Is Size All That Matters? New Predictors of Complications and Bleeding in Renal Angiomyolipoma.

Purpose: Renal angiomyolipoma (AML) is the most common benign renal tumor. Whilst generally asymptomatic, they can cause life-threatening bleeding. Selective angioembolization (SAE) may be used to treat large symptomatic and asymptomatic AMLs. We aimed to evaluate the efficacy of SAE for symptomatic and asymptomatic renal AMLs and determine characteristics that predict spontaneous bleeding. Patients and Methods: Data were retrospectively collected from a prospectively maintained database from July 2011 to April 2022. Patients were included if AML was >4cm and they underwent subsequent SAE. Follow-up imaging was analyzed to calculate mean reduction in AML size. Clinical notes were reviewed to analyze lesion characteristics including vascularity, fat content and presence of aneurysm as well as post-procedural complications. Results: 26 patients with 30 AMLs were identified. Interval of follow-up imaging ranged from 1 to 60 months. 25 AMLs were embolized electively with 5 emergency embolizations performed for bleeding. Mean reduction in AML volume was 41% at 3 months (p=0.013) and 63% at 12 months (p=0.007). All 5 bleeding AMLs had a rich vascularity with 60% also having either aneurysms or a low fat content. Complications included post-embolic syndrome (n=9), segmental renal parenchyma devascularization (n=3), acute bleeding requiring re-embolization (n=2), nephrectomy for ongoing bleeding (n=1) and delayed bleeding managed conservatively (n=1). No deterioration in renal function was observed. Conclusion: SAE is an effective procedure for managing symptomatic and asymptomatic renal AML, with minimal significant complications. AML vascularity, fat content and aneurysms may be useful characteristics to assess future risk of bleeding in patients with renal AML.

Implementation of a clinical practice guideline for assessment and management of renal colic in the emergency department.

INTRODUCTION: Renal colic is a common emergency department (ED) presentation. Variations in assessment and management of suspected renal colic may have significant implications on patient and hospital outcomes. We developed a clinical practice guideline to standardize the assessment and management of renal colic in the ED. We subsequently compared outcomes before and after guideline implementation. METHODS: The guideline standardizes the analgesia regimen, urology consult criteria, imaging modality, patient education, and followup instructions. This is a single-center, observational cohort study of patients presenting to the ED with renal colic prospectively collected after guideline implementation (December 2018 to May 2019) compared to a control group retrospectively collected before guideline implementation (December 2017 to May 2018). A total of 528 patients (pre-guideline n=283, post-guideline n=245) were included. Statistical analysis was performed with SPSS using multivariate linear regression. RESULTS: ED length of stay (LOS) was significantly shorter after guideline implementation (pre-guideline 295.82±178.8 minutes vs. post-guideline 253.2±118.2 minutes, p=0.017). The number of computed tomography (CT) scans patients received was significantly less after guideline implementation (pre guideline 1.35±1.34 vs. post-guideline 1.00±0.68, p=0.034). Patients discharged for conservative management had a lower re-presentation rate in the post-guideline group (12.6%) than the pre-guideline group (17.2%); however, this did not reach statistical significance (p=0.18). CONCLUSIONS: Implementation of a clinical practice guideline for ureteric stones reduces the ED LOS and the total number of CT scan in patients who present with renal colic. Standardizing assessment and management of ureteric stones can potentially improve patient and hospital outcomes without compromising the quality of care.

Anatrophic nephrolithotomy and pyelolithotomy for dual staghorn calculi in bifid collecting system.

A bifid ureter is an atypical anatomical variation that occurs with an incidence of 1-10%. This anomaly is in a continuum of duplex collecting systems and most commonly involves a common distal ureter. This is usually asymptomatic and is predominantly an incidental diagnosis, nevertheless, is a potential risk factor for urolithiasis formation. Current surgical management of larger staghorn calculi favours percutaneous nephrolithotomy (PCNL) over traditional open surgery, however for multiple calculi and complex anatomy PCNL would require multiple punctures, with increased risk of bleeding, pleural injury, sepsis and ultimately failed stone clearance. We describe the case of a 71-year-old female with multiple calculi in bifid anatomy. A single open approach, aided with cold-ischaemia was successfully utilized in this context.

Cytosolic phospholipase A2-alpha: a potential therapeutic target for prostate cancer.

PURPOSE: Cytosolic phospholipase A2-alpha (cPLA2-alpha) provides intracellular arachidonic acid to supply both cyclooxygenase and lipoxygenase pathways. We aim to determine the expression and activation of cPLA2-alpha in prostate cancer cell lines and tissue and the effect of targeting cPLA2-alpha in vitro and in vivo. EXPERIMENTAL DESIGN: The expression of cPLA2-alpha was determined in prostate cancer cells by reverse transcription-PCR, Western blot, and immunocytochemistry. Growth inhibition, apoptosis, and cPLA2-alpha activity were determined after inhibition with cPLA2-alpha small interfering RNA or inhibitor (Wyeth-1). Cytosolic PLA2-alpha inhibitor or vehicle was also administered to prostate cancer xenograft mouse models. Finally, the expression of phosphorylated cPLA2-alpha was determined by immunohistochemistry in human normal, androgen-sensitive and androgen-insensitive prostate cancer specimens. RESULTS: cPLA2-alpha is present in all prostate cancer cells lines, but increased in androgen-insensitive cells. Inhibition with small interfering RNA or Wyeth-1 results in significant reductions in prostate cancer cell numbers, as a result of reduced proliferation as well as increased apoptosis, and this was also associated with a reduction in cPLA2-alpha activity. Expression of cyclin D1 and phosphorylation of Akt were also observed to decrease. Wyeth-1 inhibited PC3 xenograft growth by approximately 33% and again, also reduced cyclin D1. Immunohistochemistry of human prostate tissue revealed that phosphorylated cPLA2-alpha is increased when hormone refractory is reached. CONCLUSIONS: Expression and activation of cPLA2-alpha are increased in the androgen-insensitive cancer cell line and tissue. Inhibition of cPLA2-alpha results in cells and xenograft tumor growth inhibition and serves as a potentially effective therapy for hormone refractory prostate cancer.

Oncogenic action of secreted phospholipase A2 in prostate cancer.

Mortality from prostate cancer is associated with progression of tumors to androgen-independent growth and metastasis. Eicosanoid products of both the cyclooxygenase (COX) and lipoxygenase (LOX) pathways are important mediators of the proliferation of prostate cancer cells in culture and regulate tumor vascularization and metastasis in animal models. Pharmacologic agents that block either COX or LOX products effectively reduce the size of prostate cancer xenografts. Phospholipase A(2) (PLA(2)) enzymes regulate the provision of arachidonic acid to both COX- and LOX-derived eicosanoids, and a secreted form of the enzyme (sPLA(2)-IIA) is elevated in prostate cancer tissues. Here, we show by immunohistochemistry, in patients receiving androgen ablation therapy, that sPLA(2)-IIA remains elevated in remaining cancer cells relative to benign glands after treatment. Furthermore, sPLA(2)-IIA expression seen in benign glands is substantially decreased after androgen depletion, whereas cytosolic PLA(2)-alpha (cPLA(2)-alpha) levels are unchanged. sPLA(2)-IIA mRNA expression is detectable and inducible by androgen (0.01-10 nmol/L) in the androgen-sensitive cell line LNCaP, and exogenous addition of sPLA(2)-IIA (1-100 nmol/L), but not an inactive sPLA(2)-IIA mutant (H(48)Q), results in a dose-dependent increase in cell numbers or the fraction of cells in G(2)-M phase, which is inhibited by sPLA(2)-IIA-selective inhibitors. The effect of exogenous sPLA(2)-IIA can also be blocked by inhibition of cPLA(2)-alpha, suggesting a role for cPLA(2)-alpha in mediating sPLA(2)-IIAlpha action. sPLA(2)-IIA inhibitors suppressed basal proliferation in LNCaP cells and in the androgen-independent, sPLA(2)-positive cell line PC3 but not in the sPLA(2)-IIA-negative androgen-independent cell line DU145. Established PC3 xenograft tumors grew more slowly in mice treated with sPLA(2)-IIA inhibitors than those treated with saline only. The PLA(2) enzymes, and sPLA(2)-IIA in particular, thus represent important targets for the treatment of sPLA(2)-IIA-positive androgen-independent prostate cancer.

Papillary Renal Cell Carcinoma Seeding along a Percutaneous Biopsy Tract.

We report a case of tumour seeding caused by percutaneous biopsy of a papillary renal cell carcinoma detected on pathological assessment of the partial nephrectomy specimen in a 50-year-old male. Whilst percutaneous biopsy of renal masses is considered to be safe and can be a valuable tool in the assessment of certain renal lesions, it is not without risks. This rare complication should be taken into consideration before contemplating its use in a patient.