Open adrenalectomy for medium sized adrenocortical tumour: How I do it?

INTRODUCTION: The aim of our work was to report our experience in managing cases with medium-sized adrenocortical carcinoma by the high retroperitoneal extra pleural approach. METHODS: During the past 2 years, 10 patients with suspected adrenocortical carcinoma were managed by our technique: the high supra 10th rib, retroperitoneal extra pleural approach. We included cases with 5 to 10 cm adrenal masses, suspected as adrenocortical carcinoma. RESULTS: The mean patient age was 38 years (range: 26-44), the median tumour volume was 7 cm (range: 5-8). Of the 10 patients, 7 were female. Of the patients, 6 had right- and 4 had left-sided tumours. Intraoperatively, all cases had proper surgical removal, with no apparent residual tumour tissue. No single patient required a chest tube or developed respiratory problems. There were no major vascular injuries during surgery. We did not compare our findings to the standard lateral or subcostal approaches, as in our institution we adopt this high lateral approach for medium-sized tumours, while managing larger tumours with transperitoneal subcostal approach and smaller tumours laparoscopically. CONCLUSION: The high supra 10th lateral retroperitoneal, extra pleural approach is a safe, doable technique, allowing easy access to medium-sized suprarenal tumours and its vasculature, for cases suspected to be adrenocortical carcinoma.

Pressure transmission through ureteric stents: a novel in vivo human study.

OBJECTIVE: To document, in an in vivo study, the pressure transmission from the urinary bladder to the upper tract through ureteric stents in human patients. Stents have acquired special importance in the urological armamentarium. Flank pain and hydronephrosis are associated with stenting in 50% and 18% of cases, respectively. Pressure transmission from urinary bladder to the upper tract through the stent is the logical explanation for loin pain and hydronephrosis. METHODS: This study was conducted in a prospective manner. We did not select patients or modify their management; instead, we studied patients who, during the course of urological management of some upper tract disease, are left with both a ureteric stent and a nephrostomy tube. Twenty patients fulfilled our criteria. After written consent, a pressure-flow study was done monitoring pressure changes in the renal pelvis during different phases of bladder filling in sitting and recumbent positions. RESULTS: Pressure-flow curves showed almost equal transmission of pressure from the bladder to the renal pelvis throughout all phases of bladder filling and emptying. Any voluntary and involuntary rise of pressure in the bladder was instantly and almost equally transmitted to the renal pelvis. A subgroup of patients with infravesical obstruction resulting from benign prostatic hyperplasia also showed equal transmission of the elevated intravesical pressure during voiding to the renal pelvis. CONCLUSION: Pressure from the lower urinary tract is transmitted to the upper tract through the stent, posing a threat to the renal parenchyma and function. Stent placement, when indicated, should be used for the shortest period possible, in sterile urine.

Recurrence pattern in patients with locally advanced renal cell carcinoma: The implications of clinicopathological variables.

OBJECTIVES: Recurrence rates for patients with locally advanced renal cell carcinoma (LARCC) remain high. To date the predictors of recurrence in those patients remain controversial. The aim of the present study was to assess the relapse pattern in those patients and identify predictors for recurrence. PATIENTS AND METHODS: We evaluated retrospectively 112 consecutive patients who underwent surgery for LARCC (T3-T4N0M0) between January 2000 and December 2010. Clinical and pathological data were collected from hospital medical records and compiled into a computerized database. Studied variables were age, mode of presentation, Tumour-Node-Metastasis (TNM) stage, Fuhrman nuclear grade, histological subtype, tumour size, venous thrombus level, collecting-system invasion and sarcomatoid differentiation. Recurrence-free survival (RFS) was estimated using the Kaplan-Meier method. Univariate and multivariate analyses were conducted. RESULTS: Patients were followed for a mean and median follow-up of 33 and 24 months, respectively, after surgery. During the follow-up, recurrences (distant and/or local) were recorded in 58 patients, representing 52% of the cohort. The mean and median times to recurrence were 25 and 13 months, respectively. Sites of recurrence were multiple in 36 patients (62%), lung only in 14 (24%), and local in eight (14%). RFS rates at 1, 2, and 5 years were 50%, 43% and 34%, respectively, while the median RFS was 23.7 months. Using univariate analysis, RFS after nephrectomy was significantly shorter in patients aged <70 years, symptomatic at presentation, with larger tumours, higher nuclear grade, collecting-system invasion, and/or sarcomatoid differentiation. After multivariate analysis, T-stage, nuclear grade and sarcomatoid differentiation retained their power as independent predictors of RFS (P = 0.032, <0.001 and 0.003, respectively). CONCLUSIONS: For patients with LARCC, T-stage, grade and sarcomatoid differentiation independently dictate the risk of tumour recurrence. Considering these variables in the postoperative surveillance protocols and in the need for a multimodal therapeutic approach is highly recommended.

Value of intravenous urography before shockwave lithotripsy in the treatment of renal calculi: a randomized study.

PURPOSE: To study the impact of preprocedure intravenous urography (IVU) on the outcome of SWL for renal stones. PATIENTS AND METHODS: Two hundred patients with radiopaque renal stones