The incidence of multifocal renal cell carcinoma in patients who are candidates for partial nephrectomy

PURPOSE

A prospective study was performed to determine the incidence of multifocal renal cell carcinoma in patients who are candidates for partial nephrectomy.

MATERIALS AND METHODS

Preoperative imaging studies and surgical specimens in 44 patients suitable for partial nephrectomy but undergoing radical nephrectomy were prospectively reviewed.

RESULTS

Of 44 renal cell cancers 11 (25%) demonstrated pathological multifocality, while 10 of 11 multifocal tumors (91%) occurred in the face of a primary tumor 5 cm. or smaller. Tumor multifocality was independent of the size of the primary renal tumor but occurred with a slightly higher frequency in tumors of stage T3A or greater even if the primary tumor was small.

CONCLUSIONS

Partial nephrectomy in patients with unilateral renal cancer should be approached with caution and should not be performed simply because it is technically feasible.

Arteriovenous malformation of ureter

Congenital arteriovenous malformations of the genitourinary tract are rare. We report the first case of an arteriovenous malformation of the ureter. The patient presented with recurrent hematuria and left flank pain. Evaluation included an intravenous urogram, cystoscopy, and retrograde pyelography. A pedunculated lesion thought to be a fibroepithelial polyp was seen at the time of ureteroscopy, and the lesion treated by excisional biopsy and fulguration. Pathologic examination demonstrated an arteriovenous malformation. After thirty-month follow-up, the patient remains asymptomatic and free of recurrence.

Hepatobiliary complications of polyarteritis nodosa

Although polyarteritis nodosa (PAN) may result in thrombosis or aneurysm formation in any organ in the body, hepatobiliary complications are unusual. We reviewed seven cases that demonstrated the diagnostic difficulties and therapeutic options available in the management of hepatobiliary PAN. No consistent sign that indicated the severity of hepatobiliary PAN could be identified. In cases of thrombotic PAN, acalculus cholecystitis usually could be diagnosed preoperatively. Early tissue diagnosis and aggressive intervention are required for appropriate patient treatment. If the diagnosis is unclear, a preoperative muscle or skin biopsy specimen is often helpful in establishing a tissue diagnosis of PAN, even if no obvious pathologic condition is evident. Patients who undergo celiotomy for acalculus cholecystitis or peritoneal signs of an unclear origin should have tissue specimens (gallbladder wall, liver, or omentum) submitted for pathologic study. Angiography may be diagnostic preoperatively or when results of biopsies are equivocal. In addition, early angiography can define the extent of visceral involvement and permit control by embolization of hemorrhage secondary to aneurysm rupture. Awareness of the possibilities of thrombotic, ischemic, or bleeding complications from PAN allows more aggressive and rapid management of abdominal complaints, especially in patients who are receiving immunosuppressant therapy.

Gianturco-Rosch biliary stents: preliminary experience

Results of long-term follow-up are reported for nine patients who underwent placement of Gianturco-Rosch expandable metallic stents. Seven patients had malignant disease. The average duration of patency was 7 months. In one patient with inactive primary sclerosing cholangitis (PSC), the stents remained patent at 22 months, but recurrent stent closure was seen in a second patient with PSC. In the patient population studied, no advantages were seen with use of the stents; however, they may have an application in certain patients with benign disease.

Flow cytometric analysis of localized adenocarcinoma of the prostate: the use of archival DNA analysis in conjunction with pathological grading to predict clinical outcome following radical retropubic prostatectomy

Fifty-four specimens from patients undergoing radical prostatectomy for clinically confined prostate cancer between 1983 and 1987 were reviewed to determine the potential for flow cytometric (FCM) analysis of DNA ploidy and replication rate to predict disease recurrence. Each specimen was deparaffinized for FCM analysis and the pathology slides were reviewed by a single pathologist. FCM characteristics were correlated with pathological grade and stage, and both were correlated with disease status. In this series of patients, routine FCM analysis of DNA ploidy and replication rate failed to significantly enhance the ability of standard histopathological grading to predict disease recurrence in patients having clinically localized prostate cancer. Aneuploid tumors pathologically confined to the prostate did not appear to negatively affect prognosis.

Maintaining quality of life after palliative diversion for malignant ureteral obstruction

The records of 71 consecutive patients who underwent percutaneous nephrostomy for malignant ureteral obstruction were reviewed. The average post-nephrostomy survival time was seven months, of which 25% was spent in the hospital. When comparing these figures to older studies of open nephrostomy, the percutaneous procedure is associated with less morbidity and an increased percentage of time spent at home (75% compared to 36%). Long-term survival, however, is still poor, with only 25% of patients alive at one year. We suggest that the criteria previously adopted for open nephrostomy generally remain appropriate for patients being considered for percutaneous urinary diversion.

Total occlusions of the femoropopliteal artery: high technical success rate of conventional balloon angioplasty

Seventy patients 48-93 years of age underwent standard percutaneous transluminal angioplasty (PTA) for femoropopliteal artery occlusions 1-10 cm long. PTA was accomplished through an antegrade puncture of the common femoral artery. The angiographic criterion for technical success was restoration of the vessel lumen with no significant residual stenosis. The authors report technical success in 64 (91%) of their patients, an improvement over a technical success rate of 74% in their previous series of 46 other PTA patients with occlusions 1-20 cm long. In this series, no complications related to PTA necessitated emergency surgical intervention. Refinements in PTA can be attributed to changes in patient selection and medication, improvements in balloon catheters and guide wires, and greater proficiency on the part of angiographers. This update reflects currently achievable results with standard angioplasty techniques, and it is against such results that all new vascular recanalization techniques, including laser-assisted PTA, should be compared.

Percutaneous transjejunal approaches to the biliary system

The authors report 10 cases in which various retrograde manipulations in the biliary tract were performed via percutaneous access from the jejunum in patients who had previously undergone Roux-Y biliary surgery. The first cases involved attempted retrograde cholangiography through the jejunal limb in children who had undergone Roux-Y portoenterostomies, followed by cases of percutaneous placement of U tubes and an attempt at percutaneous creation of an hepaticojejunostomy. When a limb from the Roux-Y has been brought to the skin and marked with clips, jejunal puncture is easily performed, is well tolerated by patients, and may be repeated frequently. It also appears that after Roux-Y choledochojejunostomy, the Roux-Y limb is fixed and may be punctured with relative safety. Since access from below is more favorable for intrabiliary manipulations, the transjejunal approach expands the armamentarium of the interventional radiologist in the combined radiologic and surgical management of complex biliary disease.

Percutaneous drainage of intra-abdominal abscesses following abdominal trauma

Between January 1, 1984, and June 30, 1987, we performed percutaneous catheter drainage (PCD) of 28 intra-abdominal abscesses in 21 postoperative trauma patients. During this period only three patients had abdominal re-exploration for drainage of abdominal abscess. The PCD patients were predominantly young men who had sustained penetrating abdominal injuries (81% GSW or SW; 19% MVA). Seventeen (81%) patients had multiple abdominal organ injuries with the colon being the most frequently injured (57%). Multiple abscesses were identified in 33% of the patients. All 21 patients had successful treatment of their abscesses by PCD alone. There was one complication (4.8%) from PCD (pneumothorax) and no deaths in this group. Our data suggest that in most cases, PCD can be safe, effective, and definitive treatment for postoperative intra-abdominal abscesses following abdominal trauma. We recommend PCD in all postoperative trauma patients who develop accessible abdominal abscesses before resorting to re-exploration.

Percutaneous creation of a hepaticojejunostomy

A procedure is described whereby a direct anastomosis may be created percutaneously between the biliary system and a Roux-en-Y limb; in effect a percutaneous hepaticojejunostomy. Although it will have limited applications, it represents a further extension of percutaneous techniques in the biliary system for complex problems.