days, his serum sodium level increased to 135 mEq/l and systolic blood pressure ranged between 110 and 130 mmHg. On the basis of dehydration and high urinary sodium excretion at the onset of chemotherapy, we diagnosed this clinical condition as RSWS. We abandoned neo-adjuvant chemotherapy, and performed total cystectomy and ileal conduit. Since 4 months after surgery, he has been free from recurrence and metastasis.

[A case of micropapillary bladder carcinoma].

A case of urothelial carcinoma containing micropapillary variant in the urinary bladder is reported. The micropapillary bladder carcinoma isa rare variant of urothelial carcinoma and has an aggressive clinical course. A 45-year-old man complained of hematuria in October, 2009. He visited a hospital and was diagnosed with a bladder tumor. Transurethral resection of the bladder tumor was performed at the hospital. The transurethral resection demonstrated poorly differentiated adenocarcinoma invading the bladder muscle layer. Then he consulted our hospital. Our pathologist diagnosed the case as micropapillary variant of urothelial carcinoma in the urinary bladder. Accordingly, radical cystectomy and pelvic lymph nodes dissection were performed. After the operation, he received three courses of gemcitabine and cisplatin as adjuvant chemotherapy. The patient remains free of tumor recurrence and metastasis for 28 months after the cystectomy.

[A case of interstitial pneumonia during gemcitabine and cisplatin chemotherapy for locally advanced bladder cancer].

A 76-year-old woman received chemotherapy with gemcitabine and cisplatin (GC therapy) for local advanced bladder cancer. She suffered from dyspnea on day 19 during the first course of GC therapy. Both chest X-ray and computed tomography (CT) images revealed diffuse bilateral interstitial infiltrates. She was diagnosed as having drug-induced interstitial pneumonia. We identified gemcitabine as the causative agent based on the results of examinations (CT, X-ray, KL-6 level, drug lymphocyte stimulation test (DLST)). After three months of steroid therapy, her interstitial pneumonia was completely resolved on CT scans. Although gemcitabine-induced interstitial pneumonia is a rare adverse event, it should be considered a severe complication because delayed diagnosis and treatment can lead to a fatal outcome. Thus, early detection of drug-induced interstitial pneumonia is extremely important during GC therapy.

[A case of complicated perioperative management of radical nephrectomy in a patient with a drug-eluting stent].

Drug-eluting stents (DES) are commonly used for coronary artery disease and patients with DES require antiplatelet therapy because of the risk of late stent thrombosis. Accordingly problems can occur in the perioperative period due to late thrombosis of a stent after discontinuation of antiplatelet therapy before surgery. A 64-year-old man was diagnosed as having a right renal tumor (T1aN0M0) and his performance status was 4. Three years earlier, a DES had been placed in a coronary artery and he was taking aspirin plus ticlopidine. These drugs were stopped at 7 days before surgery and we started heparin (15,000 U/day). Heparin was continued during and after radical nephrectomy. Although operative blood loss was only 178 ml, the amount of bleeding within 5 hours after surgery was 1,620 ml. The wound was re-opened, but there was no obvious bleeding source, so oozing from the muscle was controlled. His blood pressure dropped and cardiac arrest occurred at 22 hours after re-operation, but he was resuscitated with blood transfusion and the bleeding stopped after the dose of heparin was reduced. Three days after the operation, antiplatelet therapy was re-started and heparin was ceased at 10 days after surgery. The blood clot in the right retroperitoneal space formed an abscess at 28 days after radical nephrectomy. After drainage, the retroperitoneal space was washed twice a day for about 40 days. The wound healed, and he currently has no evidence of recurrence or metastasis and has no cardiac sequelae.

Malignant epithelioid angiomyolipoma in the kidney and liver of a patient with pulmonary lymphangioleiomyomatosis: lack of response to sirolimus.

A 26-year-old woman with lymphangioleiomyomatosis (LAM) was hospitalized for the surgical excision of a giant abdominal tumor of right kidney origin. The pathological diagnosis of the tumor was conventional angiomyolipoma (AML). After 8 months, 2 liver tumors appeared and grew rapidly. The tumors were resected, and the pathological finding of these tumors was epithelioid AML. Thereafter, metastatic multiple lung tumors appeared, and there was local recurrence of the liver tumors. Sirolimus, an mTOR protein inhibitor, was used to treat epithelioid AML. However, the drug did not inhibit the rapid growth of the tumor at all. This finding suggests that sirolimus might not be effective against epithelioid AML, and in such cases, complete surgical resection should be the treatment of choice.

Migration of a metal clip into the urinary bladder.

Migration of metal clips into the urinary tract is rare. We present a case in which migration of a metal clip into the urinary bladder occurred after retropubic radical prostatectomy. A 75-year-old man, who had undergone retropubic radical prostatectomy three years before, presented with painful micturition and gross hematuria. Radiography and cystoscopy showed two vesical stones. As treatment for these stones, transurethral holmium laser lithotripsy was performed. One of the stones had formed around a metal clip that had presumably migrated into the urinary bladder. After removal of both stones, the patient was able to void freely. In conclusion, it is important to remember that metal clips may migrate postoperatively and cause secondary complications. Therefore, metal clips should be applied sparingly at the vesicourethral anastomosis during retropubic radical prostatectomy.

Changes of bladder activity and connexin 43-derived gap junctions after partial bladder-outlet obstruction in rats.

INTRODUCTION: We investigated changes of vesical gap junctions in relation to changes of the micturition reflex in rats with partial bladder-outlet obstruction (BOO). MATERIALS AND METHODS: A total of 66 female Sprague-Dawley rats were divided into six groups: sham operation (control); 3, 14, and 28 days after BOO; and 3 and 28 days after relief of BOO lasting for a three-day period. Under urethane anesthesia, isovolumetric cystometry was performed on each group. Expression of mRNA for the gap-junction protein connexin 43 (Cx43) in the bladder was measured in each group. Immunohistochemistry using Cx43 antibody was also performed on the bladder after BOO. RESULTS: The interval between bladder contractions was shorter in all of the other groups than in the control group. Expression of Cx43 mRNA was increased 3, 14, and 28 days after BOO (the peak increase was twofold), and three days after the relief of BOO, but it returned to the control level by 28 days after relief of BOO. Histologically, smooth muscle hypertrophy was detected in the bladder after BOO and punctate staining of the smooth muscle by Cx43 antibody increased after BOO. CONCLUSION: These results suggest that partial BOO produces detrusor overactivity that may depend on increased intercellular communication via gap junctions in the bladder. Relief of BOO led to a decrease of Cx43 mRNA, but detrusor overactivity persisted in the chronic phase, suggesting a reversible change of vesical gap junctions and an irreversible change of bladder activity after BOO.

Changes of bladder activity and glycine levels in the lumbosacral cord after partial bladder outlet obstruction in rats.

OBJECTIVES: We investigated the time course of changes in bladder activity as well as in spinal and serum levels of glutamate and glycine after partial bladder outlet obstruction (BOO) in rats. METHODS: A total of 36 female rats were divided into six groups: sham operation (control); 3 days, 14 days, and 28 days after BOO; 3 days and 28 days after relief of BOO. Under urethane anesthesia, isovolumetric cystometry was carried out in each group. Then, spinal and serum levels of glutamate and glycine were measured. RESULTS: The interval between bladder contractions was shorter in all of the groups compared with the control group. The amplitude and duration of bladder contractions was decreased at 3 days, 14 days, and 28 days after BOO, and at 3 days after relief of BOO. Spinal and serum glutamate levels showed no changes. However, the spinal glycine level was decreased at 14 days and 28 days after BOO, and at 28 days after relief of BOO. Serum glycine level was also decreased at 28 days after BOO and 28 days after relief of BOO. CONCLUSIONS: Detrusor overactivity during the chronic phase of partial BOO is partly caused by a decrease of glycinergic neuronal activity in the lumbosacral cord. A 3-day period of BOO produces detrusor overactivity, which might be due to an irreversible decrease of spinal glycinergic neuronal activity.

Restoration of bladder contraction by bone marrow transplantation in rats with underactive bladder.

We attempted to increase bladder contraction by bone marrow cell transplantation in rats with underactive bladder due to bladder outlet obstruction (BOO). Twelve female rats were anesthetized with halothane to create BOO. After 1 month, the urethral obstruction was removed and they were divided into a transplant group and a sham-operated group (n = 6 each). Bone marrow cells (1 x 10(7) / 0.2 mL) isolated from green fluorescent protein transgenic rats were injected into the bladder wall of the transplant group. Rats from the sham-operated group received injection of culture medium alone. One month after transplantation, isovolumetric cystometry parameters and histological features of bladder were observed as well as intact control rats (n = 6). The amplitude of bladder contractions was larger and the interval between contractions was shorter in the transplant group than the sham-operated group, and there were no differences in these parameters between the transplant group and the control group. Some green fluorescent muscle layers were found in the bladder wall of the transplant group, and these layers were also labeled by anti alpha-smooth muscle actin antibody. These results suggest that transplanted bone marrow cells may improve bladder contractility by differentiating into smooth muscle-like cells.

Investigation of biochemical factors related to non-bothersome nocturnal urination.

We investigated the factors related to nocturnal urination that was not considered bothersome by comparing various parameters between subjects who felt nocturnal urination as bothersome and those who did not. A total of 94 persons (50 males and 44 females) were enrolled. They urinated >or= once per night. Each subject's perception of nocturnal urination was examined, and the subjects were divided into a bothersome group and a non-bothersome group. Blood biochemical data and urinary condition were compared between the two groups and various subgroups. There were 60 subjects (56 +/- 17 years old) in the non-bothersome group, and 34 subjects (57 +/- 17 years old) in the bothersome group. The serum melatonin level was significantly lower and the total score of the International Prostatic Symptom Score questionnaire (IPSS) and the quality of life (QOL) score were significantly higher in the bothersome group than in the non-bothersome group. Among 50 subjects with nocturnal urination >or= twice per night, the serum melatonin level was also significantly lower and the QOL score was significantly higher in the bothersome group than in the non-bothersome group. In conclusion, nocturnal urination might be not considered bothersome when subjects maintain sufficient levels of melatonin.

Intravesical instillation of bacille Calmette-Guérin for superficial bladder cancer: cost-effectiveness analysis.

OBJECTIVES: Frequent recurrence of superficial bladder cancer is a major problem that impairs patients' quality of life. We studied the current treatment of superficial bladder cancer, including the economic aspects of intravesical instillation. METHODS: A total of 138 superficial bladder cancers were assessed. The tumor characteristics and treatments were investigated during a mean observation period of 86 months by univariate and multivariate analyses. The costs associated with intravesical instillation of bacille Calmette-Guérin (BCG) and its side effects were subjected to cost-effectiveness analysis. RESULTS: Tumor histologic examination revealed grade 1 in 21 lesions, grade 2 in 60 lesions, grade 3 in 40 lesions, and unclassified in 17 lesions. The pathologic stage was Stage Ta in 85 lesions, T1 in 47 lesions, and Tis in 6 lesions. Univariate and multivariate analyses showed that intravesical instillation of BCG was the most significant factor preventing recurrence, and intravesical chemotherapy had no impact on recurrence. The 5-year recurrence-free survival rate was 78% and 28% for tumors with and without BCG instillation, respectively. The cost-effectiveness ratio of BCG instillation was approximately 3900 dollars/5-yr recurrence-free period. CONCLUSIONS: Our results have indicated that BCG is an effective adjuvant therapy after transurethral resection of superficial bladder cancer in the current medical environment.

Relationship between serum cholinesterase level and urinary bladder activity in patients with or without overactive bladder and/or neurogenic bladder.

We compared the serum cholinesterase (ChE) level and various parameters between patients with or without overactive bladder (OAB) and/or neurogenic bladder (NB). A total of 258 patients who met the following criteria were enrolled: the presence/absence of OAB and/or NB was documented, laboratory data were available, and liver and renal functions were normal. Patients were divided into the 3 groups: 1) a NB+/OAB+ group who had both NB and OAB, 2) a NB-/OAB+ group who had OAB alone, and 3) an OAB- group who did not have OAB. The relationship between the presence of OAB and various biochemical parameters were examined, as well as the therapeutic outcome in relation to the same biochemical parameters. Forty-three patients had both NB and OAB (NB+/OAB+), 66 patients had OAB without NB (NB-/OAB+), and 149 patients had no OAB (OAB-). Serum ChE, total protein, and albumin levels were lower in the NB-/OAB+ group than the NB+/OAB+ group or the OAB- group. In the NB-/OAB+ group, a higher serum albumin or ChE level was associated with a better therapeutic outcome. These results suggest that a decrease of serum ChE level is related to the occurrence of OAB and the poor response to treatment in OAB patients without NB.

Effect of vitamin B6 deficiency on glyoxylate metabolism in rats with or without glyoxylate overload.

We examined the effect of vitamin B6 deficiency on glyoxylate metabolism and hepatic alanine: glyoxylate aminotransferase (AGT) activity in rats with normal or high glyoxylate intake. Male rats were divided into four groups: a control group, a vitamin B6-free diet group, a glyoxylate water group, and a vitamin B6-free diet + glyoxylate water group. Each group was given special diet (control or vitamin B6-deficient diet) and drinking water (plain or 0.5% glyoxylate water) for 4 weeks, after which biochemical parameters and hepatic AGT mRNA level were measured. Compared with control rats, the urinary oxalate/creatinine ratio was higher in each of the other 3 groups. The urinary glycolate/creatinine ratio was also higher in the vitamin B6-free diet group and the vitamin B6-free diet + glyoxylate water group than the control group, while the urinary glycine/creatinine and citrate/creatinine ratio was lower in both groups. The hepatic AGT mRNA level was reduced in the vitamin B6-free diet group, but was increased in the glyoxylate water group than the control group. These results suggest that vitamin B6 is necessary for glyoxylate metabolism as a coenzyme of AGT. Especially in the presence of a high glyoxylate intake, vitamin B6 deficiency leads to severe hyperoxaluria and hypocituria.

Gastrointestinal oxalic acid absorption in calcium-treated rats.

We studied whether urinary oxalate excretion after an acute oral load of oxalic acid is influenced by concomitant administration of calcium in rats. Male Wistar rats weighing approximately 180 g were divided into six groups of five animals each. After inducing anesthesia, the animals were orally (via a gastrostomy) given 110 micromol of oxalic acid along with 0, 27.5, 55, 110, or 220 micromol of calcium (0, 27.5, 55, 110, or 220 micromol Ca group, respectively). Saline was given to the control group instead of oxalic acid. Urine specimens were collected before administration and then at hourly intervals up to 5 h afterward. Urinary oxalate and citrate levels were measured by capillary electrophoresis, while urinary calcium, magnesium, and phosphorus levels were measured by ICP spectrophotometry. Urinary oxalate excretion peaked at 1 h after administration and was higher in the 0, 27.5, and 55 micromol Ca groups than in the control group. The urinary recovery of oxalate in these groups was 10-15%, while the recovery rate was less than 3% in other groups. Urinary Ca excretion showed no significant changes, either over time or between groups. Free oxalic acid is absorbed more readily from the gastrointestinal tract than calcium oxalate, while simultaneous administration of calcium appears to block intestinal oxalic acid absorption in a dose-dependent manner.