Intratumor C-reactive protein as a biomarker of prognosis in localized renal cell carcinoma.

PURPOSE: Serum C-reactive protein has been shown to have prognostic value in localized and metastatic renal cell carcinoma. However, the prognostic value of intratumor C-reactive protein remains unknown. MATERIALS AND METHODS: A total of 95 patients with resected, clinically localized (T1-T4N0M0) clear cell renal cell carcinoma were followed postoperatively. Intratumor C-reactive protein expression was assessed in surgical specimens using immunohistochemical analysis. Patients were categorized by staining intensity into low risk (staining 0 to 1), intermediate risk (staining 2) and high risk (staining 3) groups. Kaplan-Meier and multivariate Cox regression analyses were used to examine overall survival across patient and disease characteristics. Variables examined in multivariate Cox regression analysis included T stage, Fuhrman nuclear grade, tumor size, preoperative serum C-reactive protein and intratumor C-reactive protein staining. RESULTS: Followup extended up to 46 months with a mean (SD) of 29.8 (11.0) months. Twelve patients (12.6%) died during followup. Of all tumors 49.5%, 25.3% and 25.3% were graded by intratumor C-reactive protein staining as low risk (0 to 1), intermediate risk (2) and high risk (3), respectively. After controlling for variables significant on univariate analysis, patients in the high risk (3) group experienced a 27-fold increased risk of overall mortality compared to those in the low risk (0-1) group (HR 27.767, 95% CI 1.488-518.182). After adjusting for tumor staining, preoperative serum C-reactive protein was not a significant predictor of overall survival (p = 0.741). CONCLUSIONS: Intratumor C-reactive protein may be a robust biomarker of prognosis in patients with localized renal cell carcinoma.

Absolute preoperative C-reactive protein predicts metastasis and mortality in the first year following potentially curative nephrectomy for clear cell renal cell carcinoma.

PURPOSE: C-reactive protein is an inflammatory biomarker associated with tumor burden and metastasis in renal cell carcinoma. Recent studies suggest that preoperative C-reactive protein predicts metastasis and mortality after nephrectomy for localized renal cell carcinoma. However, these studies dichotomized C-reactive protein (typically 10 mg/l or greater vs less than 10 mg/l). Considering the continuous range of C-reactive protein (less than 1 mg/l to greater than 100 mg/l) we assessed the ability of absolute preoperative C-reactive protein to predict metastases and mortality as a continuous variable. MATERIALS AND METHODS: Patients with clinically localized (T1-T3N0M0) clear cell renal cell carcinoma were followed for 1 year postoperatively. Metastases were identified radiologically and mortality was determined by death certificate. Univariate and multivariate binary logistic regression analyses examined 1-year relapse-free survival and overall relative survival across patient and disease characteristics. RESULTS: Of the 130 patients in this study metastases developed in 24.6% and 10.8% of the patients died. Mean (SD) preoperative C-reactive protein for patients in whom metastases did and did not develop was 89.17 (74.17) and 9.16 (30.62) mg/l, respectively. Mean preoperative C-reactive protein for patients who did and did not die was 102.61 (77.32) and 19.52 (46.10) mg/l, respectively. On multivariate analysis SSIGN score (p <0.001) and preoperative C-reactive protein (B 0.027, SE 0.003, p <0.001) were significant predictors of relapse-free survival, and preoperative platelets (p = 0.009) and preoperative C-reactive protein (B 0.011, SE 0.008, p <0.001) were significant predictors of overall relative survival. CONCLUSIONS: Absolute preoperative C-reactive protein is a robust predictor of metastasis and mortality after nephrectomy for localized renal cell carcinoma. Clinicians should consider absolute preoperative C-reactive protein to identify high risk patients for closer surveillance or additional therapy. In addition, predictive algorithms and models of metastasis should consider incorporating C-reactive protein as a continuous variable to maximize predictive ability.

Laparoscopic pyeloplasty.

Open pyeloplasty has long been considered the gold standard for the relief of ureteropelvic junction (UPJ) obstruction, but the incisional morbidity led urologists to explore less invasive alternatives such as endopyelotomy and the Acucise cutting balloon. Laparoscopic pyeloplasty was introduced in 1993 and has since been performed in patients as young as 2.5 years. The operation should be considered in patients with UPJ obstruction caused by a crossing vessel, high ureteral insertion, failed prior procedures, high-grade hydronephrosis, or marginal differential renal function. Hynes-Anderson, Foley Y-V, and Fenger procedures can all be performed laparoscopically, generally with excellent results. The procedure requires advanced laparoscopic skills and so is available in only a few medical centers at present.

Citrate in the management of urolithiasis.

Citrate therapy for recurrent calcium urolithiasis has become common over the last decade. The hypotheses that chronic stone formers must have biochemical defects that increase recurrence risks have instigated medical therapy directed at these defects. The utilization of stone clinics, detailed metabolic evaluations, and meticulous follow-up of recurrent stone formers has led to a greater understanding and knowledge of treatment options. Citrate therapy has been used like aspirin in the medical community perhaps without a clear understanding of its mechanism of action and indications. This article provides a synopsis of citrate use in the medical and surgical treatment of urolithiasis.

Comparison and analysis of laparoscopic intracorporeal suturing devices: preliminary results.

BACKGROUND AND PURPOSE: One of the most challenging aspects of laparoscopic surgery is intracorporeal suturing and knot tying. A loss of depth perception and tactile sense and visual obstruction make placing accurate and well-tied knots a difficult and time-consuming task. Two devices conceived to ease the task of suturing and knotting while presumably speeding performance are the Suture Assist (SA; Ethicon Endo-Surgery) and EndoStitch (ES; US Surgical/Tyco). We set out to objectively assess suture placement accuracy and knot speed and strength of these two suturing devices and conventional laparoscopic suturing (CS). MATERIALS AND METHODS: To date, six surgeons with laparoscopic experience were trained on the three suturing techniques. A pelvic trainer was set up with a freshly marked and incised swine renal pelvis and ureter. Each surgeon placed four sutures of 2-0 polyester suture with each technique (repeated on three separate occasions) with five half-hitches for a total of 216 knots. Time, strength, and accuracy were measured for each suture/knot placement. The knot distance was then measured from the marked target using calipers and carefully dissected from the tissue. Each knot was individually tested on a Monsanto Model 10 tensiometer, whereby slippage, strength, and breakage points were determined. RESULTS: The mean times (min:sec) and accuracy (millimeters) were as following: CS 5:08 and 0.457, ES 2:45 and 0.660, and SA 2:40 and 0.508. The difference in time was found to be statistically significant (P < 0.001), while the difference in accuracy was not. Only 182 of 216 knots were able to be included for analysis because of either a small knot lumen or device failure. Device failures necessitating intervention were encountered only with the SA, which had a misfire rate of 9.7% (7 of 72). The mean knot strength was measured at 41.1 N for CS, 57.3 N for SA, and 28.0 for ES. Knot break percentage (breakage) was calculated as 50.8% for CS, 20.7% for ES, and 95% for SA. CONCLUSION: Preliminary results show that each of the laparoscopic suturing devices has distinct advantages over conventional intracorporeal suturing and tying. Decreased times and comparable, if not greater, knot strengths may translate into improved laparoscopic suturing/tying performance for laparoscopic intracorporeal suturing devices.

Postoperative better than preoperative C-reactive protein at predicting outcome after potentially curative nephrectomy for renal cell carcinoma.

OBJECTIVES: Preoperative C-reactive protein (CRP) predicts metastasis and mortality in localized renal cell carcinoma (RCC). However, the predictive potential of after resection of localized RCC remains unclear. Therefore, we assessed the absolute ability of postoperative CRP to predict metastases and mortality as a continuous variable. METHODS: Patients with clinically localized (T1-T3N0M0) clear-cell RCC were followed for 1 year postoperatively. Metastases were identified radiologically and mortality by death certificate. Univariate and multivariate binary logistic regression analyses examined 1 year relapse-free survival (RFS) and overall survival (OS) across patient and disease characteristics. RESULTS: Of the 110 patients in this study, 16.4% developed metastases and 6.4% died. Mean (SD) postoperative CRP for patients who did and did not develop metastases were 69.06 (73.55) mg/L and 5.27 (7.80), respectively. Mean (SD) postoperative CRP for patients who did and did not die were 89.31 (69.51) mg/L and 10.88 (30.32), respectively. In multivariate analysis, T-stage (OR: 12.452, 95% CI: 2.889-53.660) and postoperative CRP ((B: .080, SE: .025; P < .001) were significant predictors of RFS. T-Stage (OR: 11.715; 95% CI: 1.102-124.519) and postoperative CRP (B: .017; SE: .007; P < .001) were also significant predictors of OS. After adjusting for postoperative CRP, preoperative CRP was not predictive of these outcomes. CONCLUSIONS: Postoperative, not preoperative, CRP is the better predictor of metastasis and mortality following nephrectomy for localized RCC. Clinicians should consider absolute postoperative CRP to identify high-risk patients for closer surveillance or additional therapy. Predictive algorithms should consider incorporating postoperative CRP as a continuous variable to maximize predictive ability.

The role of 99mtechnetium dimercapto-succinic acid renal scans in the evaluation of occult ectopic ureters in girls with paradoxical incontinence.

PURPOSE: We describe the use of 99mtechnetium (Tc) dimercapto-succinic acid (DMSA) renal scintigraphy to document poorly functioning and/or ectopic renal units associated with occult ectopic ureters. MATERIALS AND METHODS: During the last 8 years 6 toilet-trained girls were referred for lifelong continuous urinary dribbling. Initial radiological evaluation included renal and bladder sonography in 6, excretory urography in 4, a mercaptoacetyltriglycine-3 renal scan in 1 and cystovaginoscopy in 2. Ultimately a 99mTc-DMSA renal scan was performed in all 6 girls before surgical intervention. RESULTS: Sonography failed to establish the diagnosis of ureteral ectopia in all cases, and revealed a normal solitary kidney in 3, normal kidneys in 1, an apparently uncomplicated unilateral duplication without hydroureteronephrosis in 1 and a contralateral uncomplicated duplication in 1. Excretory urography in 4 cases was inconclusive and showed a solitary kidney in 1, ipsilateral duplication without a normal appearing upper pole collecting system in 1, contralateral uncomplicated duplication in 1 and normal kidneys in 1. A mercaptoacetyltriglycine-3 renal scan in another girl with a solitary kidney on sonography failed to demonstrate a contralateral small ectopic kidney. Cystovaginoscopy performed in 2 patients by other pediatric urologists was nondiagnostic. 99mTc-DMSA renal scintigraphy was diagnostic in all 6 cases, and revealed a small poorly functioning ectopic kidney in 3 and a poorly functioning dysplastic upper pole moiety in 3, which were consistent with a diagnosis of ureteral ectopia. An ectopic ureter was confirmed by cystoscopic and surgical findings in all girls. CONCLUSIONS: 99mTc-DMSA renal scintigraphy reliably detects and localizes hypoplastic ectopic kidneys and poorly functioning upper pole moieties associated with occult ectopic ureters in girls with continuous urinary leakage.