Smith Institute for Urology

Gastric signet-ring carcinoma can metastasize to unusual sites. Occult cardiac metastasis, disseminated cutaneous lesions without involvement of internal organs, secondary prostatic involvement, and breast metastasis have all been described (1-4). We were able to find only 4 reported cases of metastatic signet-cell adenocarcinoma to the urinary bladder, three of which were found in the Japanese literature. We report a case of gastric signet-ring adenocarcinoma with bladder metastasis.

We evaluated any correlation between measured renal parenchymal area on computerized tomography and differential function on 99m technetium-mercaptoacetyltriglycine renal scan to ascertain whether computerized tomography measurements could predict differential renal function. Materials and Methods: Between 2005 and 2007 we identified 111 patients who underwent computerized tomography and renal scan. Average renal parenchymal thickness was calculated by measurements made at the upper and lower poles of each kidney. The product of average renal parenchymal thickness and renal length was calculated bilaterally and the ratio of parenchymal area was compared to the differential shown on renal scan. Results: The average difference between predicted and observed renal function was 4.73% (Pearson's correlation coefficient 0.959). Patients with positive urine cultures at renal scan were compared to the other 89. The average functional difference was 6.54% vs 4.28% (Pearson's correlation 0.955 vs 0.965, p ϭ 0.0045). The 89 uninfected patients were then compared based on contrast vs noncontrast computerized tomography and obstructed vs unobstructed renal units. No statistical difference was found with contrast administration. When compared based on evidence of obstruction, unobstructed kidneys resulted in a lower Pearson correlation (0.743 vs 0.975) but they had a statistically significant average functional difference in favor of unobstructed units (3.28% vs 5.10%, p ϭ 0.0036). No difference was found in the obstructed group with prior drain placement. Conclusions: Differential renal parenchymal area measured by computerized tomography strongly correlates with differential function on renal scintigraphy and it may obviate the need for nuclear renal scan in some circumstances.

Purpose: Laparoscopic radical nephrectomy has been accepted as the preferred management for low stage renal masses not amenable to partial nephrectomy. Early in the mid 1990s several studies suggested that obesity should be a relative contraindication to laparoscopy. We present our surgical outcomes and complications in patients undergoing open and laparoscopic nephrectomy, stratified by body mass index. Materials and Methods: We retrospectively identified 88 patients, of whom 43 underwent open nephrectomy and 45 were treated laparoscopically. All patients were stratified by body mass index to compare multiple perioperative end points and pathological outcomes of laparoscopy. Results: Overall our data showed that compared to open nephrectomy laparoscopic nephrectomy resulted in statistically significant lower estimated blood loss (147.95 vs 640.48 cc, p Ͻ0.0002), operative time (156.11 vs 198.95 minutes, p Ͻ0.003) and hospital stay (3.7 vs 5.9 days, p Ͻ0.004). When stratified by body mass index less than 25, 25 to 29.9 and 30 kg/m 2 or greater, there was a statistically significant difference in estimated blood loss and hospital stay that was in favor of the laparoscopic approach in each body mass index category. Operative time did not show a statistical difference in the subgroups but all laparoscopic procedure times were shorter than open procedure times in each body mass index category. When patients with a body mass index of greater than 30 kg/m 2 were further subgrouped into 35 kg/m 2 or greater and 40 kg/m 2 or greater, there was a statistically significant difference in estimated blood loss and hospital stay that was again in favor of the laparoscopic method. Conclusions: Laparoscopic radical nephrectomy is technically more challenging as body mass index increases due to many factors but our data show that it is feasible and safe in experienced hands. Laparoscopy appears to result in perioperative outcomes that are superior to those of open nephrectomy in this high risk population with a complication profile that is equivalent to that of the open method for each stratified body mass index category.

Objectives. To review our experience with minimal fat angiomyolipomas (AMLs) and correlate the confirmed pathologic diagnosis with preoperative radiologic features to evaluate the feasibility of an accurate diagnosis preoperatively. On rare occasions, renal AMLs contain minimal amounts of fat that are not identified on cross-sectional imaging. Methods. From November 1998 to August 2003, 6 patients (seven lesions) underwent renal surgery with the preoperative diagnosis of renal cell carcinoma as determined by preoperative imaging studies, and the finding of AML was unexpected. A single pathologist and radiologist reviewed all pathologic specimens and radiologic examinations. The characteristic findings were recorded and compared with those in published reports.

Objectives. To review our experience with minimal fat angiomyolipomas (AMLs) and correlate the confirmed pathologic diagnosis with preoperative radiologic features to evaluate the feasibility of an accurate diagnosis preoperatively. On rare occasions, renal AMLs contain minimal amounts of fat that are not identified on cross-sectional imaging. Methods. From November 1998 to August 2003, 6 patients (seven lesions) underwent renal surgery with the preoperative diagnosis of renal cell carcinoma as determined by preoperative imaging studies, and the finding of AML was unexpected. A single pathologist and radiologist reviewed all pathologic specimens and radiologic examinations. The characteristic findings were recorded and compared with those in published reports.

Gastric signet-ring carcinoma can metastasize to unusual sites. Occult cardiac metastasis, disseminated cutaneous lesions without involvement of internal organs, secondary prostatic involvement, and breast metastasis have all been described (1-4). We were able to find only 4 reported cases of metastatic signet-cell adenocarcinoma to the urinary bladder, three of which were found in the Japanese literature. We report a case of gastric signet-ring adenocarcinoma with bladder metastasis.

Adenine phosphoribosyl transferase (APRT) deficiency is a rare genetic condition that often presents with recurrent dihydroxyadenine (DHA) urolithiasis. To our knowledge, no CT imaging of DHA stones has been previously reported in English medical literature. We report a case of an 86-year-old woman with a large DHA stone in her upper left ureter. On CT imaging the stone was low density and had an unusual linear central lucency. We also review the literature for this rare disorder.

Kidney cancer is a common genitourinary malignancy. The incidence of kidney cancer has progressively increased in the past few decades, with the greatest increase noted for incidentally discovered small renal masses. Along with the change in presentation and diagnosis of kidney cancer, surgical treatment of kidney cancer also has evolved dramatically during the past 5 decades, moving from universal use of radical extirpation to more frequent nephron-sparing and minimally invasive surgeries. This article reviews the contemporary management of localized kidney cancers and discusses the impact of surgery on oncologic and nononcologic outcomes. Am J Kidney Dis. 58 :846-854.

Therapeutic donor insemination (TDI), also known as artificial insemination by donor, is one of the oldest forms of male infertility treatment. With the advent of assisted reproductive technologies and in vitro fertilization techniques over the past few decades, the use of TDI in male infertility treatment has decreased dramatically. Knowledge of its use, indications, efficacy, and related psychosocial issues has also declined among urologists treating male infertility. Despite the change in popularity of the procedure, though, TDI remains an appropriate therapeutic option for certain cases of male infertility, particularly in patients who have failed multiple cycles of in vitro fertilization/intracytoplasmic sperm injection or in men with no available sperm even after attempted microdissection testicular sperm extraction. Further consideration and research should be focused on the potential uses and indications for TDI.

treatment including total cystectomy, radiation and chemotherapy, whereas T1G3 NMIBC has less invasive treatment options including re-TURBT or BCG instillation as bladder preservation therapy. Between these two tumor's groups the treatment selection is drastically changed, however, the relationship between these groups and ADC value has not yet been clearly identified. We investigated the difference between T1G3 NMIBC and MIBC by evaluating ADC value measured from DWI. METHODS: Diffusion-weighted MRI (DW-MRI) at 1.5 Tesla using b-values of 0, 1000 s/mm2 was taken before transurethral resection or total cystectomy by 156 bladder urothelial tumor patients in our hospital. ADC value was measured and its relationship with clinicopathological factors were analyzed. Fisher's exact test, receiver operating characteristic (ROC) curve analysis and logistic regression analysis were performed for data analysis. RESULTS: Among 156 cases of bladder urothelial tumor, 34 and 42 cases were diagnosed as T1G3 NMIBC and MIBC, respectively. Area under the ROC curve for differentiating between T1G3 NMIBC and MIBC by using ADC value was 0.701, with optimal thereshold of 0.91x10-3mm/s2, which was associated with a sensitivity of 50.0%, specificity of 88.1%. Multivariate analysis showed that ADC value less than 0.91x10-3mm/s2(OR: 0.148, p¼0.035) and lymphatic invasion (ly) (OR: 10.540, p¼0.006) were significant predictive factors for distinguishing between T1G3 NMIBC and MIBC. CONCLUSIONS: This is the first report which indicated that ADC value was significant predictive biomarker differentiating between T1G3 NMIBC and MIBC, which would be useful prior to treatment for patient counseling and treatment selection, especially about bladder preservation. Consequently it may provide more accurate diagnosis between these two groups, which leads to avoid unnecessary invasive treatment.