Conservative management of renal masses in the elderly: our experience

Objectives To analyse a group of patients with clinically and radiologically detected renal neoplasms who were conservatively treated for various reasons. The patients were followed-up radiologically and intervened only if symptomatic. The natural progression of these masses and also a brief review of the literature is done. Methods The series was collected retrospectively from the case-notes of patients coded for renal neoplasms. Of the 13 patients followed up conservatively, eight were deferred surgery in view of their age (mean age—83.25 years), one patient had a single kidney, two were unwilling for surgery and two had severe co-morbidities which made them unfit for surgery. Results The mean age at diagnosis was 80.4 years (median—82; range 66–88). Seven females and six males were followed up for a mean and median follow-up of 38.38 and 34 months respectively (range—19 to 105 months). Six patients died during follow-up (mean-41.57 months). The average longest dimension at diagnosis and when last reviewed were 5.01 cm and 5.57 cm. However, only one of these died due to metastasis which developed during follow-up and two had to be angio-embolised for hematuria. The average rate of growth along the longitudinal dimension was 0.17 cm/year while the average change in volume was 11.97 cc/year. Conclusions Malignant renal neoplasms grow at a relatively slow rate. Without tumour growth the risk of metastasis appears limited. Thus expectant management can be considered as an alternative for a selected group of patients who are either unwilling or unfit or high risk for surgery.     

The art of surgery in the 21st century: based on natural sciences and new ethical dimensions

Background and aims In the future, new surgical techniques will only be introduced in clinical practice if evidence-based results—frequently the results of controlled clinical trials—are presented. Unlike any other medical discipline, surgeons provide their diagnostic and operative skills through the surgeons’ hand and the use of technical equipment, which ranges from instruments and devices employed during operation to the use of surgical robots. Results Analysing the fundaments of surgery on the turn of the century, there is only a little doubt about the increasing impact of data deriving from natural sciences on knowledge in medicine and management of diseases. The natural scientific method of detecting, measuring, and verifying facts is the methodological basis of surgery as well. The autonomy of the surgeon’s clinical decision making is significantly restricted by the definition of guidelines. They shift the decision from a single patient to a collective panel. Patient safety and the efficiency of new treatment modalities compared with previous standards are the criteria for the judgement of innovative surgery today. The communication and interaction between surgeon-scientist and patients is guaranteed legally by written consensus. But beside of the high probability of benefit from therapy and written consensus, the surgeon–patient relation is determined by these factors: limitation of time for care of an individual patient, increase of time for administration and documentation, increase of bureaucratic barriers for medical research, and health cost constraints. Conclusion The medical mandate to cure a sick patient is an individual mandate to take action. Measures, numbers, and images are only preconditions for a surgeon’s action in daily clinical work; they can never replace it. The call for an ethical imperative in scientific surgery that is dependent on technology is justified when the state of science and uncritical use of surgical skills and financial constraints have major impact on providing medical care.     

Evidence-based Surgery: A Passing Fad?

Recent years have witnessed the development of a new movement within health care: the promotion of “evidence-based medicine” (EBM). EBM is about integrating individual clinical expertise and the best external evidence derived from scientific research. Advocates claim that much medical practice is based too much on opinion and experience and insufficiently on research evidence. Their approach would increase the quality of care and its efficiency. This paper describes the principal steps in the evidence-based approach—systematic reviews of the literature and meta-analyses—and its shortcomings in surgery. These include the reliance of EBM on randomized trials, the lack of generalizability of scientific evidence to individual patients, the lack of attention to third party interests, the threat to the “art” of medicine, and the dangers of an oversimplistic approach. Although EBM clearly has a place, it does not have all the answers.     

Hypophosphatemia: the common denominator of all rickets

Rickets is a disease of the hypertrophic chondrocytes in the growth plate and is caused by hypophosphatemia—a derived defect in terminal chondrocyte apoptosis. This highlights the critical role of phosphorous in cartilage and bone metabolism. This review shows the role of phosphorous metabolism, transport and function in maintaining phosphorous supply to the growth plate, bone osteoblast and the kidney. Given that phosphorous is the common denominator of all rickets, this review proposes a new classification for the differential diagnosis of rickets, which is based on the mechanisms leading to hypophosphatemia—high PTH activity, high FGF23 activity or renal phosphaturia.     

Experience with Brulamycin therapy in dialysed patients

Forty-two patients with chronic renal insufficiency were subjected to Brulamycin therapy to combat complications such as sepsis, infection of the lower respiratory tract (bronchopneumonia) or of the urinary tract, Cimino fistula inflammation or peritonitis when the pathogenic agent was sensitive to nothing but aminoglycosides. The proper Brulamycin dose was selected under close clinical and laboratory control so as to fit the dialysed patient and his state of impaired renal function. The various forms of dialysis have been studied to determine their Brulamycin blood level diminishing effects. Familiarity with these effects is as important as with the patient's age, sex, body weight and actual state of renal function. The results confirm the experience gained by other authors that Brulamycin treatment—in curative non-toxic doses as indicated by the blood level index—is useful against severe infectious complications in anuric patients     

Long-term prognosis of chronic glomerulonephritis

The dependence of actuarial survival rates on morphological and clinical manifestation of chronic glomerulonephritis (CGN) has been studied in 520 patients followed up for 2–42 years. In grouping the patients along two sings—histological lesion and relapse incidence—the survival in different morphological forms of CGN was found to be similarly dependent on the illness activity. It was high in rare and the lowest in frequent and persisting relapses. Hypertension, high-grade tubulo-interstitial changes and sclerosis over 50 per cent of glomeruli indicate a poor prognosis as signs of severe renal damage under which each relapse may hasten the lethal outcome. Identification of the histological appearance is of high importance in CGN prognosis because of their different manifestations and tendency to relapse.     

Vesicoureteral reflux, a benign condition

The combination of urinary tract infection (UTI) and vesicoureteral reflux (VUR) is commonly thought to predispose the child to pyelonephritis, renal scarring and, later in life, to hypertension or end-stage renal disease (ESRD). This paradigm has led to the active search, follow-up and treatment of VUR, and also prevention of recurrent UTI in children. The causality of VUR and ESRD is controversial, however. According to recent meta-analyses it is uncertain whether we can prevent renal scarring or ESRD by treating VUR. Studies on VUR are abundant, but the findings and conclusions are confounding. Because of the lack of evidence of the role of VUR, reasonable doubt has recently been presented on the rationale of imaging all children with UTI and treating the children with VUR. The overall importance of VUR is confounded because of the natural tendency of VUR to resolve spontaneously, its dynamic nature, and its different grades in children. The historical studies showing that VUR is much more common, even among healthy children, than usually claimed, have been forgotten. Since it seems that we are referring too many healthy children to unpleasant and possibly unnecessary imaging tests for VUR, we are uncertain when and what kind of VUR—if any—we should treat, and whether our present rationale of addressing VUR truly makes any difference to renal scarring or ESRD in children, we should critically revisit the subject of VUR.     

Cervical Rhytidectomy

Based on anatomical and clinical considerations, a new classification of the six most common neck problems is presented. In general there are three types of necks—lean, fatty, and medium—which can involve three kinds of tissue—skin, muscle, and fat—that develop wrinkles, laxities, and adiposities. Different magnitudes and combinations of these problems are observed in these three kinds of patients. Medial plication of the platysma is emphasized as a natural way to deal with neck bands.     

Membranoproliferative glomerulonephritis

Membranoproliferative glomerulonephritis is an uncommon kidney disorder characterized by mesangial cell proliferation and structural changes in glomerular capillary walls. It can be subdivided into idiopathic and secondary forms, which are differentially diagnosed by a review of clinical features, laboratory data, and renal histopathology. Three types—I, II, and III—have been defined by pathologic features. All three types are associated with hypocomplementemia, but they manifest somewhat different mechanisms of complement activation. Type II, also known as “dense deposit disease”, is associated with the presence of C3-nephritic factor. Membranoproliferative glomerulonephritis primarily affects children and young adults, with patients presenting with nephrotic or nephritic syndrome or with asymptomatic renal disease. This type of glomerulonephritis often progresses slowly to end-stage renal disease, and it tends to recur after renal transplantation, especially type II. The efficacy of various forms of treatment remains controversial; however, long-term steroid treatment seems to be effective in children with nephrotic-range proteinuria. Improvement in renal outcomes largely relies on the evaluation of more selective agents in carefully controlled studies.     

Neuromuscular monitoring and postoperative residual curarization

Editor—In their meta-analysis of neuromuscular monitoringand postoperative residual curarization (PORC), Naguib and colleagues¹conclude that they ‘... could not demonstrate that theuse of an intraoperative neuromuscular function monitor decreasedthe incidence of PORC’. We agree that given their hypothesis(that intraoperative neuromuscular monitoring, including bothobjective and non-objective methods, would reduce the incidenceof PORC) and the chosen methodology (a meta-analysis based onboth comparative and non-comparative studies), this conclusionon their work is correct. However, we do question the relevanceof both the hypothesis and the use of a meta-analysis—andaccordingly also their conclusion. In fact, the authors themselvesalso doubt the conclusion reached, based on     

Renal involvement in lymphoma: prevalence and various patterns of involvement on abdominal CT

Objective The kidney is a frequent site of involvement in lymphoproliferative disorders. The aim of this study was to demonstrate the prevalence and spectrum of morphologic appearances of renal involvement in patients with lymphoma on helical computed tomographic (CT) scan. Methods Three phases of post-contrast helical CT of the abdomen in 74 patients with lymphoma were reviewed for possible renal involvement: the cortico-medullary, nephrographic and delayed excretory phases. Tumor characteristics, patterns of distribution and enhancement features were evaluated. Results Of the 74 patients with lymphoma, 11 had CT evidence of renal involvement—ten with non-Hodgkin’s lymphoma and one with Hodgkin’s lymphoma—representing 15% of all patients scanned for routine staging of histologically diagnosed lymphoma. Five types of renal involvement were observed: enlarged lobular non-enhancing kidneys (four patients); bilateral multiple renal masses (two patients); focal single non-enhancing mass (two patients); perirenal infiltrations from retroperitoneal extension (two patients); bilateral diffuse areas of non-enhancing hypo-densities (one patient). Conclusion Five distinct patterns of renal involvement with lymphoma were detected with helical CT. The most common appearance was enlarged lobular kidneys. CT with intravenous contrast enhancement is currently the approach of choice for both the evaluation of renal involvement as well as for accurate staging of lymphoma. Awareness of different patterns of renal involvement in lymphoma allows proper differentiation from other similar diseases.     

Effect of pneumoperitoneum on renal perfusion and function: A systematic review

Background The precise physiologic consequences of insufflating carbon dioxide into the abdominal cavity during laparoscopy are not yet fully understood. This systematic review aimed to investigate whether pneumoperitoneum results in decreased renal blood flow (RBF) or renal function. Methods A literature search was conducted electronically using Medline, Embase, and the Cochrane libraries on 1 July 2005. Various combinations of the medical subject headings—renal blood flow, pneumoperitoneum, renal function, and laparoscopy—were searched in all three databases. Reference lists from articles fulfilling the search criteria were used to identify additional articles. Results The literature search retrieved 20 articles concerning RBF and 25 articles concerning renal function during pneumoperitoneum. It was found that 17 of the 20 studies identified a decrease in RBF, and 20 of the 25 studies identified a decrease in renal function during pneumoperitoneum. Conclusion There appears to be sufficient evidence to conclude that both renal function and RBF are decreased during pneumoperitoneum. The magnitude of the decrease is dependent on factors such as preoperative renal function, level of hydration, level of pneumoperitoneum, patient positioning, and duration of pneumoperitoneum.     

Classification of Lymph Node Metastases from Carcinoma of the Stomach: Comparison of the Old (1987) and New (1997) TNM Systems

The pN classification of gastric cancer is currently based on the distance of metastatic nodes from the primary tumor (TNM—1987). The UICC (Union Internationale Contre le Cancer) has recently proposed a new classification system based on the number of the involved nodes (TNM—1997). The present prospective study is aimed at verifying whether the two classifications (1) assign approximately a similar rank to individual patients and (2) give comparable prognostic information. The Cox regression model was used to evaluate the prognostic significance of either the distance or the number of positive nodes, controlling for sex, age, site, histology and depth of tumor invasion, in a group of 175 patients who underwent curative surgery for gastric cancer from March 1988 to October 1997. Among the patients classified as N1 and N2 according to TNM—1987, 81.8% (36/44) and 35.8% (19/53), respectively, were coded as N1 and N2 by the new classification. The survival probabilities of N1 and N2 categories were similar in both classifications. The N2 category of TNM—1987 comprised also 10 cases with >15 positive nodes (N3 category of TNM—1997), who presented a large excess mortality (RR = 35.14 with respect to N0). When the site and number of positive nodes are combined in a new variable, both appear to be important from a prognostic point of view. Both anatomic location and number of nodes with metastasis are important predictors of survival in gastric cancer patients. Caution should be used when replacing the old classification with the new one, as they group patients in a different way.     

The impact of pregnancy and childbirth in the urethra of female rats

The aim of this study was to evaluate the modifications in the amount of collagen, muscular, and elastic fibers in the mid-urethra of adult female rats during the pregnancy and after the natural childbirth, cesarean, and after simulated trauma of childbirth. The authors evaluated the histomorphometric aspects (collagen, muscular, and elastic fibers) in the mid-urethra of 70 animals distributed in seven groups: group 1 (n = 10)—control, group 2 (n = 10)—pregnant female rats, group 3 (n = 10)—female rats submitted to cesarean, group 4 (n = 10)—female rats with natural childbirth, group 5 (n = 10)—virgin female rats with simulated trauma of childbirth, group 6 (n = 10)—female rats submitted to cesarean followed by simulation of childbirth trauma, and group 7 (n = 10)—female rats with natural childbirth followed by simulation of childbirth trauma. The average concentration of collagen and elastic fibers and the collagen/muscular fiber correlation in groups 1, 2, and 3 were similar and significantly inferior to groups 4, 5, 6, and 7. The average of muscular fibers was similar in groups 1, 2, and 3 and significantly superior to groups 4, 5, 6, and 7. Pregnancy and cesarean did not induce alterations in collagen, muscular, and elastic fibers. However, the vaginal delivery and simulation of childbirth trauma determined the decrease in muscular fibers and the increase in collagen and elastic fibers and the correlation collagen/muscular fiber.     

Effects of pegylated interferon α-2a on hepatitis-C-virus-associated glomerulonephritis

Hepatitis C virus (HCV) infection leads to chronic liver disease, but it has also been associated with extrahepatic manifestations. Membranoproliferative glomerulonephritis (MPGN) is the most common renal disease associated with HCV. Although renal disease related to HCV in adults has been well studied, it has not been well studied in children because it is rare. A recent study found that antiviral therapy was effective for adult patients with HCV-associated MPGN. We report a 9-year-old girl with HCV-associated MPGN. Her HCV genotype was 1b, and her virus load was high. The first renal biopsy showed mesangial proliferation and partial double contours of the basement membrane on light microscopy and immunofluorescence staining with immunoglobulin (Ig) M, IgG, and C3. The patient was successfully treated with pegylated interferon (IFN) α-2a monotherapy. The antiviral therapy was generally well tolerated. After antiviral therapy, a sustained virological response—defined as negative HCV ribonucleic acid (RNA) at least 24 weeks after antiviral treatment—was achieved, the proteinuria disappeared, and the second renal biopsy showed improvement.     

Complete obstetric brachial plexus palsy: surgical improvement to recover a functional hand

Objective   Complete obstetrical brachial plexus palsy remains a difficult situation for the child and his/her family. The quality of spontaneous reinnervation is rarely good and always leads to a non-sensitive and non-functional hand, even if abduction of the shoulder and elbow flexion do spontaneously recover. The aim of this study was to assess the results from nerve reconstruction in cases of complete palsy and to demonstrate the effect of a change in surgical technique on the outcome of hand function. Methods   Thirty pediatric patients with complete obstetric brachial plexus palsy were operated on in our department between 1987 and 2003. Twenty-five of these patients were clinically reviewed and evaluated by a physiotherapist and a surgeon (not the surgeon who performed the surgery). Functional assessment was based on the Gilbert shoulder score, the Gilbert–Raimondi score for elbow function and the Raimondi hand score. All children underwent a nerve reconstruction as graft and/or intra- or extra-plexual neurotization. Our neural surgical strategy changed between 1995 and 1996 to one that addresses the function of the hand and the wrist. A secondary surgical intervention was required in 18 cases. The most frequent procedures were a radial rotation osteotomy and a tendon transfer restoring wrist extension. Results   Mean follow-up was 7 years and 10 months. Among children operated on with the first surgical strategy—the pre-1995–1996 period—hand function was good in three cases, satisfactory in four cases and unsatisfactory in one case. Among children for whom the second surgical strategy was used—1995–1996 and later—hand function was good or very good in eight cases, satisfactory in four cases and unsatisfactory in two cases. When the 25 patients were assessed for shoulder function, the functional result was good or very good in 12 cases, satisfactory in seven cases and unsatisfactory in six cases. In terms of elbow function, the results were good or very good in 14 cases, satisfactory in eight cases and unsatisfactory in three cases. All hands recovered sensation to a certain degree. Conclusion   The surgical results are encouraging in terms of shoulder and elbow function, but not as good for hand function. With the change in neural surgical strategy in 1995–1996, when more focus was placed on the hand (second surgical strategy), the results on hand function improved relative to those obtained with the first surgical strategy. It must also be noted that hand recovery requires more time, which may partially explain why functional results are not as good for the hand as for the shoulder and elbow. These results demonstrate that early surgical exploration is useful in complete obstetrical brachial plexus palsies and that there is a need for neural reconstruction of the lower trunk.     

Treatment Options for Tauopathies

To date, there are no approved and established pharmacologic treatment options for tauopathies, a very heterogenous group of neuropsychiatric diseases often leading to dementia and clinically diagnosed as atypical Parkinson syndromes. Among these so-called Parkinson plus syndromes are progressive supranuclear palsy (PSP), also referred to as Steele-Richardson-Olszewski syndrome; frontotemporal dementia (FTD); and corticobasal degeneration (CBD). Available treatment strategies are based mainly on small clinical trials, miscellaneous case reports, or small case-controlled studies. The results of these studies and conclusions about the efficacy of the medication used are often contradictory. Approved therapeutic agents for Alzheimer′s dementia, such as acetylcholinesterase inhibitors and memantine, have been used off-label to treat cognitive and behavioral symptoms in tauopathies, but the outcome has not been consistent. Therapeutic agents for the symptomatic treatment of Parkinson’s disease (levodopa or dopamine agonists) are used for motor symptoms in tauopathies. For behavioral or psychopathological symptoms, treatment with antidepressants—especially selective serotonin reuptake inhibitors—could be helpful. Antipsychotics are often not well tolerated because of their adverse effects, which are pronounced in tauopathies; these drugs should be given very carefully because of an increased risk of cerebrovascular events. In addition to pharmacologic options, physical, occupational, or speech therapy can be applied to improve functional abilities. Each pharmacologic or nonpharmacologic intervention should be fitted to the specific symptoms of the individual patient, and decisions about the type and duration of treatment should be based on its efficacy for the individual and the patient’s tolerance. Currently, no effective treatment is available that targets the cause of these diseases. Current research focuses on targeting tau protein pathology, including pathologic aggregation or phosphorylation; these approaches seem to be very promising.     

Pathophysiology of hypercalciuria in children

Urinary excretion of calcium is the result of a complex interplay between three organs—namely, the gastrointestinal tract, bone, and kidney—which is finely orchestrated by multiple hormones. Hypercalciuria is believed to be a polygenic trait and is influenced significantly by diet. This paper briefly reviews calcium handling by the renal tubule in normal and in hereditary disorders as it relates to the pathophysiology of hypercalciuria. The effects of dietary sodium, potassium, protein, calcium, and phosphate on calcium excretion, and the association of hypercalciuria with bone homeostasis is discussed, leading to recommendations on means to address excessive urinary calcium excretion.     

Inflammation and cachexia in chronic kidney disease

Chronic inflammation is associated with cachexia and increased mortality risk in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Inflammation suppresses appetite and causes the loss of protein stores. In CKD patients, increased serum levels of pro-inflammatory cytokines may be caused by reduced renal function, volume overload, oxidative or carbonyl stress, decreased levels of antioxidants, increased susceptibility to infection in uremia, and the presence of comorbid conditions. Cachexia is brought about by the synergistic combination of a dramatic decrease in appetite and an increase in the catabolism of fat and lean body mass. Pro-inflammatory cytokines act on the central nervous system to alter appetite and energy metabolism and to provide a signal—through the nuclear factor-κB and ATP-ubiquitin-dependent proteolytic pathways—that causes muscle wasting. Further research into the molecular pathways leading to inflammation and cachexia may lead to novel therapeutic therapies for this devastating and potentially fatal complication of chronic disease.     

Novel technique for in situ cold perfusion in laparoscopic partial nephrectomy

Background  Following clamping of the renal hilus, warm ischemia is an issue in laparoscopic partial nephrectomy. If ischemia longer than 30 min is anticipated, special protective measures are needed. The aim of this study was to develop a solely laparoscopic technique for in situ cold perfusion of kidneys during laparoscopic partial nephrectomy to increase the tolerance of renal parenchyma to ischemic damage in a porcine model. Methods  Six animals were used in this study. We tried to develop a technique that allowed us to cannulate the renal artery, introduce a catheter to perform an in situ cold perfusion and—the most important feature—secure the catheter throughout the laparoscopic partial nephrectomy. Results  A modified laparoscopic vascular bulldog clamp was ultimately ideal to fulfil expectations. In five pigs, a successful partial nephrectomy in in situ perfusion was performed. The median warm ischemia time, starting from occlusion of the renal artery and vein to the commencement of cold perfusion, was 130 s (range 75–165 s). The subsequent median cold ischemia time in which a partial nephrectomy was simulated was 42 min (range 26–52 min). Conclusions  The newly developed technique expands the armamentarium of the urologist in laparoscopic partial nephrectomy, if the anticipated time of ischemia exceeds 30 min and renal hypothermia is indicated.