The natural history of renal functional decline in patients undergoing surveillance in the DISSRM registry.

OBJECTIVE: To describe the natural history of renal function in patients on active surveillance (AS) for small renal masses (SRM) in the Delayed Intervention and Surveillance for Small Renal Masses Registry. METHODS: Delayed Intervention and Surveillance for Small Renal Masses is a prospective, multi-institutional registry of patients with SRM (≤ 4 cm) who choose intervention or AS. Of these, 64 patients on AS had longitudinal serum creatinine (sCr) values and underwent analysis of estimated glomerular filtration rate (eGFR). eGFR was calculated using the Modification of Diet in Renal Disease formula. The Kidney Disease Outcomes Quality Initiative chronic kidney disease (CKD) classification was used to categorize patients' eGFR values. RESULTS: Median age was 74 (range: 34-88) years at onset of AS. Overall, 9% (6/64) of patients had CKD at baseline. Median initial tumor size was 2.1cm (range: 0.8-4.0). Median Charlson comorbidity index score was 4 (range: 0-8). Median baseline sCr was 1.0mg/dl (range: 0.4-2.1) and median baseline eGFR was 70.25 (range: 24.07-165.52). After a median follow-up of 17 (range: 2-46) months, 64% of patients experienced a decrease in eGFR, with average yearly decrease in eGFR of 1.82 ml/min/1.73 m(2) (P = 0.092) and average yearly increase in sCr of 0.046 (P = 0.012). A total of 15 (24%) patients experienced an upstaging in classification of CKD. DISCUSSION: Nearly two-thirds of patients on AS experienced a decrease in eGFR and nearly one-fourth had upstaging of CKD classification. The annual eGFR decline experienced by patients on AS minimally exceeded the annual decline of 1.49 ± 0.3 ml/min/1.73 m(2) that an individual who was 70 to 79 years of age can expect from aging alone. Further follow-up is necessary to assess this in a more definitive manner, but this trend should be considered when evaluating AS as an alternative to interventional therapies for SRM.

Endoscopic management of intraluminal ureteral endometriosis.

OBJECTIVE: To present the largest experience on the ureteroscopic management of ureteral obstruction secondary to intraluminal endometrial implantation. MATERIALS AND METHODS: We retrospectively evaluated patients who underwent ureteroscopic management of intraluminal endometriosis from 1996 to 2012. All patients were diagnosed with ureteroscopic biopsy and underwent at least 1 ureteroscopic ablation with a holmium YAG (Ho:Yag) laser. Patients were monitored for evidence of disease persistence, recurrence, or progression with computed tomography, sonography, renal scan, ureteroscopy, and retrograde urography. Success was defined as the complete eradication of ureteral endometriosis, resolution of symptoms, and maintenance of renal function. RESULTS: Five patients were identified. Mean age was 37.5 years. All patients had hydroureteronephrosis at presentation whereas 2 had severely impaired renal function. Three patients were successfully treated with a single ablative procedure, whereas 2 had persistent symptomatic hydroureteronephrosis and underwent repeat ablation. Of those requiring repeat ablation, 1 became disease-free after the second ablation, whereas the other had persistence of disease, requiring nephroureterectomy. Three patients developed ureteral strictures, requiring balloon dilation and serial stent exchanges. At a median follow-up of 35 months (16-84), overall success rate was observed in 4 of 5 patients (80%). CONCLUSION: Endometriosis affects approximately 15% of premenopausal women and can present anywhere along the urinary tract including the ureters, which might result in urinary obstruction and impaired renal function. Although surgical resection is the conventional treatment option for intraluminal endometriosis, ureteroscopic management is a viable nephron-sparing alternative. Follow-up imaging, including ureteroscopic surveillance and retrograde urography is recommended to detect disease recurrence or progression, or both.