Impact of tumour morphology on renal function decline after partial nephrectomy.

OBJECTIVE: To examine the association of renal morphology with renal function after partial nephrectomy (PN). PATIENTS AND METHODS: We conducted a multi-institutional retrospective analysis of 322 PNs performed between 2003 and 2011. The RENAL nephrometry score for each lesion was determined and the estimated glomerular filtration rate (eGFR) was calculated preoperatively and at last follow-up. We divided patients into two RENAL nephrometry score groups, low (<8) and high (≥8), and analysed and compared the outcomes of each group. The primary outcome was median change in eGFR between preoperative and last follow-up (ΔeGFR). The secondary outcome was eGFR <60 mL/min/1.73 m(2) at last follow-up. Multivariable analysis was conducted to evaluate the risk factors for eGFR <60 mL/min/1.73 m(2) at last follow-up. RESULTS: The median (interquartile range) follow-up was 25.2 (13.5-39.3) months. Low (n = 165) and high (n = 157) RENAL score groups were well-matched for baseline eGFR. The median tumour size (4.2 vs 2.4 cm, P < 0.001) was greater for the high group. In all, 64% of the low and 88.2% of the high RENAL score group (P < 0.001) had decreased eGFR at last follow-up. Median eGFR was -7 for the low vs -13.8 mL/min/1.73 m(2) for the high group (P = 0.001); eGFR <60 mL/min/1.73 m(2) at last follow-up was 27.3% for the low vs 37.6% for the high group (P = 0.057). Linear regression analysis showed that for each 1-point increase in RENAL score, there was 2.5% decrease in eGFR (P = 0.002); for each 1-cm increase in tumour size, there was 1.8% decrease in eGFR (P = 0.013). Area under curve analyses showed no significant difference between RENAL score and tumour size for prediction of de novo eGFR <60 mL/min/1.73 m(2) (P = 0.920) and ΔeGFR ≥50% (P = 0.85). Multivariable analysis showed that increasing RENAL score (odds ratio [OR] 1.24, P = 0.046) and decreasing preoperative eGFR (OR 1.10, P < 0.001) were risk factors for eGFR <60 mL/min/1.73 m(2) at last follow-up. CONCLUSIONS: Increasing RENAL nephrometry score is an independent risk factor for eGFR <60 mL/min/1.73 m(2) after PN. RENAL nephrometry score may serve as an additional measure for risk stratification before PN, but further investigation is required.

Does radical nephrectomy increase the risk of erectile dysfunction compared with partial nephrectomy? A cohort analysis.

UNLABELLED: Study Type - Therapy (prospective cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). We hypothesized that partial nephrectomy (PN) would limit development of ED compared with radical nephrectomy (RN), primarily due to renal function preservation, and found that patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN; in addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. To our knowledge, this is the first study demonstrating an increased risk of ED after RN compared with PN. OBJECTIVES: • To evaluate prevalence and risk factors for development of erectile dysfunction (ED) in patients who underwent radical nephrectomy (RN) and partial nephrectomy (PN). • ED is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). PN confers superior renal functional preservation compared with RN; however, the impact on ED is unclear. METHODS: • This was a retrospective study of 432 patients (264 RN/168 PN, mean age 58 years, mean follow-up 5.8 years) who underwent surgery for renal tumours between January 1998 and December 2007. • The primary outcome was rate of de novo ED postoperatively. Secondary outcomes included development of CKD (estimated GFR < 60 mL/min/1.73 m(2) ) and response to phosphodiesterase-5 inhibitors. • Multivariate analysis was performed to determine risk factors for de novo ED postoperatively. RESULTS: • RN and PN groups had similar demographics and comorbidities. • Tumour size (cm) was larger for RN (RN 7.0 vs PN 3.7, P < 0.001) and more preoperative ED existed in PN vs RN (P= 0.042). No differences were observed for preoperative CKD, hyperlipidaemia and diabetes mellitus. • Postoperatively, higher rates of de novo ED (29.5% vs 9.5%, P < 0.001) and CKD (33.0% vs 9.8%, P < 0.001) developed in RN vs PN cohorts, respectively. • Of men with ED, 63% responded to phosphodiesterase inhibitors, without significant difference between the two groups (P= 0.896). • Multivariate analysis demonstrated de novo ED to be associated with RN (odds ratio [OR] 3.56, P < 0.001), hypertension (OR 2.32, P= 0.014), preoperative (OR 8.77, P < 0.001) and postoperative (OR 2.64, P= 0.001) CKD, and postoperative diabetes mellitus (OR 2.93, P < 0.001). CONCLUSIONS: • Patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN. In addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. • Further investigation on effects of surgically induced nephron loss on ED is requisite.

Ureteroscopy in pediatric patients with spinal abnormalities.

BACKGROUND AND PURPOSE: Ureteroscopy (URS) is considered a safe and effective treatment modality for ureteral stones in the pediatric population. Patients with scoliosis or spinal hardware, however, may have anatomic variability that makes URS challenging because of ureteral deviation or tortuosity. We reviewed 130 ureteroscopic procedures at our institution to determine if presence of spinal hardware or severe spinal deformities was associated with increased complications or worsened treatment efficacy. PATIENTS AND METHODS: A retrospective chart review was performed on 130 ureteroscopic procedures in 102 patients. Patients were divided into two groups: Those with normal spinal anatomy and those with spinal abnormalities including spinal hardware or moderate to severe scoliosis. Parameters evaluated included patient demographics, stone burden, intraoperative complications (including urinary extravasation, bleeding, or need to abort procedure), and stone-free status. RESULTS: Of 130 ureteroscopic procedures between 2002 and 2010, 25 URS were performed for purposes other than stone disease (gross hematuria, filling defects, or encrusted ureteral stents). The remainder of URS (105) were performed for stone disease. Nine patients had spinal hardware or significant spinal deformities including moderate to severe scoliosis. When comparing both the intraoperative complications as well as stone-free status, there was a difference between those patients with spinal abnormalities and those without. Of 90 URS performed for stones in normal anatomy patients, the stone-free rate was 61%, compared with 35.7% in patients with spinal deformities. There were 13 total complications (Satava grade I or II): 40% in spinal deformity patients compared with 6.1% in normal anatomy patients. CONCLUSION: Spinal hardware and spinal deformities contribute to increased complications and worsened stone-free rates during pediatric URS compared with pediatric patients with normal anatomy. Our experience with URS in patients with spinal deformities suggests it may not be as safe or efficacious as in the general pediatric population but it can still be used as a primary modality.