Ralph A. Straffon

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.

Radical Cystectomy without Radiation Therapy for Carcinoma of the Bladder

A review of a 20-year experience of radical cystectomy identified 99 patients who had not undergone preoperative radiation therapy. The 5-year survival rate of patients with clinical high stage lesions (T3, T4a) was 40 per cent. Life-table analyses showed that survival rate in this group was comparable with that reported for other groups receiving preoperative radiation therapy. The pelvic recurrence rate was 9 per cent and was frequently related to either urethral or nodal disease. Unquantifiable patient selection factors may well limit the reliability of these results.

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.

Surgery for renal cell carcinoma extending into the inferior vena cava.

We have reviewed 26 patients with renal cell carcinoma extending into the inferior vena cava, 21 of whom underwent radical nephrectomy with either venacavotomy and tumor thrombectomy, or vena cava resection. Of 12 patients who presented with localized neoplasm 6 (50 per cent) are currently alive. Poor results were obtained in 9 patients who had preoperative metastatic disease. Over-all operative mortality was 14 per cent and morbidity was minimal, with no pulmonary emboli intraoperatively or postoperatively.

Partial Nephrectomy in the Treatment of Renal Adenocarcinoma

During a 20-year period 17 patients underwent partial nephrectomy as primary curative therapy for renal adenocarcinoma. In 15 patients (88 per cent) partial nephrectomy was performed satisfactorily in situ with free margins of resection. Eleven patients are alive (65 per cent) and only 3 (17 per cent) died of recurrent malignant disease. There was no operative mortality and postoperative complications were minimal. A review of the literature reveals that partial nephrectomy is an effective form of therapy for patients with bilateral renal carcinoma or carcinoma occurring in a solitary kidney.

Renal trauma and hypertension

Eleven cases of hypertension after renal trauma were reviewed. The average age of the patients was 22 years on first examination at the Cleveland Clinic. Ten patients were asymptomatic; 4 were not aware that they had suffered specific renal trauma. The onset of hypertension occurred at very different intervals after the traumatic event, sometimes after several years, thus making imperative long-term observation of patients suspected of having sustained renal trauma. Nephrectomy ameliorated hypertension in 7 of 8 patients, 6 of whom became normotensive; more conservative operations failed to relieve hypertension in 2 of 3 patients. Mechanisms of post-traumatic renal hypertension include parenchymal compression from hematomas (analogous to the cellophane-wrapped kidney of Page) and renal artery stenosis or occlusion (analogous to the Goldblatt kidney).

Mortality and morbidity in pretransplant bilateral nephrectomy Analysis of 305 cases

The surgical riks were analyzed in 305 patients with end stage renal failure who underwent bilateral nephrectomy through midabdominal approach in preparation for kidney transplantation. The over-all mortality rate was 3.6 per cent. Age was the most significant risk factor in the mortality. Patients less than fifty years of age had an operative mortality rate of 3.1 per cent while those more than fifty years had an operative mortality of 11.1 per cent. Other pertinent risk factors were preoperative complications of renal failure and additional surgical procedures at the time of bilateral nephrectomy. The leading causes of death were those of cardiovascular complications and infection. The morbidity rate was 58.7 per cent being major in 18 per cent and minor in 40.7 per cent. Bilateral nephrectomy is recommended selectively in patients with (1) chronic pyelonephritis with urinary tract infection, (2) major vesicoureteral reflux, (3) immunologically active glomerulonephritis, (4) severe hypertension uncontrollable by adequate dialysis, and (5) extremely large or infected polycystic kidneys.

Chronic viral hepatitis in renal transplant recipients with allografts functioning for more than 20 years.

BACKGROUND The impact of infection with hepatotropic viruses (hepatitis B virus [HBV] and hepatitis C virus [HCV]) on morbidity and mortality, and allograft function in renal transplant recipients with allografts functioning for >20 years is not known. METHODS AND RESULTS Seventy-nine of 511 renal transplants performed at the Cleveland Clinic Foundation from January 1963 to January 1978 are known to have functioned for at least 20 years (level 5A). Fifty-four of these patients had hepatitis testing updated after their 19th year of transplantation. Fifteen patients had evidence of ongoing viral infection: persistent hepatitis B surface antigen in three (6%), HCV antibody (enzyme-linked immunosorbent assay II supplemented by recombinant immunoblot assay) in 11 (20%), and both viruses in one (2%). Of the 10 surviving patients, 8 were tested further for viral replication. HCV RNA (polymerase chain reaction; Amplicore) was positive in 6/7 (86%), and HBV DNA (hybridization) was positive in 1/2 (50%). An elevated alanine aminotransferase (>35 U/L) was present in all hepatitis patients, alpha-fetoprotein >10 ng/ml in 2/8 (25%), and cryoglobulins >50 microg/ml in 3/6 (50%) infected with HCV. No hepatocellular carcinoma was detected by hepatic ultrasound. In patients with chronic viral hepatitis, probable cirrhosis developed in 20% (3/15) compared to one patient in the group without hepatitis, but there was no mortality from liver failure in either group. Diabetes mellitus was significantly more common in those with than without hepatitis (11/15 vs. 10/39; P=0.002), but severe infection was not (9/15 vs. 15/39). Five hepatitis patients (33%) have died of non-hepatic causes (one from meningitis, one from unknown cause, and three from coronary heart disease [CHD] vs. only two individuals without hepatitis [5%]; P= 0.014). Although the more frequent occurrence of CHD among those with hepatitis was not significant (7/15 vs. 8/39; P=0.09), CHD as a cause of death in those with HCV was significantly increased (P=0.03). CONCLUSIONS Twenty-year renal transplant recipients infected with hepatotropic viruses (HBV and HCV) have a high rate of active viral replication (88%), a greater frequency of diabetes (P=0.01), and a higher overall mortality (P=0.014).

The Role of Renal Autotransplantation in Complex Urological Reconstruction

From 1972 to 1988, 108 patients underwent renal autotransplantation for renal artery disease (67), ureteral replacement (27), or renal cell carcinoma present bilaterally or in a solitary kidney (14). The most common indication for renal autotransplantation was to allow extracorporeal repair of complex branch renal artery lesions. Of the 54 patients in this group technically satisfactory branch renal arterial reconstruction and a successful clinical outcome were achieved in 52 (96%). Renal autotransplantation is the treatment of choice in these patients and also in selected children with main renal artery disease. Renal autotransplantation provided excellent results in 25 of 27 patients (92%) who required replacement of all or a major portion of the ureter. Over-all renal function was well preserved in these patients and only 1 has experienced chronic bacteriuria. Renal autotransplantation is a useful alternative to ileal interposition in this setting. Extracorporeal partial nephrectomy and renal autotransplantation were successful in 12 of 14 patients (85%) undergoing a nephron-sparing operation for renal cell carcinoma. In situ techniques are associated with less morbidity and currently are preferred in this group.

Conservative Surgery for Transitional Cell Carcinoma of the Renal Pelvis

From 1972 to 1986, 14 patients underwent a conservative operation for transitional cell carcinoma of the renal pelvis. Most of these patients had low grade (12), noninvasive (10) tumors involving a solitary functioning kidney (12). The operations performed were open pyelotomy with tumor excision and fulguration (8 patients), partial nephrectomy (5) and percutaneous nephroscopic fulguration (1). There was 1 operative death. Of the 13 surviving patients 8 (62 per cent) remained free of transitional cell carcinoma postoperatively, while 5 (38 per cent) had recurrent disease. Six patients (46 per cent) presently are free of tumor 6 months to 5 years postoperatively. Conservative surgical techniques can provide satisfactory treatment for selected patients with renal pelvic transitional cell carcinoma when preservation of functioning renal parenchyma is necessary to avoid kidney failure.