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170 CHANGE OF RENAL FUNCTION AFTER RENAL INJURY: LONG TERM FOLLOW UP MORE THAN 10 YEARS
University Hospital of Toulouse Rangueil, Dept. of Urology and Andrology, Toulouse, France, 2University Hospital of Toulouse Larrey, Dept. of Endocrinology, Toulouse, France 1
Introduction & Objectives: Adrenal carcinoma (AC) is a rare malignant tumour, whose prognosis remains poor, and unchanged for 15 years. Our objective was to study the impact of the quality of the surgery on prognosis in patients operated for AC. Materials & Methods: In a series of 367 adrenalectomies carried out between 1996 and 2010, 17 had an AC (Weiss score above 3). In addition, we treated postoperatively 6 patients who had been operated for AC in other health facilities of our region. Post-operative management and follow-up were identical for all AC patients. Cases operated in our institution and elsewhere did not differ in socio-demographic variables (age, BMI, sex, size of the lesion) and diseases characteristics. Among the 23 AC, 2 were of stage I, 9 of stage II, 6 of stage III and 6 of stage IV. Fourteen (60%) were considered preoperatively as secreting. Surgery consisted of a laparoscopic adrenalectomy in 2 cases (8.5%), an open adrenalectomy in 11 cases (48%), associated with nephrectomy in 5 cases (22%), with nephrectomy and thrombectomy in 2 cases (8.5%), and with hepatectomy in 3 cases (13%). Surgical margins were positive in 7 cases (30%). Tumor extensions reached the liver in 3 cases, the kidney in 5 cases, and a tumoral thrombus was found in the vena cava in 2 cases. All alive patients were interviewed in August 2010. Survival was estimated using the Kaplan Meyer method, and comparisons between sub-groups using the log rank test. Results: During follow-up, 4 patients (17%) had a metastatic evolution, 6.25 ± 8.5 months (1-19) after the surgery. Seven patients (30%) had a local or remote recurrence, 12.7 ± 11.1 months (1-33) and 16.7 ± 19.8 months (4-60) after the surgery, respectively. The local recurrences were treated by surgery in 3 cases (2 nephrectomies and 1 lymphadenectomy) and radiotherapy in 1 case. Four patients with a metastatic evolution had a chemotherapy (36%) and the others mitotane only. At the date of the survey, 7 patients disease free with an average followup of 48.6 ± 36.4 months (5-114). Sixteen patients had died of their disease, the death occurring 25.67 ± 26.4 months (2-84) after the surgery. Prognostic factors of survival were the stage (log rank, p< 0.001), the Weiss score (log rank, p=0.002), the existence positive surgical margins (log rank, p< 0.001), having an age younger than 55 years (log rank, p< 0.001). The patients operated in other health facilities than the university hospital also had a lower survival rate (log rank, p=0.005). There was no difference according to the type of surgery difficulty of the surgery, blood loss, Op' DDD level, or the secreting character. Conclusions: In addition to the prognostic factors already highlighted (stage, histological score, positive margins, age), we observed that in AC, the quality of surgical management had a prognostic impact on the disease. These results plead for the management of these rare tumors in expert centers.
167
withdrawn
168
Determination of the best biochemical evaluation for the diagnosis of pheochromocytoma
Huyghe E. , Berbé J. , Hamdi S. , Bennet A. , Caron P. , Plante P. 1 University Hospital of Toulouse Rangueil, Dept. of Urology and Andrology, Toulouse, France, 2University Hospital of Toulouse Purpan, Dept. of Biochemistry, Toulouse, France, 3University Hospital of Toulouse Larrey, Dept. of Endocrinology, Toulouse, France 1
2
2
3
3
1
Introduction & Objectives: All available data concerning the biochemical dosages used for the diagnosis of pheochromcytoma were obtained in series of patients presenting with hypertension, and they almost always include extra-adrenal tumors (paraganglioma), whose secretion is different from pheochromocytoma. Nowadays, the major clinical presentation of pheochromocytoma is an incidentaloma. Therefore, we aimed at re-evaluating the diagnostic performances of the various dosages and combinations of dosages of catecholamines and metabolites. Materials & Methods: Design, setting and participants: one center cohort study of patients tested for suspicion of pheochromocytoma between 1998 and 2007. The analysis included 51 patients in whom we had at least one preoperative urine dosage of catecholamines and their metabolites prior to surgery. We divided the population into 2 groups, group 1 (n=38) with patients who had histopathological confirmation of pheochromocytoma and group 2 (n=13) with patients whose histology was different from pheochromcytoma. Main outcome measures: sensitivity and specificity, receiver operating characteristic (ROC) curves for each biochemical tests including adrenaline (A), noradrenaline (NA), dopamine (D), metanephrine (M) and normetanephrine (NM) and for all combinations of A, NA, M and NM by 2 or 3. The same measures were applied for subgroups with M and NM less than four times normal value (4N). Results: in group 1, all parameters were significantly higher than in group 2 (p<0.05). The higher sensitivity was for M (78.9%). All combinations of 2 tests gave a better sensitivity than M alone, ranging from 92 % for M+NM to 81.6% for A+NA. On the contrary, adjunction of a third dosage did not improve sensitivity except adjunction of A to M+NM that enabled a slight increase of sensitivity (+2%). Comparison of
the area under the ROC curve (AUC) for each test showed that M had the best concordance coefficient at 0.90. When Normetanephrine > 2400 μg/24h (4N) or Metanephrine > 1400 μg/24h (4N), sensitivity was 100%. For patients with M and NM < 4N, only NM and A were significantly higher in the group 1 than in group 2 (0.0026 and 0.018, respectively). The sensitivity of all tests decreased below 40%, except M (sensitivity: 64.3%). Among combinations of 2 tests, M + NA ranked first with a sensitivity of 78.6% and specificity at 100%. Compared to combinations of 2 dosages, combinations of 3 parameters enabled to increase sensitivity with sensitivity at 85.7% with A+NA+M, A+NA+NM and A+M+NM. Conclusions: We recommend to measure the level of urine M and NM at first and to prescribe a more thorough evaluation, including urine A and/or NA, if both M and NM are below 4 fold normal range. This strategy may be more cost effective and may improve the diagnosis of pheochromocytoma.
169
Management of Pelvic Fracture Urethral Distraction Defects (PFUDD) in a developing country
Hussain M., Rizvi S.A.H., Lal M., Askari S.H., Hussain Z. Sindh Institute of Urology and Transplantation, Dept. of Urology, Karachi, Pakistan Introduction & Objectives: Stricture clinic is the oldest clinic at our institute since 1972 where patient visit per year is 5760, and indoor admission of urethral stricture disease is 274. The gold standard of managing these patients is by suprapubic cystostomy followed by delayed urethroplasty but complications like restricture formation, erectile dysfunction, infertility and incontinence can occur post operatively which needs to be managed at an early stage. To report the results of management of PFUDD in adult patients with post operative complications and to high light the role of specialized clinic in early diagnosis and rehabilitation of these patients Materials & Methods: During the periods January 2000 to September 2010, 357 patients with (PFUDD) were managed by suprapubic cystostomy followed by excision and primary anastomosis by elaborated transperineal approach. Many patients were referred to us by past history of multiple failed procedures. After management all these patients were followed regularly in dedicated stricture clinic of institute for complications, uroflowmetry, urine culture and urethrogram. Those who found to have erectile dysfunction, infertility, stress incontinence were investigated by duplex ultrasound, semen analysis, urodynamics and were managed appropriately. Results: Out of 357 patients only 300 completed the follow up till October 2010, of these 59 (19.5%) developed recurrence of stricture and were treated by Dviu or urethral dilation, erectile dysfunction after urethroplasty was seen in 36 (12.5%), infertility in 89 (29.8%), retrourethral fistula in 1 (0.3%) and stress incontinence was seen in 3% while blood transfusion was needed in 12%. Operative time ranged from 2-5 hours and hospital stay was 3-7 days. Conclusions: Recurrence of stricture, erectile dysfunction, infertility remains the long term problem in these patients. Specialized referral centers and clinics are of great help to identify these problems at an early stage and rehabilitation of these young patients.
170
Change of renal function after renal injury: Long term follow up more than 10 years
Song J.H., Lee N.K. Medical College of Soonchunhyang University, Dept. of Urology, Cheonan, South Korea Results: Of the 272 renal injuries, 235 (86%) were managed nonoperatively. DMSA scans were obtained on average 11years after renal trauma. Mean decrease in renal function for grade III,IV and V renal injuries was 20%,32% and 70% respectively (Figure). Univarate analysis showed a significant relationship between renal function and AAST grade. Conclusions: This long term follow up study of renal injury shows that change in renal function in strongly correlated with AAST renal injury grade.
171
Treatment of ureteral lesions with vermiform appendix: A report of 14 cases
Komyakov B.K., Ochelenko V.A., Nikolaev N.M. Saint-Petersburg State Medical Academy of I.I. Mechnikov, Dept. of Urology, SaintPetersburg, Russia Introduction & Objectives: Ureteral reconstruction remains one of the most important problems of urology. The incidence of recurrent and complicated ureteral strictures increases but, results of reconstructive surgery are still poor. We believe that ureteral substitution with appendix is a perspective direction in this field of urology. Materials & Methods: From 1998 to 2010 we performed 14 ureteral substitutions with appendix. There were 13 (92.9%) females and only 1 (7.1%) male with a median age of 48±2.6 years (range from 28 to 71 years). Except of ureteral damage 1 female has uretero-vesical fistula and another one has uretero-cutaneous fistula. In 1 patient who developed ureteral stricture after gunshot wound, we performed
Eur Urol Suppl 2011;10(2):77
Introduction & Objectives: Adrenal carcinoma (AC) is a rare malignant tumour, whose prognosis remains poor, and unchanged for 15 years. Our objective was to study the impact of the quality of the surgery on prognosis in patients operated for AC. Materials & Methods: In a series of 367 adrenalectomies carried out between 1996 and 2010, 17 had an AC (Weiss score above 3). In addition, we treated postoperatively 6 patients who had been operated for AC in other health facilities of our region. Post-operative management and follow-up were identical for all AC patients. Cases operated in our institution and elsewhere did not differ in socio-demographic variables (age, BMI, sex, size of the lesion) and diseases characteristics. Among the 23 AC, 2 were of stage I, 9 of stage II, 6 of stage III and 6 of stage IV. Fourteen (60%) were considered preoperatively as secreting. Surgery consisted of a laparoscopic adrenalectomy in 2 cases (8.5%), an open adrenalectomy in 11 cases (48%), associated with nephrectomy in 5 cases (22%), with nephrectomy and thrombectomy in 2 cases (8.5%), and with hepatectomy in 3 cases (13%). Surgical margins were positive in 7 cases (30%). Tumor extensions reached the liver in 3 cases, the kidney in 5 cases, and a tumoral thrombus was found in the vena cava in 2 cases. All alive patients were interviewed in August 2010. Survival was estimated using the Kaplan Meyer method, and comparisons between sub-groups using the log rank test. Results: During follow-up, 4 patients (17%) had a metastatic evolution, 6.25 ± 8.5 months (1-19) after the surgery. Seven patients (30%) had a local or remote recurrence, 12.7 ± 11.1 months (1-33) and 16.7 ± 19.8 months (4-60) after the surgery, respectively. The local recurrences were treated by surgery in 3 cases (2 nephrectomies and 1 lymphadenectomy) and radiotherapy in 1 case. Four patients with a metastatic evolution had a chemotherapy (36%) and the others mitotane only. At the date of the survey, 7 patients disease free with an average followup of 48.6 ± 36.4 months (5-114). Sixteen patients had died of their disease, the death occurring 25.67 ± 26.4 months (2-84) after the surgery. Prognostic factors of survival were the stage (log rank, p< 0.001), the Weiss score (log rank, p=0.002), the existence positive surgical margins (log rank, p< 0.001), having an age younger than 55 years (log rank, p< 0.001). The patients operated in other health facilities than the university hospital also had a lower survival rate (log rank, p=0.005). There was no difference according to the type of surgery difficulty of the surgery, blood loss, Op' DDD level, or the secreting character. Conclusions: In addition to the prognostic factors already highlighted (stage, histological score, positive margins, age), we observed that in AC, the quality of surgical management had a prognostic impact on the disease. These results plead for the management of these rare tumors in expert centers.
167
withdrawn
168
Determination of the best biochemical evaluation for the diagnosis of pheochromocytoma
Huyghe E. , Berbé J. , Hamdi S. , Bennet A. , Caron P. , Plante P. 1 University Hospital of Toulouse Rangueil, Dept. of Urology and Andrology, Toulouse, France, 2University Hospital of Toulouse Purpan, Dept. of Biochemistry, Toulouse, France, 3University Hospital of Toulouse Larrey, Dept. of Endocrinology, Toulouse, France 1
2
2
3
3
1
Introduction & Objectives: All available data concerning the biochemical dosages used for the diagnosis of pheochromcytoma were obtained in series of patients presenting with hypertension, and they almost always include extra-adrenal tumors (paraganglioma), whose secretion is different from pheochromocytoma. Nowadays, the major clinical presentation of pheochromocytoma is an incidentaloma. Therefore, we aimed at re-evaluating the diagnostic performances of the various dosages and combinations of dosages of catecholamines and metabolites. Materials & Methods: Design, setting and participants: one center cohort study of patients tested for suspicion of pheochromocytoma between 1998 and 2007. The analysis included 51 patients in whom we had at least one preoperative urine dosage of catecholamines and their metabolites prior to surgery. We divided the population into 2 groups, group 1 (n=38) with patients who had histopathological confirmation of pheochromocytoma and group 2 (n=13) with patients whose histology was different from pheochromcytoma. Main outcome measures: sensitivity and specificity, receiver operating characteristic (ROC) curves for each biochemical tests including adrenaline (A), noradrenaline (NA), dopamine (D), metanephrine (M) and normetanephrine (NM) and for all combinations of A, NA, M and NM by 2 or 3. The same measures were applied for subgroups with M and NM less than four times normal value (4N). Results: in group 1, all parameters were significantly higher than in group 2 (p<0.05). The higher sensitivity was for M (78.9%). All combinations of 2 tests gave a better sensitivity than M alone, ranging from 92 % for M+NM to 81.6% for A+NA. On the contrary, adjunction of a third dosage did not improve sensitivity except adjunction of A to M+NM that enabled a slight increase of sensitivity (+2%). Comparison of
the area under the ROC curve (AUC) for each test showed that M had the best concordance coefficient at 0.90. When Normetanephrine > 2400 μg/24h (4N) or Metanephrine > 1400 μg/24h (4N), sensitivity was 100%. For patients with M and NM < 4N, only NM and A were significantly higher in the group 1 than in group 2 (0.0026 and 0.018, respectively). The sensitivity of all tests decreased below 40%, except M (sensitivity: 64.3%). Among combinations of 2 tests, M + NA ranked first with a sensitivity of 78.6% and specificity at 100%. Compared to combinations of 2 dosages, combinations of 3 parameters enabled to increase sensitivity with sensitivity at 85.7% with A+NA+M, A+NA+NM and A+M+NM. Conclusions: We recommend to measure the level of urine M and NM at first and to prescribe a more thorough evaluation, including urine A and/or NA, if both M and NM are below 4 fold normal range. This strategy may be more cost effective and may improve the diagnosis of pheochromocytoma.
169
Management of Pelvic Fracture Urethral Distraction Defects (PFUDD) in a developing country
Hussain M., Rizvi S.A.H., Lal M., Askari S.H., Hussain Z. Sindh Institute of Urology and Transplantation, Dept. of Urology, Karachi, Pakistan Introduction & Objectives: Stricture clinic is the oldest clinic at our institute since 1972 where patient visit per year is 5760, and indoor admission of urethral stricture disease is 274. The gold standard of managing these patients is by suprapubic cystostomy followed by delayed urethroplasty but complications like restricture formation, erectile dysfunction, infertility and incontinence can occur post operatively which needs to be managed at an early stage. To report the results of management of PFUDD in adult patients with post operative complications and to high light the role of specialized clinic in early diagnosis and rehabilitation of these patients Materials & Methods: During the periods January 2000 to September 2010, 357 patients with (PFUDD) were managed by suprapubic cystostomy followed by excision and primary anastomosis by elaborated transperineal approach. Many patients were referred to us by past history of multiple failed procedures. After management all these patients were followed regularly in dedicated stricture clinic of institute for complications, uroflowmetry, urine culture and urethrogram. Those who found to have erectile dysfunction, infertility, stress incontinence were investigated by duplex ultrasound, semen analysis, urodynamics and were managed appropriately. Results: Out of 357 patients only 300 completed the follow up till October 2010, of these 59 (19.5%) developed recurrence of stricture and were treated by Dviu or urethral dilation, erectile dysfunction after urethroplasty was seen in 36 (12.5%), infertility in 89 (29.8%), retrourethral fistula in 1 (0.3%) and stress incontinence was seen in 3% while blood transfusion was needed in 12%. Operative time ranged from 2-5 hours and hospital stay was 3-7 days. Conclusions: Recurrence of stricture, erectile dysfunction, infertility remains the long term problem in these patients. Specialized referral centers and clinics are of great help to identify these problems at an early stage and rehabilitation of these young patients.
170
Change of renal function after renal injury: Long term follow up more than 10 years
Song J.H., Lee N.K. Medical College of Soonchunhyang University, Dept. of Urology, Cheonan, South Korea Results: Of the 272 renal injuries, 235 (86%) were managed nonoperatively. DMSA scans were obtained on average 11years after renal trauma. Mean decrease in renal function for grade III,IV and V renal injuries was 20%,32% and 70% respectively (Figure). Univarate analysis showed a significant relationship between renal function and AAST grade. Conclusions: This long term follow up study of renal injury shows that change in renal function in strongly correlated with AAST renal injury grade.
171
Treatment of ureteral lesions with vermiform appendix: A report of 14 cases
Komyakov B.K., Ochelenko V.A., Nikolaev N.M. Saint-Petersburg State Medical Academy of I.I. Mechnikov, Dept. of Urology, SaintPetersburg, Russia Introduction & Objectives: Ureteral reconstruction remains one of the most important problems of urology. The incidence of recurrent and complicated ureteral strictures increases but, results of reconstructive surgery are still poor. We believe that ureteral substitution with appendix is a perspective direction in this field of urology. Materials & Methods: From 1998 to 2010 we performed 14 ureteral substitutions with appendix. There were 13 (92.9%) females and only 1 (7.1%) male with a median age of 48±2.6 years (range from 28 to 71 years). Except of ureteral damage 1 female has uretero-vesical fistula and another one has uretero-cutaneous fistula. In 1 patient who developed ureteral stricture after gunshot wound, we performed
Eur Urol Suppl 2011;10(2):77