Gastrocystoplasty: Long-Term Followup

PURPOSE

The use of stomach has become controversial in pediatric lower urinary tract reconstruction. Recent series have reported a high incidence of hematuria-dysuria syndrome and metabolic abnormalities, which has prompted a significant decrease in its use at our institution during the last 5 years.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of children who underwent urinary reconstruction with gastrocystoplasty. Patients were excluded from consideration if they had less than 5 years of followup.

RESULTS

From 1989 to 1997, 18 males and 26 females were identified. Median patient age at time of reconstruction was 4.5 years and median followup was 9.8 years. Urinary continence was present in 89% of cases, and upper tract dilatation was stable or improved in 91%. No patient had chronic metabolic alkalosis. Major surgery was required for complications of the gastrocystoplasty in 6 cases, including patch contraction and ureteral obstruction necessitating excision in 1. Two patients had severe hematuria while anuric from renal failure which was managed conservatively with bladder cycling and H2 blockers. Symptoms resolved completely after renal transplantation in both cases. Febrile urinary tract infection occurred in 20% of cases and asymptomatic bacteriuria was present in 36%.

CONCLUSIONS

The use of stomach segments in pediatric urinary reconstruction can be beneficial in patients with chronic renal insufficiency, metabolic acidosis or short gut syndrome. Despite negative reports concerning serious complications of gastrocystoplasty, our long-term data confirm that it remains an important option in our reconstruction armamentarium.

Loin pain hematuria syndrome: case series

Loin pain hematuria syndrome (LPHS) is a rare condition manifested by flank pain, hematuria, and occasional low-grade fevers. Usually there are no physical findings other than hematuria. Although numerous etiological theories exist, the pathophysiology of LPHS is unknown and diagnosis remains one of exclusion. Renal autotransplantation has been suggested as an effective procedure to control the severe and debilitating pain. However, pain often recurs in the long term. This paper reviews our experiences with the diagnosis and management of this condition.

The effect of finasteride on the expression of vascular endothelial growth factor and microvessel density: a possible mechanism for decreased prostatic bleeding in treated patients

PURPOSE

Several studies have confirmed the benefit of finasteride in limiting hematuria from benign prostatic hyperplasia. Vascular endothelial growth factor (VEGF), a potent stimulator of angiogenesis, and microvessel density have been independently evaluated in the mechanism of decreased bleeding observed in patients treated with finasteride. We evaluated the expression of VEGF and suburethral prostatic microvessel density in patients with benign prostatic hyperplasia treated with finasteride.

MATERIALS AND METHODS

The study included 24 patients undergoing prostatic surgery for benign disease, of whom 12 were given finasteride for a minimum of 6 weeks before surgery and the remaining 12 served as controls. Sections from the prostatic urothelium and hyperplastic prostate were individually stained for CD34 specific for nascent blood vessels and VEGF. Analysis of each specimen was performed in a blinded fashion. Microvessel density was calculated by counting the number of positively stained blood vessels on 10 consecutive, nonoverlapping, high power fields within the suburethral and hyperplastic prostate compartments. VEGF expression was examined by immunohistochemistry. Statistical analysis of the results was performed using Student's t test.

RESULTS

Prostatic suburethral VEGF expression and microvessel density were significantly lower in the finasteride group compared to controls (p <0.05). Differences in VEGF expression and microvessel density at the level of the hyperplastic prostate were not found to be significantly different between the 2 groups. CONCLUSIONS Decreased expression of VEGF by finasteride inhibits angiogenesis and significantly decreases microvessel density in prostatic suburethral tissue. This sequential relationship provides histochemical insight into the mechanism by which finasteride reduces prostatic urethral bleeding.

Acute renal failure in IgA nephropathy: aggravation by gross hematuria due to anticoagulant treatment

IgA nephropathy is one of the most common forms of glomerulonephritis. Macroscopic or microscopic hematuria with mild proteinuria are the main symptoms. Without complicating factors, IgA nephropathy has a favourable long-term prognosis. We report a case of reversible acute renal failure (ARF) as a complication of mild IgA nephropathy while oral anticoagulants were administered. Diagnosis was based on a renal biopsy showing marked granular mesangial IgA-deposition. In addition, numerous tubules were extended and completely obstructed by red blood cell casts. After hemodialysis treatment and parallel anti-inflammatory steroids and after stopping anticoagulation, renal function gradually improved up to complete remission. This report indicates that anticoagulatory treatment may have negative effects on the long-term prognosis of IgA nephropathy with respect to development of ARF or tubulo-interstitial inflammation.

Ambulatory blood pressure monitoring in children with isolated haematuria

Ambulatory blood pressure monitoring (ABPM) was performed in 29 children, ages 8.5-10.5 years (mean 11.6+/-3.0) with isolated haematuria (IH) and in 27 age, sex, weight and height matched healthy controls (C). Isolated haematuria was defined as >or=5 RBC/HPF on three separate urinalyses over a 3-month period with normal renal function, a normal appearing ultrasound examination of the kidneys and the absence of hypercalciuria. Haematuria had been documented for at least 3 years prior to ABPM. Daytime and nighttime periods were 0800-2200 and 2200-0800 hours, respectively. The total number of successful blood pressure readings was 21.8 and 20.7 per subject (90.0 and 86.1% of all attempted measurements) in IH and C, respectively. Mean 24-h, daytime and nighttime heart rate, mean arterial pressure, and systolic and diastolic blood pressure in IH did not differ from that of controls. Nocturnal dipping was present in all IH patients and was of equal magnitude to C (9.5 vs 8.4 and 13.7 vs 10.3% for average systolic blood pressure (SBP) and diastolic blood pressure (DBP) dips, respectively). We conclude that normal blood pressure values, as well as the circadian rhythm of blood pressure, are maintained in children with IH of at least 3 years' duration.

A repeat biopsy study in spontaneous crescentic glomerulonephritis mice

BACKGROUND

Spontaneous crescentic glomerulonephritis (SCG)/Kj mice are a candidate for suitable animal model of human pauci-immune crescentic glomerulonephritis (GN). In the present study, we used renal biopsy technique and analyzed time sequence correlations among crescent formation and glomerular neutrophil infiltration in SCG/Kj mice.

METHODS

We observed the progress of GN in SCG/Kj mice according to the urinary abnormalities, and performed the serial renal biopsies. The kinetics of histopathology and glomerular neutrophil influx corresponding disease stage were examined by enzyme-histochemistry and immunohistochemistry.

RESULTS

We divided natural course of GN into three periods in view of urinalysis: a proteinuria-negative/hematuria-negative (P- H-) period, followed by a proteinuria-positive/hematuria-negative (P+ H-) period, and finally a proteinuria-positive/hematuria-positive (P+ H+) period. Endocapillary proliferation phase existed in P+ H- period, whereas crescent formation occurred and extended in P+ H+ period. In P+ H- period, prominent glomerular neutrophil infiltration was observed, while these numbers decreased with the progression of crescent formation.

CONCLUSION

These observations suggest that there is a good correlation between urinalysis and histopathological events of SCG/Kj mice, and that endocapillary proliferation, which contains neutrophil infiltration, may contribute to the subsequent crescent formation in these mice.

Renal complications of sickle cell disease: managing for optimal outcomes

A broad spectrum of renal changes is observed in patients with sickle cell anemia, and ideal therapeutic measures for the management of these alterations are still being studied. Affected patients have deficient urinary concentration and potassium excretion. Perhaps owing to a compensatory mechanism, the proximal tubules are in a condition of "hyperfunction", with increased sodium and phosphorus reabsorption and greater creatinine and uric acid secretion. Mild tubular acidosis may be present. No treatment has been reported for these tubular changes, except for care in the maintenance of hydration. The use of anti-inflammatory drugs is being studied in order to inhibit the prostaglandins involved in the process. Increased renal blood flow, glomerular filtration rate, and filtration fraction are frequent findings. Hematuria commonly occurs as a consequence of red blood cell sickling in the renal medulla, papillary necrosis, or even renal medullary carcinoma. Measures such as increased fluid ingestion, urine alkalinization and, if necessary, administration of epsilon-aminocaproic acid and certain invasive procedures have been proposed to treat hematuria. Nephropathy in patients with sickle cell anemia can be manifested by proteinuria and, more rarely, nephrotic syndrome. Drugs such as prednisone and cyclophosphamide are ineffective for the treatment of patients with nephrotic syndrome. Angiotensin converting enzyme inhibitors decrease proteinuria, but their long-term effect in preventing the progression of glomerular disease has not been established. Chronic renal failure, although infrequent, may be one of the manifestations of this disease. Hemodialysis and transplantation are satisfactory therapeutic options for patients with end-stage renal disease.

Estrous influences on micturition thresholds of the female rat before and after bladder inflammation

Recent evidence suggests that lower urinary tract functions may be influenced by reproductive status, particularly under pathophysiological conditions. This study used repeated cystometrograms via a transurethral catheter to investigate the influence of estrous stage on micturition thresholds before and after turpentine-induced bladder inflammation in urethane-anesthetized female rats. Whereas there were no estrous influences on micturition threshold in the uninflamed bladder, micturition thresholds after bladder inflammation were significantly lower in rats in proestrus or estrus than in rats in metestrus or diestrus. Furthermore, the risk that the initial urethral catheterization and preinflammation cystometrogram would produce hematuria was significantly lower in estrus than in the other stages. These estrous influences are not readily explicable by levels of ovarian hormones at the time of testing and may relate instead to dynamic interactions between these hormones and other neuroactive molecules. In addition, the results here have relevance to interpretations of cystometrographic findings in the clinic and basic research.

Pain management in polycystic kidney disease

Pain is a common complaint in patients with autosomal-dominant polycystic kidney disease, and a systematic approach is needed to differentiate the etiology of the pain and define an approach to management. A thorough history is the best clue to the multifactorial causes of the pain, superimposed upon an understanding of the complex innervation network that supplies the kidneys. The appropriate use of diagnostic radiology (especially MRI) will assist in differentiating the mechanical low back pain caused by cyst enlargement, cyst rupture and cyst infection. Also, the increased incidence of uric acid nephrolithiasis as a factor in producing renal colic must be considered when evaluating acute pain in the population at risk. MRI is not a good technique to detect renal calculi, a frequent cause of pain in polycystic kidney disease. If stone disease is a possibility, then abdominal CT scan and/or ultrasound should be the method of radiologic investigation. Pain management is generally not approached in a systematic way in clinical practice because most physicians lack training in the principles of pain management. The first impulse to give narcotics for pain relief must be avoided. Since chronic pain cannot be "cured," an approach must include techniques that allow the patient to adapt to chronic pain so as to limit interference with their life style. A detailed stepwise approach for acute and chronic pain strategies for the patient with autosomal dominant polycystic kidney disease is outlined.

Assessment of haematuria: automated urine flowmetry vs microscopy

BACKGROUND

Microscopy of the urine sediment may be a useful method in the distinction between a glomerular and a non-glomerular source of urinary bleeding. However, microscopic techniques are time consuming and hampered by inter-observer variations. In the present study we have therefore compared bright-field microscopy with automated urine flowmetry (Sysmex UF-100), examining their ability to differentiate between glomerular and non-glomerular haematuria.

METHODS

Fresh urine samples were obtained from 112 patients with a well-defined, single cause of a positive dipstick test. Their urine specimens were examined within 4 h in a blinded manner. Of them, 79 specimens had a positive dipstick for blood and thus could be evaluated for haematuria.

RESULTS

The Sysmex UF-100 had a sensitivity and specificity of 0.83 and 0.94 respectively in detecting non-glomerular bleeding. The positive and negative predictive values were 0.95 and 0.78 respectively. The corresponding values of microscopy were 0.79 and 0.90 respectively, and 0.93 and 0.74 respectively.

CONCLUSIONS

Automated flowmetry can be used in the distinction between glomerular and non-glomerular haematuria.

Red cell traverse through thin glomerular basement membranes

BACKGROUND

How red cells enter the urinary filtrate in most cases of hematuria of glomerular origin has remained a mystery despite the frequent ultrastructural examination of renal biopsy material.

METHODS

Serial sections of glutaraldehyde-fixed, resin-embedded material from a case of sporadic microhematuria were examined by transmission electron microscopy when the site of a red cell traversing the glomerular capillary wall was fortuitously discovered on routine examination.

RESULTS

The red cell assumed a dumbbell shape and traversed a localized gap 2.25 microm in diameter in the glomerular endothelium and basement membrane. Serial sections suggested a transcellular route. Apart from the thinning of the basement membrane (167 nm), there were no other generalized abnormalities.

CONCLUSION

Red cells can traverse through gaps in the glomerular capillary walls to gain access to Bowman's space. This may be the origin of glomerular hematuria in common noninflammatory forms of glomerular disease, including thin basement membrane nephropathy.

The value of cystoscopy as an initial diagnostic modality for asymptomatic microscopic hematuria

For the patients who visit outpatient clinics due to asymptomatic microscopic hematuria, cystoscopy has been looked upon as rather invasive compared to other diagnostic methods. We tried to elucidate the actual diagnostic value of cystoscopy in the initial evaluation of asymptomatic microscopic hematuria. We reviewed the results of cystoscopic examinations in 213 patients who visited our hospital due to asymptomatic microscopic hematuria. No definite lesion that could explain the microscopic hematuria was detected by means of IVP, urine cytology, and other nephrologic evaluations for all the patients. Among the abnormal cystoscopic findings in 55 patients, the lesions suspected to be directly related to microscopic hematuria were classified as 'significant lesions' (31 patients, 17.6%) which include entities such as bladder cancer (1.31%). 27 of 31 patients with significant lesions (85.2%) were over 50 yr old, and furthermore, 3 patients who were diagnosed as bladder tumor by cystoscopy were over 60 yr. Cystoscopy should be utilized as initial diagnostic modality in older patients with asymptomatic microscopic hematuria to rule out any possibility of bladder cancer occurrence. Further studies are needed to justify implementation of cystoscopy as an initial diagnostic modality in younger patients with asymptomatic microscopic hematuria.

Insight into the physiological function(s) of uteroglobin by gene-knockout and antisense-transgenic approaches

To determine the physiological function(s) of uteroglobin (UG), a steroid-inducible, homodimeric, secreted protein, we have generated transgenic mice that either are completely UG-deficient due to UG gene-knockout (UG-KO) or are partially UG-deficient due to the expression of UG antisense RNA (UG-AS). Both the UG-KO and UG-AS mice develop immunoglobulin A (IgA) nephropathy (IgAN), characterized by microhematuria, albuminuria, and renal glomerular deposition of IgA, fibronectin (Fn), collagen, and C3 complement. This phenotype of both UG-KO and UG-AS mice is virtually identical to that of human IgAN, the most common primary glomerulopathy worldwide. The molecular mechanism by which UG prevents this disease in mice appears to center around UG's interaction with Fn. Since Fn, IgA, and UG are present in circulation and high plasma levels of IgA-Fn complex have been reported in human IgAN, we sought to determine whether UG interacts with Fn and prevents Fn-Fn and/or IgA-Fn interactions, essential for abnormal tissue deposition of Fn and IgA. Our coimmunoprecipitation studies uncovered the formation of Fn-UG heteromers in vitro and these heteromers are detectable in the plasma of normal mice, but not UG-KO mice. Further, high plasma levels of IgA-Fn complex, a characteristic of human IgAN patients, were also found in UG-KO mice. Finally, coadministration of UG + Fn or UG + IgA to UG-KO mice prevented glomerular deposition of Fn and IgA, respectively. Our results define a possible molecular mechanism of IgAN and provide insight into at least one important physiological function of UG in maintaining normal renal function in mice.

Vascular C3 deposits on renal biopsy in pediatric patients with hematuria

Isolated deposition of the third component of complement (C3) in the renal arterioles has been noted on biopsy specimens in patients with hematuria. This entity is of little known significance and reports of this finding in pediatric patients with hematuria are rare. We reviewed the clinical histories and biopsies of 17 children with hematuria and vascular C3 deposition on biopsy at Texas Children's Hospital over an 14-year period. The mean age of presentation was 10.8 (range 4.5-16.6) years with a male preponderance (71%). Family history for hematuria was positive in 6 of 17 patients (35%). Light microscopy was normal or showed only minor abnormalities. Immunofluorescence was negative for IgA and IgG in all patients. Seven patients (41.1%) were noted to have diffuse or focally thin basement membranes on electron microscopy in addition to positive C3 immunofluorescence. The mean follow-up time was 23.8 months, during which 2 of 17 patients (12%) developed worsening proteinuria. The etiopathogenesis of this condition remains unclear, but an underlying immunological process cannot be ruled out. It is possible that this condition represents a stage of an acute glomerulonephritis. Clinical follow-up of these patients is warranted, as the long-term prognosis remains unclear.

Aminoguanidine induces haematuria of non-glomerular origin in spontaneously hypertensive rats

BACKGROUND

Administration of N(G)-nitro-L-arginine methyl ester (L-NAME), a non-selective inhibitor of nitric oxide synthase (NOS), induces glomerulosclerosis in spontaneously hypertensive rats (SHR). We investigated the effects of administering aminoguanidine (AG), a selective inhibitor of inducible NOS (iNOS), on glomerular histology, serum creatinine concentration, albuminuria and haematuria in SHR.

METHODS

SHR and Wistar Kyoto rats (WKR) (age, 7 weeks) were given a daily water supply with or without 0.1% AG. Every 4 weeks, 24 h urine samples were collected and checked for haematuria by a dipstick method, and systolic blood pressure was measured. After 16 weeks, serum creatinine, albuminuria and glomerulosclerosis indices (GSI) were evaluated, and the size of urinary erythrocytes in AG-treated SHR was measured by flow cytometry. Glomeruli were observed by transmission and scanning electron microscopy. Some AG-treated SHR received a furosemide injection and then urinary erythrocyte size was determined.

RESULTS

Systolic blood pressure, serum creatinine, albuminuria and GSI were similar between the untreated and AG-treated groups in both strains. However, AG treatment induced significant haematuria in SHR, but not in WKR. Electron microscopy did not provide any evidence for glomerular bleeding sites in AG-treated SHR. In urine with osmolalities exceeding 750 mOsm/kg, haematuria of AG-treated SHR consisted of erythrocytes smaller in size than venous erythrocytes. After furosemide injection leading to near isotonic urine, the size of urinary erythrocytes was similar to that of venous erythrocytes.

CONCLUSIONS

The absence of morphological evidence for glomerular bleeding sites and similar intrinsic size between urinary and venous erythrocytes suggest that AG induces a non-glomerular type of haematuria in SHR.

Clinicopathologic correlations in lupus nephritis in Lima, Peru

BACKGROUND

We assessed whether immunohistologic markers for glomerular or tubulointerstitial injury might provide better correlations with ongoing renal function and disease activity as compared with the WHO classification or the NIH activity and chronicity indices in lupus nephritis.

METHODS

Thirty-three patients with clinically defined systemic lupus underwent renal biopsy over a 1-year period at Hospital Loayza in Lima, Peru. Biopsy specimens were evaluated for macrophages, proliferating cells, alpha-actin expression, and type IV collagen deposition in both glomeruli and the tubulointerstitium and the results compared with the current WHO and NIH classifications in relation to the clinical presentation.

RESULTS

Patients with WHO class IV lupus nephritis were more likely to have lower serum complements, greater proteinuria and hematuria, and worse renal function. An elevated NIH activity index correlated with microhematuria, proteinuria, and impaired renal function, whereas an elevated chronicity index correlated with renal function, hypertension, and microhematuria, but not with proteinuria. The presence of glomerular macrophages correlated with both glomerular alpha-actin expression and type IV collagen deposition, but did not correlate with renal function or proteinuria. In contrast, interstitial macrophages correlated not only with interstitial collagen deposition and myofibroblast accumulation, but also correlated with both renal function and the presence of nephrotic syndrome.

CONCLUSIONS

Both the WHO classification and the NIH activity/chronicity indices correlate with clinical manifestations of lupus nephritis. While glomerular macrophage accumulation correlates with mesangial cell activation (alpha-actin expression) and collagen deposition, and interstitial macrophage accumulation correlates with interstitial fibroblast activation and collagen deposition, only interstitial macrophages correlate with renal function. Of particular interest will be future studies to determine whether these markers correlate with the prognosis.

Glomerular disease in the elderly population

This brief review of glomerular disease in the elderly contains several lessons for the Geriatric Nephrologist. Remember the atypical presentation of acute nephritis in older individuals. Remember the common causes of nephrotic syndrome in the elderly; namely, membranous glomerulonephritis, minimal change disease, proliferative glomerulonephritis and amyloidosis. Remember the special risks of cytotoxic drug therapy of glomerular disease. Remember the importance of pauci-immune crescentic glomerulonephritis and polyangiitis associated with antineutrophil cytoplasmic antibody in the aging population. Remember the value of and use of urinary erythrocyte dysmorphism in the differential diagnosis of hematuria in the elderly.

Anaemia and iron deficiency in athletes. Practical recommendations for treatment

Trained athletes frequently experience low levels of blood haemoglobin (13 to 14 g/100ml in men and 12 g/100ml in women) plus low haematocrit and low ferritin levels. These parameters define the concept of 'sports anaemia'. Low iron levels may be due to mechanical haemolysis, intestinal bleeding, haematuria, sweating, low iron intake or poor intestinal absorption. The resulting decrease in blood gas transport and muscle enzyme activity impairs performance. The concept of sports anaemia can be criticised. Simply measuring the blood levels does not take into account the haemodilution that occurs in athletes because of training. The lack of these measurements makes it difficult to diagnose anaemia or evaluate any treatment. Anaemia is treated by preventing decreased iron stores through a balanced food intake or iron supplements. Self-medications must be discouraged because of intolerance, risk of overdose and many other drug interactions.

Major hemorrhage in children with idiopathic thrombocytopenic purpura: immediate response to therapy and long-term outcome

OBJECTIVES

We retrospectively characterized children with idiopathic thrombocytopenic purpura (ITP) who had major hemorrhage to determine response to therapy and long-term outcome.

STUDY DESIGN

We reviewed the medical records of 332 children with ITP diagnosed at our center during the last 10 years for occurrence of major hemorrhage, defined as (1) intracranial hemorrhage, (2) epistaxis requiring cautery or nasal packing, (3) gross hematuria, or (4) other bleeding causing a decline in hemoglobin concentration.

RESULTS

Of 332 patients with ITP, 58 (17%) had 68 episodes of major hemorrhage; 56 of these episodes were treated with corticosteroids, intravenous immunoglobulin, or both. The platelet count rose to > or =20,000/mm3 within 24 hours after presentation after only 18% of evaluated events, and 28% of patients with major hemorrhage still had a platelet count <20,000/mm3 after 7 days. Twenty-seven of 49 patients available for evaluation had resolution of ITP within 6 months, 21 had chronic ITP, and 1 died of sepsis.

CONCLUSIONS

We observed that 17% of children with ITP had major hemorrhage. Only a minority of these patients had an immediate rise in platelet count after receiving intravenous immunoglobulin, corticosteroid treatment, or both. Prospective studies of childhood ITP focusing on short-term outcome variables in addition to platelet count should be performed to better define optimal treatment for each affected child.

[Renal angiomyolipoma. Apropos of 11 cases]

The authors report their experience of 11 cases of renal angiomyolipoma over an interval of 20 years, observed in 10 women (90.9%) and one man (9.1%) with a mean age of 46 years (range: 21 to 63). Clinical symptoms were dominated by loin pain (100%), haematuria (45.4%), lumbar mass (72.7%), fever (18%). In one woman, AML was associated with "tuberous sclerosis". Preoperatively, the diagnosis was established by ultrasound and CT scan in 45.4% of patients. The size of the tumour varied from 7 to 14 cm in 10 patients and in one patient was only about 3.6 cm. Two women had bilateral tumours. Treatment consisted of total nephrectomy in 7 patients, partial nephrectomy in 3 patients and tumourectomy in one patient. The purpose of this study is to analyse the epidemiologic, diagnostic and therapeutic aspects of this disease.

[Cancer of the kidney in adults. Apropos of 60 cases]

The authors report a series of 60 cases of renal cancer observed over a 10-year period. Patients consisted of 35 women (58%) and 25 men (42%), with a mean age of 52 years (range: 21-72 years). The clinical features were polymorphic, dominated by loin pain (76%), haematuria (75%), a lumbar mass (46%), alteration of the general state (30%). The diagnosis was established by ultrasonography in 58 patients and CT scan in 38 patients. The mean tumour diameter was 11.5 cm (5-25 cm) and two cases presented bilateral tumours. The tumour was located in the upper pole in 40% of cases and was mid-renal in 30% of cases. The time to diagnosis ranged from 2 months to 3 years. Staging reflected the advanced stage of the cancer. Treatment was surgical for 53 patients (88%). A lumbar incision was generally performed (83%). The surgical procedure consisted of nephrectomy and regional or hilar lymph node dissection. Nephrectomy was simple for 27% of patients, radical for 69% of patients and partial for 4% of patients. The postoperative course was marked by one death due to pulmonary embolism, and a stercoral fistula in 2 patients. Histological examination of the specimen showed clear cell adenocarcinoma in 92% of cases. The tumour weight was often considerable, with a maximum of 3.750 kg. The lymph nodes removed were invaded in 50% of cases. The mean follow-up was 46 months (12 to 120 months). Follow-up was normal at 3 years for 23 patients (43%) and at 10 years for 4 patients (8%). Tumour recurrence in the renal compartment was observed in 3 patients after 3 years. Asynchronous metastases occurred in 10 patients (23%). The mean interval to metastases was 20 months (4 to 36 months).