Christen Henriksson

Natural history of renal artery aneurysm elucidated by repeated angiography and pathoanatomical studies.

The findings from repeated angiographies in 16 female and 5 male patients with altogether 34 renal artery aneurysms were studied. The mean interval between the first and last angiography was 35 months. Seven patients had multiple aneurysms. Two to four angiographies were performed in each patient. They showed no change in 28 aneurysms and slight or minimal enlargement, thrombosis or calcification in the other 6. The clinical course was uneventful except for severe hypertension in 3 patients. No rupture occurred. Eight patients, of whom 5 had solitary, saccular aneurysms, were operated upon. Pathoanatomically, fibromuscular dysplasia or secondarily changed fibromuscular dysplasia was found in 7 of them. Four died of unrelated disease having been followed up for 55-204 months (mean 102 months). Nine were alive and symptomless at the end of follow-up 11-195 months (mean 97 months) after the first angiography. The study supports the view that the risk of rupture of a renal artery aneurysm is very small, and indicates that fibromuscular dysplasia is common even when the angiography shows solitary, saccular aneurysm only.

Surgical removal of bone and muscle metastases of renal cancer

Fifteen men and six women with renal cancer underwent surgical removal of metastatic lesions in bone (19 patients) or muscle (two patients). The operation was carried out 2 years before nephrectomy/renal resection in two patients, on the same occasion in four, and 1-196 months after in 15. Surgical interventions of various kinds were undertaken, resulting in the loss of a lower limb in seven patients and an upper limb in one. The observed 5-year survival was 4 out of 10. Six patients were alive at follow-up, five of them without evidence of disease. Eight of the remaining 15 patients died of an unrelated disease (five without evidence of tumor); the other seven patients died of metastatic tumor disease. Local recurrence was diagnosed, and removed, in two patients. The results compare favourably with reports on surgically removed pulmonary metastases of renal cancer and seem to justify an aggressive attitude towards solitary bone and muscle metastases of renal cancer.

Skeletal Metastases in 102 Patients Evaluated Before Surgery for Renal Cell Carcinoma

During a 3-year period a consecutive series of 102 patients were treated for renal cell carcinoma at one urological unit. Thirty-three patients (32.4%) had metastatic spread, but bone metastases were found in six patients only, i.e. 5.9% of the whole series and 18.2% of the patients with metastases preoperatively. The bone metastases had in all six patients given local symptoms first indicating radiography, and thereafter radionuclide scintigraphy of the entire skeleton. Bone scintigraphy performed merely by routine in 70 patients did not reveal one single case of bone metastasis. Only one patient had a solitary bone metastasis, and this metastasis was considered inoperable because of its location and size and the patients age. The decision about nephrectomy was not in any case altered by the finding of bone metastases. Solitary bone metastasis must be diagnosed early since they may be radically removed. Routine scintigraphy of the skeleton in symptomless patients, however, has a low yield. Screening for skeletal metastases may therefore be best performed by careful physical examination and history-taking.

Treatment of urothelial tumors of the upper urinary tract by nephroureterectomy, renal autotransplantation, and pyelocystostomy

Nephroureterectomy, renal autotransplantation, and pyelocystostomy have been performed in eight patients with urothelial tumors of the upper urinary tract. One patient had tumors in a solitary kidney, two patients had bilateral tumors, and five patients had unilateral tumors. Three patients have had recurrent calyceal tumors which were successively managed by the transurethral route. In one patient the kidney had to be removed after 4.5 years because of infiltrating tumor recurrence. Two patients died; the renal pelvis of the graft was tumor free at autopsy in both cases. The other five patients are alive and free from tumor recurrence. The procedure implies increased radicality compared with conventional conservative treatment and simplified follow‐up. It may be considered in patients with bilateral tumors or tumors of a solarity kidney, and in selected patients with unilateral low‐grade, low‐stage tumors.

Angiographically Discovered, Non-Operated Renal Artery Aneurysms

Angiographies (a total of approximately 9 500) and patient records revealed 56 patients with renal artery aneurysm during the period 1960 to 1974. Fifteen patients were operated upon electively and 3 were lost for follow-up. Rupture occurred in four leading to acute nephrectomy. Thus, 34 patients were left for studies on the natural course. They were 29-82 years old (mean 58 years) at diagnosis and were followed for at least 90 months. Twelve were males and 22 females. The aneurysms had a diameter of 3-25 mm (mean 12 mm), were fusiform in 7 and saccular in 27 cases; 9 were calcified. Repeated angiographies were carried out in 7 patients at intervals of up to 73 months showing slight enlargement of one aneurysm, disappearance of another and no change in 5. Sixteen patients were alive at the end of the follow-up period 90-220 months (mean 157 months) after the first or only angiography. Eighteen patients died after 2-204 months (mean 84 months), 14 of cardiovascular disease unrelated to the renal arteries, 3 of malignant tumour and one of pancreatitis. Autopsy in 12 patients did not show rupture of any renal artery aneurysm. Thus, in a considerable number of patients the disorder was uncomplicated and compatible with a long life.

Bilateral asynchronous renal cell carcinoma : computed tomography of the contralateral kidney 10-43 years after nephrectomy

Computed tomography (CT) was carried out in 31 patients 10-43 years after surgery for renal cell carcinoma, 10 belonging to a consecutive series of patients operated upon at one urological department 10 years previously. Twenty-eight patients were symptomless, and 3 had flank pain, severe fatigue and hematuria, respectively. Cancers in the remaining kidney were found 13-21 years after nephrectomy in 4 of 31 patients (12.9%). The 3 patients with symptoms were among these 4. An adenoma was found in 1 patient 10 years after nephrectomy. The cancers were treated by renal resection in 2 patients, multiple tumors made nephrectomy necessary in 1 patient and 1 patient was not operated upon because of disseminated disease. The adenoma indicated future checkup by CT. Three of the 4 new cancers had a dismal outcome. The renal parenchyma was found to be essentially normal in all the other 26 patients, irrespective of the widely varying time interval between nephrectomy and CT. Asynchronous bilateral renal cell carcinoma has a poor outcome which presumably can be improved by early diagnosis and aggressive treatment. CT is the method of choice for early detection and follow-up of renal tumors. It should be carried out every other year after nephrectomy for renal cell carcinoma.

Percutaneous Renal and Ureteric Stone Extraction: Report on the First 500 Operations

A consecutive series of the first 500 percutaneous renal and ureteric stone extractions in 451 patients was analysed. During the period studied, percutaneous extraction was offered to all patients with conventional indication for stone removal except a few, very early ureteric stone patients in whom open lithotomy was carried out. Ureteroscopy and extracorporeal shock wave lithotripsy had not come into routine use. Four hundred and seventy-eight stone operations (96%) could be performed by the percutaneous route; early in the series, 21 open operations and one transurethral Dormia basket extraction were performed, mainly because of failed mobilisation of ureteric stones (12 patients) or various peroperative complications (9 patients). The target stones were completely removed in 88% of all percutaneous procedures, with the best results in the largest group of patients with 6-20 mm solitary stones or 2-3 stones less than or equal to 10 mm. Stones in the ureter and pelvi-ureteric junction without any other concomitant stones were all completely removed. Bleeding was the most frequent peroperative complication. No kidney was lost. An 84-year-old man died of intercurrent disease postoperatively.

Pulmonary embolism in renal cell carcinoma with vena cava extension

Of 18 patients with renal cell carcinoma extending into the inferior caval vein, 11 underwent nephrectomy and cavathrombectomy and were examined by pulmonary scintigraphy pre- and postoperatively. In 7 patients, who underwent non-radical surgery or no surgery at all and had died of generalized tumour, the postmortem examination reports were scrutinised. On pulmonary scintigraphy, altogether 6 patients (55%) were free from perfusion defects preoperatively. Between the pre- and postoperative examination, perfusion defects appeared, disappeared, varied in size or were unchanged. Only 4 patients (36%) had acquired new defects. The total number of defects preoperatively was 14 and postoperatively 12. Most defects engaged less than a pulmonary segment and only 2 a whole segment. None gave clinical symptoms. No macroscopic pulmonary emboli were found in any patient at the postmortem examination.

Autologous Renal Transplantation and Pyelocystostomy after Unsuccessful Pyeloplasty

A total of 4 patients with persistent outflow obstruction after pyeloplasty for hydronephrosis was reoperated with renal autotransplantation and pyelocystostomy. All 4 patients had undergone an unsuccessful Anderson-Hynes pyeloplasty and 2 also had had a second operation. All patients had relief of pain, normalization of urine outflow and improved renal function during an observation of 27 to 37 months. Occasional asymptomatic bacteriuria occurred in 2 patients. Thus, renal autotransplantation and pyelocystostomy may be considered a useful and safe method to eliminate persistent outflow obstruction after unsuccessful pyeloplasty.

Successful Kidney Transplantation in a Man with Dacron “Trouser” Prosthesis

The case history of a male patient, 62 years old, in preterminal uremia at transplantation with a cadaveric kidney is described. Twelve years before the transplantation he was operated on because of an aortic aneurysm where the abdominal aorta and both iliac arteries were substituted with a Dacron prosthesis. The kidney was anastomosed to this vessel substitute and functioned excellently for more than five years and the patient was completely rehabilitated.