Clarence B. Hewitt

The role of adjunctive nephrectomy in patients with metastatic renal cell carcinoma.

The results of therapy for 78 patients with disseminated renal cell carcinoma are evaluated. Symptoms related to the primary tumor were noted in only 28 per cent of the patients and were not difficult to manage in those patients not undergoing nephrectomy. Adjuctive nephrectomy, therefore, is a more appropriate term than palliative nephrectomy when referring to removal of the primary tumor as part of an aggresive combined therapeutic approach. Of patients receiving an adjunctive nephrectomy those with osseous metastases only had a better 1-year survival rate (36 per cent) than those with metastases to other sites (18 per cent). Complete regression of metastases was noted in 12 per cent of patients treated with medroxyprogesterone acetate and adjunctive nephrectomy. The role of adjunctive nephrectomy combined with embolic infarction, hormonal therapy, chemotherapy and/or immunotherapy is discussed.

Lymphoceles associated with renal transplantation: Report of 15 cases and review of the literature

Abstract Within a 27 month period (from July 1, 1971 to October 1, 1973), during which 83 renal allotransplantations were performed at the Cleveland Clinic, a lymphocele developed in 15 patients (18.1 per cent). Early clinical symptoms, occurring within 6 weeks after transplantation, were suprapubic or lower abdominal swelling in 14 patients, leg swelling ipsilateral to the allograft in 12, nonpitting edema in the allograft area in 10 and lymph drainage from the wound in 8. An intravenous pyelogram demonstrated a lymphocele in 13 patients from 1 to 34 weeks after transplantation (mean 7.8 weeks), although an earlier suggestion of bladder displacement and deformity was found retrospectively in 5 patients between 1 and 3 weeks after transplantation. Lymphangiograms aided in the diagnosis in nine patients. The major complication of the lymphoceles was obstructive uropathy that developed in nine patients between 2 and 34 weeks after transplantation (mean 10.3 weeks). Lymphoceles mimicked rejection, urine extravasation, pyelonephritis, thrombophlebitis and a seroma, and occurred concurrently with rejection and pyelonephritis. Treatment by external surgical drainage was more effective than aspiration both in resolving the lymphocele and in avoiding infection. Three lymphoceles drained spontaneously 1 to 2 weeks after transplantation, and three are under observation. Chemical and protein analyses were made of the lymphocele fluid obtained from seven patients. Numerous factors may contribute to the formation of a lymphocele by increasing lymph flow. The most prominent factors are the extent of surgical dissection, the occurrence of rejection, and the use of diuretics, large doses of corticosteroids, and anticoagulants. The literature on lymphoceles in renal allograft recipients is reviewed, and pertinent comparisons are made with the more numerous reports of lymphoceles in nontransplant patients.

Half and Total Body Radiation for Carcinoma of the Prostate

Despite recent advances in the treatment of stage D carcinoma of the prostate many patients become refractory to all therapeutic modalities. Progressive and incapacitating pain is one of the most difficult symptoms to manage. Ten patients with severely symptomatic metastatic adenocarcinoma of the prostate have been treated with either single or sequential doses of half body radiation using 800 rad delivered by a Linac 10 mV linear accelerator. There were 15 courses of half body radiation delivered and a good to excellent response was noted in 11 instances. Results often were immediate and the duration of the response was variable. Treatment was well tolerated with no fatal complications. Half and total body radiation appears to offer significant palliation and its use with other forms of therapy warrants further investigation.

Update on Intracavitary Radiation in the Treatment of Bladder Tumors

A 15-year experience with intracavitary radiation for the treatment of selected bladder tumors is presented. The age range of these patients was 39 to 91 years, with an average of 65 years. There were 38 men and 17 women with multiple stage A bladder tumors and carcinoma in situ. Some patients were poor risks for treatment by total extirpative surgery. A simplified technique using a 25 mg. radium capsule as a central source is described for administration of 4,000 to 5,000 rad to the surface of the bladder. Most patients tolerate the presence of the radium catheter with little difficulty. No morbidity and no mortality were reported. In this series more than 60 per cent of the patients benefited from the therapy, with no recurrence noted in some cases after up to 8 1/2 years of followup. Intracavitary radiation is used in few clinics. Use of this modality does not preclude or complicate the subsequent use of other conservative measures or radical therapy if required. It is an effective procedure for treatment of multiple superficial and noninvasive tumors, including primary or recurrent carcinoma in situ, that are uncontrolled by other conservative measures.

The Surgical Complications of Renal Transplantation

The complications related to renal transplant surgery are important causes of autograft failure and patient mortality. Complications observed by the authors as well as others were related to preparation of the iliac fossa for implantation of the kidney, and to the methods used for vascular anastomoses or reconstitution of the urinary tract.

Renal Autotransplantation: Current Perspectives

Autotransplantation, with or without an extracorporeal renal operation, has been done 39 times in 37 patients. Indications for the procedure included severe ureteral injury in 4 patients, failed supravesical diversion in 2, renal carcinoma in a solitary kidney in 1, renovascular hypertension in 1 and donor arterial reconstruction before renal transplantation in 29. Success was obtained in all but 2 procedures, both of which involved previously operated kidneys with severe inflammation and adhesions involving the renal pelvis and pedicle. Based on our experience and a review of currently available literature we believe that renal autotransplantation and extracorporeal reconstruction can provide the best solution for patients with severe renovascular and ureteral disease not correctable by conventional operative techniques. The technique can be of particular value in removing centrally located tumors in solitary kidneys and in preparing donor kidneys with abnormal arteries for renal transplantation. The role of autotransplantation in the management of advanced renal trauma and calculus disease is less clear. A long-term comparison of patients treated by extracorporeal nephrolithotomy versus conventional lithotomy techniques will be necessary before a conclusion is reached in these disease categories.

Management of Extensively Destroyed Ureter: Special Reference to Renal Autotransplantation

Renal autotransplantation has been attempted 6 times in 4 patients for the correction of extensive ureteral disease. Indications in these patients include trauma secondary to ureterolithotomy and spinal fusion, and failed supravesical diversionary procedures. Included in our report is the first case of autotransplantation associated with ureterosigmoidostomy. Renal autotransplantation is an effective method to restore or preserve renal function in patients with extensive ureteral damage or disease. However, the procedure should not be considered in poor risk patients with good contralateral renal function or in patients in whom standard reparative procedures are possible. The hazard is real of vascular spasm, poor perfusion and ultimate autograft failure in kidneys with advanced chronic pyelonephritis and/or inflammation involving the renal pedicle. Autotransplantation should be considered only as a last resort in such patients.

TESTIS TUMORS: REVIEW OF 125 CASES AT THE CLEVELAND CLINIC

One hundred twenty-five cases of testicular tumor are reviewed. The prognostic significance of clinical features, certain laboratory test results, and histologic type are evaluated, and treatment results are presented. The most important prognostic clinical feature is the presence or absence of clinically evident metastases. The urinary gonadotropin levels are useful prognostically, but the intravenous pyelogram and lymphangiogram are statistically unreliable. The presence of tumor in retroperitoneal lymph nodes influenced survival only in the patients with embryonal carcinoma. Tumor type influenced survival more than any other pathologic factor. Vascular invasion, local extension, and Leydig cell hyperplasia did not correlate with tumor behavior in germinal neoplasms. Patients with clinical Stage IA or IB teratocarcinoma had an 85 per cent survival rate with a wide variety of treatment.

Bilateral Testicular Tumors of Germ Cell Origin

Four cases of primary testicular tumor of germ cell origin are reported. Three cases were bilateral, while the remaining case involved a unilateral tumor in a non-twin brother of 1 patient with bilateral tumors. Because of the increased likelihood of a second primary tumor developing in a patient who has had a malignant germinal cell tumor and because the changes may be subtle, localized to the testis and occur after a tumor-free interval of many years, careful examination of the contralateral testis and long-term followup are indicated even when systemic chemotherapy for malignancy has been used. This is the seventh time familial occurrence of testis tumors in non-twin brothers has been reported but the first time that one of the brothers had bilateral tumors.

Renal transplantation I. Use of donor organs with multiple vessels

Abstract The Cleveland Clinic experience in transplanting 46 kidneys with multiple vessels is reported. Suggested surgical techniques for the vascular anatomosis are recommended and long-term results of function and complications are reported. These kidneys can be safely and effectively used from both related living and cadaver donors.