Outcomes of Conservative Management of Splenic Injury Incurred During Percutaneous Nephrolithotomy.

Purpose: Splenic injury is a rare complication after left-sided percutaneous nephrolithotomy (PCNL). Although initial observation is often espoused, the natural history of nonoperative conservative management is not well established and the implications of splenic injury are not fully defined in this context. We sought to describe outcomes of conservative management of splenic injury incurred at PCNL. Patients and Methods: We performed a multi-institutional retrospective review of individual patients who underwent PCNL complicated by trans-splenic nephrostomy access injury. Demographic info, intraoperative data, management strategies, and outcomes were reviewed. Results: Nine patients suffered splenic injury after left PCNL. All patients had supracostal upper pole access under fluoroscopic guidance. Splenic injury was identified by computed tomography (CT) in the eight of nine (89%) who had imaging on first postoperative day. All eight patients were managed conservatively with nephrostomy dwell time of 2-21 days, one of whom (11%) required blood transfusion. The remaining patient (11%)-who had tubeless PCNL without postoperative imaging presented 5 days postoperatively with a delayed bleed and underwent emergent splenectomy. Seven of the nine (78%) were managed nonoperatively and without need for transfusion or embolization. Conclusion: The majority of patients incurring splenic injury during PCNL can be managed conservatively with maintenance of nephrostomy tube for ≥2 days. Consequences of unrecognized splenic injury may include splenic bleed and may prompt transfusion and/or splenectomy, underscoring role of routine postoperative CT to allow timely diagnosis, particularly in those undergoing upper pole supracostal left-sided percutaneous renal access.

Locally advanced prostate cancer treated with concomitant radiation and 5-fluorouracil: Southwest Oncology Group Study 9024.

PURPOSE: Radiation is considered the standard treatment for locally advanced (T3 and T4) prostate cancer but cure with radiation alone is infrequent. Studies have shown that adding androgen ablation improves the results but there is still much room for improvement. We performed a phase II multi-institutional study to explore the feasibility of concomitant chemoradiotherapy. MATERIALS AND METHODS: Eligible patients had prostate cancer with clinical evidence of invasion through the prostatic capsule or into the seminal vesicles without evidence of nodal or distant metastasis. Prior prostatectomy was not allowed and patients could not be candidates for surgical resection due to medical reasons or refusal of surgery. Radiation consisted of 7,020 cGy in 39 fractions. Continuous infusion 5-fluorouracil at a dose of 200 mg/m2 daily was started on day 1 and continued 7 days weekly until the last day of radiation. RESULTS: All 30 eligible patients were evaluated for toxicity. Diarrhea was the most common toxicity with grade 3 and 4 diarrhea in 2 and 1 patients, respectively. The only other grade 4 toxicity was hemorrhagic cystitis in 1 patient. There was 1 incident each of grade 3 stomatitis, congestive heart failure, edema, proctitis and hematuria. No patient with grade 3 or 4 toxicity required treatment delay. Ten patients (33%) achieved a negative biopsy and 13 (43%) achieved prostate specific antigen less than 1.0 ng/ml. Six patients (20%) achieved a complete response, defined as negative biopsy and prostate specific antigen less than 1.0 (95% CI 8 to 39). Patients without any biopsies or without prostate specific antigen followup were assumed to be nonresponders. CONCLUSIONS: Toxicity was acceptable. The modest response rate indicates that better chemotherapy that improves local and systemic failure is necessary to improve the results. This study confirms the feasibility of a combined chemoradiotherapy approach.