case a 45 year old man with recurrent pain in the right flank & hematuria.pdf

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case records of themassachusetts general hospital

The new england journal of

medicine

n engl j med 351;20

www.nejm.org november 11, 2004

2102

Founded by

Richard C. CabotNancy Lee Harris, m.d.,

Editor

Jo-Anne O. Shepard, m.d.

,Associate Editor

Stacey M. Ellender,Assistant Editor

Sally H. Ebeling,Assistant Editor

Christine C. Peters,Assistant Editor

Case 34-2004: A 45-Year-Old Manwith Recurrent Pain in the Right Flank

and Hematuria

Douglas M. Dahl, M.D., Peter R. Mueller, M.D., and Robert H. Young, M.D.

From the Departments of Urology (D.M.D.),Radiology (P.R.M.), and Pathology (R.H.Y.),Massachusetts General Hospital; and theDepartments of Surgery (D.M.D.), Radiol-ogy (P.R.M.), and Pathology (R.H.Y.), Har-vard Medical School.

N Engl J Med 2004;351:2102-10.

Copyright 2004 Massachusetts Medical Society.

Dr. Donald S. Kaufman (HematologyOncology): A 45-year-old man was admitted to the

hospital because of recurrent flank pain, hematuria, and a mass in the renal pelvis.The patient had had an episode of hematuria and pain in the right flank 11 months

earlier, which had been evaluated at another hospital. At that time, an intravenous pye-logram showed a high-grade obstruction on the right side. Right retrograde nephro-

ureterography performed at the same time a stent was placed showed a filling defect inthe right proximal ureter that was consistent with a uric acid stone. A radiograph after

the procedure showed the stent in good position and also showed at least two areas ofdensity indicating calcification that were believed to be calculi; both were 1 cm in diam-

eter and were in the region of the middle of the right kidney.Two months later, the stent was removed because of associated pain and an increase

in both urinary urgency and frequency. A computed tomographic (CT) scan of the ab-

domen and pelvis showed a calcific opacity, 2 mm in diameter, within the lower pole ofthe right kidney that was believed to be a nonobstructing renal stone. The patient had

been well otherwise. He drank alcohol rarely and had smoked cigarettes in the past, buthad stopped 15 years previously.

Two weeks before the admission to this hospital, he had had a sudden, sharp pain in

the right flank that radiated to the right groin and was associated with mild hematuria.He was evaluated five hours later in an emergency department near his home. The tem-

perature was 36.9C, the blood pressure 142/76 mm Hg, the pulse 96 beats per minute,and the respiratory rate 24 breaths per minute. An intravenous pyelogram showed a

dilated collecting system on the right and no contrast material in the right ureter. A di-

agnosis of a stone in the right kidney was made; hydromorphone and ketorolactromethamine were administered for pain, and promethazine for nausea. Urinalysis

showed a pH of 7.5; the urine was positive for occult blood (+++), the red cells were toonumerous to count, and no white cells or bacteria were seen. The patients symptoms

improved, but during the next seven hours the pain returned, with epigastric discomfort,chills, and a temperature as high as 38.5C. He was given additional analgesic and anti-

emetic medication, levofloxacin, and famotidine. He was transferred to this hospital.

pres en t at i on of cas e

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On examination, the temperature was 36.6C,

the blood pressure 151/100 mm Hg, the pulse 70beats per minute, and the respiratory rate 20 breathsper minute. The abdomen was soft, with mild ten-

derness in the right lower quadrant and right flank;there were no masses. The examination was other-

wise normal. Urinalysis showed a pH of 6.5, and theurine tested positive (+++) for occult blood; there

were between 50 and 100 red cells, between 5 and10 white cells, and a few bacteria per high-power

field. A complete blood count; electrolyte levels;results of liver-function tests; the values for uric acid,urea nitrogen, creatinine, protein, amylase, and

lipase; and the prothrombin and partial-thrombo-plastin times were all within normal ranges. Meper-

idine, hydroxyzine, morphine sulfate, ampicillin,and gentamicin were given, and fluids were admin-istered intravenously. The fever and pain resolved

over the course of the following nine hours.

On the next day, a CT scan of the abdomen with-out the administration of contrast material showeda nonobstructing stone, 3 mm in diameter, in the

lower pole of the right kidney (Fig. 1A). There wasmild dilatation of the right renal collecting system,

with periureteral and perirenal stranding sugges-tive of a recently passed stone (Fig. 1B). Ultrasono-graphic examination of the right kidney showed a

soft-tissue density within the right renal pelvis withareas of high attenuation that were believed to rep-

resent blood clots (Fig. 2). There was no evidenceof hydronephrosis or masses within the kidneys.

No calculi were identified. The patient was dis-

charged later that day with instructions to strain hisurine for stones, take levofloxacin for two weeks,

take oxycodone and acetaminophen for pain, andreturn if worsening hematuria, severe pain, or fever

developed.Eleven days after discharge, he returned as an

outpatient for follow-up CT of the abdomen afterthe oral and intravenous administration of contrastmaterial. The scan showed a nonobstructing stone,

0.4 cm in diameter, in the lower pole of the rightkidney, with a density of 300 Hounsfield units. De-

layed images, which show the excretory phasebetter, were obtained after the administration of

contrast material, and they revealed an irregularlyshaped soft-tissue mass, 2.6 cm by 2.0 cm, in theright renal pelvis (Fig. 1C).

Three days later, the patient was readmitted tothe hospital, and a diagnostic procedure was per-

formed.

Figure 1. Computed Tomographic (CT) Scans of the Ab-

domen and Pelvis.

CT scanning without the administration of contrast ma-terial (Panel A) showed a nonobstructing stone, 2 to 3 mm

in diameter (arrow), in the lower pole of the right kidney

in a location where calcific densities had been seen sev-

eral months earlier. In contrast to what was shown onthe earlier CT scan, there was mild dilatation of the right

collecting system (Panel B) that contained high-density

material (arrows) within the pelvocaliceal system, consis-tent with the presence of blood. CT scanning after the ad-

ministration of contrast material 11 days later (Panel C)

shows an irregular filling defect (arrow) within the rightpelvocaliceal system, with no other abnormalities.

A

B

C



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Dr. Kaufman:

May we review the radiology studies?

Dr. Peter R. Mueller: The films from the other hos-pital are not available.

At the time of the mans first admission here, aroutine stone protocol CT study was performed;this consists of a helical CT scan of the abdomen

and pelvis obtained without the administration ofeither oral or intravenously administered contrast

material.

1

This is now considered the standard ap-proach to the evaluation of suspected stone disease.

The resulting scans showed a nonobstructing stone,

2 to 3 mm in diameter, in the lower pole of the rightkidney in a location where calcific densities had

been seen several months earlier (Fig. 1A). How-ever, on this CT scan there was mild dilatation of

the right collecting system that contained high-density material within the pelvocaliceal system,

consistent with the presence of blood (Fig. 1B).There was perirenal and periureteral stranding, butno stone was seen in the pelvocaliceal system or

ureter. No specific cause of hydronephrosis wasnoted.

This study was followed by an ultrasonograph-ic examination on the same day to evaluate the col-

lecting system. The ultrasonogram showed a soft-tissue density within the pelvocaliceal system withassociated hydronephrosis (Fig. 2). It was difficult

to determine on this study whether the dense areawas a clot or a tumor.

Eleven days later a specialized CT procedure toevaluate hematuria was performed. This consists

of standard CT that extends through the kidneys,

di fferen t i al di ag n os i s

ureters, and bladder, which is then followed by CT

scanning performed after the intravenous admin-istration of contrast material, with delayed images.This delay allows the pelvocaliceal system, ureter,

and bladder to be imaged in the excretory phase.

2

Tumors of the kidney, parenchyma, and pelvocal-

iceal system can be evaluated by this method. De-layed imaging makes possible visualization of the

collecting system, ureters, and bladder; the resultis analogous to an intravenous pyelogram, but with

better resolution. On this examination, an irregularfilling defect was noted within the right pelvocal-iceal system, with no other abnormalities (Fig. 1C).

When the density of this filling defect on imagesobtained with and without added contrast material

was compared, evidence of enhancement with con-trast material was seen.

Dr. Kaufman:

Dr. Mueller, does a case like this

require radiologists to rethink the standard ap-

proach to hematuria, especially when it occurs in ayounger person?

Dr. Mueller:

The role of radiologic imaging in pa-

tients with suspected stone disease or hematuria,or both, has changed dramatically in the past five

years.

3

CT, because of its ability to scan thin sec-tions in short periods of time and because of theavailability of multiplanar reconstruction, has re-

placed intravenous urography as the primary diag-nostic tool in both settings.

1,2

A CT scan obtained

without the administration of contrast material isused to diagnose a stone; the addition of intrave-

nously administered contrast material with delayed

images is used to diagnose tumors. The accuracyand sensitivity of a noncontrast-enhanced CT scan

for renal, ureteral, and bladder stones approach100 percent.

4

Tumors as small as 1 cm in diameter

can be visualized by contrast-enhanced CT scan-ning.

5

Dr. Kaufman:

Dr. Harisinghani, should every pa-tient with hematuria undergo a contrast-enhancedstudy?

Dr. Mukesh Harisinghani (Radiology): Yes. Untilrecently, the imaging algorithm for evaluating pa-

tients with hematuria was to obtain a scan withoutenhancement and if stones were identified, no con-

trast material was administered. However, smalltumors can be missed with this technique. Withthe use of intravenous contrast material, such tu-

mors can be diagnosed.

Dr. Kaufman:

I have asked Dr. Dahl, who cared

for this patient, to review the differential diagnosisof hematuria and discuss the evaluation and man-

agement of this case.

Figure 2. Ultrasonogram of the Kidney.

An area of soft-tissue density is visible within the pelvo-

caliceal system.



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Dr. Douglas M. Dahl:

This 45-year-old man, with

a history of cigarette smoking, had recurrent epi-sodes of right renal colic and hematuria and radio-graphic findings of renal obstruction and a stone.

The differential diagnosis of hematuria is broadand includes pathologic processes in the renal pa-

renchyma, upper urinary collecting system, ureter,bladder, and urethra, as well as extrinsic processes

that encroach on the urinary drainage system.

6

Thefocus is narrowed by the knowledge of a localizing

symptom and radiographic findings of an obstruc-tion in the upper urinary tract. I will discuss sourcesof bleeding from the upper urinary tract that could

explain this patients clinical syndrome.Urinary stone disease is common, occurring in

1 in 10 people over a lifetime. Symptoms includesevere colicky flank pain. Gross hematuria is pres-

ent in 15 percent.

3

The renal pelvis and ureter con-tain highly vascular epithelium that, when irritated,

can cause bleeding. Blood clots may form and ob-struct the flow of urine, which results in pain. Stonesmay contain either calcium or uric acid. A patient

with uric acid lithiasis typically has a very low uri-nary pH value. Uric acid is insoluble at a pH of 5.75

but soluble above this range.

7

In this patient theurinary pH was 6.5. Primary neoplasms of the renalparenchyma or transitional-cell epithelium must

also be considered. The most common renal neo-plasm is renal-cell carcinoma. Neoplasms may

cause microscopic or gross hematuria. Either thetumor or the blood clots can obstruct the collecting

system, which results in the clinical picture of pain.

The overwhelming likelihood at the time of hisinitial presentation was that this patients hematu-

ria was the result of a stone or another benign pro-cess. At the time his stent was placed, the urologist

would have evaluated the urethra and bladder forother findings that could explain hematuria. The

part of the picture that does not fit with the expec-tations is that the patient had a tiny stone that didnot appear to be in a location to cause obstruction,

pain, or gross hematuria. At the time of his secondpresentation, with a large amount of material that

could be blood in the renal pelvis, the stone had notmoved. This finding raises the concern that the

material in the pelvis may represent another patho-logic process.

Ultrasonography should easily distinguish a

stone from a clot or a tissue mass. Tumors tend tobe adherent to the pelvis and have an irregular

contour, whereas stones are not adherent and havea smooth contour. In this case, ultrasonography

showed that the defect was not a stone, but the pro-

cedure could not distinguish between a clot and a

tumor. The results of cytologic examination of theurine are abnormal in most cases of high-gradetransitional-cell tumors. Unfortunately, cytologic

samples are less commonly diagnostic for low-grade neoplasms.

3

The finding of a filling defect in the renal pelvismakes the possibility of a primary neoplasm the

immediate focus in the clinical evaluation. Transi-tional-cell tumors of the renal pelvis account for 95

percent of neoplasms arising in the renal collectingsystem.

8

Since these tumors can be highly aggres-sive, an evaluation of suspected transitional-cell

tumors should be done as soon as possible. Transi-tional-cell carcinomas have been estimated to make

up 5 percent of all renal masses,

8

but in my experi-ence this is an overestimate. This disease appears

most often in the sixth and seventh decades of life.It is more common in men than in women. Cigarette

smoking increases the risk of upper urinary tracttransitional-cell tumors by a factor of as much as4.5.

8

This man with a history of smoking thus has

some risk factors for this disease.In this patients case, the clinical diagnosis was

a primary transitional-cell carcinoma of the renalpelvis. The next step in the evaluation was endo-scopic exploration of the bladder and ureter under

general anesthesia. Cystourethroscopy with a care-ful examination of the bladder was performed, since

pelvic tumors are often associated with other le-sions, most commonly in the bladder. Cystoscopy

revealed a small erythematous area on the posterior

right side of the bladder wall, and a biopsy speci-men was obtained.

Retrograde urography, in which standard intra-venously administered radiographic contrast mate-

rial is passed by way of a catheter up the ureter andinto the renal pelvis, was then performed. This test

is highly sensitive for detecting dilatation of the col-lecting system and space-occupying lesions, whichappear as filling defects. Once the catheter is placed

in the ureter, but before the instillation of contrastmaterial, samples can be obtained for cytologic

examination. In this case, retrograde pyelographydemonstrated a filling defect in the renal pelvis,

which corresponded to that seen on the CT scan.Unless active, brisk bleeding limits visualization,

ureteroscopic evaluation is helpful in further char-

acterizing the source of bleeding in the upper uri-nary tract. The use of flexible ureteroscopes permits

visualization of the ureter, renal pelvis, and all majorrenal calices. Most stones can be identified, broken

up, and removed. Primary neoplasms can be seen



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and biopsy specimens can be obtained. Percutane-

ous access to the kidney, followed by endoscopicevaluation of the renal pelvis, is possible, but thistechnique is more invasive and can increase the

risk of bleeding and tumor dissemination.

9,10

Inthis case, ureteroscopy showed a large pedunculat-

ed papillary neoplasm of the renal pelvis, with noother abnormalities. Biopsy specimens and wash-

ings were obtained for cytologic evaluation, and astent was placed in the renal pelvis.

Transitional-cell carcinoma of the right renal pelvis.

Dr. Robert H. Young:

The small fragment of tissuethat was examined microscopically showed the typ-

ical features of a histologic grade 1 papillary transi-tional-cell carcinoma of the urinary tract (Fig. 3A).Delicate fibrovascular cores were covered by hyper-

plastic, minimally atypical transitional cells. Therewas no evidence of invasion, but the limited amount

of tissue available for evaluation left open the pos-sibility of invasion in unsampled tissue. The speci-men from the bladder showed no abnormalities.

Cytopathological examination of the fluid from therenal pelvis showed atypical urothelial cells in clus-

ters, which may suggest low-grade papillary transi-tional-cell carcinoma.

The spectrum of epithelial neoplasms derived

from the renal pelvic epithelium parallels that inthe urinary bladder and includes transitional-cell

carcinoma and its variants, rare occurrences of puresquamous-cell carcinoma and pure adenocarcino-

ma, and even benign neoplasms, such as the in-verted papilloma. As in the urinary bladder, the

transitional-cell carcinomas range from being lowgrade and noninvasive with a good prognosis tohigh-grade, deeply invasive tumors, with a poor

prognosis.

Dr. Kaufman: Dr. Dahl, how did you treat this

patient?

Dr. Dahl:

This patient had an uncommon tumor, a

transitional-cell carcinoma of the renal pelvis. How-ever, the physicians at this hospital who reviewed

the images agreed that it was localized, withoutmetastatic disease. The biopsy specimen showed

a low-grade tumor, and tumors such as these are

likely to be noninvasive. The patient was otherwisehealthy.

The standard management of a primary neo-

plasm of the upper urinary tract is radical nephro-ureterectomy, with removal of the kidney and entire

ureter. Transitional-cell carcinomas may be multi-focal, and cytologic atypia is frequently found in

areas of grossly uninvolved renal pelvis and ureter.In cases in which a primary lesion of the renal pelvis

is treated only by nephrectomy, at least 16 percentof patients will later have neoplasms within the ipsi-lateral ureter.

11,12

Before a decision could be made

about surgical management in this particular case,we had to evaluate the patients overall fitness for

major surgical intervention, including an evaluationof renal function, to predict whether there would

be detrimental consequences from the removal ofone kidney.

Small tumors of the renal pelvis can be removedby noninvasive techniques. One approach is abla-tion by ureteroscopy, with the use of laser or electri-

cal energy. The holmium laser, which is commonlyused to treat kidney and ureteral stones, can be used

for the ablation of certain tissue lesions. Ureteros-copy can be performed in an outpatient surgicalsetting. However, several studies show that tumors

may be assigned a lower stage when evaluated byendoscopic biopsy and then turn out to be more ag-

gressive and invasive than suspected.

13

In addition,several procedures may be required to accomplish

successful ablation, and vigilant surveillance for

recurrence must be conducted; thus, the patient iscommitted to undergoing many procedures under

general anesthesia.Another approach would be removal by means

of nephroscopy.

9

After the placement of a nephros-tomy tube into the renal calyx

,

nephroscopy is com-

monly performed to remove large renal stones, andit can be used to remove tumors. Standard trans-urethral resectoscopic instruments can be used to

resect the tumor and ensure adequate hemostasis.Adjacent tissue can be biopsied to rule out cytologic

atypia. With an increase in the manipulation of therenal parenchyma, however, there is a substantial

increase in the possibility of damage to the majorbranches of the renal vasculature. It is also impor-tant to be aware of the possibility of the implanta-

tion of tumor cells outside the renal collectingsystem, into the retroperitoneum or along the per-

cutaneous access tract.Because of their limitations and complications,

dr. doug las m . dah l s di ag n os i s

pat h olog i cal di s cus s i on

di s cus s i on of m an ag em en t



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I believe that ureteroscopic and percutaneous re-

section should be reserved for those rare circum-stances in which the patient cannot tolerate radicalnephrectomy, either because of poor renal function

or the presence of a solitary kidney, and when thereis confirmation that the tumor is of a low grade and

superficial.In a young, healthy patient with normal renal

function and two kidneys, complete surgical remov-al of the kidney and ureter, including the intravesi-

cal portion, is indicated. In addition, lymph-nodedissection should be performed along the right per-icaval region. This procedure can be accomplished

by an open surgical technique, through either twoincisions a flank incision to mobilize and resect

the kidney followed by a lower abdominal incisionto resect the distal ureter and its intravesical seg-

ment or through one large abdominal incision.This highly invasive intervention is the standard of

care in many institutions today.Advances in optical technology and instrumen-

tation have allowed surgeons to perform nephro-

ureterectomy and retroperitoneal lymph-node dis-section with laparoscopic techniques. A complete

resection of the kidney, the surrounding renal fat,adjacent lymph-node tissue, and the entire ureter ispossible, typically with five small laparoscopic ports.

Published case series from several institutions havevalidated the efficacy of this procedure and demon-

strated substantially improved morbidity.

14,15

Be-cause of the propensity of transitional-cell carci-

noma to spread and seed, particularly within the

peritoneal cavity, this procedure should only be per-formed by experienced laparoscopic surgeons.

After a discussion of the options, this patientelected to undergo a laparoscopic nephroureterec-

tomy. This procedure was performed two weeksafter the biopsy (Fig. 4). We removed the kidney and

ureter, dissecting the ureter well into the muscle bythe transabdominal approach, but we stopped shortof entering the mucosa of the bladder. Surgical clips

were left at the most distal portion of the ureter,and the ureter was clipped proximally before it was

divided to prevent tumor spillage. We also per-formed a retroperitoneal lymph node dissection

along the vena cava. The patient had no complica-tions and was discharged three days later.

Dr. Young:

The Pathology Department received a

kidney with an attached ureter, 27 cm long, andsurrounding soft tissue. When the kidney was sec-

tioned, a friable papillary neoplasm, 4 cm at its max-imal dimension, was visible within the renal pelvis.

Microscopical evaluation showed a papillary pattern

Figure 3. Histologic Sections of the Mass in the Renal Pelvis (Hematoxylinand Eosin).

The biopsy specimen (Panel A) represents a typical low-grade papillary tran-sitional-cell carcinoma, in which delicate fibrovascular cores are covered byhyperplastic, minimally atypical transitional cells. The specimen from the re-sected tumor (Panel B) has an unusual inverted pattern of growth, with largenests of tumor cells within the lamina propria. This does not represent trueinvasion. At higher magnification (Panel C), the tumor cells resemble normaltransitional cells, as is typical of a low-grade tumor.

A

B

C



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similar to that seen in the biopsy specimen. Themorphology was somewhat unusual because of thepresence of large bulbous aggregates of low-grade

neoplastic transitional cells inverting into the under-lying lamina propria (Fig. 3B and 3C). The picture

was similar to that seen in some transitional-cellcarcinomas of the urinary bladder, and is referredto as an inverted pattern of growth.

16

This picture

is different from that seen in a benign urinary tractneoplasm, the inverted papilloma, which has a more

compact arrangement and generally lacks a surfacepapillary component. The inverted growth pattern

is not considered to represent true invasion, which

produces irregular stromal penetration. There wereno lymph-node metastases.

Dr. W. Scott McDougal

(Urology): Dr. Dahl, under

what circumstances might you recommend an open

nephroureterectomy?

Dr. Dahl:

The most important factor is probably

the experience of the surgeon. Patient factors thatmake laparoscopic surgery more difficult include ahistory of abdominal surgery, any major procedures

involving the kidney, or ureteral surgery. For an in-vasive tumor with bulky lymph-node involvement,

management by laparoscopic techniques becomesmore difficult and the length of time required for

the procedure could be more than that for an opensurgical technique.

Five months after the nephrectomy, I performed

cystourethroscopy while the patient was under anes-thesia and performed a marsupialization procedure

with the remaining 3 mm of the distal ureter, so thatit can now be observed by standard office cystosco-

py, and removed the clip (Fig. 4B). Surveillance cys-toscopy is necessary for any patient with a history

of urothelial carcinoma, because of the possibilitythat other neoplasms will develop, either within theremaining ureter or in the bladder. As a rule, I per-

form cystoscopy in the office every three monthsfor the first two years after a resection, every six

months for five years, and once a year thereafter.

17

In this case, 18 months after the nephroureterec-tomy, the patient continues to undergo regular cys-

tourethroscopic examinations with cytologic exam-ination of urine specimens, and he remains free of

disease.

Papillary transitional-cell carcinoma of the renal

pelvis, low grade.

an at om i cal di ag n os i s

references

1.

Fielding JR, Silverman SG, Samuel S,Zou KH, Loughlin KR. Unenhanced helicalCT of ureteral stones: a replacement for ex-cretory urography in planning treatment.AJR Am J Roentgenol 1998;171:1051-3.

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McNicholas MM, Raptopoulos VD,Schwartz RK, et al. Excretory phase CT urog-raphy for opacification of the urinary col-lecting system. AJR Am J Roentgenol 1998;170:1261-7.

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Grossfeld GD, Litwin MS, Wolf JS Jr, etal. Evaluation of asymptomatic microscopichematuria in adults: the American Urologi-cal Association best practice policy. II. Pa-tient evaluation, cytology, voided markers,

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Schreyer HH, Uggowitzer MM, Rup-pert-Kohlmayr A. Helical CT of the urinaryorgans. Eur Radiol 2002;12:575-91.

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Jamis-Dow CA, Choyke PL, JenningsSB, Linehan WM, Thakore KN, WaltherMM. Small (< or = 3-cm) renal masses: de-tection with CT versus US and pathologiccorrelation. Radiology 1996;198:785-8.

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Cohen RA, Brown RS. Microscopic he-maturia. N Engl J Med 2003;348:2330-8.

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Gutman AB, Yu TF. Uric acid nephroli-thiasis. Am J Med 1968;45:756-79.

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Donat SM, Herr HW. Transitional cellcarcinoma of the renal pelvis and ureters: di-agnosis, staging, management, and progno-sis. In: Oesterling JE, Richie JP, eds. Urologiconcology. Philadelphia: W.B. Saunders,1997:215-34.

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Goel MC, Mahendra V, Roberts JG. Per-cutaneous management of renal pelvic uro-thelial tumors: long-term followup. J Urol2003;169:925-9.

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Ong AM, Bhayani SB, Pavlovich CP. Tro-car site recurrence after laparoscopic neph-roureterectomy. J Urol 2003;170:1301.

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Hisataki T, Miyao N, Masumori N, et al.Risk factors for the development of bladder

Figure 4 (facing page). Laparoscopic Technique

for Radical Nephroureterectomy.

In laparoscopic radical nephroureterectomy, the kidney

and ureter are mobilized and dissected away from the

peritoneum and vessels. Careful circumferential dissec-tion (Panel A) is used to divide the detrusor muscle fibers

from the intramuscular portion of the ureter. Traction is

placed on the ureter until the entire distal ureter is visual-

ized as it enters the bladder. The distal ureter is ligatedwith surgical clips (inset). The proximal ureter is ligated,

and the ureter is divided. In this patient, five months lat-

er at cystoscopy (Panel B), the distal right ureteral tunnelwas calibrated and estimated to be 3 mm long. A resec-

toscope sheath was introduced into the bladder and a

knife was used in marsupialization of the ureteral tunnel.The surgical clip left at the time of nephrectomy was ex-

tracted with biopsy forceps. The transitional epithelium

at the base was coagulated, eliminating any remainingtumor tissue.



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cancer after upper tract urothelial cancer.Urology 2000;55:663-7.

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Nocks BN, Heney NM, Daly JJ, PerroneTA, Griffin PP, Prout GR Jr. Transitional cellcarcinoma of renal pelvis. Urology 1982;19:472-7.

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Daneshmand S, Quek ML, Huffman JL.Endoscopic management of upper urinarytract transitional cell carcinoma: long-termexperience. Cancer 2003;98:55-60.

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El Fattouh HA, Rassweiler JJ, Schulze M,

et al. Laparoscopic radical nephroureterec-tomy: results of an international multicenterstudy. Eur Urol 2002;42:447-52.

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McNeill SA, Chrisofos M, Tolley DA.The long-term outcome after laparoscop-ic nephroureterectomy: a comparison withopen nephroureterectomy. BJU Int 2000;86:619-23.

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Amin MB, Gomez JA, Young RH.Urothelial transitional cell carcinoma withendophytic growth patterns: a discussion of

patterns of invasion and problems associat-ed with assessment of invasion in 18 cases.Am J Surg Pathol 1997;21:1057-68.

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Linehan WM, Zbar B, Bates SE, ZelefskyMJ, Yang JC. Cancer of the kidney and ureter.In: De Vita VT Jr, Hellman S, Rosenberg SA,eds. Cancer: principles & practice of oncolo-gy. 6th ed. Philadelphia: Lippincott Wil-liams & Wilkins, 2001:1362-96.

Copyright 2004 Massachusetts Medical Society.

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standard 35-mm projector. These slides, which illustrate the current cases in the Journal,

are mailed from the Department

of Pathology to correspond to the week of publication and may be retained by the subscriber. Each year approximately

250 slides from 40 cases are sent to each subscriber. The cost of the subscription is $450 per year. Application forms forthe current subscription year, which began in January, may be obtained from Lantern Slides Service, Department of

Pathology, Massachusetts General Hospital, Boston, MA 02114 (telephone 617-726-2974).

Slides from individual cases may be obtained at a cost of $35 per case.

Copyright 2004 Massachusetts Medical Society All rights reservedDownloaded from www.nejm.org on March 29, 2005 . This article is being provided free of charge for use in Indonesia.

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