nephroureterectomy

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Article of the Week: Identifying predictors of renal function decline after surgery

November 5, 2014/by admin Z.9

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Preoperative predictors of renal function decline after radical nephroureterectomy for upper tract urothelial carcinoma

Matthew Kaag, Landon Trost*, R. Houston Thompson*, Ricardo Favaretto†, Vanessa Elliott, Shahrokh F. Shariat‡, Alexandra Maschino†, Emily Vertosick†, Jay D. Raman and Guido Dalbagni†

Penn State Hershey Medical Center, Hershey, PA, *Mayo Clinic, Rochester, MN, †Memorial Sloan-Kettering Cancer Center, New York, NY, USA, and ‡Medical University of Vienna, Vienna, Austria

Read the full article

OBJECTIVES

To model renal function after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). To identify predictors of renal function decline after surgery, thereby allowing the identification of patients likely to be ineligible for cisplatin-based chemotherapy in the adjuvant setting.

PATIENTS AND METHODS

We retrospectively identified 374 patients treated with RNU for UTUC at three centres between 1995 and 2010. Estimated glomerular filtration rate (eGFR) was calculated using Chronic Kidney Disease Epidemiology Collaboration equation before RNU and at early (1–5 months after RNU) and late (>5 months) time points after RNU. Only patients deemed eligible for cisplatin-based chemotherapy before RNU (preoperative glomerular filtration rate [GFR] ≥60 mL/min/1.73 m²) were included. Multivariable analysis identified the preoperative predictors of eGFR after RNU at early postoperative and late postoperative time points.

RESULTS

A total of 163 patients had an eligible early post-RNU eGFR measurement and 172 had an eligible late eGFR measurement. The median eGFR declined by 32% and did not show a significant trend toward recovery over time (P = 0.4). On multivariable analysis preoperative eGFR and patient age were significantly associated with early and late postoperative eGFR, while Charlson comorbidity index score was significantly associated with late postoperative eGFR alone.

CONCLUSIONS

In patients with normal preoperative eGFR (≥60 mL/min/1.73 m²), renal function decreases by one-third after RNU and does not show evidence of recovery over time. Elderly patients and those with pre-RNU eGFR closer to 60 mL/min/1.73 m² (lower eGFR in the present cohort) are more likely to be ineligible for adjuvant cisplatin-based chemotherapy regimens because of renal function loss after RNU.

Editorial: ‘Discontent is the first necessity of progress’, Thomas A. Edison

November 5, 2014/by Surena Matin

This study from Kaag et al. [1] investigates predictors of renal functional decline after radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC). They evaluate early (2 months) and late (6 months) predictors of renal functional decline, finding that on a multivariable model only age at surgery and preoperative renal function were independently associated with early postoperative function. This is an intuitive finding whereby we expect older patients and those with lower renal function to have a more dramatic decrease in renal function after RNU.

Age, preoperative renal function, and Charlson score were associated with late functional recovery. The latter is a counterintuitive finding, as higher Charlson score was associated with less decrease in renal function. Charlson comorbidity was not significant on univariate analyses. Why it would become significant on multivariate is unclear. Whether it is an artifact related to study methodology or is a real phenomenon will require further study.

Unquestionably, this study [1] adds to the growing discontent of our current management of UTUC. The authors cogently discuss the issues related to better risk stratification as a natural consequence of instituting a neoadjuvant chemotherapy paradigm in those with high-risk disease. Multiple retrospective studies have failed to show a benefit of adjuvant chemotherapy, whereas now we have a matched-cohort study showing significant rates of downstaging and complete remission [2], and as well significantly improved 5-year survival, with institution of a neoadjuvant paradigm [3]. One cannot view the dismal outcomes of this disease without being discontent and wishing for progress. We need to continue getting out the message to not only urologists who reflexively institute RNU in patients with a risk-unstratified upper tract filling defect, but as well many medical oncologists who can only function based on guidance from level I data, which for this disease, will be a long time coming.

Read the full article

Surena F. Matin

Department of Urology, MD Anderson Cancer Center, Houston, TX, USA

References

1 Kaag M, Trost L, Thompson RH et al. Pre-operative predictors of renal function decline following radical nephroureterectomy for upper tract urothelial carcinoma. BJU Int 2014; 114: 674–9

2 Matin SF, Margulis V, Kamat A et al. Incidence of downstaging and complete remission after neoadjuvant chemotherapy for high-risk upper tract transitional cell carcinoma. Cancer 2010; 116: 3127–34

3 Porten S, Siefker-Radtke AO, Xiao L et al. Neoadjuvant chemotherapy improves survival of patients with upper tract urothelial carcinoma. Cancer 2014; 120: 1794–9

An Unusual Case of Duplex kidney: Giant Hydroureter of Upper Moiety presenting as abdominal lump

September 29, 2011/by admin Z.9

We report a case of giant hydroureter of an upper moiety presenting as abdominal lump.

Authors: Javali, Tarun; Gupta, Narmada

Corresponding Author: Tarun Javali, A.I.I.M.S., Urology department, New Delhi, India. Email: [email protected]

Introduction

Most patients with duplex kidneys are asymptomatic, with genitourinary abnormalities being detected incidentally on imaging performed for some other reasons. In complete duplication, the upper pole ureter usually drains caudal and medial to the lower pole ureter (Weigert Meyer rule). Ectopic insertion of the upper pole ureter may cause hydronephrosis as a consequence of stenosis of the ureteric orifice. However massive dilatation of just the upper pole ureter (with a small and atrophic upper pole renal moiety) is rare. Here we report a case of giant hydroureter of an upper moiety presenting as abdominal lump.

Case report

A 31 year old male presented with dull ache in his right flank and progressively increasing abdominal swelling for the previous 8 months. There was no history of fever or lower urinary tract symptoms. The patient also gave a history of constipation for the past month. Examination revealed an ill-defined abdominal mass, soft in consistency, and occupying the right flank and right hypochondrium, extending into the right iliac fossa and umbilical regions.

On rectal examination, a soft cystic mass was palpable anterior to the rectum and causing extrinsic rectal compression.

Routine blood and urine tests were within normal limits. A contrast enhanced CT scan of the kidneys, ureters and bladder [Fig. 1] and an MR urogram [Fig. 2] were performed.

Figure 1. CT scan of the kidneys, ureters and bladder

Figure 2. MR urogram

A voiding cystogram showed no evidence of vesicoureteric reflux. On cystoscopic examination, the ectopic orifice of the right upper moiety ureter could not be identified. The right lower moiety ureter was stented. Transperitoneal laparoscopic upper pole nephroureterectomy was performed [Fig.3].

Figure 3. Transperitoneal laparoscopic upper pole nephroureterectomy

After ligating the upper pole renal vessel, the abnormal ureter was dissected close to its wall. The giant hydroureter contained 8 litres of turbid urine. The ectopic ureter was found opening into the posterior urethra. A 3cm Gibson incision was performed for specimen removal [Fig.4].

Figure 4. A 3cm Gibson incision was performed for specimen removal

Figure 5.

Discussion

This case has been reported to highlight the extent to which a ureter can dilate. There are only a few cases of duplex kidney/ectopic ureter reported in the literature in which the ureter has assumed such massive proportions, completely overshadowing the renal pelvis and parenchyma. Uson et al reported a case of a giant ectopic ureter presenting as an abdominal mass in a newborn infant [1]. Mahajan et al reported a case of an adult woman who had unilateral upper-pole giant hydroureter in a duplex kidney which was incidentally detected during cesarean section [2]. Heminephrectomy was performed, and the hydroureter was found to contain 2 litres of fluid. Whitmore et al reported a case of giant hydronephrosis of a duplex system associated with ureteral ectopia [3].

In the present case, the ectopic ureter of upper moiety of the right kidney was dilated to such an extent, that it presented as an abdominal mass and also caused constipation due to extrinsic rectal compression. Laparoscopic upper pole nephroureterectomy was successfully carried out and the patient’s symptoms were relieved after surgery.

References

1. Uson AC, Womack CE, Berdon WE. Giant ectopic ureter presenting as an abdominal mass in a newborn infant. The Journal of Pediatrics. 1972; 80:473-76.

2. Mahajan NN, Sahay S, Kale A, Nasre M. Unilateral upper-pole giant hydroureter in a duplex renal system: an incidental finding in cesarean section. Arch Gynecol Obstet. 2008; 278:149-51.

3. Whitmore RB, Schellhammer PF. Giant hydronephrosis of a duplex system associated with ureteral ectopia. J Urol. 1989; 141:1186-8.

Date added to bjui.org: 29/09/2011