Drasko Brkovic

The role of radical surgery for renal cell carcinoma with extension into the vena cava.

PURPOSEnNew operative technologies, such as the bypass procedures that have become established in the last decade, have led to improved prognosis in patients with renal cell carcinoma and vena caval thrombi. We report the outcome of stage dependent surgical strategies in patients with renal cell carcinoma extending into the vena cava.nnnMATERIALS AND METHODSnFrom January 1987 to August 1998, 93 patients with renal cell carcinoma invading the inferior vena cava were seen at our institution. Of the patients 79 underwent radical nephrectomy, phlebotomy and thrombus extraction, including 74 who underwent surgical treatment with cardiopulmonary bypass and deep hypothermic circulatory arrest. In 2 patients with retrohepatic thrombi we placed a pump driven femoro-axillary shunt during surgical resection of the retrohepatic tumor portion.nnnRESULTSnDistant metastases and lymph node involvement proved to be highly significant prognostic factors for survival, while the cranial extent of the tumor thrombi had no prognostic impact. Patients without distant metastases had a 5-year survival rate of 34%, which improved to 39% if regional lymph nodes were not involved. There were 5 perioperative deaths (6.3%) and the highest perioperative mortality rate (40%) was seen in patients with supradiaphragmatic thrombi.nnnCONCLUSIONSnRadical surgery for renal cell carcinoma extending to the vena cava is justified when the tumor thrombus does not extend beyond the level of the diaphragm in the cranial direction. In view of the high perioperative mortality decisions about radical surgery must be made individually in patients with level IV thrombi, even if long-term survival is possible.

Aetiology, diagnosis and management of spontaneous perirenal haematomas

This study focuses on the diagnostic and therapeutic challenge posed by spontaneous perirenal haematomas (SPHs). The medical records of 18 patients with SPHs seen in the past 8 years were reviewed with respect to aetiology, diagnosis and therapeutic management. SPH was secondary to angiomyolipoma (n = 4), polycystic kidneys (n =4), panarteritis nodosa (n = 3), renal cell carcinomas (RCCs, n = 2), glomerulonephritis, pyelonephritis, Morbus Wegener and cortical adenoma (one each). One case remained unclear. With appropriate imaging techniques (computed tomography and angiography) the underlying disorder was detected in 72%; in 4 cases the diagnosis was revealed by exploration and biopsy. Surgery was necessary in 16 patients. The cause of bleeding can be revealed by appropriate imaging in most cases. When imaging procedures fail to reveal the cause of SPH, exploration and biopsy are mandatory to exclude RCC. If the cause of SPH remains unclear even after exploration, patient monitoring by CT is justified.

Surgical treatment of invasive penile cancer : The Heidelberg experience from 1968 to 1994

OBJECTIVESnThis study was performed to establish oncological guidelines for the surgical treatment of invasive penile cancer.nnnMATERIALS AND METHODSnThe medical records of 51 patients with invasive penile cancer seen between 1968 and 1994 were reviewed in respect to treatment and long-term outcome.nnnRESULTSnFor stage T1 tumors treated with organ-preserving procedures the local recurrence rats was 56%, whereas no patient experienced a local recurrence after partial amputation. For stage T2 tumors, local recurrence rate was 100% (organ preservation) versus 20% (amputative procedures). There was no significant difference related to regional recurrence between surveillance, inguinal radiation and lymphadenectomy for stage N0 tumors. For N+ stages, survival was related to the extent of inguinal metastasis after dissection (5-year survival rate for N1: 71 vs. 33% for N2/3).nnnCONCLUSIONSnOrgan-preserving procedures include a high risk of local and regional recurrence. Adjuvant regional lymphadenectomy seems beneficial only in patients with solitary metastasis.

Impaired Bone Metabolism following Augmentation Cystoplasties in Growing Rats

Objective: The aim of this study was to evaluate the possible risk of impaired bone metabolism following augmentation cystoplasties with different gastrointestinal segments.Method: 60 young rats underwent augmentation cystoplasties using gastric, ileal or sigma segments, or sham operations. An additional group undergoing sigma–cystoplasty received the bisphosphonate ibandronate to inhibit osteoclast–mediated bone resorption. Bone mass in the lumbar spine and tibia was analyzed monthly by in vivo densitometry. Bone turnover was assessed monthly using current bone metabolism markers for a period of 16 weeks. Bone ashing and serum analyses of the osteotropic hormones parathyroid hormone (PTH), and 25–OH vitamin D3 were performed at study conclusion.Results: Following ileocystoplasty, reduced bone mineral density (BMD) was seen throughout the observation period; this was pronounced in the trabecular bone. The decline in BMD was associated with decreased serum 25–OH vitamin D3 levels. Following sigmacystoplasty, bone calcium content was significantly decreased; this could be prevented by ibandronate. No skeletal changes occurred in the gastrocystoplasty group. Serum pH was not altered in any group, and markers of bone resorption indicated normal bone resorption rates.Conclusion: There is a significant correlation between impaired bone metabolism and the type of segment used for bladder augmentation. While the use of the ileum (and probably the colon too) causes osteopenia, gastrocystoplasties seem to have little influence on bone turnover.

The role of surgery in renal cell carcinoma

SummaryRenal cell carcinoma accounts about three percent of all adult neoplasms. This review provides a current status about the surgical management of renal cell carcinoma. In localised carcinomas radical nephrectomy is still the standard treatment and provides 5 Year survival rates up to 98 %. As nephron-sparing surgery in mandatory indications can achieve similar survival doubt can be expressed whether lymphadenectomy or adrenalectomy are necessary in every case. Nephron-sparing surgery is associated with a higher rate of operative complications up to 40 % and probably with a higher risk of local recurrence. However, parenchymal-sparing surgery in elective indications is possible for small tumors, if long term follow up is guaranteed. But there is no convincing advantage of nephron-sparing surgery to recommend this procedure as a general approach in patients with a normal contralateral kidney. Radical surgery in renal carcinomas invading to the vena cava still remains a challenging surgical intervention. Nevertheless, in selected patients surgery can realise long term survival in over a third of cases. Palliative nephrectomy in metastatic renal carcinomas is only justified in real palliative indications (bleeding, pain) or in clinical trials investigating cytoreductive surgery before immunotherapy. In highly selected patients with metastatic renal carcinoma a radical surgical approach including nephrectomy and complete metastasectomy can achieve long term survival.ZusammenfassungDas Nierenzellkarzinom (NZK) stellt ca. 3 % aller malignen Nierentumoren im Erwachsenenalter dar. Die folgende Übersicht zeigt den Stellenwert der Chirurgie für die unterschiedlichen Stadien des NZK. Bei organbegrenzten Nierentumoren kann nach radikaler Tumornephrektomie eine 5 JÜR bis 98 % erwartet werden. Wegen ähnlich guter Überlebensraten nach organerhaltender Nierentumorresektion wird zur Zeit der Sinn von Lymphadenektomie und Adrenalektomie als integrale Bestandteile der Tumornephrektomie kontrovers diskutiert. Während die organerhaltende Nierentumorchirurgie bei imperativen Indikationen etabliert und mit guten Überlebensraten belegt ist, ist der Wert von Tumorresektionen bei kontralateral gesunder Niere noch unklar. Aufgrund der im Vergleich zur Nephrektomie deutlich erhöhten perioperativen Komplikationsrate (bis 40 %) und bei möglicherwiese erhöhter Rezidivrate muß der Benefit der organerhaltenden Nierentumorchirurgie in elektiven Indikationen noch definiert werden. Die Chirurgie des NZK mit Kavazapfen bleibt trotz der Entwicklung stadiengerechter Operationstechniken eine Herausforderung, dennoch ist bei einem selektionierten Patientengut eine 5 JÜR von über 1/3 der Fälle zu erreichen. Die Nephrektomie des metastasierenden NZK ist nur in palliativen oder im Kontext einer multimodalen Therapie (Immuntherapie, Metastasenchirurgie) gerechtfertigt.

Gemcitabin/Cisplatin vs. MVAC

ZusammenfassungVon insgesamt 405xa0Patienten einer internationalen prospektiv randomisierten Phase-III-Studie zur systemischen Chemotherapie des fortgeschrittenen Urothelkarzinoms [maximal 6 Zyklen Gemcitabin/Cisplatin (GC) vs. Methotrexat/Vinblastin/Adriamycin/Cisplatin (MVAC)] wurden 70xa0Patienten aus bundesdeutschen uroonkologischen Zentren rekrutiert. Zu diesen Patienten, die innerhalb der Arbeitsgemeinschaft Urologische Onkologie empfohlenen Studie ABxa012/96 rekrutiert wurden, wird über das 5-Jahres-Langzeitüberleben sowie über therapierelevante Daten berichtet. Die Tumorremissionsraten (GC=54%, MVAC=53%) sowie die 5-Jahres-Gesamtüberlebensrate (GC=10%, MVAC=18%), die tumorspezifische Überlebensrate (GC=14%, MVAC=22%) und die progressionsfreie Überlebensrate (GC=13%, MVAC=7%) waren in den beiden Behandlungsarmen nicht signifikant unterschiedlich.Die Anzahl von Patienten mit hämatologischer Grad-III/IV-Toxizität (Anämie und Thrombopenie) war signifikant größer im Gemcitabin/Cisplatin-Behandlungsarm (Anämie Gradxa0III/IV, GC=52%, MVAC=20% und Thrombopenie Gradxa0III/IV, GC=54%, MVAC=17%) mit einer signifikant höheren Transfusionsrate für Erythrozytenkonzentrate im GC-Arm. Neutro- bzw. leukopenisches Fieber trat nur unter der MVAC-Therapie bei 3xa0Patienten auf. Die zum Zeitpunkt der Auswertung noch lebenden Patienten zeichnen sich vorwiegend durch ein lokal fortgeschrittenes Tumorstadium bzw. in Einzelfällen durch eine lymphatische bzw. solitäre Metastasierung aus. Von Patienten mit viszeralen Metastasen lebt nach 30 Monaten Beobachtungszeit keiner mehr.AbstractOf 405 patients with stage IV transitional cell carcinoma from an international multicenter phase III trial, 70 were randomized in Germany to receive either gemcitabine/cisplatin or standard MVAC systemic chemotherapy for locally advanced or metastatic urothelial cancer. Overall survival as the primary endpoint of the study was similar in both arms (median survival GC 15.4xa0months vs MVAC 16.1xa0months), as were tumor-specific survival and time to progressive disease. In the intent-to-treat analysis, the 5-year overall survival rate was 10% for patients randomized to GC and 18% randomized to MVAC. Tumor overall response rates (GC 54%, MVAC 53%) were similar. The toxic death rate was 0% in the GC arm and 3% (one patient) in the MVAC arm. Significantly more GC than MVAC patients experienced grade 3/4 anemia (GC 52%, MVAC 20%) with significantly more red blood cell transfusions in the GC arm.Significantly more GC than MVAC patients had grade 3/4 thrombocytopenia (GC 54%, MVAC 17%) without grade 3/4 hemorrhage or hematuria in either arm. More MVAC patients experienced grade 3/4 neutropenia (GC 56%, MVAC 61%, p=1.000), neutropenic or leukopenic fever (GC 0%, MVAC 10%, p=0.237), mucositis (GC 0%, MVAC 7%, p=0.495), and alopecia (GC 6%, MVAC 36%, p=0.004). GC represents a reasonable alternative for the palliative treatment of patients with locally advanced and metastatic transitional cell carcinoma. Sustained long-term survival was only found for patients with locally advanced cancer, lymphatic metastases, or solitary distant metastasis but not for visceral metastatic disease.

Stellenwert der organerhaltenden Chirurgie beim Nierenzellkarzinom

ZusammenfassungDie Indikationen für eine organerhaltende Nierentumorchirurgie haben sich in den letzten 10 Jahren erweitert. Anerkannte Indikationen sind bilaterale Nierentumoren, Nierentumoren bei Patienten mit funktionellen und anatomischen Einzelnieren sowie bei Patienten mit eingeschränkter Nierenfunktion, denen nach Tumornephrektomie eine dialysepflichtige Niereninsuffizienz droht (imperative Indikationen). Durch operationsstrategische Verbesserungen – wie Perfusion in Hypothermie und Work-bench-Chirurgie können auch Patienten mit multiplen und fortgeschrittenen Nierentumoren zu über 95 % vor einer Nephrektomie mit anschließender Dialyse bewahrt werden. Beeinflußt durch die exzellenten Fünfjahresüberlebensraten von über 80 % nach organerhaltender Nierentumorchirurgie in imperativen Indikationen empfehlen zunehmend mehr Zentren die Ausweitung der parenchymsparenden Nierentumorchirurgie auf ein selektioniertes Patientengut mit kontralateral gesunder Niere (elektive Indikationen). Hier zeigen sich bei Nachbeobachtungszeiten von durchschnittlich 40 Monaten ähnliche Überlebensraten wie nach Tumornephrektomie. Bei einer Inzidenz bilateraler Nierenkarzinome von lediglich 2 % erscheint jedoch der Benefit der elektiven Resektion gering. Die lokale Rezidivrate nach elektiver organerhaltender Nierentumorchirurgie ist zwar bisher gering (durchschnittlich unter 5 %), allerdings kann die tatsächliche Häufigkeit der sich meist nach 4 Jahren manifestierenden Spätrezidive wegen noch kurzer Nachbeobachtungszeiten noch nicht abgeschätzt werden. Die Prognose nach Manifestation lokaler Rezidive ist in den meisten Fällen infaust.SummaryNephron-sparing surgery in renal cell carcinoma is an accepted approach in patients with bilateral carcinomas, solitary kidneys and in patients with chronic renal failure in whom radical nephrectomy would necessitate immediate renal replacement therapy (mandatory indications). Because of the improvement of operative techniques – like renal perfusion in hypothermia or work-bench surgery – over 95 % of patients can spared dialysis even if multiple tumors or locally advanced renal cancer is present. Based on the excellent outcome of nephron-sparing surgery in mandatory indications (5-year survival rates over 80 %), several centers advocate extending the use of partial nephrectomy to selected patients with a normal opposite kidney (elective indications). Several reports on nephron-sparing surgery in elective indications with a median follow-up time of 40 months document similar survival rates compared to radical nephrectomy. Nevertheless, due to the low incidence of bilateral renal carcinomas (under 2 %), only 2 of 100 patients would benefit from this approach. Furthermore, local recurrence after nephron-sparing surgery occurs mostly after 4 years (late recurrence); therefore, it seems doubtful whether the short follow-up times really reveal the the true recurrence rate. The prognosis after development of a local recurrence is poor.

Spontanruptur einer Niere post partum aufgrund eines urothelialen Karzinoms

SummaryThe case of a spontaneous kidney rupture due to an urothelial carcinoma one week after delivery is presented. Diagnosis was made during operation. In comparison to the carcinoma, which is diagnosed and treated in time, the prognosis is poor. The patient deserved continous gynecological follow-up and showed the classic symptoms of an urothelial carcinoma for six months. In spite of regular sonographic controls during pregnancy the tumor was not diagnosed. Diagnosis and management of renal carcinomas during pregnancy are discussed.ZusammenfassungDer Fall einer Spontanruptur der Niere aufgrund eines Urothelkarzinoms eine Woche post partum wird vorgestellt. Die Diagnose wurde erst intraoperativ gestellt. Die Prognose ist im Vergleich zum rechtzeitig erkannten und therapierten Karzinom infaust. Die Patientin war in regelmäßiger gynäkologischer Betreuung und wies über 6 Monate die typischen Symptome eines Urothelkarzinoms auf. Der Tumor wurde trotz regelmäßiger sonographischer Kontrollen in der Schwangerschaft nicht diagnostiziert. Die Diagnostik und Behandlung von Nierenzellkarzinomen in der Schwangerschaft wird diskutiert.

Magnetic resonance urography. First clinical results

ZusammenfassungWir berichten über erste klinische Erfahrungen mit einer neuartigen Meßsequenz zur Darstellung des gesamten Harntraktes mit Hilfe der Magnetresonanztomographie (MRT). Unter Verwendung des paramagnetischen Kontrastmittels Gadolinium-DTPA ist es gelungen, eine mit der konventionellen Ausscheidungsurographie vergleichbare Abbildung des gesamten Harntraktes zu erreichen. Wesentlicher Vorteil der Methode ist, daß neben einer guten morphologischen Darstellung des Harntrakts gleichzeitig die Gadolinium-DTPA-Ausscheidung beurteilt werden kann. Anhand von Fallbeispielen werden unsere vorläufigen Ergebnisse dargestellt.SummaryWe report our preliminary results using a new magnetic resonance imaging technique for visualization of the urinary tract. Using the paramagnetic contrast medium gadolinium diethylene triamine penta-acetic acid (DTPA), we were able to obtain images of the urinary tract comparable to those obtained by conventional excretory urography. The major advantage of our technique is that besides good morphologic visualization, the excretion of gadolinium-DTPA can be studied simultaneously. We demonstrate our preliminary results in selected cases.