[Safety and feasibility of outpatient flexible ureteroscopy for urinary stones: A retrospective single-center study]. / Faisabilité de l'urétéroscopie souple en ambulatoire pour la prise en charge des calculs urinaires : une étude rétrospective monocentrique.

AIM: Management of urolithiasis has changed over the past decades. Outpatient surgery has become a major issue for healthcare systems. The aim of this study was to assess the feasibility of outpatient flexible ureteroscopy. METHODS: A single-center retrospective study has been conducted including all patients who underwent an outpatient flexible ureteroscopy between January 2012 and December 2013. Failure of outpatient management was defined as length of hospital stay>12 hours or readmission within 48 hours after discharge. Univariate analysis was performed to seek for predictors of failure of outpatient management. RESULTS: One hundred and fifty-seven patients who underwent a total of 174 procedures were included. They were mostly men (57.5 %), with a mean body mass index of 25.2kg/m2 (±4.3). The stones were mostly unique (64.3 %), with a mean size of 14.2mm (±11.2). Eighty patients had a double J stent preoperatively (46.5 %), and mean operative time was 64.2 minutes (±34.1). An ureteral access sheath was used in 39 procedures (22.4 %). A double J stent was left postoperatively in 103 patients (59.1 %). In total, 165 procedures (94.8 %) were performed successfully as outpatient surgery. On postoperative imaging, the stone-free rate was 69.5 %. Postoperative complications occurred in 3.4 % of cases and were mostly minor (i.e. Clavien 1-2; 83.3 %). Predictive factors of failed outpatient management were male gender (P=0.04), BMI (P=0.03), and anticoagulants intake (P=0.003). CONCLUSION: Outpatient flexible ureteroscopy for urinary stones is feasible and its low failure and complications rate may allow a wider spread of its use. LEVEL OF EVIDENCE: 4.

[Oncologic and perioperative outcomes of robot-assisted radical cystectomy: A single-center prospective series]. / Résultats oncologiques et périopératoires de la cystectomie totale robot-assistée pour cancer : une série prospective monocentrique.

INTRODUCTION: The aim of this study was to report perioperative and oncological outcomes of robot-assisted radical cystectomy (RARC) in a single-center series and to evaluate the impact of the experience on perioperative outcomes. METHODS: Between March 2012 and January 2016, 41 patients underwent RARC associated with extended pelvic lymphadenectomy for muscle-invasive bladder cancer. All RARC included were performed by a single-surgeon in one center. Perioperative and oncological datas were collected prospectively. Recurrence-free (RFS), overall (OS) and cancer-specific survivals (CSS) were estimated using the Kaplan-Meier Method. The impact of the experience on perioperative data was estimated using Spearman's correlation test. RESULTS: Mean age was 67,7years (±10.6). Most patients underwent neoadjuvant chemotherapy (73.2%). Mean operative time and mean estimated blood loss were respectively 319.5minutes (±85.3) and 662.5mL (±360.9). Eight patients needed perioperative blood transfusion (19.5%). Conversion to open surgery was necessary in 3 cases (7.3%). Ileal neobladder was performed in 26.8% of the cases (54.5% being performed intracorporeal), and non-continent urinary diversion in 73.2%. Mean nodal yield was 17.7 (±9.3). Positive surgical margins were observed in 1 patient (2.3%). Mean length of stay was 13.2 days (±9.8). Postoperative complication rate was 46,3%. After a median follow-up of 16months, estimated 2 year-OS and CSS were respectively 62 and 76.1%. Estimated 2-year RFS was 67.6%. Perioperative outcomes improved with experience with a significant decrease in operative time (P=0.04) and a significant increase of nodal yield (P=0.05). CONCLUSION: In this single-center prospective study, satisfactory perioperative and oncological outcomes after RARC were observed despite the learning curve. Perioperative outcomes improved with surgeon's experience. Further studies are needed to confirm these findings. LEVEL OF EVIDENCE: 4.

Paracetamol, aspirin and indomethacin display endocrine disrupting properties in the adult human testis in vitro.

STUDY QUESTION: Do mild analgesics affect the endocrine system of the human adult testis? SUMMARY ANSWER: Mild analgesics induce multiple endocrine disturbances in the human adult testis in vitro. WHAT IS KNOWN ALREADY: Mild analgesics have recently been incriminated as potential endocrine disruptors. Studies of the effects of these widely used molecules on the androgenic status of men are limited and somewhat contradictory. This prompted us to investigate whether these compounds could alter the adult human testicular function. We therefore assessed in parallel the effects of paracetamol, aspirin and indomethacin on organo-cultured adult human testis and on the NCI-H295R steroid-producing human cell line. STUDY DESIGN, SIZE, DURATION: Adult human testis explants or NCI-H295R adrenocortical human cells were cultured with 10(-4) or 10(-5) M paracetamol, aspirin or indomethacin for 24-48 h. The effect of 10(-5) M ketoconazole, used as an anti-androgenic reference molecule, was also assessed. PARTICIPANTS/MATERIALS, SETTING, METHODS: Testes were obtained from prostate cancer patients, who had not received any hormone therapy. The protocol was approved by the local ethics committee of Rennes, France and informed consent was given by the donors. Only testes displaying spermatogenesis, as assessed by transillumination, were used in this study. Hormone levels in the culture media were determined by radioimmunoassay (testosterone, insulin-like factor 3), Enzyme-Linked Immunosorbent Assay (inhibin B) or Enzyme Immunosorbent Assay [prostaglandin (PG) D2, and PGE2]. Tissues were observed and cells counted using classical immunohistochemical methods. MAIN RESULTS AND THE ROLE OF CHANCE: The three mild analgesics caused multiple endocrine disturbances in the adult human testis. This was particularly apparent in the interstitial compartment. Effective doses were in the same range as those measured in blood plasma following standard analgesic treatment. The production of testosterone and insulin-like factor 3 by Leydig cells was altered by exposure to all these drugs. Inhibin B production by Sertoli cells was marginally affected by aspirin only. Our experiments also revealed that mild analgesics display direct anti-PG activity, which varied depending on the drug used, the dose and the duration of exposure. Nevertheless, associations between the alteration of the PG and testosterone profiles were not systematically observed, suggesting that a combination of mechanisms of endocrine disruption is at play. LIMITATIONS, REASONS FOR CAUTION: Our studies were performed in vitro. WIDER IMPLICATIONS OF THE FINDINGS: We provide the first evidence that direct exposure to mild analgesics can result in multiple endocrine disturbances in the human adult testis. Caution, concerning the consumption of mild analgesics by men, should be strengthened, particularly in high-risk population subgroups such as elite athletes.

Human testis steroidogenesis is inhibited by phthalates.

BACKGROUND: Phthalic acid esters are widely used in the manufacture of plastics. Numerous studies have shown that these phthalates impair testicular testosterone production in the rat. However, the scarce and contradictory data concerning humans have cast doubt over whether these compounds are also anti-androgenic in man. We therefore investigated the direct effects of di-(2-ethylhexyl) phthalate (DEHP) and mono-(2-ethylhexyl) phthalate (MEHP) on organo-cultured adult human testis and a human cell line. METHODS: Adult human testis explants or NCI-H295R adrenocortical human cells were cultured with DEHP or MEHP. The effects of ketoconazole, used as a reference molecule, were also assessed. RESULTS: In both models, DEHP and MEHP significantly inhibited testosterone production. The effects of both phthalates appeared to be specific for steroidogenesis, as INSL3 production by Leydig cells was not altered. Furthermore, the phthalates of interest had no effect on inhibin B production by Sertoli cells or on germ cell apoptosis. As only a small fraction of the phthalates added was found in the testis explants, and as these compounds were found to be metabolized, we estimate that the anti-androgenic effects observed occurred at concentrations of phthalates that are of the same order of magnitude as exposures reported in the literature for men. CONCLUSIONS: We provide the first evidence that DEHP and MEHP can inhibit testosterone production in the adult human testis. This is consistent with recent epidemiological findings of an inverse correlation between exposure to MEHP and testosterone concentrations.

[Renal LESS surgery: Slight modification or surgical revolution?]. / La néphrectomie laparoscopique par accès ombilical unique : évolution ou révolution chirurgicale ?

OBJECTIVE: to present our initial experience of laparoendoscopic single site (LESS) renal surgery. METHODS: between May 2009 and March 2010, nine nephrectomies and one cyst decortication were performed in nine patients. Eight of the procedures were done with three 5mm trocars inserted through a unique peri-umbilical incision. In two cases, a specific single-port device was used. All operations were achieved with a 5-mm 30° lens and conventional laparoscopic instruments. The specimens were entrapped in a 10mm endoscopic bag and extracted through the umbilical incision. RESULTS: mean age was 56 years old. Mean BMI was 23.5 [19-34]. Mean operative time was 149min [80-240], and estimated blood loss was 90ml [20-250]. None of the patients required blood transfusion. Mean length of stay was 4.1 days [3-5]. Only one major complication occurred (functional occlusion). One conversion to conventional laparoscopy was necessary in a case of inflammatory kidney. Histologic exam showed benign lesions (cyst and non functional kidney) in seven cases, and papillary carcinoma in three cases. CONCLUSION: LESS surgery is feasible. Its advantages over conventional laparoscopy are not clear. LESS is a new procedure that should benefit from the improvement of technical instrumentation.

[Study of the expression of Aurora kinases in renal cell carcinoma]. / Étude de l'expression des kinases Aurora dans le carcinome à cellules rénales.

OBJECTIVES: The Aurora kinase family plays a crucial role in the regulation of mitosis. Over-expression of Aurora A and B has been reported in many malignant tumors. The objective of this study was to analyze the expression of Aurora A and B in renal cell carcinoma (RCC) and its correlation with usual clinical and pathological parameters. METHODS: In a retrospective study, have been studied the tumoral samples of 40 consecutive patients who had been operated between 2003 and 2006 for a renal tumor. RNA was extracted from frozen corresponding tumoral samples. Thirty-one samples were retained based on RNA quality. RT-PCR was done on each of these samples to assess the expression of Aurora A and B genes. Statistical analysis was performed using Chi-square test to compare Aurora A and B levels. RESULTS: Median age was 65 years (35-82). Seven (22%) patients had nodal invasion and eight (26%) had distant metastases. Most of the tumors (74%) were grade 3 or 4. Eighteen patients (58%) had clear cell cancer histology, 12 (39%) had papillary histology, and one a Bellini type tumor. Aurora A overexpression was associated with lymph node invasion (p=0.001). Aurora B over-expression was associated with both nodal involvement (p=0.02) and histologic subtype (significantly over-expressed in clear cell tumors; p=0.001). CONCLUSIONS: Aurora A and B were differentially over-expressed in clear cell RCC and primary tumors of patients with lymph node involvement.

[Optical spectroscopy: a new approach to assess urological tumors]. / La spectroscopie optique : une nouvelle approche pour l'étude des tumeurs urologiques.

INTRODUCTION: Optical spectroscopy refers to a group of novel technologies that uses interaction of light with tissues to analyze their structure and chemical composition. The objective of this article is to describe these technologies and detail their potential for assessing urological tumors. MATERIAL AND METHODS: It has been shown that optical spectroscopy can accurately analyse multiple solid tumors. Several publications specifically aimed at assessing prostate cancers, renal carcinomas and urothelial tumors. RESULTS: There are three types of spectroscopy that all use light focussed on a tissue and thereafter collect a specific reflected optical signal. Optical spectroscopy can differentiate benign (adenoma or inflammation) and malignant (adenocarcinoma) prostatic tissues. It can also distinguish normal bladder tissue from inflammatory or cancerous cells. Regarding renal tumors, spectroscopy can identify normal and tumoral tissue and differentiate benign and malignant tumors. Its diagnostic accuracy is about 85%. However, reported studies only concentrate on in vitro or ex vivo specimen and the numbers of patients are quite small. CONCLUSION: Optical spectroscopy can be envisioned as an "optical biopsy" tool. Potential applications in the clinical field are promising. Larger studies on in vivo specimen need to be undertaken to confirm phase I preliminary reports.

[Prognostic value of erythrocyte polyamines levels in renal cell carcinoma. Prospective study in 418 cases]. / Valeur pronostique des polyamines érythrocytaires dans le cancer du rein. Etude chez 418 patients.

OBJECTIVES: Polyamines: Spermine (Spm) and Spermidine (Spmd), are essential for cell proliferation and differentiation. A measurement of erythocytes polyamines (EPA) was developed in our institution. Our objective was to evaluate this marker as a new prognostic factor in renal cell carcinoma. PATIENTS AND METHODS: A blood sample was prospectively taken before surgery, among 418 patients who had an enlarged nephrectomy (n=318) or a partial nephrectomy (n=100) to quantify EPA rates by using the HPLC technique. The qualitative and quantitative variables have been compared using chi(2) and Student statistical analyses. The survivals have been normalized by the Kaplan Meier and Cox methods. RESULTS: The average age of our population was 64 years (21-88). The average decline was 41 months (1-214). The median size of tumors was 6.5cm (1-24). The median rate of Spm and Spmd were respectively 4.7 (1-83) and 9 (2-86)nmol/8.10(9) erythrocytes. Spm and Spmd were linked to the T stage (p=0.001), and the ECOG (p=0.001 and 0,008). Spm was not linked at N and M stages but at the Fuhrman grade (p=0.001). Spmd was linked to the N, M stages (p=0.04). With univariate analysis, the tumor diameter, the TNM stage, the Fuhrman grade as well as Spm and Spmd (p<0.0001) were predictors of specific survival. With multivariate analysis, some prognostic factors remained independent: the TNM stage, the ECOG and Spmd, a continuous variable (p=0.0001), pushing the rank of Fuhrman out of the model. When Spm and Spmd were dichotomized in quantitative variables, they were both independent factors. CONCLUSION: The EPA is a new prognostic tool, before surgery, which will be tested for its integration into prognostic normograms.

[What is the clinical practice of partial nephrectomy in France?]. / Quelle pratique de la néphrectomie partielle en France ?

OBJECTIVE: To describe the practice of partial nephrectomy (PN) in France and assess its results in terms of morbidity and cancer control. MATERIAL AND METHOD: Seven French University Hospitals in which nephron sparing surgery represents at least 30% of the total number of nephrectomies for renal tumour, participated in this study. All centres included, as exhaustively as possible, all their PN cases. For each patient, 70 variables were harvested in order to characterize the patient population, the indications, the operative technique, the per- and postoperative course and complications, the tumor specificities, the carcinologic control and renal function follow-up. RESULTS: Seven hundred and forty-one PN, of which 579 for malignant tumours were analysed. The mean tumour size was 3.4+/-2.1 cm (0.1-18) and 20.8% of the tumours were larger than 4 cm. In 30.1% of cases, the indication was imperative. Among the PN, 12.2% were performed laparoscopically. The mean operating time was 151+/-54.2 min (55-420). The medical and surgical complications rates were respectively 15.2 and 14.7%. At a mean 38 months follow-up, the local recurrence rate was 3.5% and the specific death rate was 4.5%. CONCLUSION: PN is nowadays getting a more and more widely used technique in France. This expansion is completely justified by its results and urologists must consider nephron sparing surgery as the gold standard treatment for renal tumours measuring less than 4 cm.

[Do broader indications for partial nephrectomy result in excess morbidity?]. / Elargir les indications de la néphrectomie partielle induit-il un surcroît de morbidité? Une étude multicentrique française.

OBJECTIVE: To evaluate the morbidity of partial nephrectomy (PN) according to tumour size and the type of indication based on a multicentre retrospective study. MATERIALS AND METHODS: Seven French teaching hospitals participated in this study. Data concerning tumour size, indication for PN (elective or necessity), age, gender, TNM stage, histological type, Fuhrman grade, ASA score and performance status (ECOG) were analysed. Medical and surgical complications, intraoperative blood loss, blood transfusion rate and length of hospital stay were also studied. Statistical analysis of qualitative and quantitative variables was performed with Chi-square test (Fisher's test) and Student t-test. RESULTS: Six hundred and ninety one patients were included. The median tumour diameter was 3cm (0.4-18). Tumours measuring less or equal to 4cm and incidental tumours represented 77.7 and 80.7% of cases, respectively. Clear cell carcinomas represented 75.1% of malignant tumours. Some 89.1% of tumours were T1, 1.6% were N+ and 2.3% were M+. In the 486 elective indications: the operating time (p = 0.03), mean blood loss (p = 0.04), and urinary fistula rate (p = 0.01) were significantly higher in tumours greater than 4cm. These differences were not associated with an increase in the medical (p = 0.7) or surgical complication rate (p = 0.2), or the length of hospital stay (p = 0.4). CONCLUSION: Broader indications for elective PN is associated with an increased morbidity but which remains acceptable. This is an important point for patient information and to guide the choice of surgical strategy, particularly in elderly, frail patients or patients with major comorbidities.

[Combined liver-kidney transplantation: indications and results]. / Transplantation foie-rein combinée: indications et résultats.

PURPOSE: The purpose of this article is to report our experience concerning the indications and results for combined liver-kidney transplantation in our centre. MATERIAL AND METHOD: From July 1991 to October 2006, 26 patients underwent combined liver-kidney transplantation in our establishment. This group comprised 16 men and 10 women with a mean age of 50.1 years (range: 19 to 68 years). The main indications were as follows: hepatorenal polycystic disease, type I hyperoxaluria, cirrhosis associated with end-stage renal failure. RESULT: The median follow-up was 62.73 (+/-50.9) months. Only two patients of this series died, one at 70 months from gastric cancer, and the other at 89 months from cerebral metastases. Nine patients developed surgical complications (29%). Liver function was normal in the 24 surviving patients. Only one case of loss of renal graft was observed at 12 years and this patient is currently on dialysis. The mean creatinine level in these patients (apart from the dialysed patient) at the last follow-up visit was 120.3 (+/-30.43)micromol/l. CONCLUSION: Combined liver-kidney transplantation can be performed with acceptable morbidity and mortality and excellent long-term results.

[Diagnosis and management of posterior urethra disruptions]. / Diagnostic et traitement des ruptures de l'urètre postérieur.

Rupture of posterior urethra is usually seen in major traumas with associated pelvic fractures. Clinical presentation classically associates blood at the uretral meatus and urinary retention. Urinary diversion should be achieved by suprapubic puncture and major associated traumatic injuries (abdominal, orthopaedic, and neurological lesions) must be treated prior to urological management. Retrograde uretrocystography is performed a few days later in order to localize and classify the urethral lesion. Treatment of posterior urethral ruptures has evolved over the years. Immediate open repair is no longer recommended. The supra-pubic catheter can be left in place until resorption of the pelvic hematoma. Obliteration occurs in 100% of the cases and is treated by open surgery at 3 months. More and more patients are treated by early endoscopic realignment which has diminished by half the incidence of urethral strictures. Impotence and incontinence secondary to trauma or surgery occur in 20% and 10% of the patients respectively. Long term follow-up should be achieved in every patient.

Spinal cord compression in metastatic prostate cancer.

INTRODUCTION: Spinal cord compression (SCC) in metastatic prostate cancer is not rare occurring in 1 to 12% of patients. We have analysed patients treated for this condition in our institution assessing outcome and prognostic factors. MATERIAL AND METHODS: Retrospective analysis of the notes of 24 patients hospitalised with SCC due to metastatic prostate cancer from 1987 to 2001. RESULTS: At presentation 3 patients were ambulant with mild neurological deficit, 12 patients were paraparetic and 9 patients were paraplegic. Diagnosis was established by emergency myelogram, CT-scan or MRI of the spine. 8 patients had received no hormone treatment prior to diagnosis of SCC. 19 patients presented dorsal or lumbar pain requiring opioid treatment on average 60 days before onset of neurological symptoms (range 10-840). All patients underwent steroid treatment; the 8 patients without prior hormone therapy were treated with bilateral orchidectomy, 1 out of these 8 patients had castration without other treatments; 12 patients underwent radiotherapy alone and 9 radiotherapy and laminectomy; 2 patients were in terminal conditions and receive only steroid treatment. Overall 15/24 patients were ambulant after treatment. 8 out of 9 patients treated by laminectomy and radiotherapy were ambulant after treatment versus 7 out of 12 patients treated by radiotherapy alone.17 patients died during follow-up with a median survival of 4 months (2 weeks to 49 months). 7 patients were alive at the last control with a mean follow-up of 10 months (range 4-40). CONCLUSION: Outlook in patients with spinal cord compression from metastatic prostate cancer is poor. Efforts must be concentrated on prevention of spinal cord compression. Patients with hormone resistant prostate cancer who develop persistent back pain should undergo imaging studies (bone scan, spine CT-scan or MNR) and prophylactic local radiotherapy to the spine if bony metastases are identified.

[Carcinomatous degeneration on augmentation ileocystoplasty for tuberculous bladder]. / Dégénérescence carcinomateuse sur iléocystoplastie d'agrandissement pour vessie tuberculeuse.

The development of cancer on the ileal graft after augmentation ileocystoplasty for benign bladder disease is a little known complication. The authors report a case of squamous cell carcinoma in the ileal bladder occurring 37 years after augmentation ileocystoplasty for tuberculous bladder, in a 68-year old patient. Carcinomatous degeneration is usually occurs more than ten years after cystoplasty. Patients treated by this operation must be submitted to annual cystoscopy combined with guided biopsies at the slightest doubt. This surveillance should be started between the 5th and the 10th postoperative year.

Factors influencing adrenal metastasis in renal cell carcinoma.

OBJECTIVES: We determine the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluate the role of adrenalectomy as part of radical nephrectomy. MATERIAL AND METHODS: From 1993 to 1999, 210 patients with renal cell carcinoma (RCC), (139 men and 71 women, mean age 60.8 years, range 12-96) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, groupl) and 104 with advanced (stage T3-4N01M01, group2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared to postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis. RESULTS: Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p < 0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4 to 21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC. CONCLUSIONS: Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.

Real indications for adrenalectomy in renal cell carcinoma.

OBJECTIVES: We determined the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluated the role of adrenalectomy as part of radical nephrectomy. PATIENTS AND METHODS: From 1993 to 1999, 210 patients with renal cell carcinoma (RCC) (139 men and 71 women, mean age 60.8 years, range 12-96 years) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, group 1) and 104 with advanced (stage T3-4N01M01, group 2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared with postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis. RESULTS: Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p < 0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4-21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC. CONCLUSIONS: Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.