RESUMEN
BACKGROUND: Although partial nephrectomy (PN) has been associated with improved renal function compared with radical nephrectomy (RN) for renal cell carcinoma, the impact on overall survival (OS) remains controversial. OBJECTIVE: To evaluate comparative OS and renal function in patients following PN and RN for a renal mass where malignancy was not a confounding factor. DESIGN, SETTING, AND PARTICIPANTS: Using the Mayo Clinic Nephrectomy Registry, we retrospectively identified 442 patients with unilateral sporadic benign renal masses treated surgically with PN or RN between 1980 and 2008. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome measures were OS and the incidence of new-onset stage IV chronic kidney disease (CKD), determined using the Kaplan-Meier method. Cox models were used to test the association of nephrectomy type with these outcomes. RESULTS AND LIMITATIONS: Overall, 206 and 236 patients with benign renal masses were surgically treated with RN and PN, respectively. Patients who underwent RN were older (median age: 67 vs 64 yr; p=0.02) and had larger tumors (median size: 5.0 vs 2.7 cm; p<0.001). Median follow-up for patients still alive at last follow-up was 8.3 yr (range: 0.1-27.9 yr). Estimated OS (95% confidence interval [CI]) rates at 10 and 15 yr were 69% (62-76%) and 53% (45-62%) for RN compared with 80% (73-87%) and 74% (65-83%) following PN (p=0.032). After adjusting for covariates of interest, patients treated with RN were significantly more likely to die from any cause (hazard ratio [HR]: 1.75; 95% CI, 1.08-2.83; p=0.023) or develop stage IV CKD (HR: 4.23; 95% CI, 1.80-9.93; p<0.001) compared with patients who underwent PN. Limitations include the retrospective design, selection bias for surgical approach, and referral bias to a tertiary care facility. CONCLUSIONS: Our data suggest that PN may confer a clinical benefit for improved renal function and better OS compared with RN after excluding the confounding effect of malignancy.
Asunto(s)
Carcinoma de Células Renales/cirugía , Neoplasias Renales/cirugía , Nefrectomía/efectos adversos , Insuficiencia Renal Crónica/epidemiología , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Carcinoma de Células Renales/mortalidad , Carcinoma de Células Renales/patología , Distribución de Chi-Cuadrado , Progresión de la Enfermedad , Femenino , Tasa de Filtración Glomerular , Humanos , Incidencia , Estimación de Kaplan-Meier , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Análisis Multivariante , Nefrectomía/mortalidad , Modelos de Riesgos Proporcionales , Sistema de Registros , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/mortalidad , Insuficiencia Renal Crónica/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Carga Tumoral , Adulto JovenRESUMEN
PURPOSE: Although minimal evidence exists, bladder calculi in men with benign prostatic hyperplasia are thought to be secondary to bladder outlet obstruction induced urinary stasis. We performed a prospective, multi-institutional clinical trial to determine whether metabolic differences were present in men with and without bladder calculi undergoing surgical intervention for benign prostatic hyperplasia induced bladder outlet obstruction. MATERIALS AND METHODS: Men who elected surgery for bladder outlet obstruction secondary to benign prostatic hyperplasia with and without bladder calculi were assessed prospectively and compared. Men without bladder calculi retained more than 150 ml urine post-void residual urine. Medical history, serum electrolytes and 24-hour urinary metabolic studies were compared. RESULTS: Of the men 27 had bladder calculi and 30 did not. Bladder calculi were associated with previous renal stone disease in 36.7% of patients (11 of 30) vs 4% (2 of 27) and gout was associated in 13.3% (4 of 30) vs 0% (0 of 27) (p <0.01 and 0.05, respectively). There was no observed difference in the history of other medical conditions or in serum electrolytes. Bladder calculi were associated with lower 24-hour urinary pH (median 5.9 vs 6.4, p = 0.02), lower 24-hour urinary magnesium (median 106 vs 167 mmol, p = 0.01) and increased 24-hour urinary uric acid supersaturation (median 2.2 vs 0.6, p <0.01). CONCLUSIONS: In this comparative prospective analysis patients with bladder outlet obstruction and benign prostatic hyperplasia with bladder calculi were more likely to have a renal stone disease history, low urinary pH, low urinary magnesium and increased urinary uric acid supersaturation. These findings suggest that, like the pathogenesis of nephrolithiasis, the pathogenesis of bladder calculi is likely complex with multiple contributing lithogenic factors, including metabolic abnormalities and not just urinary stasis.
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Hiperplasia Prostática/complicaciones , Cálculos de la Vejiga Urinaria/etiología , Obstrucción del Cuello de la Vejiga Urinaria/complicaciones , Anciano , Humanos , Masculino , Enfermedades Metabólicas/complicaciones , Estudios ProspectivosRESUMEN
OBJECTIVE: To assess the surgeon factors influencing the surgical treatment decisions for symptomatic stone disease. The factors influencing the selection of shock wave lithotripsy (SWL), ureteroscopy, or percutaneous nephrolithotomy to treat symptomatic stone disease are not well studied. METHODS: Electronic surveys were sent to urologists with American Medical Association membership. Information on training, practice, and ideal treatment of common stone scenarios was obtained and statistically analyzed. RESULTS: In November 2009, 600 surveys were sent and 180 were completed. High-volume SWL practices (>100 cases annually) were more common in community practice (P < .01), and high-volume ureteroscopy and percutaneous nephrolithotomy practices were more common in academic practice (P = .03). Community practice was associated with SWL selection for proximal urolithiasis and upper pole nephrolithiasis (P < .005). An increasing time since urologic training was associated with SWL selection for proximal urolithiasis and upper pole nephrolithiasis (P < .01). Urologists reporting shock wave lithotriptor ownership were 3-4 times more likely to select SWL for urolithiasis or nephrolithiasis compared with urologists who did not own a lithotripter (P < .01). Routine concern for stent pain and rigid ureteroscope preference (vs flexible) were associated with SWL selection (P < .03). CONCLUSION: Surgeon factors significantly affected urolithiasis treatment selection. SWL was associated with community urology practice, increasing time since training, shock wave lithotriptor ownership, concern for stent pain, and ureteroscope preference.
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Servicios de Salud Comunitaria/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Urolitiasis/terapia , Urología/estadística & datos numéricos , Centros Médicos Académicos/estadística & datos numéricos , Adulto , Recolección de Datos , Humanos , Litotricia/estadística & datos numéricos , Persona de Mediana Edad , Nefrolitiasis/terapia , Nefrostomía Percutánea/estadística & datos numéricos , Propiedad/estadística & datos numéricos , Dolor/etiología , Stents/efectos adversos , Factores de Tiempo , Estados Unidos , Ureteroscopios , Ureteroscopía/estadística & datos numéricos , Urología/educaciónRESUMEN
OBJECTIVE: To determine the metastatic potential of renal masses based on original tumour size. MATERIALS AND METHODS: We identified 2651 patients who had undergone surgical resection for a unilateral, sporadic renal tumour between 1990 and 2006. Associations of tumour size with synchronous metastasis at presentation [M1 renal cell carcinoma (RCC)] and development of metastases, death from RCC, and death from any cause after surgery were evaluated using logistic and Cox proportional hazards regression. RESULTS: Of the 2651 patients studied, 182 (6.9%) presented with M1 RCC. Tumour size was significantly greater in patients with M1 RCC than in patients with M0 RCC (a median size of 10 vs 4.5 cm; P < 0.001). Only 1 of the 629 patients (0.2%) with a tumour <3 cm had M1 RCC and that tumour was 2.5 cm. The risk of M1 RCC increased from 1.1% for patients with tumours 3-3.9 cm to 16.5% for patients with tumours ≥7 cm. Of the 2124 patients with M0 RCC, 430 developed distant metastases at a median (range) of 1.4 (0.1-16.2) years after surgery. Only 9 of the 498 patients (1.8%) with a tumour <3 cm developed distant metastases after surgery. Each 1-cm increase in tumour size increased the risk of death from RCC by 20%[hazard ratio (HR) 1.20; 95% confidence interval (CI) 1.18-1.22; P < 0.001] and death from any cause by 10% (HR 1.10; 95% CI 1.09-1.12; P < 0.001). For the 1346 patients who were still alive at last follow-up, the median (range) duration of follow-up was 6.9 (0.1-19.7) years. CONCLUSIONS: Tumour size is significantly associated with metastases in patients with renal masses. Patients with tumours <3 cm have a low risk of synchronous metastatic disease.
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Carcinoma de Células Renales/patología , Neoplasias Renales/patología , Metástasis de la Neoplasia , Carga Tumoral , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Renales/mortalidad , Carcinoma de Células Renales/secundario , Carcinoma de Células Renales/cirugía , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Renales/mortalidad , Neoplasias Renales/cirugía , Masculino , Persona de Mediana Edad , Nefrectomía , Pronóstico , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: ⢠To assess the risk of metachronous renal cell carcinoma (RCC) and benign renal tumours after surgical treatment of primary renal oncocytoma. PATIENTS AND METHODS: ⢠Patients treated for primary renal oncocytoma between 1970 and 2007 were identified. Tumours were reviewed by a urological pathologist and patients were followed for subsequent renal tumours. RESULTS: ⢠Of 424 patients with a median follow up of 7.1 year, 17 (4.0%) patients were diagnosed with a metachronous renal tumour at a median of 3.0 years (range 0.3-16 years). Of the 17 metachronous tumours, eight were oncocytoma, four were RCC and five were not resected or biopsied. ⢠Eleven metachronous tumours occurred after solitary unilateral oncocytoma, five occurred after multifocal unilateral oncocytoma, and one occurred after multifocal bilateral oncocytoma. ⢠Estimated 10-year tumour-free and RCC tumour-free survival was 94.8% and 98.7%, respectively. Patients with primary multifocal oncocytoma were at higher risk of metachronous tumour (hazard ratio 4.0; P = 0.007). Initial oncocytoma size (hazard ratio 1.1; P = 0.11) was not highly associated with risk of tumour recurrence. CONCLUSIONS: ⢠To our knowledge, we report the largest cohort of oncocytoma after surgical management. Metachronous renal neoplasm in a patient with previous oncocytoma is more likely to be benign compared with patients who present with a renal tumour for the first time. Multifocal primary oncocytoma is associated with metachronous renal tumours. ⢠Overall, the risk of metachronous RCC in a patient with an oncocytoma is similar to that of the general population, which does not support the use of routine cross-sectioning imaging surveillance.
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Adenoma Oxifílico/cirugía , Carcinoma de Células Renales/etiología , Neoplasias Renales/cirugía , Neoplasias Primarias Secundarias/etiología , Complicaciones Posoperatorias/etiología , Adulto , Anciano , Carcinoma de Células Renales/cirugía , Ablación por Catéter , Criocirugía , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Neoplasias Primarias Secundarias/cirugía , Complicaciones Posoperatorias/cirugía , Factores de Riesgo , Segunda Cirugía , Espera Vigilante , Adulto JovenRESUMEN
PURPOSE: Retroperitoneal lymph nodes are a recognized site of relapse in patients undergoing nephroureterectomy (NU) for high grade upper tract urothelial carcinoma (UC). Retrospective studies suggest that retroperitoneal lymph node dissection (RPLND) may be curative at the time of NU for high grade upper tract UC. We hypothesized that chemotherapy followed by RPLND may successfully salvage select patients with isolated retroperitoneal relapse of upper tract UC following prior NU. MATERIALS AND METHODS: We identified four patients with metastatic UC isolated to the subdiaphragmatic retroperitoneal lymph nodes after NU for upper tract UC. These patients had either a stable response or a complete response to chemotherapy and subsequently underwent a complete full bilateral template RPLND. Our primary study endpoints were disease-specific survival and recurrence-free survival. RESULTS: There was no perioperative mortality or long lasting surgery related sequelae in any patient. Two patients had no pathologic evidence of viable cancer at RPLND and are disease-free at 56 and 74 months from surgery. Two patients had evidence of active residual disease and subsequently developed distant disease at 2 months and 32 months after surgery. Both of these patients died of progressive disease at 3 months and 42 months following RPLND. The 5 year DSS and RFS rates were 50% and 50%. CONCLUSIONS: Chemotherapy followed by RPLND for isolated retroperitoneal recurrence after NU for upper tract UC urothelial carcinoma is a feasible and safe treatment that may be potentially therapeutic in select patients.
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Carcinoma de Células Transicionales/tratamiento farmacológico , Carcinoma de Células Transicionales/cirugía , Neoplasias Renales/cirugía , Escisión del Ganglio Linfático , Neoplasias Primarias Secundarias/tratamiento farmacológico , Neoplasias Primarias Secundarias/cirugía , Nefrectomía , Neoplasias Retroperitoneales/tratamiento farmacológico , Neoplasias Retroperitoneales/cirugía , Uréter/cirugía , Neoplasias Ureterales/cirugía , Adulto , Anciano , Terapia Combinada , Humanos , Escisión del Ganglio Linfático/métodos , Masculino , Persona de Mediana Edad , Espacio Retroperitoneal , Estudios Retrospectivos , Factores de TiempoRESUMEN
PURPOSE: Percutaneous nephrolithotomy is standard therapy for upper tract calculi larger than 2 cm. However, the role of percutaneous nephrolithotomy in patients with autosomal dominant polycystic kidney disease has not been well evaluated. We report our experience with percutaneous nephrolithotomy in patients with autosomal dominant polycystic kidney disease. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients with autosomal dominant polycystic kidney disease and subsequent renal calculi managed by percutaneous nephrolithotomy from October 1981 to the present. RESULTS: We identified 9 patients. Percutaneous nephrolithotomy was performed in 11 kidneys. Flank pain was the presenting symptom in 6 patients. Average stone burden was 2.5 cm (range 1.6 to 3.6). Two access tracts were necessary in 5 kidneys. No intraoperative complications occurred. In 2 kidneys a second stage endoscopic procedure with ultrasonic lithotripsy was required to achieve stone-free status. Nephrostogram 24 hours after the final procedure showed no residual stone fragments in 9 of 11 kidneys (82%). The remaining 2 patients underwent percutaneous basket extraction to render them stone-free. There were no postoperative complications or recurrent stones. No patient required blood transfusion. Mean followup was 2.7 years (range 0.3 to 4). Mean calculated creatinine clearance was stable at 85.6 (range 45.9 to 126.6) and 89.5 mg/dl per minute (range 39.6 to 126.6) preoperatively and at last followup, respectively (p = 0.783). CONCLUSIONS: Autosomal dominant polycystic kidney disease increased operative complexity, the need for multiple percutaneous access tracts and the likelihood of repeat endoscopy. Despite the altered anatomy percutaneous nephrolithotomy was a safe, efficacious approach for autosomal dominant polycystic kidney disease. At last followup there was no stone recurrence and renal function was stable.
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Cálculos Renales/complicaciones , Cálculos Renales/cirugía , Nefrostomía Percutánea , Riñón Poliquístico Autosómico Dominante/complicaciones , Adolescente , Adulto , Femenino , Humanos , Cálculos Renales/patología , Masculino , Persona de Mediana Edad , Nefrostomía Percutánea/métodos , Estudios Retrospectivos , Adulto JovenRESUMEN
OBJECTIVE: Ureteral fibroepithelial polyps (UFP) are rare lesions that may mimic ureteral malignancy, and management is not well defined. We report our experience with the management of UFP. MATERIALS AND METHODS: Between 1945 and 2008, review of our clinical database identified 27 patients who were found to have UFP. Single-pathologist review excluded five patients (three papilloma, one inflammatory pseudopolyp, and one nondiagnostic). Fisher's exact methods were utilized to assess significance of clinical associations. RESULTS: Mean age at diagnosis was 40 years (range 7-73 years) and 68% were male. Mean follow-up was 37 months (range 2-276 months). History of urologic conditions occurred in 13 patients: 7 (32%) urolithiasis, 2 (9%) ureteral stents, 1 (5%) recurrent urinary tract infection, and 3 (14%) ureteropelvic junction obstruction. Mean UFP diameter was 2 cm (range 0.5-4 cm). UFP was more common in the left ureter (68%, 15/22). UFP location within the ureter was proximal in 13 (59%, 15/22), mid in 4 (18%, 4/22), and distal in 4 (18%, 4/22) with multiple UFP along the length of one ureter. Six patients (27%) had multiple UFP. Open surgery, last performed in 1994, was the initial treatment in 10 (45%, 10/22) patients. Endoscopic treatment was performed in 12 (55%, 12/22) patients and was successful in 11. After endoscopic treatment, open surgical treatment was required in 3 patients with ureteral stricture and 1 patient with incomplete polyp resection. UFP reoccurred in 1 patient (1/12) at 26 months and was successfully treated with ureteroscopy. CONCLUSIONS: We conclude that UFP can be successfully managed with endoscopic techniques. Postoperative surveillance is recommended for potential early detection of ureteral stricture or recurrence.