The role of gamma-glutamyl transpeptidase in the preoperative metastatic evaluation of renal cell carcinoma.

PURPOSE: We evaluated gamma-glutamyl transpeptidase as an indicator of metastatic disease in patients with renal cell carcinoma. MATERIALS AND METHODS: We reviewed the records of 53 patients with metastatic renal cell carcinoma, and compared serum alkaline phosphatase and gamma-glutamyl transpeptidase with the site of metastases. These results were then compared to those in 29 patients with clinically localized renal cell carcinoma. RESULTS: Overall gamma-glutamyl transpeptidase was elevated in 37 patients (69.8%) with metastatic disease, while alkaline phosphatase was elevated in 16 (30.2%, p < 0.025). Gamma-glutamyl transpeptidase was increased in more patients with hepatic metastases only than alkaline phosphatase (p < 0.025) and in all groups it was a better predictor of metastases than alkaline phosphatase. Gamma-glutamyl transpeptidase was also increased in significantly more patients with metastatic renal cell carcinoma (37 of 53) compared to 1 of the 27 with localized renal cell carcinoma (p < 0.001). CONCLUSIONS: Gamma-glutamyl transpeptidase was increased in a large percent of patients with metastatic renal cell carcinoma, and it was normal in the majority with localized renal cell carcinoma. We conclude that gamma-glutamyl transpeptidase should be included as well as alkaline phosphatase in the preoperative metastatic evaluation of patients with renal cell carcinoma. Elevated gamma-glutamyl transpeptidase should prompt a search for bone as well as liver metastases.

Adrenal metastases from renal cell carcinoma: role of ipsilateral adrenalectomy and definition of stage.

OBJECTIVES: We undertook this study to establish criteria for adrenalectomy in patients with renal cell carcinoma. METHODS: We retrospectively reviewed the records of 162 patients undergoing radical nephrectomy from 1979 to 1993 at University Hospitals of Cleveland. Simultaneous ipsilateral adrenalectomy was performed in 57 patients (35%). RESULTS: Three of these 57 patients (5.3%) had ipsilateral adrenal metastases. All 3 patients had large, left-sided, upper-pole tumors that extended through the renal capsule (Stage T3a). All 3 patients with adrenal metastases had progression to disseminated disease, with an average time to progression of 7.2 months, whereas only 13 (24%) of the 54 patients without adrenal metastases developed metastatic disease (none to adrenal), with an average time to progression of 27.6 months. No patient with organ-confined disease (Stage T1 or T2) or extracapsular disease in the midkidney or lower pole had adrenal metastases identified histologically. CONCLUSIONS: The prognosis is poor for renal cell carcinoma with ipsilateral adrenal involvement, even with complete removal. Because of this poor prognosis, we believe that adrenal involvement should constitute a separate stage category. We propose that patients with ipsilateral adrenal metastases via direct extension should be classified as having pathologic Stage pT3d. If the patient has an ipsilateral adrenal metastasis not via direct extension, contralateral adrenal metastasis, or bilateral adrenal metastases, the pathologic stage should be M1. Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on computed tomographic scan or if gross disease is seen at the time of nephrectomy although its removal may not benefit the patient.

Perineal abscess after embolization for high-flow priapism.

High-flow priapism is unusual and is most often due to blunt perineal trauma with resultant laceration of the cavernosal artery, creating an arteriocavernosal fistula. Although few cases have been reported, the consensus on management appears to be embolization of the fistula with autologous clot, alone or in combination with Gelfoam. We present a case of high-flow priapism treated in this manner. The embolized pseudoaneurysm evolved into an abscess that eventually spread to the perineum. The rarity of this entity and the postprocedural morbidity are reported.

A new protocol for the followup of renal cell carcinoma based on pathological stage.

There is no consensus concerning which laboratory and imaging studies should be obtained to assess patients after radical nephrectomy for renal cell carcinoma. We retrospectively reviewed 158 patients who underwent radical nephrectomy with a final pathological diagnosis of renal cell carcinoma. Of the patients 21 had node-positive or metastatic disease and 137 had no evidence of metastases at diagnosis. Of the latter group 19 had pathological stage T1N0M0, 82 stage T2N0M0 and 36 stage T3N0M0 (18 stage T3a, 10 stage T3b and 8 stages T3a and b) tumor. Disease recurred in 0%, 14.6% and 52.8% (50%, 44.4% and 75%) of the patients, respectively. The average interval to recurrence was 29.5 months (range 3.5 to 88.8) for patients with stage T2 carcinoma and 22 months (range 3 to 138) for those with stage T3 disease. Based upon our data, followup studies should include a symptom history, serum liver function studies and chest x-rays at defined intervals. Routine use of bone scans and computerized tomography does not appear to be necessary.

Trimethoprim-sulfamethoxazole prophylaxis against urinary tract infection in the chronic spinal cord injury patient.

Suppressive therapy with antibiotics has long been thought to decrease the number of complications from the neuropathic bladder in spinal cord injury patients, but it may also induce resistance to antibiotics which subsequently causes difficulties in treating symptomatic urinary tract infections. Forty-three chronic spinal cord injury patients were randomized to continue to receive daily trimethoprim-sulfamethoxazole (TMP-SMX) urinary tract prophylaxis versus discontinuing antibiotic prophylaxis. Patients were all at least 6 months after spinal cord injury. Patients were followed for a minimum of 3 months, with weekly catheter urine cultures. The difference in the colonization rate at onset and after 3 months (percent of cultures with asymptomatic bacteriuria) between the control and prophylaxis group was not statistically significant (P > 0.1). There was a significant decrease in the percentage of TMP-SMX resistant asymptomatic bacteriuria in the control group, 78.8%, compared to 94.1% in the suppressive group (P < 0.05). There was no significant difference in the number of symptomatic urinary tract infections following the withdrawal of suppressive therapy between the control group, 0.035/week, and the prophylaxis group, 0.043/week (P > 0.5). There was a larger percentage of TMP-SMX resistant symptomatic urinary tract infections in the treated group, 42.5% versus 37.5% in the control group, but the difference was not significant (P > 0.5). Irrespective of the method of bladder management, suppressive therapy with TMP-SMX did not reduce the incidence of symptomatic bacteriuria and did increase the percentage of cultures resistant to TMP-SMX in asymptomatic patients.