Histopathological analysis of the non - tumour parenchyma following radical nephrectomy: can it predict renal functional outcome?

ABSTRACT Introduction Radical nephrectomy (RN), a recommended treatment option for patients with Renal cell carcinoma (RCC) leads to an inevitable decline in global renal function. Pathological changes in the non-tumour parenchyma of the kidney may help predict the function of the remaining kidney. Materials and Methods Aim of this prospective, observational study was to find histopathological factors in the non-tumor renal parenchyma that could predict the decline in global renal function postoperatively and its association with co-morbidities like diabetes (DM). Data of consecutive patients undergoing RN from December-2013 to January-2015 was collected. Non-tumor parenchyma of the specimen was reported by a dedicated histopathologist. eGFR was calculated using Cockcroft-Gault formula before the surgery and at last follow up of at least 12 months. Results 73 RN specimens were analyzed. Mean follow up was 12.3 months. The mean decrease in eGFR was 22% (p=.0001). Percent decrease in eGFR did not show association with any of the histopathological parameters studied. DM was significantly associated with decrease in percent eGFR (p<0.05) and increase in arteriolar hyalinosis (p=0.004), Glomerulosclerosis (p=0.03) and Interstitial fibrosis/ Tubular atrophy (p=.0001). Maximum size of the tumor showed a negative correlation with percentage change in eGFR (p=.028). Conclusion Histological parameters in the non-tumour portion of the RN specimen may not be able to predict renal function outcome over a short follow up. However, presence of DM was associated with adverse pathological changes and significant decrease in renal function postoperatively.

Does MRI help in the pre - operative evaluation of pelvic fracture urethral distraction defect? - a pilot study

ABSTRACT Objectives To study the usefulness of MRI in preoperative evaluation of PFUDD. Can MRI provide additional information on urethral distraction defect (UDD) and cause of erectile dysfunction (ED)? Materials and Methods In this prospective study, consecutive male patients presenting with PFUDD were included from Feb 2011 till Dec 2012. Those with traumatic spinal cord injury and pre-existing ED were excluded. Patients were assessed using IIEF questionnaire, retrograde urethrogram and micturating cystourethrogram (RGU+MCU) and MRI pelvis. Primary end point was erectile function and secondary end point was surgical outcome. Results Twenty patients were included in this study. Fourteen patients (70%) were ≤40years; fifteen patients (75%) had ED, seven patients (35%) had severe ED. MRI findings associated with ED were longer median UDD (23mm vs. 15mm, p=0.07), cavernosal injury (100%, p=0.53), rectal injury (100%, p=0.53), retropubic scarring (60%, p=0.62) and prostatic displacement (60%, p=0.99). Twelve patients (60%) had a good surgical outcome, five (25%) had an acceptable outcome, three (15%) had a poor outcome. Poor surgical outcome was associated with rectal injury (66.7%, p=0.08), cavernosal injury (25%, p=0.19), retropubic scarring (18.1%, p=0.99) and prostatic displacement (16.7%, p=0.99). Five patients with normal erections had good surgical outcome. Three patients with ED had poor outcome (20%, p=0.20). Conclusions MRI did not offer significant advantage over MCU in the subgroup of men with normal erections. Cavernosal injury noted on MRI strongly correlated with ED. Role of MRI may be limited to the subgroup with ED or an inconclusive MCU.

Erectile dysfunction.

With phosphodiesterase inhibitors, a safe and effective oral therapy has emerged for erectile dysfunction. Increasing awareness, particularly through the media, is inducing more men to seek help for this condition. Erectile dysfunction is defined as the persistent inability to achieve or maintain an erection adequate for satisfactory sexual activity. The prevalence increases with age. Basic and clinical research is identifying the neurovascular and humoral control of the mechanisms. The initial evaluation should differentiate erectile dysfunction from premature ejaculation and loss of libido. Myocardial insufficiency, hypogonadism and peripheral neuropathy should be looked for. Initial laboratory investigations should be restricted to identifying previously undetected medical illness that may directly contribute to erectile dysfunction. Discussing the available options with the couple is an important aspect. If erectile dysfunction is secondary to other treatable disorders these should be treated simultaneously. When other diseases that require intervention are ruled out and if there are no contraindications, therapy may be initiated with a phosphodiesterase inhibitor. In selected cases, psychosexual therapy may be beneficial. If phosphodiesterase inhibitors are contraindicated, vacuum constriction devices may be tried. Further options include intracavemosal injection, intraurethral instillation, penile revascularization and prosthesis. The availability of effective and well-tolerated oral medications has dramatically changed the clinical approach to erectile dysfunction. Pharmacotherapy is the preferred cost-effective first-line therapy in the vast majority of patients. A stepped-care approach is followed in the primary care and family practice settings. Appropriate urological, endocrine and psychiatric referrals, and shared decision-making with the couple will enable effective treatment of men with erectile dysfunction.