[AN ISOLATED INTERNAL ARTERY ANEURYSM WITH COMPLETE THROMBOTIC OCCLUSION FOR WHICH PREOPERATIVE DIAGNOSIS WAS DIFFICULT: A CASE REPORT].

A 74-year-old man was incidentally discovered during treatment of prostate cancer to have a pelvic tumor, measuring 8 cm in diameter. Enhanced abdominal computed tomography (CT) showed a roundish-shaped hypovascular solid tumor compressing the left internal iliac artery to the inner back side. Values on endocrinological examination were within normal ranges. The tumor was suspected to be chronic abscess, angiosarcoma, or gastrointestinal stromal tumor (GIST) or neurogenic tumor, but no definitive diagnosis was able to be established before operation. During laparotomy, given its location relative to the internal iliac artery wall, the tumor was extracted by sacrificing periphery of the artery. The pathological diagnosis was an internal artery aneurysm with complete thrombotic occlusion. Isolated internal iliac aneurysm is rare, and this is the first case which resulted in complete thrombotic occlusion.

Laparoscopic simultaneous bilateral adrenalectomy for testosterone-secreting bilateral adrenal tumors.

Laparoscopic adrenalectomy is widely accepted as a safe and minimally-invasive procedure. Although it is a standard procedure for the surgical treatment of adrenal tumors, its simultaneous use with bilateral adrenalectomy is relatively rare. A 21-year-old woman was referred to Hamamatsu University School of Medicine University Hospital complaining of a deepening voice, hirsutism and secondary amenorrhea. Abdominal computed tomography showed bilateral adrenal tumors, and hormonal examinations showed that the tumors secreted excessive testosterone, resulting in virilizing symptoms. Laparoscopic simultaneous bilateral adrenalectomy was carried out. Postoperatively, serum testosterone levels immediately recovered to within the normal range. Menstruation began the month after the operation, and the hirsutism gradually regressed. This is the third reported case of bilateral virilizing adrenal tumors, and the first to be successfully treated with laparoscopic simultaneous bilateral adrenalectomy.

[Surgery without blood transfusion for pheocromocytoma in a Jehovah's Witness patient: a case report].

A 59-year-old woman who identified as a Jehovah's Witness was diagnosed with pheochromocytoma in the left adrenal gland, measuring 11 cm in diameter, during treatment for hypertension. Given her desire to undergo transfusion-less surgery for religious reasons, we obtained fully informed consent and had the patient sign both a transfusion refusal and exemption-from-responsibility certificate and received consent to instead use plasma derivatives, preoperative diluted autologous transfusion and intraoperative salvaged autologous transfusion. To manage anemia and maintain total blood volume, we preoperatively administered erythropoiesis-stimulating agents and alpha 1 blocker, respectively. During the left adrenalectomy, the patient underwent a transfusion of 400 mL of preoperative diluted autologous blood, ultimately receiving no intraoperative salvaged autologous blood. The operation took 4 hours 42 minutes, and the total volume of blood lost was 335 mL. In conclusion, to complete transfusion-less surgery for pheochromocytoma, it is necessary to have the patient sign a generic refusal form for transfusion and exemption-from-responsibility certificate as well as outline via another consent form exactly what sort of transfusion is permitted on a more specific basis. And doctors should become skilled in perioperative management and operative technique for pheochromocytoma and make the best effort by all alternative medical treatment in order to build trust confidence with a patient.

Successful treatment for adrenocorticotropic hormone-independent macronodular adrenal hyperplasia with laparoscopic adrenalectomy: a case series.

INTRODUCTION: Adrenocorticotropic hormone-independent macronodular adrenal hyperplasia, characterized by bilateral macronodular adrenal hypertrophy and autonomous cortisol production, is a rare cause of Cushing's syndrome. Bilateral adrenalectomy is considered the standard treatment for adrenocorticotropic hormone-independent macronodular adrenal hyperplasia but obliges the patient to receive lifetime steroid replacement therapy subsequently, and may increase the patient's risk of adrenal insufficiency. These circumstances require surgeons to carefully consider operative strategies on an individual basis. CASE PRESENTATION: We performed successful laparoscopic adrenalectomy on four patients with adrenocorticotropic hormone-independent macronodular adrenal hyperplasia. Computed tomography scans showed bilateral adrenal enlargement in all patients. Case 1: a 56-year-old Japanese woman presented with obvious Cushing's symptoms during treatment for diabetes mellitus and hypertension. Case 2: a 37-year-old Japanese man also presented with Cushing's symptoms during treatment for diabetes mellitus and hypertension. These patients were diagnosed as Cushing's syndrome caused by adrenocorticotropic hormone-independent macronodular adrenal hyperplasia based on endocrinologic testing, and underwent bilateral laparoscopic adrenalectomy. Case 3: an 80-year-old Japanese woman was hospitalized due to unusual weight gain and heightened general fatigue, and was diagnosed as Cushing's syndrome caused by adrenocorticotropic hormone-independent macronodular adrenal hyperplasia. She underwent unilateral laparoscopic adrenalectomy due to high operative risk. Case 4: a 66-year-old Japanese man was discovered to have bilateral adrenal tumors on medical examination. He did not have Cushing's symptoms and was diagnosed as subclinical Cushing's syndrome due to suppressed adrenocorticotropic hormone serum levels and loss of cortisol circadian rhythm without abnormal levels of serum cortisol. He underwent unilateral laparoscopic adrenalectomy. During follow-up, serum cortisol levels were within the normal range in all cases, and serum adrenocorticotropic hormone levels were not suppressed. Further, cases with Cushing's syndrome experienced clinical improvement. CONCLUSIONS: We were able to effectively treat adrenocorticotropic hormone-independent macronodular adrenal hyperplasia in patients with obvious Cushing's symptoms by laparoscopic bilateral adrenalectomy, which promptly improved symptoms. Further, unilateral adrenalectomy was effective for treating an older patient at high operative risk and a patient with subclinical Cushing's syndrome.

[Rupture of renal artery aneurysm into the renal pelvis].

We report a case of ruptured renal artery aneurysm into the renal pelvis. A 48-year-old woman presented with complaints of gross hematuria and right back pain. Abdominal ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) revealed the aneurysm, which was 5 x 5 cm in diameter. Enhansed CT revealed blood flow from the renal artery aneurysm into the renal pelvis. Radical nephrectomy was performed. Rupture of renal artery aneurysm into the renal pelvis is the 3rd case in the Japanese literatures. Pathogenesis and management of this rare condition are discussed.

[A clinical study of laparoscopic adrenalectomy for pheochromocytoma--analysis of clinical parameters influencing operative time and intraoperative systolic blood pressure].

PURPOSE: We retrospectively analyzed the preoperative clinical parameters which influence operative time and intraoperative maximum systolic blood pressure in patients undergoing laparoscopic adrenalectomy for pheochromocytoma. MATERIALS AND METHODS: Between January 1992 and September 2010, we performed 28 laparoscopic adrenalectomies for pheochromocytoma at Hamamatsu University School of Medicine. These 28 cases were characterized based on the following parameters: body mass index (BMI), tumor size, history of hypertension, preoperative blood pressure, serum concentration of catecholamine, and 24-h urinary excretion of catecholamine metabolite. We retrospectively analyzed whether or not these parameters influenced operative time or intraoperative maximum systolic blood pressure. RESULTS: All 28 cases of laparoscopic adrenalectomy were performed safely and without intraoperative complications and needed neither blood transfusion nor conversion to laparotomy. The median operative time was 203 minutes, and intraoperative hypertension (systolic blood pressure > 200 mmHg) occurred in 46% (13/28) of cases. Median day of discharge in all patients was post-operative day 5. Significant positive correlation was shown between tumor size and operative time and between intraoperative maximum systolic blood pressure and serum concentration of catecholamine or 24-h urinary excretion of catecholamine metabolite (p < 0.05). CONCLUSION: The lengthened operative time for large tumors and elevated intraoperative blood pressure for tumors with high preoperative catecholamine activity necessitate careful perioperative management in patients receiving laparoscopic adrenalectomy for pheochromocytoma.

[Clinical course of patient with malignant pheochromocytoma who was treated with CVD chemotherapy and alpha-methyl-p-tyrosine].

A 31-years-old woman was diagnosed as pheocromocytoma by the various endocrine testings and 131I-MIBG scintigraphy. The CT scan and bone scintigraphy showed right adrenal tumor, along with liver metastasis, lymph nodes swelling around aorta and multiple bone metastases. She underwent chemotherapy consisting with Cyclophosphamide, Vincristine, Dacarbazine (CVD) and alpha-methyl-p-tyrosine (alphaMT), resulting in stable disease for 27 months. However, catecholamine levels increased gradually four weeks later. We would have planned 131I-MIBG therapy, but bone marrow suppression did not allow us to do it. She died of DIC.

BK virus nephropathy: clinical experience in a university hospital in Japan.

OBJECTIVES: To review the medical records of patients with BK virus nephropathy (BKVN) following kidney transplantation in our institution. METHODS: We screened patients for decoy cells using urine cytology, assessed serum creatinine levels, and conducted a graft biopsy, as well as assessed the presence of plasma BK virus DNA by quantitative real-time polymerase chain reaction. The treatment of BKVN was based on the decreased use of immunosuppressants. RESULTS: Overall, six male patients were studied (mean age 40.8 years, range 18-58; mean donor age 45.2 years, range 15-67). A positive urine cytology screen led to the subsequent detection of plasma BK virus DNA in the five patients with urine cytology results positive for decoy cells. In the four patients in whom plasma BK virus DNA was detected, a maximum value of DNA of > or = 10 000 copies/mL was observed. Time elapsed from transplantation to BKVN diagnosis ranged from 3 to 62 months. Although the two cadaver grafts were lost, the loss was not due to any effects directly associated with BKVN. The other four grafts are still functioning with a mean creatinine level of 1.8 mg/dL. Most of the patients with BKVN were regarded as being in a state of heightened immunosuppression. BK virus transition to blood was prevented in one patient. CONCLUSIONS: Early diagnosis of BKV infection with reduction of immunosuppression may potentially counter BK viremia and retard progression of BKV nephropathy. Decoy cell screening by urine cytology as well as plasma BK virus DNA screening should be considered in addition to the required graft biopsy in kidney transplant recipients, particularly in those with impaired graft function.

Impact of thymidine phosphorylase-expressing macrophages for surgical margin in partial nephrectomy.

OBJECTIVES: We investigated the relationship between the surgical margin in partial nephrectomy (PN) and thymidine phosphorylase (TP)-expressing macrophages in peritumoral tissue of renal cell carcinoma (RCC). METHODS: In 46 patients who underwent radical nephrectomy, we measured TP protein levels in tumor tissue, peritumoral tissue and normal tissue, and conducted immunohistochemical staining for TP and macrophages. In addition, we prospectively conducted PN with a 5-mm margin in 11 patients with pT1a RCC. RESULTS: The TP protein level and TP-positive macrophages were correlated with T classification, histological grade, mode of infiltration and venous invasion. However, for pT1 RCC, TP-positive macrophages in pT1a were significantly lower than in pT1b (p = 0.0140), while there was no significant difference in TP protein levels between pT1a and pT1b. No surgical margin was positive in 11 patients who underwent PN with a 5-mm margin, and no patient had local recurrence or distant metastasis during follow-up. CONCLUSIONS: The TP protein level and TP-positive macrophages in the peritumor area are thought to be associated with tumor progression in RCC, while a similar relationship was not found in pT1a RCC. These data suggest that a 5-mm margin might be safe to reduce the risk of local recurrence when PN is performed for treatment of solitary pT1a RCC.

Significance of 5-fluorouracil-related enzyme activities in predicting sensitivity to 5-fluorouracil in bladder carcinoma.

BACKGROUND: The association between 5-fluorouracil (5-FU)-related enzyme activity and the sensitivity of bladder urothelial carcinoma (BUC) to 5-FU were investigated, and methods to improve 5-FU sensitivity were analyzed. MATERIALS AND METHODS: Tumor specimens were obtained from 127 patients. Orotate phosphoribosyl transferase (OPRT) activity was analyzed by the paper disc method and thymidine phosphorylase and dihydropyrimidine dehydrogenase (DPD) activities were measured by ELISA. 5-FU sensitivity was assessed in 99 cases by an in vitro chemosensitivity test. RESULTS: A significant positive correlation between OPRT activity level and the sensitivity of BUC to 5-FU was identified. Moreover, the combination of 5-FU and 5-chloro-2,4-dihydroxypyrimidine significantly enhanced 5-FU sensitivity in BUC, particularly in cases showing higher DPD activity. CONCLUSION: OPRT was the most important enzyme in predicting sensitivity to 5-FU in BUC. These results may have implications for tailor-made medication using 5-FU-related compounds as postoperative adjuvant chemotherapy in BUC patients.

Impact of calcineurin inhibitors on urinary excretion of mycophenolic acid and its glucuronide in kidney transplant recipients.

Concomitant cyclosporine interacts with mycophenolic acid (MPA) through inhibition of the biliary excretion of its glucuronide (MPAG). The aim of this study was to evaluate the influence of calcineurin inhibitors on the plasma disposition and urinary excretion of MPA and MPAG in kidney transplant recipients. Twelve recipients treated with tacrolimus and 18 treated with cyclosporine at 30 days after transplantation were enrolled. AUC from 0 to 12 hours (AUC(0-12)) of MPA was significantly higher in tacrolimus-treated than in cyclosporine-treated recipients. In contrast, there was no significant difference in MPAG AUC(0-12) between calcineurin inhibitor medications. Unbound fractions of MPA and MPAG did not change significantly in a comparison between the tacrolimus and cyclosporine treatments (0.90% vs 1.27% in MPA; 20.0% vs 19.3% in MPAG). The ratio of renal clearance to creatinine clearance (CL(R)/CL(Cr)) of MPA was significantly lower in tacrolimusthan in cyclosporine-treated recipients (0.054 vs 0.100). In contrast, no significant difference was observed in the CL(R)/CL(Cr) of MPAG between the tacrolimus and cyclosporine treatments (0.19 vs 0.18). In conclusion, concomitant calcineurin inhibitors influenced the urinary excretion of MPA but not MPAG in kidney transplant recipients. The results suggest the presence of renal tubular secretion in the urinary excretion process of MPA.

How to use laparoscopic surgical instruments safely.

The development of laparoscopic surgery has been accompanied by a rapid increase in the number of laparoscopic surgical procedures carried out in the field of urology. In 2002 laparoscopic nephrectomy was approved for coverage under Japanese national health insurance, and in 2003 there were over 1000 registered cases in which this procedure was carried out. This suggests that laparoscopic nephrectomy, a procedure formerly conducted at only a few institutions, is now spreading to hospitals across Japan. Laparoscopic surgery involves the use of specialized instruments within a restricted field of vision, and risky surgical techniques can potentially result in visceral or vascular damage. In order to promote the use of safe laparoscopic surgery procedures, the Japanese Urological Association and the Japanese Society of Endourology and Extracorporeal Shock Wave Lithotripsy (ESWL) have inaugurated a certification program for urologic laparoscopy. This program not only encourages development in this field of surgery and provides technical certification to ensure appropriate levels of expertise, but also reviews methods for the correct use of instruments such as trocars and hemostats. The purpose of this video is to present correct methods for the use of a variety of laparoscopic instruments, in order to increase the safety of this procedure. The video has been designed to be useful not only for practitioners who are just beginning laparoscopy, but also for those who already have extensive laparoscopic experience. The video discusses five laparoscopic instruments (trocar, electric surgical devices, ultrasonic surgery devices, clips and clip appliers and endo-staplers), and demonstrates their correct use. In addition, animal models are used to illustrate the potential complications that can be associated with some methods of use.

Cyclosporine concentration-dependent increase in concentration ratio of mycophenolic acid acyl and phenol glucuronides to mycophenolic acid in stable kidney transplant recipients.

OBJECTIVES: The aim of this study was to evaluate the influence of cyclosporine (CyA) and tacrolimus (Tac) on the pharmacokinetics of mycophenolic acid (MPA) and its glucuronides. DESIGN AND METHODS: Kidney transplant recipients treated with mycophenolate mofetil and CyA (n=18) or Tac (n=17) in the stable phase were enrolled. The dependence of the trough concentration (C(0)) ratios of MPA acyl glucuronide (AcMPAG) to MPA (AcMPAG/MPA) and MPA phenol glucuronide (MPAG) to MPA (MPAG/MPA) on CyA C(0) or Tac C(0) was evaluated. RESULTS: AcMPAG C(0) and MPAG C(0) were significantly higher in CyA- than Tac-treated recipients (P=0.04 and 0.02, respectively). AcMPAG/MPA and MPAG/MPA were significantly correlated to CyA C(0) (r=0.75, P<0.01 and r=0.81, P<0.01, respectively), but not to Tac C(0). CONCLUSIONS: CyA increased AcMPAG/MPA as well as MPAG/MPA in a concentration-dependent manner, suggesting that higher CyA may cause AcMPAG-related adverse reactions. Tac did not alter pharmacokinetics of MPA and its glucuronides.

Comparison of pharmacokinetics of mycophenolic acid and its glucuronide between patients with lupus nephritis and with kidney transplantation.

The pharmacokinetics of mycophenolic acid (MPA) and its glucuronide (mycophenolic acid phenolic glucuronide, MPAG) in lupus nephritis (LN) have not been fully characterized. The aim of this study was to evaluate the pharmacokinetics of MPA and MPAG in LN patients by comparing the pharmacokinetics with those of kidney transplant (KT) recipients. Six LN patients (World Health Organization class IV and V) and 24 KT recipients [8 recipients treated with tacrolimus (Tac) and 16 with cyclosporine (CyA)] during the early posttransplantation period were enrolled. Pharmacokinetic parameters of MPA and MPAG were compared between LN patients and Tac-treated or CyA-treated KT recipients. The area under the concentration-time curve (AUC0-12) of MPA normalized to mycophenolate mofetil (MMF) dose (mg/kg) was significantly lower in LN patients and CyA-treated KT recipients than in Tac-treated KT recipients [median (range), 2.19 (0.87-4.23), 2.36 (1.13-5.74), and 4.86 (3.25-6.75) microg x h/mL per mg/kg, P < 0.05 and P < 0.01, respectively]. Dose-normalized MPAG AUC0-12 was significantly lower in LN patients and slightly lower in Tac-treated KT recipients than in CyA-treated KT recipients [median (range), 35.0 (8.34-69.8), 51.6 (34.4-94.8), and 84.1 (34.7-152) microg x h/mL per mg/kg, P < 0.05 and P = 0.13, respectively]. The ratio of MPA AUC5-12 to AUC0-12, an estimate of MPA enterohepatic recirculation, was slightly higher in LN patients and Tac-treated KT recipients than in CyA-treated KT recipients [median (range), 0.44 (0.35-0.56), 0.45 (0.42-0.61), and 0.34 (0.22-0.55), P = 0.29 and P = 0.10, respectively]. Serum creatinine was significantly lower in LN patients than in Tac-treated and CyA-treated KT recipients. In conclusion, the pharmacokinetics of MPA in LN patients is characterized by high MPA clearance and in CyA-treated KT recipients. Despite this higher clearance of MPA, MPAG AUC0-12 was lower in LN patients most likely due to better renal function in LN patients.

Influence of metal cations on plasma trough concentration of mycophenolic Acid and its glucuronide in tacrolimus-treated and cyclosporine-treated kidney transplant recipients.

The aim of this study was to evaluate the plasma trough concentrations (C(0)) of mycophenolic acid (MPA) and its major metabolite MPA 7-O-glucuronide (MPAG) in metal cation (MC)(-) (non-treated) and MC(+) (co-treated) patients who received tacrolimus (Tac) or cyclosporine (CyA). Fifty-nine Japanese stable kidney transplant recipients receiving immunosuppressive regimens containing mycophenolate mofetil (MMF) and a calcineurin inhibitor (CNI) were included in this study. Seven in the 25 patients receiving Tac and 8 in the 34 patients receiving CyA were treated with concomitant MCs administration. Multiple regression analysis revealed that concomitant MCs and CyA administration influenced MPA C(0). Their standardized partial regression coefficients were -0.29 and -0.41, respectively. Stratified analysis based on CNI treatment revealed that MPA C(0) decreased significantly by 56% with concomitant MCs administration in Tac-treated patients. There was no significant difference in MPA C(0) between the MC(-) and MC(+) groups in CyA-treated patients. With respect to MPAG C(0), MC(+) group tended to be lower by 26% than MC(-) group in Tac-treated patients. There was no significant difference in MPAG C(0) between the MC(-) and MC(+) groups in CyA-treated patients. Concomitant MCs administration did not affect the C(0) ratio of MPAG to MPA in either Tac- or CyA-treated patients. In conclusion, MCs co-administration decrease MPA C(0) in patients receiving Tac and may cause lower MPA exposure. There are little pharmacokinetic interactions between MMF and concomitant MCs in CyA-treated patients.

Retrospective comparative study of 59 cases of laparoscopic radical prostatectomy: transperitoneal anterior versus transperitoneal posterior approach.

OBJECTIVE: We retrospectively compared perioperative parameters, as well as the oncological and functional results, for laparoscopic radical prostatectomy (LRP) carried out via the posterior and anterior approaches in our hospital. METHODS: We recorded pre-, peri-, and postoperative parameters and complications, and evaluated the oncological and functional results to compare the posterior approach (group 1, n = 25) with the anterior approach (group 2, n = 34). RESULTS: There were no significant differences regarding the preoperative characteristics of the two groups. The incidence of major complications, positive surgical margins, and continence at 3 and 6 months postoperatively showed no significant differences between the two groups. Although mean blood loss (including urine) was not significantly different, the mean prostatectomy time was significantly shorter in group 2 (174.21 +/- 57.97 min) than in group 1 (224.76 +/- 66.72 min) (P = 0.003 by Student's t-test). Also, the postoperative recovery period until discharge was 5.94 days in group 2, and was significantly shorter than in group 1 (7.48 days) (P = 0.02 by Student's t-test). CONCLUSIONS: This retrospective comparative study shows that the anterior approach yields similar, if not better results than the posterior approach for LRP.

Ureteroscopic evaluation and laser treatment of chronic unilateral hematuria.

PURPOSE: Chronic unilateral hematuria is characterized by intermittent or continuous gross hematuria that cannot be diagnosed using standard radiology and hematology methods. We evaluated patients with unilateral renal hematuria to determine the cause of bleeding and investigated the usefulness of ureteroscopic laser treatment for this condition. MATERIALS AND METHODS: In a total of 23 patients with chronic unilateral hematuria radiology and hematology tests failed to reveal the source of hematuria since no abnormal findings could be detected. Preoperative urine cytology also showed no abnormalities. Subsequently all patients were investigated via ureteroscopy. In the case of a lesion being identified after complete inspection of the collecting systems the bleeding site was treated ureteroscopically with a holmium:YAG laser alone or in combination with a neodymium:YAG laser. RESULTS: The entire ureter and intrarenal collecting systems were inspected in all patients. Discrete lesions were found via ureteroscopy in 18 patients, including minute venous rupture in 14, hemangioma on a renal papilla in 2 and calculus in 2. In the remaining 5 patients no lesions were detected by ureteroscopic evaluation. Nine of the 18 patients with detected lesions were treated ureteroscopically with the laser because active bleeding spots were recognized during the ureteroscopic procedure. In all treated patients hematuria resolved with no recurrence during a median followup of 73 months (range 18 to 110). CONCLUSIONS: A patient in whom the cause of hematuria is unknown should undergo ureteroscopic evaluation. Ureteroscopic laser treatment is an excellent method for chronic unilateral hematuria.

BK virus subtype IV nephropathy occurring 5 years after kidney transplantation.

We report on a BK virus-associated nephropathy in a 28-year-old man. His symptoms occurred 5 years after he had received a kidney transplantation. He was treated with tacrolimus, azathioprine, and prednisolone. The progress of the disease was monitored by quantitative real-time polymerase chain reactions for BK virus DNA. An analysis of viral DNA showed that the BK virus in the patient's plasma belonged to genotype IV.

Laparoscopic nephrectomy, ex vivo repair, and autotransplantation for a renal artery aneurysm: Report of a case.

A 57-year-old woman was hospitalized with a left renal artery aneurysm (RAA). The aneurysm measured 35 mm in diameter and was located at the renal artery bifurcation. We performed a laparoscopic nephrectomy using a retroperitoneal approach and performed an ex vivo repair of the renal artery. The reconstructed kidney was then autotransplanted at the left iliac fossa. The patient's postoperative course was uneventful. A laparoscopic nephrectomy and ex vivo repair are both considered to be effective for treating complex RAA.

[Primary ureteral carcinoma composed of both transitional cell carcinoma and mucinous carcinoma: a case report].

We present a case of primary ureteral carcinoma composed of both transitional cell carcinoma and mucinous carcinoma. A 79-year-old woman visited her home doctor with the chief complaint of right lower abdominal pain. Abdominal computed tomographic scan (CT) disclosed a tumor measuring about 5 cm in diameter at the right lower quadrant of the abdomen. Percutaneous nephrostomy was performed for hydronephrosis and pyonephrosis. The urinary cytology revealed class V, transitional cell carcinoma. Re-abdominal CT showed further enlargement of tumor diameter, but the primary site of the tumor was not identified. Her general condition worsened, and she died 42 days after her initial complaint. Pathologic examinations upon autopsy revealed both mucinous carcinoma and transitional cell carcinoma in the right ureter. Pathogenesis and management of this rare condition are discussed.