Common Laboratory Values Are Unreliable in Identifying the Presence of Metastatic Renal Cell Carcinoma in the Liver and Bones


Introduction: Evaluation of patients with newly diagnosed renal cell carcinoma (RCC) often includes evaluating serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP). Traditional teaching is these laboratory values, if elevated, may indicate the presence of metastatic disease to the liver (AST and ALT) or bones (ALP). We analyzed our institutional RCC database to determine how consistently aberrations in these values were present when metastatic RCC was present.

Materials and Methods: A retrospective chart review was completed, identifying 315 patients diagnosed with RCC who had AST, ALT, and ALP values available for review. Overall rates of aberration, as well as rates of aberration in those patients presenting with metastatic RCC, were calculated.

Results: Of the 315 patients in the study cohort, 61 (19.4%) presented with an elevation in 1 or more of the laboratory values in question. Of these 61 patients, 58 (95%) presented with clinically localized disease. The remaining 3 patients (5%) presented with lung metastasis identified on imaging and had isolated elevations of ALP ranging from 130 IU/L to 278 IU/L; these 3 patients were of the 9 in the cohort who presented with lung metastasis. Five patients presented with metastatic lesions to the bone with no elevation of ALP present. Five patients presented with metastatic lesions to the liver, and none of these patients had any elevation of ALT or AST. However, 1 of these 5 patients did have minimal elevation in ALP, 130 IU/L, but also had a concomitant lung metastasis.

Conclusion: Elevation in ALP, while not seen in patients with bone metastasis in this cohort, was present in 33.3% of patients presenting with lung metastasis. Therefore, an identified aberration in ALP may be considered to direct closer pulmonary evaluation. Regarding AST and ALT, elevations of these laboratory values were not present in any patients with liver metastasis. These observations highlight that AST, ALT, and ALP are unreliable in suggesting the presence of metastatic RCC lesions in liver or bone, and underscore the importance of imaging.

Joshua E. Logan, David A. Staneck, Mary H. James, Jack W. Lambert, Robert W. Given, Raymond S. Lance, Michael D. Fabrizio, Stephen B. Riggs

Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia, USA

Submitted April 18, 2013 - Accepted for Publication June 30, 2013

KEYWORDS: Renal cell carcinoma, metastases, laboratory values, AST, ALT, alkaline phosphatase

CORRESPONDENCE: Joshua E. Logan, MD, Fellow, Institute of Urologic Oncology, Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California, United States ()

CITATION: UroToday Int J. 2013 August;6(4):art 46.


Successful En-Bloc Kidney Transplantation from a 7-Month-Old Donor Weighing 14.3 Pounds Into an Adult Recipient: A Case Report



We report a case of successful transplantation of en-bloc kidneys (EBK) from a 7-month-old male pediatric donor weighing 14.3 pounds into a 94.8-pound, 18-year-old female recipient. The cause of brain death in the infant was pseudomonas meningitis, and the donor and recipient received appropriate intravenous antibiotics. Both ureters were implanted separately and stented. The postoperative course was uneventful except for 2 episodes of acute cellular rejection. She remains well at more than 36 months post-transplantation, with a serum creatinine of 48 µmmol/L. We recommend en-bloc kidney transplantation into suitable adults if the pediatric donor weighs less than 33 pounds. 

Taqi F. Toufeeq Khan, Suhaib Kamal, Basem Koshaji, Faheem Akhtar

Submitted May 2, 2013 - Accepted for Publication June 16, 2013

KEYWORDS: 14.3-pound pediatric donor, bacterial meningitis, en-bloc kidneys, kidney transplantation, adult recipient

CORRESPONDENCE: Taqi F. Toufeeq Khan, Section of Kidney Transplantation, Department of Surgery, Riyadh Military Hospital, 11159 Riyadh, Kingdom of Saudi Arabia ()

CITATION: UroToday Int J. 2013 August;6(4):art 45.


Analysis of the Feasibility and Efficacy of Ambulatory/Day Care Percutaneous Nephrolithotomy: An Initial Experience


Purpose: Tubeless percutaneous nephrolithotomy (PCNL) is a well-accepted procedure for uncomplicated renal calculi. We prospectively evaluated the safety, feasibility, and efficacy of day care/ambulatory PCNL (totally tubeless, discharge within 24 hours) for selected patients for which only few case series have been reported.

Materials and Methods: Total tubeless PCNL was planned in 40 easily accessible patients with uncomplicated renal calculi, with single infracostal punctures, normal intraoperative events, and acceptable postoperative parameters (visual analogue pain score, parenteral analgesic requirement, bleeding, urinary soakage, hemodynamic stability), allowing an early discharge within 24 hours. Parameters like pain score and analgesic requirement, any complications, and return date to normal work were evaluated at follow-up. Ultrasonography was performed after a week to document stone clearance.

Results: Mean patient age was 38.6 years (22 to 62), stone size was 21.4 mm (15.4 to 30), and operating time was 72 minutes (42 to 106) without blood transfusion. Regional anesthesia was used in 13 cases while general anesthesia was used in the rest of the patients. Average pain score after 6 hours of surgery was 2.3 (1.8 to 3.6) with vitals in the normal range, and hospital stay was 12.5 hours (5.5 to 23.5). Six patients were excluded due to peri- and postoperative events (2: multiple punctures, 1: hematuria, 1: urine leak, 2: pain). This data was taken with the intention to treat the analysis with a successful application of study protocol in 34 (85%) of preoperatively selected cases. Out of 34 patients that qualified for a complete study protocol, 11 were discharged on the same day of surgery while the rest were discharged the next morning. Postoperative USG confirmed no residual calculus, and all patients had uneventful recoveries. Three patients had minor complications (mild hematuria/urine leaks), which were managed conservatively.

Conclusion: Our experience with ambulatory PCNL in properly selected cases suggests it as a feasible and effective option that can safely be offered to patients, providing uncomplicated surgery and favorable postoperative parameters.

Adittya K. Sharma, M. Nagabhushan, G. N. Girish, A. J. Kamath, C. S. Ratkal, G. K. Venkatesh

Submitted May 20, 2013 - Accepted for Publication June 16, 2013

KEYWORDS: Percutaneous nephrolithotomy, nephrolithiasis, kidney calculi

CORRESPONDENCE: Adittya K. Sharma, MCh, Institute of Nephro-Urology, Victoria Hospital Campus, Bangalore, Karnataka, India (, )

CITATION: UroToday Int J. 2013 August;6(4):art 44.


Predictors of Unsuccessful Trials without Catheters in Acute Urinary Retention Secondary to Benign Prostatic Hyperplasia



Introduction: Acute urinary retention (AUR) is the most important event in the natural history of benign prostatic hyperplasia (BPH) that calls for urinary catheterization. Trial without catheter (TWOC) is an ambulatory care protocol, failure of which requires re-catheterization, a follow-up visit, subsequent evaluation, and surgical intervention. The aim of the study was to identify independent predictors of unsuccessful TWOC.

Methods: The present study enrolled 83 patients with a first episode of AUR secondary to BPH. We have recorded details of various factors, including age, international prostate symptom score (IPSS), total prostate volume (TPV), transition zone volume (TZV), transition zone index (TZI), intravesical prostatic protrusion (IPP), and residual urine volume (RUV) drained following catheterization. Administration of 0.4 mg of tamsulosin once a day for 7 days was given to all following catheterization and TWOC performed on the eighth day. Our definition of unsuccessful trial was the inability to pass urine or post-void residual urine > 150 mL on ultrasound, with a maximum flow rate < 10 mL/sec. Statistical Package for the Social Sciences (SPSS) 16.0 was used for statistical analysis. Multivariate analysis was performed to identify independent predictors. Independent t-test and Fisher’s exact tests were used for other statistical analysis where a P value of < 0.05 was considered significant. Receiver operating characteristic curves (ROC) were constructed using cutoff values for independent predictors.

Results: TWOC was unsuccessful in 48 (57.83%) patients. Multivariate analyses revealed that age (odds ratio = 1.069; 95% CI = 1.002-1.140; P value = 0.042), TZV (odds ratio = 1.662; 95% CI = 1.035-2.670; P value = 0.035), TZI (odds ratio = 0.00; 95% CI = 0.00-0.150; P value = 0.032), and RUV (1.003, 1.000-1.007, 0.38) are independent predictors of a failed trial. The failure rates of the voiding trial based on grades I to III IPP were 2.08% (1 of 48 cases), 10.41% (5 of 48), and 18.75% (9 of 48).

Conclusion: Our data suggested that age, IPP, TZV, TZI, and RUV are significant risk factors for unsuccessful TWOC. Evaluation of a first episode of AUR secondary to BPH in respect to the previously mentioned factors may guide urologists during subsequent evaluation and treatment without giving a failed trial.

Bijit Lodh, Somarendra Khumukcham, Sandeep Gupta, Kaku Akoijam Singh, Rajendra Singh Sinam

Submitted May 4, 2013 - Accepted for Publication June 14, 2013

KEYWORDS: Acute urinary retention, benign prostatic hyperplasia, trial without catheter, intravesical prostatic protrusion, transition zone index

CORRESPONDENCE: Bijit Lodh, MS (General Surgery), MCh (Trainee in Urology), Regional Institute of Medical Sciences, Imphal, Manipur, India ()

CITATION: UroToday Int J. 2013 August;6(4):art 43.


The Use of Tamsulosin in Voiding Cystourethrograms for Pelvic Floor Urethral Distraction Injuries



Purpose: To analyze the utility of tamsulosin in patients with pelvic floor urethral distraction injuries (PFUDD) undergoing voiding cystourethrograms (VCUG) to assess the posterior urethra for length of the distraction defect.

Materials and Methods: A prospective randomized analysis of 107 patients with PFUDD who underwent VCUG from August 2007 to September 2011 at our tertiary referral center for urethral stricture. Patients were randomized into 2 groups. A dosage of 0.4 mg of tamsulosin, a potent selective alpha-blocker, was administered orally to patients in the study group (N = 53) undergoing VCUG in whom the posterior urethra was not delineated due to competency of the bladder neck. A repeat voiding film was taken 10 to 12 hours after administering tamsulosin. The control group (N = 54) did not receive tamsulosin. Instead, they underwent further diagnostic techniques (magnetic resonance imaging [MRI], bougiogram, and antegrade cystourethroscopy) to assess the distraction defect.

Results: Out of the 53 patients in the study group all 53 patients responded to oral tamsulosin. In the control group 32 patients required MRI, 20 patients required antegrade cystourethroscopy, and 2 patients required bougiograms.

Conclusion: Tamsulosin effectively relaxed the bladder neck and allowed the delineation of the posterior urethra in patients of PFUDD with a competent bladder neck. This prevented the patients from undergoing further invasive diagnostic techniques (bougiogram and antegrade cystourethroscopy). Further prospective studies with a larger number of patients with multicenter experience will be required to validate these results.

Nandan R. Pujari, Sanjay B. Kulkarni

Submitted March 21, 2013 - Accepted for Publication May 19, 2013

KEYWORDS: Tamsulosin, VCUG, distraction defect

CORRESPONDENCE: Nandan R. Pujari, MS, DNB (Department of Urology), MGM Medical College, Mumbai, Maharashtra, India ()

CITATION: UroToday Int J. 2013 August;6(4):art 42.


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