An asfaliogenic complication arising from profit-motivated decision-making.

Abstract

To the Editor. In the report by Dr Joseph1 on the section on urology annual meeting, a summary of the abstract presented by Kessler et al2 on “The Necessity for Contralateral Renal Exploration in Wilms' Tumor Patients” is presented.These authors presented their experience with Wilms' tumor at three separate institutions over an 18-year time period. This paper has recently been published. The findings of their study were that all patients with bilateral Wilms' tumor were detected preoperatively. Sixty-eight patients with suspected unilateral Wilms' tumor underwent exploration by the contralateral kidney explored by opening Gerota's fascia. They did not find any unexpected bilateral tumors. Based on these results, they suggest that the sensitivity of imaging studies in identifying bilateral Wilms' tumors is “close to 100%.”We have reviewed the experience with bilateral Wilms' tumor reported to the National Wilms' Tumor Study (NWTS)-4 (1986–1994).3 Of 122 patients with synchronous bilateral Wilms' tumor enrolled, 7% had the diagnosis of bilaterality missed by the preoperative imaging studies. With the exception of 1 patient, all of these children had been imaged with either computed tomography (CT), ultrasound, or magnetic resonance imaging (MRI). Seven of the lesions were missed by preoperative CT. Although this is a small number, it is clear that even with modern imaging studies, small bilateral tumors can be missed preoperatively and therefore the National Wilms' Tumor Study Group (NWTSG) continues to recommend contralateral exploration. It is important to identify bilateral disease, as the treatment of these children is different from that of unilateral Wilms' tumor. These patients undergo preoperative chemotherapy in an attempt to allow for nephron-sparing procedures.One factor that might explain the apparent increased sensitivity in detection of bilateral tumors in the report by Kessler et al is the limited number of bilateral tumors encountered. There were only 7 patients with bilateral Wilms' tumor in this series. As noted from the NWTSG review, less than 1 in 10 tumors in the contralateral kidney were missed on the preoperative studies.The authors have also commented on the decreased rate of small bowel obstruction in patients undergoing preoperative chemotherapy for bilateral tumors. None of the 8 patients with bilateral tumors in this series had small bowel obstruction. They noted 5 (7.4%) cases of intestinal obstruction in the patients undergoing treatment for unilateral tumors. In the conclusion of the article, they suggest that avoiding contralateral exploration might mitigate the high incidence of postoperative intestinal obstruction.A prior review of surgical complications in NWTSG-3 patients found a 6.9% incidence of postoperative intestinal obstruction. In this group of patients, there were 162 who did not undergo exploration of the contralateral kidney. In that group of patients, the incidence of small bowel obstruction was 5.6% (P = NS) (unpublished data). Therefore, omitting exploration of the contralateral kidney does not significantly decrease the incidence of intestinal obstruction. An unresolved question is whether the incidence of intestinal obstruction is decreased when nephrectomy is performed after preoperative chemotherapy. A recent report from the International Society of Pediatric Oncology (SIOP) found only a 2% rate of intestinal obstruction in a series of 359 patients.4 The NWTSG and SIOP are conducting a prospective study to compare surgical complications in patients treated by primary nephrectomy versus delayed nephrectomy after chemotherapy.