Renal scars masquerading as complex masses in a patient with vesicoureteral reflux nephropathy.

Vesicoureteral reflux can lead to chronic pyelonephritis, renal scarring, and renal failure. We present a case of renal scarring masquerading as bilateral, complex renal masses. A 35-year old woman who was diagnosed with vesicoureteral reflux as a child presented for evaluation of recently developed hypertension and an abnormal renal ultrasound. Her serum creatinine level was 2.5 mg/dL and she had subnephrotic-range proteinuria. A renal sonogram showed small, echogenic kidneys and bilateral complex renal masses of 3.8 (right) and 4.4 (left) cm in greatest dimensions. CT scan of the kidneys revealed slightly contrast-enhancing masses with irregular walls. Renal angiogram showed decreased blood supply to the areas coinciding with the masses consistent with renal scarring. There was no increased vascularity. This case demonstrates that renal scarring may masquerade as renal masses. A step-wise, comprehensive approach is necessary to rule out potentially malignant lesions in these patients.

Prospective pretransplant ultrasound screening in 206 patients for acquired renal cysts and renal cell carcinoma.

BACKGROUND: Numerous studies have reported an increased prevalence of renal cell carcinoma in association with acquired cystic kidney disease (ACKD). In 1995, the clinical practice guidelines of the American Society of Transplant Physicians for evaluation of renal transplant candidates recommend not screening for ACKD and renal cell carcinoma, on the basis of the low frequency of cancer and reported regression of ACKD after transplantation. The objective of this study was to prospectively evaluate the prevalence of ACKD and renal cancer during renal transplant evaluation. METHODS: A total of 206 consecutive adult patients evaluated for renal transplantation underwent a routine renal ultrasound. Patients with a suspicious ultrasound underwent a contrasted computed tomographic scan of the kidneys followed by excision of kidneys with solid, enhancing (>10 Hounsfield units) lesions. RESULTS: Sixty-three (30.6%) of 206 patients had ACKD, with a greater proportion being male, African-American, and dialysis-dependent for a longer duration. Eight patients (3.8%) had histologically proven localized cancer (six unilateral, two bilateral), seven in association with ACKD and one in association with autosomal dominant polycystic kidney disease. With a mean follow-up of 14 months (range, 3-33 mo), there has been no recurrence. The positive predictive value of a solid lesion on ultrasound was 100% (8 of 8 patients). CONCLUSION: With the high prevalence (3.4%) of renal cell carcinoma in association with ACKD and the concern that immunosuppression accelerates the growth of preexisting cancers, we continue to recommend ultrasound screening of the native kidneys before renal transplantation.

Impact of diagnostic laparoscopy in the management of the unilateral impalpable testis.

OBJECTIVE: To evaluate the impact of laparoscopy on the management of children with a unilateral impalpable testis. PATIENTS AND METHODS: The study population consisted of 27 children who underwent a primary inguinal exploration for a unilateral impalpable testis. RESULTS: Twelve of 27 (44%) children had inguinal or 'peeping' testes and 10 of 27 (37%) had blind-ending vasa and vessels in the inguinal canal; four of these 10 had atrophic tubular tissue in the excised remant. Four of 27 (15%) had blind-ending vasa and vessels proximal to the internal ring. Only one child had a testis proximal to the internal ring. Only the four children (15%) with blind-ending vasa and vessels proximal to the internal ring would have benefited from a laparoscopy by avoiding an inguinal exploration. CONCLUSIONS: Because of the time, expense and limited usefulness of laparoscopy in altering the management of children with a unilateral unpalpable testis, we reserve laparoscopy for cases where inguinal exploration has failed.

Unusual presentations of advanced prostate cancer.

With the advent of prostatic-specific antigen, transrectal ultrasound and an increasing awareness of prostate cancer among the population, prostate cancer is being detected at an increasingly early stage. Despite this, it is estimated that up to 40% of the patients present with manifestations of metastatic prostate cancer. Although the most common sites for metastases at presentation are the obturator lymph nodes and the bony skeleton, advanced prostate cancer may produce a variety of clinical scenarios by involving contagious and distant organs. Such presentations of advanced prostate cancer can add significantly to the morbidity and mortality of this disease. In brief review, we will focus on uncommon presentations of advanced prostate cancer.

The incidence and impact of early rejection episodes on graft outcome in recipients of first cadaver kidney transplants.

The objective of this study was to define the incidence and significance of acute rejection occurring in the first year following transplantation. The influence of contemporary induction immunosuppression on rejection, as well as the effect of rejection on graft and patient loss, renal function, and maintenance immunosuppression during the first year in 110 recipients of first cadaver renal transplants were analyzed. All patients received CsA, Aza, and prednisone for 30 days with withdrawal of Aza at 30 days and then prednisone at 105 days; 57 patients were prospectively randomized to receive ALG (Merieux) until serum creatinine was less than 300 mumol/L. Short-term ALG administration did not influence the incidence, severity, nature, or outcome of rejection episodes. Fifty-five (50%) patients had at least 1 rejection in the first 90 days. All patients with delayed graft function and 7/8 (88%) sensitized patients (current PRA greater than 50%) had at least 1 rejection episode; 71% (n = 35) of all rejection episodes occurred in the first 30 days posttransplant. Patients rejection free at 90 days remained rejection free the entire first year. Graft loss was 18% for rejections in the first month, 13% for rejections occurring later (P = NS); 20% (n = 11) of patients had a second rejection and 1% (n = 2) had a third rejection. The risk of graft loss was 9% with a first rejection, 38% with a second rejection, and 50% with a third rejection. Of 12 (22%) rejections that were steroid resistant, 10 (83%) were reversed with OKT3. One-year graft survival for patients without rejection, with steroid-sensitive rejection, and with steroid-resistant rejection was 96%, 88% (P = ns), and 58% (P less than 0.001), respectively; 1 year SCr was 168 +/- 93, 196 +/- 77 (P = ns), and 268 +/- 96 microMol/L (P less than 0.05), respectively. Patients free of rejection and with stable renal function continued to do well on maintenance CsA monotherapy, and they were more likely to be on CsA monotherapy than those with rejection episodes (P less than 0.01).

Sequential discontinuation of azathioprine and prednisone in renal transplantation.

We report the time course of rejections in 110 patients of first cadaver kidney grafts entered into a randomized controlled trial of induction ALG vs continuous IV CyA, with both groups receiving Aza for 30 days and Pred for 3 months. There was no difference in 1-year graft or patient survival in the two induction regimens. Despite a slight delay in time to first rejection, the number, severity, and outcome of rejections were the same in both. Fifty percent of patients never had a rejection, and 80% of these were on CyA monotherapy at 1 year vs only 22% in patients with rejections. Thirty-five percent had a rejection in the first month, and one fourth of these had a repeat in the second month. The risk of graft loss was 10% with a first, 38% with a second, and 50% with a third rejection. First rejections occurring after 30 days rarely caused graft loss and rejection after 90 days proved to be unusual.