Obstructive nephropathy refers to the mechanical or functional changes in the urinary tract that interfere with normal urinary flow. Once obstruction is set, it leads to progressive renal damage that is mainly characterized with tubulointerstitial fibrosis. Here we reviewed the pathophysiology of urinary tract obstruction and indicated future therapeutic options. Following complete unilateral ureteral obstruction, there is a progressive fall in renal blood flow and glomerular filtration rate, and is an increase in intratubular pressure. These events activate the plasma and tissue renin-angiotensin systems (RAS). It has been proved that upregulated angiotensin II is one of the crucial factors those are responsible for the subsequent deleterious process. Angiotensin II induces transforming growth factor-β, which causes overproduction of extracellular matrix (ECM) proteins like collagen, fibronectin, etc. The ECM proteins are dominantly accumulated in tubulointerstitium and result in deterioration of renal function. Along with the activation of the RAS, tissue ischemia and mononuclear leukocyte infiltration also modulate the fibrotic changes. The process from the RAS activation to renal fibrosis is observed not only in obstructive nephropathy but also in other renal diseases and is called the Final Common Pathway. Mechanical release of the obstruction is to perform in terms of the treatment, however, several promising pharmaceutical options are now under investigation.
(Purpose) An intestinal segment interposed in the urinary tract can influence the water-solute balance of the patients with urinary diversion. It seems necessary to know whether such influence is changeable with the lapse of time and is also important to know whether diuresis is beneficial or not to minimize the effect of intestinal urinary diversion. (Materials & Methods) In 8 female mongrel dogs a unilateral ileal conduit urinary diversion was constructed in the right nephroureteral units using a 20cm segment of the ileum. After two months, separate urine for exactly 3 hours was collected from the conduit stoma and the bladder catheter, and analysis was made on each solute in the urine. In 4 dogs surviving for 4 years with stable renal function the examinations were repeated to compare with previous results. Furthermore, the effect of diuresis on the water and solute excretion was examined using 6 dogs. (Results) Water was reabsorbed or excreted from the ileal conduit according to the osmolality of the urine. No significant change was observed 4 years after operation. Urinary solute excretion and osmolality of the diverted side were always lower than those of intact side throughout the period. Creatinine clearance was not influence by the interposition of an ileal segment in the urinary tract in any periods. Excretion of water and reabsorption of solute was accelerated under oliguric condition and significant reabsorption of creatinine was observed in this condition. (Conclusion) In the experimental observation using canine model with unilateral ileal conduit urinary diversion no significant differences were observed in water and solute metabolism between the early period and 4 years after operation. Diuresis appeared to be favorable to minimize the reabsorption of urinary solute from the ileal conduit.
(Purpose) The aim of current study was to review the consequence after introduction of clean intermittent catheterization (CIC) in children with neurogenic bladder dysfunction secondary to spina bifida. (Patients and Methods) We retrospectively reviewed the records of 34 children (19 girls and 15 boys) presenting our clinic in a 18-year period. The patients were divided concentrating on the radiological upper urinary tract findings when CIC was introduced. 18 children had dilated upper urinary tract. In these patients, 10 children already had dilated upper urinary tract at first visiting to our clinic (group A). In remaining 8 patients, dilatation of upper urinary tract was found out in the course of followup (group B) .16 children had normal upper urinary tract when CIC was introduced. In 7 patients, CIC was applied for post-void residual and urinary tract infection (group C). In remaining 9 patients, CIC was introduced for urodynamically low compliance bladder (group D). (Results) In group A, 5 patients underwent enterocystoplasty and 3 patients underwent anti-reflux surgery consequently. Two patients, including 1 patient who underwent enterocystoplasty, have chronic renal dysfunction. In group B, 3 patients underwent enterocystoplasty and 2 patients underwent anti-reflux surgery. In group C, all patients have normal upper urinary tract. In group D, 8 patients have normal upper urinary tract. However, 1 patients underwent enterocystoplasty for low compliance bladder with vesicoureteral reflux (VUR). (Conclusion) Some patients show the improvement of dilated upper urinary tract or VUR after introduction of CIC. However, enterocystoplasty or anti-reflux surgery was needed for many patients to prevent upper urinary tract deterioration. The patients whom CIC was introduced for post-void residual and urinary tract infection have not shown any deterioration of upper urinary tract. The efficacy of CIC for incontinence was poor because many patients have urethral sphincter incompetence.
(Purpose) We developed an innovative transurethral resection system (TURis) consisting of a uniquely-designed generator and a resectscope. The obturator nerve is protected from trouble-some reflexes during TURis because the high frequency current delivery route is via the resection loop to the sheath of the resectscope and not via a patient plate. After extensive preclinical evaluation and verification of the system using an animal model to ensure efficacy as well as operational safety, TURis was conducted for treatment of superficial bladder cancer and benign prostatic hyperplasia. (Materials and Methods) In preclinical experiments swine bladder wall was transurethrally resected using the system in a saline environment. The results were compared with data obtained from an identical resection using the conventional system using sorbitol solution irrigation. Electrolytic contents were measured after TUR for comparative evaluation vis-a-vis corresponding pre-TUR data. Also, the depth of heat degeneration was measured in the resected tissue. From December, 2000 to June, 2002, TURis was performed in 25 cases of superficial bladder cancer and 30 cases of benign prostatic hyperplasia (BPH), using saline irrigation. All 55 cases were performed under spinal anesthesia without an obturator nerve block. The output power was set at 280W for cut and 120W for coagulation. A smaller electrode than those used in conventional TUR was used to improve the cutting efficacy. Occurrence of obturator nerve reflexes, difference of hematocrit and electrolytic contents before and after TURis, operation time and total volume of irrigated saline were evaluated. (Results) TURis in animal model: No adductor contraction of a lower limb was observable except for minimal creeping during the resection of a site close to the urethra. There were no apparent anomalies relative to the blood electrolyte content after TURis. No difference was observed in the mean depth of heat-degeneration tissue change compared with the conventional system. TURis for bladder cancer and BPH: No additional skills were required for TURis compared to conventional TUR. No obturator nerve reflex was observed except for a clinically insignificant thigh movement in one case of bladder cancer. The post-TURis blood tests manifested no significant anomalies in blood electrolyte content. Mean operation time for bladder cancer and BPH were 32 and 42 minutes respectively. Mean volumes of saline consumed during TURis were 6, 083ml for bladder cancer and 16, 100ml for BPH. (Conclusions) TURis worked effectively in a saline-irrigated environment. It does not need a patient plate and obturator nerve block even in cases of bladder cancer on the lateral wall. In addition, saline was both safe and cost-effective compared to non-electrolytic solution as irrigant for TUR of BPH. This suggests that TURis may have more applications than conventional TUR.
(Purpose) The indications and the safety of non-ischemic partial nephrectomy using a micro-wave tissue coagulator were studied. (Materials and Methods) Non-ischemic partial nephrectomy was performed on 17 kidneys of 16 patients using a microwave tissue coagulator. The diagnosis was renal tumor and renal stones in eleven and five patients, respectively. Renal tumors were less than 4 centimeters in diameter, while the stones were associated with a caliceal diverticulum or secondary cortical atrophy. Excision of the tumors was done via the retroperitoneal approach through an oblique lumbar incision. The needle of the microwave tissue coagulator was inserted around the tumor (stone) 10 to 20 times, and the coagulator was activated. Then the tumor (stone) was excised with a sharp knife or scissors. Patients were encouraged to walk on the first postoperative day. (Results) Vascular clamping was necessary in one patient to reduce bleeding. Nephrectomy was done after partial nephrectomy in one patient because it was difficult to close the urinary collecting system after it was widely exposed. Although urine leakage was seen postoperatively in two patients, it ceased spontaneously at 14 and 23 days after surgery. Postoperative complications developed in one of seven patients (14%) with protruding renal tumor, in three of five patients (60%) with non-protruding renal tumor and in two patients with renal stone. Allogenic or autologous blood transfusion was not necessary, nor was any bleeding noticed post-operatively. In one patient, atrophy of the renal parenchyma occurred gradually after surgery and function was eventually lost. However, renal function was well preserved and recurrence of the problem was not observed in the other 15 patients, excluding one who died of esophageal cancer. (Conclusions) The microwave tissue coagulator is a useful surgical instrument for non-ischemic partial nephrectomy, not only in patients with renal tumors but also in patients with complicated kidney stones. However, non-protruding renal tumor in a patient with solitary kidney should be avoided for this surgery. Thermal injury to the renal parenchyma or large vessels should be avoided and urine leakage from the collecting system should be meticulously treated during the operation.
We present a case of 29-year-old female who underwent an ABO-incompatible living kidney transplantation from her father. The serum creatinine (s-Cr) level of this patient was stabilized about 1.1-1.2mg/dl during the first 3 months after the transplantation. Thereafter, the function of allograft was deteriorated gradually. A biopsy performed on post-transplant day (PTD) 520 to evaluate a rise in creatinine revealed an interstitial nephritis and chronic renal allograft nephropathy. The renal function worsened persistently, although we increased the dosage of immunosuppressant subsequently. The following biopsy performed on PTD 630 showed a suspicion of BK virus nephropathy, with a mass of tubular epithelial nuclear inclusions and an interstitial nephritis. The diagnosis of BK virus nephropathy was comfirmed on the immunohistochemistry staining using anti-SV40 antibody and PCR analysis. Despite reducing the immunosuppressants, the function of the allograft worsened progressively and was lost on PTD 912.
A case of haemangiopericytoma of right spermatic cord is reported. A 50-year old male presented with a month-lasting painless swelling of right scrotum. Ultrasonography revealed a soft tissue mass in right spermatic cord, which was about 3.5cm in diameter. Right high inguinal orchiectomy was performed. The tumor was solid, smooth surfaced and well circumscribed. Histologically, the tumor had many capillary vessels and short spindle calls around the vessels. On the silver impregnation, argyrophil fibers surrounded the tumor cells. Immunohistologically, tumor cells were positive for CD34 antigen and negative for facter VIII antigen. The mitotic rate was 2per high-power field. Accordingly, this tumor was diagnosed as benign haemangiopericytoma. The patient is doing well without any sign of recurrence, as of 30 months post-operatively. Haemangiopericytoma is a rare neoplasm of pericyte origin. It commonly occurs in retroperitoneum and lower extremities. To our knowledge, only two cases of malignant haemangiopericytoma of the spermatic cord was reported, and this case is the first benign case of the spermatic cord.
We present a case of bleeding from the prostatic artery, complicating transrectal ultrasound (TRUS) guided prostate needle biopsy, that responded to transcatheter arterial embolization (TAE). A 62-year-old man with a serum PSA of 4.1ng/ml was admitted to this institution for a prostate biopsy. He developed hypotension and marked abdominal distension 3 hours after undergoing TRUS guided prostate needle biopsy. CT scanning revealed a massive hematoma extending from the pelvis into the retroperitoneal space. Intra-arterial digital subtraction angiography (IA-DSA) showed extravasation of dye from the right prostatic artery, indicating that it had been damaged during the biopsy procedure. The bleeding was successfully stopped with TAE, using 6 micro coils. TRUS guided prostate biopsy is generally considered a safe procedure, with few complications, and cases of massive hemorrhage into the retroperitoneal space are extremely rare. In cases of arterial retroperitoneal bleeding such as this one, treatment with TAE is fast and accurate.
A 23-year-old male was admitted to our hospital for the management of pulmonary metastases. He had undergone right high orchiectomy, chemotherapy with four courses of PEB regimen (cisplatin, etoposide, bleomycin) and retroperitoneal lymph node dissection the previous year. The pathological findings showed mixed germ cell tumor (seminoma, yolk sac tumor, embryonal carcinoma) in the testis and mature teratoma in the draining lymph node. Two courses of salvage chemotherapy using a VIP regimen (etoposide, ifosfamide, cisplatin) were performed after diagnosis of pulmonary metastases, but had no affect on tumor size. Video-assisted excision of pulmonary metastases was then performed, giving a pathological diagnosis of rhabdomyosarcoma in all three resected tumors. The operation was followed by three courses of CYVADIC (cyclophosphamide, vincristine, adriamycin, dacarbazin) chemotherapy and oral cyclophosphamide, as a small residual tumor was suspected. These chemotherapeutic interventions have appeared effective, with no apparent recurrence of lesions at present, one year after the excision of pulmonary metastases.
Interferon α (IFN-α) therapy was conducted for a male patient aged 70 years old, who underwent a two-stage radical nephrectomy for bilateral renal cell carcinoma with multiple pulmonary metastasis. He was hospitalized due to leg weakness and disorientation 45 days after this treatment was started. We discontinued INF-α therapy immediately after neurologists indicated the disorder of the central and the peripheral nervous systems induced by the administration of this cytokine. Steroid pulse therapy was effective to resolve the patient's neurological symptoms. To our knowledge, this is the first case of the side effects on both central and peripheral nervous systems by IFN-α therapy for renal cell carcinoma.
A 73-year-old man presented with gross hematuria. Ultrasonography and computerized tomography showed small bladder tumors and a left renal mass protruding to renal pelvis. Transurethral resection of bladder tumor and ureteroscopic tumor biopsy were perfomed, and pathological examinations revealed transitional cell carcinoma in the bladder and renal cell carcinoma in the kidney. He underwent left radical nephrectomy. A 4-month postoperative cystoscopy revealed a solitaly non-papillary tumor in the bladder. Transurethral resection was performed and pathological diagnosis was metastasis from renal cell carcinoma. At that time, multiple metastases to ureteral stump and lung were found. He had undergone palliative treatment because of his poor general condition until he died 26 months postoperatively. Care should be taken for management of ureteral stump when diagnostic ureteroscopy was done for renal cell carcinoma invading the renal pelvis.