Organ-confined clear cell renal cell carcinoma: the prognostic impact of microvascular invasion, nuclear grade and tumour size.

The frequency of diagnosed and treated organ-confined renal cell carcinoma is increasing. The prognosis of this group of tumours is difficult to predict. The main purpose of this study was to examine the prognostic significance of microvascular invasion, tumour size and nuclear grade in a complete cohort of 76 consecutive patients with organ-confined clear cell renal cell carcinoma treated with radical nephrectomy. Patient ages ranged from 39 to 88 years (mean 66 years). Median follow-up was 10.2 years (range 0.1-19.4 years). The tumours were graded according to Fuhrman. Representative histological sections were stained for CD31, which decorates endothelial cells, in order to assess microvascular invasion (MVI). In univariate analysis, microvascular invasion (p<0.01), tumour size (TS) (p=0.01), TNM stage (p=0.01) and Fuhrman nuclear grade (p=0.02) were significant predictors of cancer-specific survival. Multivariate analysis, adjusted for age, revealed that microvascular invasion, tumour size and nuclear grade were independent covariates. According to our findings microvascular invasion is a strong independent prognostic predictor, and including this in the histopathology report should be considered together with nuclear grade and tumour size.

One or two incisions for nephroureterectomy in transitional cell renal pelvis tumours.

A retrospective study comprising 18 patients with transitional cell renal pelvis tumours (TCPT) was carried out to evaluate the results after two different surgical procedures for nephroureterectomy. The kidney was removed by a flank incision and the lower part of the ureter by either an incision in the lower part of the abdomen or intussusception of the ureter followed by transurethral resection of the ureteral orifice. Eight patients were subjected to nephroureterectomy by means of two incisions and another eight patients underwent a simple nephrectomy followed by ureteral intus-susception and transurethral resection. Two patients received other treatments. After nephroureterectomy with a separate incision for ureterectomy, the average hospital stay was 12 days, compared with 7.5 days in patients operated upon with only one abdominal incision. Recurrence of tumour or survival was not significantly different in the two groups.

Local excision of ureteral tumours.

A retrospective study was carried out on 20 patients with transitional cell ureteral tumours (TCUT). Surgical exploration of the tumour was performed in 17 patients. Biopsies for frozen section were evaluated for decision concerning the extent of operative intervention. If radical excision of the tumour could be done, and if the ureteral defect could be bridged, a conservative procedure was chosen. Thus, segmental resection of the ureter and primary end-to-end closure of the ureter was performed in 5 patients and ureteroneocystostomy in 3 patients. In nine patients local tumour excision was not feasible and nephroureterectomy was done. The survival rate at 3 and 10 years after ureteral resection as well as after nephroureterectomy was the same, 66% and 16%, respectively. Local excision of non-invasive low-grade ureteral tumours could be safely performed in selected patients, based on local findings and frozen section at the time of surgery.

The resting interstitial tissue pressure in primary varicose veins.

In 31 patients with unilateral primary varicose veins the resting interstitial pressure in the deep posterior compartment of the leg was measured in three groups: I, asymptomatic; II, symptomatic; III, symptomatic with trophic changes. Spinal anesthesia was induced in all patients, and polytetrafluoroethylene (Teflon) catheters were inserted into the deep posterior compartment of both legs. The interstitial pressure was recorded with a bioelectronic strain-guage pressure monitor with the patient in the horizontal position with complete muscle relaxation. In control legs (n = 31) mean pressure was -2.48 mm Hg (range -5 to 1). However, the measurement in affected legs (n = 31) was significantly higher at 4.61 mm Hg (range 1 to 12). Results demonstrate the following: (1) Primary varicose veins (an exclusively epifascial abnormality) were consistently associated with an increased resting interstitial pressure of the subfascial tissues in the supramalleolar area of the leg. (b) The subfascial resting interstitial pressure was elevated in all stages of varicose veins, even those with short duration of the disease and with no symptoms at all. (c) In all three groups there was a significant increase in the subfascial interstitial pressure between the affected and contralateral extremity. In patients with trophic changes (group III) this increase was significantly higher than in the remaining groups, although there was no significant difference between the increased pressure of the remaining groups (groups I & II).