Renal cell carcinoma.
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Carcinoma, Renal Cell↗
Biomedical subjects
A C Novick
Publications and source records attributed to A C Novick.
Nephron sparing surgery in incidental versus suspected renal cell carcinoma.
From 1956 to 1992 nephron sparing surgery was performed in 216 patients with sporadic renal cell carcinoma. Renal cell carcinoma was suspected in 121 patients and was an incidental finding in 95. Compared to suspected renal cell carcinoma, incidental tumors were smaller (p = 0.0004), more often unilateral (p = 0.001) and of lower pathological stage (p = 0.001). Incidental tumors were also associated with improved 5-year cancer-specific survival (p = 0.003) and a lower rate of postoperative tumor recurrence (p = 0.001). The overall 5-year cancer-specific survival rate was improved in patients with stage I versus higher stage renal cell carcinoma (p = 0.0002), unilateral versus bilateral disease (p = 0.0001), a single versus multiple tumors in the operated kidney (p = 0.01) and tumors smaller than 4 cm. versus larger tumors (p = 0.03). There were no postoperative tumor recurrences and the 5-year cancer-specific survival rate was 100% in patients with unilateral, stage I tumors smaller than 4 cm. These data define specific eligibility criteria for nephron sparing surgery in patients with localized unilateral renal cell carcinoma and a normal contralateral kidney.
Actuarial Analysis↗
Pathological effects of extracorporeally generated shock waves on calcified aortic aneurysm tissue.
This study was done to define further the limits of extracorporeal shock wave lithotripsy (ESWL) in the setting of proximate calcified aneurysms. Calcified aortic aneurysmal tissue was harvested from patients undergoing elective abdominal aneurysm repair. The aneurysmal tissue was divided into control and experimental sections, and then suspended in normal saline at the F2 focal point, and at 2 and 5 cm. away from the F2 focal point in the major parallel axis of an unmodified Dornier HM3 lithotriptor. Shock waves (200, 500 or 1,000) were delivered at 18 kv. at F2, F2 plus 2 cm. and F2 plus 5 cm. The specimens were then analyzed histopathologically first to compare control and experimental sections for differences in preexisting calcification, hemorrhage and inflammation, and then to grade them for overall evidence of tissue disruption. No significant pathological difference was found between control and experimental specimens treated under these parameters. Our study suggests that human aortic aneurysmal tissue undergoes little pathological change when subjected to therapeutic range ESWL. These findings support previous clinical observations that the presence of a proximate calcified aneurysm does not necessarily preclude ESWL for the treatment of renal or ureteral calculi. The spatial and power limits used in this study may help provide a basis for future safe management of renal and ureteral calculi with ESWL in this setting.
Aorta, Abdominal↗
Management of atherosclerotic renal artery disease in younger patients.
From 1970 to 1990, 57 patients 50 years old or younger were treated for hypertension caused by atherosclerotic renal artery disease. Predisposing factors for atherosclerosis included smoking in 43 cases, hyperlipidemia in 15, diabetes in 8 and hyperuricemia in 8. Of the patients 47 had a family history of atherosclerotic vascular disease or a significant related disorder. Evidence of generalized atherosclerosis was present in 55 patients. Atherosclerotic renal artery disease was present unilaterally in 16 cases, bilaterally in 39 and in a solitary kidney in 2. Of the patients 34 were treated surgically, 20 medically and 2 by percutaneous angioplasty. Surgically treated patients experienced significant postoperative improvement in blood pressure (p = 0.001) and renal function (p = 0.05). Medically treated patients experienced significant improvement in blood pressure (p = 0.03) but renal function deteriorated. Younger patients with atherosclerotic renal artery disease suffer from a more severe and accelerated form of atherosclerosis than older patients. Although blood pressure control can be achieved with medical treatment, surgical revascularization offers the best opportunity for stabilization or improvement of renal function.
Adult↗
Retroperitoneal hemorrhage from a ruptured renal artery aneurysm with spontaneous resolution.
Rupture of a renal artery aneurysm is an acute surgical event with a high associated mortality rate. We report an unusual case of acute retroperitoneal hemorrhage from a ruptured renal artery aneurysm that resolved spontaneously with resultant pseudoaneurysm formation. Elective surgical management was performed with a simplified technique involving ligation of the neck of the renal artery aneurysm.
Aneurysm, Ruptured↗
Angiotensin II receptor subtypes in the human renal cortex and renal cell carcinoma.
Selective antagonists were used to determine the presence of angiotensin II (Ang II) receptor subtypes (AT1 and AT2) in normal human renal cortex and renal cell carcinoma. Normal and tumor tissues were obtained from fresh radical nephrectomy specimens in 7 patients. All patients had a patent renal artery, and the mean preoperative serum creatinine level was 1.1 mg./dl. Tissues were snap frozen and sectioned (14 microns.) for in vitro autoradiography, then incubated in 125I-Ang II (0.3 nM.), with or without unlabeled Ang II or subtype selective antagonists (1 nM. to 1 microM.), rinsed, air dried and apposed to SB-5 X-ray film for 3 to 21 days. In normal renal tissue, low densities of diffuse 125I-Ang II binding sites were observed in cortical areas containing tubules. Higher densities of binding sites occurred over glomeruli and large cortical vessels. Specific binding ranged between 60 and 90% depending on the area as determined by displacement with excess unlabeled Ang II. Specific binding in large cortical vessels was displaced by the two AT2 selective antagonists PD123177 (1 microM.) or CGP 42112A (0.01 microM.), whereas these antagonists were less effective competitors for 125I-Ang II binding in glomeruli. In contrast, the AT1 selective antagonists, DuP 753 and L-158,809 (0.1 and .01 microM., respectively), were potent competitors for glomerular, but not extraglomerular, cortical vessel binding. In the normal cortical tubulointerstitium, both AT1 and AT2 antagonists caused partial displacement of specific binding (55 +/- 12% AT1, 39 +/- 12% AT2). Low density 125I-Ang II binding was present in all tumors. Specific binding averaged 59 +/- 10% as defined by displacement with unlabeled Ang II (1 microM.). As in the normal tubulointerstitial area, each of the selective antagonists produced partial displacement of the specific binding (60 +/- 12% AT1, 31 +/- 8% AT2). In conclusion, AT1 receptors predominate in glomeruli, while AT2 binding sites predominate in large preglomerular vessels of the human renal cortex. In the normal tubulointerstitium and renal cell carcinoma, a 60%/40% mixture of AT1 to AT2 receptors exists. These findings provide a pharmacologic framework for the differential effects of Ang II receptor-mediated function in the human kidney.
Angiotensin II↗
Safety of transurethral surgery in the early postoperative period following an open cardiac procedure.
A retrospective investigation was performed to determine whether patients undergoing transurethral surgery soon after cardiac surgery experienced increased morbidity or mortality rates. From 1986 to 1990, 24 patients first underwent open heart surgery and then either transurethral prostatectomy, bladder tumor resection or bladder cup biopsy during the same hospital stay. Postoperative complications included significant hematuria in 2 patients (8%), mild stress incontinence in 1 (4%) and bladder perforation in 1. One patient died of a spontaneous pneumothorax 17 days after the urological operation. None of these patients had had a previous myocardial infarction. The outcome of these patients was compared to that of 115 men who underwent transurethral prostatectomy for presumed benign disease during 1990. Complications of transurethral prostatectomy in this group included significant gross hematuria in 5 men, while 6 experienced urinary retention (1), atrial fibrillation (1), delirium (1), myocardial infarction (1), seizure (1) and intraoperative urethral injury (1). There was 1 death from multiple postoperative complications. Morbidity and mortality rates did not differ significantly between the 2 groups. Transurethral surgery performed after cardiac surgery during the same hospital stay appears to be safe, provided the patient is stable.
Aged↗
Complications of nephron sparing surgery for renal tumors.
The technical results of 259 nephron sparing operations for renal cell carcinoma or renal oncocytoma were reviewed. Local or renal related complications occurred after 78 procedures (30.1%). The incidence of complications was less for operations performed after 1988 (22% versus 37%, p = 0.009) and for incidentally detected versus suspected tumors (p = 0.009). The most common complications were urinary fistula formation (45 operations) and acute renal failure (33). Significant predisposing factors for urinary fistula formation included central tumor location (p = 0.001), tumor size greater than 4 cm. (p = 0.001), the need for major reconstruction of the collecting system (p = 0.001) and ex vivo surgery (p = 0.001). Only 1 urinary fistula required open operative repair, while the remainder resolved either spontaneously (30) or with endoscopic management (14). Significant predisposing factors for acute renal failure included a solitary kidney (p = 0.001), tumor size greater than 7 cm. (p = 0.008), greater than 50% parenchymal excision (p = 0.001), greater than 60 minutes of ischemia time (p = 0.035) and ex vivo surgery (p = 0.001). Acute renal failure resolved in 28 patients, of whom 9 required temporary dialysis, while 5 required permanent dialysis. Overall, 8 complications (3.1%) required repeat open surgery for treatment while all other complications resolved with noninterventive or endourological management. Surgical complications contributed to an adverse clinical outcome in only 7 patients (2.9%). Nephron sparing surgery can be performed safely with preservation of renal function in most patients with renal tumors.
Acute Kidney Injury↗
A new triple-balloon, four-channel vascular catheter for use in renal transplantation.
While current surgical techniques of renal transplantation afford excellent results, some steps of the operation are associated with potential morbidity. Application of vascular clamps on an atherosclerotic recipient artery can cause plaque fracture or atheroembolism. atheroembolism. Prolonged revascularization time may aggravate ischemic allograft damage. Based on the premise that arterial occlusion by an intraluminal balloon is less damaging to the vascular endothelium than an external vascular clamp, a new three-balloon, four-channel vascular catheter has been developed for use in renal transplantation. Catheters are inserted by the Seldinger technique, one catheter being positioned in each recipient external iliac artery and external iliac vein. Vascular control of the recipient vessels is obtained by inflation of the balloons. A pilot study in four dogs has confirmed the technical feasibility of using this catheter during renal transplantation. A description of the catheter, technique of surgical placement, advantages and potential uses is presented.
Animals↗
Long-term results of renal transplantation into the valve bladder.
Between 1970 and 1990 renal transplantation was performed in 16 patients with a history of posterior urethral valves. While 10 patients had undergone supravesical urinary diversion before the development of end stage renal disease, all but 1 transplant were drained to the unaugmented native bladder. The 2 and 5-year graft survival rates were 70% and 59%, respectively. Of the 15 surviving patients 11 have allografts that are functioning at a mean of 86 months after transplantation with a mean serum creatinine of 2.0 mg./dl. Urological complications occurred in 19% of the transplants. No detrimental effect of the valve bladder on long-term allograft survival or function was apparent. With appropriate treatment of vesical dysfunction, these patients can be expected to have graft function comparable to the general transplant population despite use of the unaugmented native bladder.
Adolescent↗
Renal transplantation in patients with renal cell carcinoma and von Hippel-Lindau disease.
This study reviewed the management and outcome of patients with von Hippel-Lindau disease (VHLD) who underwent renal transplantation after being rendered anephric to treat multifocal bilateral renal cell carcinoma (RCC). Five patients with bilateral RCC and VHLD underwent renal transplantation at our hospital. Initial treatment of RCC consisted of bilateral nephrectomy in 2 patients and unilateral nephron-sparing surgery with contralateral nephrectomy in 3 patients. All of the latter 3 patients experienced isolated tumor recurrence in the renal remnant at 48, 64, and 66 months postoperatively; this was managed by complete excision of the renal remnant. Renal transplantation was performed 11 to 24 months after initiation of dialysis. Postoperatively, all of the allografts functioned well with no further requirement for dialysis. Currently, 4 patients are alive at a mean post-transplant follow-up interval of 26 months (range, 7 to 66 months) with excellent graft function and no evidence of malignancy. One patient died 17 months following transplantation due to metastatic disease. Renal transplantation can provide satisfactory replacement therapy for patients with end-stage renal disease with VHLD and treated RCC.
Adult↗
Use of the thoracic aorta for renal arterial reconstruction.
PURPOSE: Thoracic aortorenal bypass is a new technique for surgical renal revascularization in patients with severe atherosclerosis of the abdominal aorta. In such cases, the thoracic aorta is often free of disease. METHODS: From 1989 to 1992, thoracic aortorenal bypass was performed in 23 patients with hypertension, abdominal aortic atherosclerosis, and celiac artery stenosis; in 21 patients, renal artery stenosis was present bilaterally or in a solitary kidney. RESULTS: There was one operative death. Among the remaining 22 patients, hypertension was cured or improved after operation in 19 (86%), and renal function was improved or stable in 21 (95%). CONCLUSIONS: Thoracic aortorenal bypass has several advantages and is a useful alternative to abdominal aortic replacement in selected older patients who require renal arterial reconstruction.
Aorta, Abdominal↗
Percutaneous transluminal angioplasty and surgery of the renal artery.
The management of patients with renal artery disease has changed in recent years. This has occurred due to the advent of PTA as an effective method of treatment for certain patients, an enhanced appreciation of advanced atherosclerotic renal artery disease as a correctable cause of renal failure, and improved results of surgical revascularisation in both older patients with severe aortic atherosclerosis and younger patients with branch renal artery disease. PTA currently yields excellent results and is the treatment of choice for patients with fibrous dysplasia of the main renal artery and non-ostial atherosclerotic lesions. Most reports in the literature indicate that surgical revascularisation provides more effective therapy for patients with ostial atherosclerotic lesions. Surgical revascularisation also remains the treatment of choice for the majority of patients with branch renal artery disease, a renal artery aneurysm, renal artery occlusion, and recurrent renal artery stenosis after failed PTA or surgery. Excellent clinical results can be achieved with both PTA and surgical revascularisation in properly selected patients.
Angioplasty, Balloon↗
Management of the incidentally detected solid renal mass.
Solid renal masses are being increasingly detected incidentally in individuals with no urologic symptoms. Contemporary imaging modalities allow the diagnosis of RCC to be established with 85% to 90% accuracy. Some solid renal masses with radiographic characteristics of RCC will ultimately prove to be a benign adenoma or oncocytoma. Recent data suggest that radical nephrectomy and nephron-sparing surgery each provide effective curative treatment for patients with a single, small, unilateral, localized RCC. The long-term renal functional advantage of nephron-sparing surgery with a normal opposite kidney remains unproven. Radical nephrectomy remains the treatment of choice for patients with larger (> 4 cm) or multiple localized renal cell carcinomas.
Carcinoma, Renal Cell↗
Management of local recurrence following radical nephrectomy or partial nephrectomy.
Surgical excision remains the preferred form of treatment for isolated local recurrence of RCC. Involvement of contiguous organs is not uncommon for local recurrence after radical nephrectomy, and en bloc excision can be a formidable task. Local recurrence after partial nephrectomy is more likely to occur as an isolated event, and many of these patients can be salvaged with repeat partial nephrectomy or total excision of the renal remnant. Local recurrence appears to be particularly common in patients with VHL disease; repeat surgical excision has yielded encouraging results in this setting. Unfortunately, we still have little to offer patients with local recurrence associated with disseminated disease. Improved forms of systemic or adjunctive therapy will be necessary for the treatment of these patients.
Carcinoma, Renal Cell↗
Evaluation and management of atherosclerotic renal vascular disease to prevent end-stage renal failure.
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Angioplasty, Balloon↗
Atherosclerotic ischemic nephropathy. Epidemiology and clinical considerations.
The development of chronic renal failure from atherosclerotic renal artery disease, termed ischemic nephropathy, has become an important clinical issue that is separate and distinct from the problem of renovascular hypertension. Studies on the natural history of atherosclerotic renal artery disease have made it possible to identify those patients in whom the disease poses a significant threat to overall renal function. Intervention to restore normal renal arterial blood flow is indicated in such patients to prevent deterioration of renal function that may culminate in the need for dialytic replacement therapy.
Arteriosclerosis↗
Secondary renal vascular reconstruction for arterial disease in the native and transplant kidney.
Secondary revascularization is the treatment of choice in patients with recurrent renal artery disease involving a functioning kidney. Nephrectomy should be reserved for patients with a nonsalvable kidney or patients in whom repeat reconstructive surgery is not possible for medical or technical reasons.
Aneurysm, False↗