No abstract

Objectives: To evaluate the long-term efficacy of topical application of a potent corticoid cream and skin stretching in the treatment of unretractable foreskin, pinpoint phimosis, balanopreputial adhesions and lichen sclerosus in prepubertal boys. Methods: 462 prepubertal boys (mean age 4.7 years) with unretractable foreskin applied a topical potent corticoid cream together with skin stretching twice daily for 6 weeks. Follow-up interview of all patients was performed to evaluate long-term results (median 22 months). Short- and long-term results were compared and evaluated. Results: 400/462 boys (86%) had a retractable prepuce after 6 weeks of treatment. 62/462 boys had no or only a partial response. After a median follow-up of 22 months, the treatment continued to be successful in 383/462 boys (83%). In 76/462 boys the foreskin was unretractable, of which 35 preferred surgical treatment. 12/462 boys presented with lichen sclerosus and the non-surgical treatment appeared efficient in 9/12 (67%). Conclusions: This study has shown that local application of a potent corticoid cream and skin stretching is a safe, simple and effective long-term treatment for all types of unretractable foreskin in prepubertal boys. The efficiency of the treatment was not related to the age of the patient or the type of unretractable foreskin.

OBJECTIVE To present our experience with nephron‐sparing surgery (NSS) for T1b renal cell carcinoma (RCC) in a high‐volume tertiary referral centre. NSS for RCC of <4 cm (T1a) is increasingly accepted, although its role for RCC of 4–7 cm (T1b) remains controversial. PATIENTS AND METHODS The records of 67 consecutive patients who had NSS for RCC of 4–7 cm at our institution were reviewed retrospectively. Data were collected on surgical indications, tumour characteristics, complications, changes in serum creatinine level, time to recurrence and time to death. Clinical progression‐free survival (CPFS), overall survival (OS), cancer‐specific survival (CSS) rates were estimated statistically. RESULTS The mean patient age was 62 years. Surgical indications were absolute in 26 (39%) patients, relative in 11 (16%) and elective in 30 (45%). Two patients (3%) required postoperative embolization, and none developed a urinary fistula. Four patients (6%) had positive resection margins; none of these developed tumour recurrence. After a median (range) follow‐up of 40.1 (1–98.3) months, 10 patients (15%) had died, of whom only one death was related to NSS (postoperative hypovolaemic shock). The tumour recurred in seven patients (10%) all of whom were alive at the last follow‐up. Three patients (4%) developed a local recurrence and four (6%) developed locoregional or distant disease. The projected 5‐year CPFS, CSS and OS rates were 84%, 99% and 72%, respectively. Seven (10%) patients developed de novo renal insufficiency. Elective and relative indications were not associated with a significant change in serum creatinine level (P = 0.22 and 0.10, respectively); in the absolute category this difference was statistically significant (P = 0.005). The main limitation is that the study was uncontrolled and retrospective, with a medium‐term follow‐up. CONCLUSIONS This study showed the excellent surgical feasibility and CSS for NSS in T1b RCC. Local cancer control was achieved in the large majority of patients, with preservation of renal function in those with elective indications. Absolute indications significantly correlated with loss of renal function.

Partial nephrectomy is performed more frequently for small, incidentally discovered, low-stage renal tumors. Importantly, one should distinguish the imperative indications for such surgery from the relative and elective indications, while taking contraindications to nephron-sparing surgery into account. The main advantage of partial nephrectomy over radical nephrectomy is the avoidance of renal insufficiency; the major disadvantages include the possibility of local recurrence and perioperative complications. In this article, the literature on nephron-sparing surgery was reviewed in order to put the management of renal cancer into a modern perspective.

The only possibility for cure in localized renal cell carcinoma (RCC) is surgery. Open radical nephrectomy (RN), as described by Robson, has long been the gold standard. Nevertheless, as a consequence of the increased use of abdominal imaging modalities, a continuing stage migration towards small, low-grade RCC lesions has become evident during the last decades. Together with this stage migration, nephron-sparing surgery (NSS), less-invasive therapies (laparoscopic RN and NSS), and minimally invasive therapies (radiofrequency ablation [RFA], cryoablation) have been developed and are gaining popularity. The value of laparoscopic RN and open NSS are acknowledged worldwide, but the value of laparoscopic NSS, RFA, and cryoablation remains to be established. Despite this evolution, there is still a place for open surgery for localized RCC. Open NSS is, at present, considered the standard of care for localized RCC less than 4 cm, while open RN still has a place for larger lesions, certainly when an extended lymph node dissection or adrenalectomy is warranted, or when a tumor thrombus is extending into the inferior vena cava. This review provides the data that support open surgery in clear, selected cases of RCC.