Hannah Kerr

Clinical phenotyping of urologic pain patients.

Purpose of review Urologic pain conditions such as chronic prostatitis/chronic pelvic pain syndrome, interstitial cystitis/bladder pain syndrome and chronic orchialgia are common, yet diagnosis and treatment are challenging. Current therapies often fail to show efficacy in randomized controlled studies. Lack of efficacy may be due to multifactorial causes and heterogeneity of patient presentation. Efforts have been made to map different phenotypes in patients with urologic pain conditions to tailor more effective therapies. This review will look at current literature on phenotype classification in urologic pain patients and their use in providing effective therapy. Recent findings There has been validation of the ‘UPOINT’ system (urinary symptoms, psychosocial dysfunction, organ specific findings, infection, neurologic/systemic and tenderness of muscle) to better categorize male chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis/bladder pain syndrome. Refinement of domain systems and recent cluster analysis has suggested possible central processes involved in urologic pain conditions similar to systemic pain syndromes such as fibromyalgia, chronic fatigue and irritable bowel syndrome. Summary Domain characterization of urologic pain conditions via phenotype mapping can be used to better understand causes of chronic pain and hopefully provide more effective, targeted and multimodal therapy.

Renal Transplantations in African Americans: A Single-center Experience of Outcomes and Innovations to Improve Access and Results

OBJECTIVE To report a single-center 10-year experience of outcomes of kidney transplantation in African Americans (AAs) vs Caucasian Americans (CA) and to propose ways in which to improve kidney transplant outcomes in AAs, increased access to kidney transplantation, prevention of kidney disease, and acceptance of organ donor registration rates in AAs. METHODS We compared outcomes of deceased donor (DD) and living donor (LD) renal transplantation in AAs vs CAs in 772 recipients of first allografts at our transplant center from January 1995 to March 2004. For DD and LD transplants, no significant differences in gender, age, body mass index, or transplant panel reactive antibody (PRA) existed between AA and CA recipients. RESULTS Primary diagnosis of hypertension was more common in AA, DD, and LD recipients. Significant differences for DD transplants included Medicaid insurance in 23% AA compared with 7.0% CA (P<.0001) and more frequent diabetes mellitus type 2 in AAs (15% vs 4.1%, P=.0009). Eighty-three percent of AAs had received hemodialysis compared with 72% of CAs (P=.02). AAs endured significantly longer pretransplant dialysis (911±618 vs 682±526 days CA, P=.0006) and greater time on the waiting list (972±575 vs 637±466 days CA, P<0001). In DD renal transplants, AAs had more human leukocyte antigen (HLA) mismatches than CAs (4.1±1.4 vs 2.7±2.1, P<.0001). Mean follow-up for survivors was 7.1±2.5 years. Among LD transplants, graft survival and graft function were comparable for AAs and CAs; however, among DD transplants, graft function and survival were substantially worse for AAs (P=.0003). In both LD and DD transplants, patient survival was similar for AAs and CAs. CONCLUSION Our data show that AAs receiving allografts from LDs have equivalent short- and long-term outcomes to CAs, but AAs have worse short- and long-term outcomes after DD transplantation. As such, we conclude that AAs should be educated about prevention of kidney disease, the importance of organ donor registration, the merits of LD over DD, and encouraged to seek LD options.

Utilization of Vascular Conduits to Facilitate Renal Transplantation in Patients With Significant Aortoiliac Calcification

OBJECTIVE To describe the use of vascular conduits (donor iliac artery or saphenous vein) in renal transplantation recipients with extensive aortoiliac calcification. MATERIALS AND METHODS Vascular conduits were used in 10 renal transplants with severe vascular calcification at Cleveland Clinic from 2009 to 2013. Both iliac artery (N = 8) and saphenous vein (N = 2) grafts were used. Surgical technique is reviewed in detail. Surgical complications, patency on renal transplant ultrasonography, and serum creatinine level at multiple time points were reviewed. RESULTS Mean follow-up time was 26 months (7-44 months). Mean serum creatinine level was 1.42 mg/dL (1.04-1.74 mg/dL) at 6 months, 1.35 mg/dL (0.83-1.86 mg/dL) at 12 months, and 1.43 mg/dL (0.79-1.81 mg/dL) at last follow-up. All patients were demonstrated postoperatively to have patent vasculature on renal ultrasonography. No patients experienced lower extremity vascular complications. Death-censored graft survival was 100%. One patient died from complications after mitral valve replacement, and one patient died from metastatic squamous cell carcinoma of the tongue. Both patients had functioning grafts at the time of death. CONCLUSION Vascular conduits can be used to facilitate renal transplantation in the setting of severe recipient aortoiliac calcification, thus allowing for successful transplantation of these complex recipients.

The use of bovine pericardium for complex urologic venous reconstruction.

OBJECTIVE To describe the use of bovine pericardium (BP) in several scenarios for venous patching and as a tubularized graft in urologic surgery. METHODS BP was used as patch or tubularized graft in 7 patients between 2010 and 2013. Clinical scenarios and operative indications were reviewed. We used BP as a patch graft for the inferior vena cava (IVC) (N = 3) and for the iliac venous system (N = 1) to restore venous outflow. Tubularized grafts were used (N = 2) to replace the left renal vein in oncology procedures and during renal autotransplantation (N = 1). Surgical technique is reviewed in detail. RESULTS We used BP as a venous patching in 4 cases and as a tubularized graft in 3 cases. There was no evidence of venous thrombosis of the replaced system with a mean of 14.8 months (range, 9-26) follow-up. CONCLUSION The use of BP as a patch or tubularized graft is an option for complicated urologic venous reconstruction. Although the follow-up interval is relatively short and this initial series small, our initial results are promising.

Fibrin Glue Injections: A Minimally Invasive and Cost-Effective Treatment for Post-Renal Transplant Lymphoceles and Lymph Fistulas.

Pelvic lymphoceles/lymph fistulas are commonly observed after kidney allotransplantation, especially when the kidney is placed in a retroperitoneal position. While the majority are <5 cm in diameter and resolve without intervention, some may continue to enlarge, and cause local or systemic symptoms or graft dysfunction. Among 1662 recipients of both living and deceased donor kidney transplants between January 2003 and July 2014, we found 46 (2.7%) patients with symptomatic lymphoceles requiring intervention. We studied the clinical outcomes and charges for three treatment modalities including open surgical drainage (22), laparoscopic surgical drainage (11), and percutaneous fibrin glue injections into the drained lymphocele cavity (13). The patient demographics and clinical characteristics were comparable for each treatment group, although maintenance immunosuppressive drugs differed by era. We found fibrin glue injections resulted in significantly lower (p = 0.04) rates of recurrence (1; 7.7%) than either laparoscopic (6; 54%) or open surgical drainage (6; 27.3%). In addition, fibrin glue injections generated significantly (p < 0.001) lower median (

2316 DOES THE USE OF URETERAL STENTS IN RENAL TRANSPLANT ALLOGRAFTS INCREASE THE RISK OF MULTI-DRUG RESISTANT URINARY TRACT INFECTIONS OR DECREASE LONG TERM FUNCTION OF THE ALLOGRAFT?

4559) charges compared to either laparoscopic (

Low Testosterone at Time of Transplantation is Independently Associated with Poor Patient and Graft Survival in Male Renal Transplant Recipients

26 330) or open surgical drainage (

MP3-20 RENAL AUTOTRANSPLANTATION: AN UNDERUTILIZED OPERATION FOR COMPLEX UPPER TRACT PATHOLOGY

23 758). Fibrin glue treatment has the advantage of being an outpatient procedure, performed with the patient under local anesthesia, and does not incur the expense of an operative procedure or hospital admission associated with laparoscopic or open surgery.

2123 UTILIZATION OF ARTERIAL VASCULAR CONDUITS TO FACILITATE RENAL TRANSPLANTATION IN PATIENTS WITH SIGNIFICANT AORTOILIAC CALCIFICATION

INTRODUCTION AND OBJECTIVES: Post renal transplant infectious complications are largely due to urinary tract infections (UTIs). We determined whether the use of a stent increased the risk of developing a multi-drug resistant urinary tract infection in renal transplant patients or affected long term function of the allograft. METHODS: We retrospectively analyzed our transplant cases from 2006-2009 (N 172). We divided our cohort into stented or nonstented. We analyzed the cases for development of first post transplant UTI. We further analyzed these positive urine cultures for the presence of multidrug resistance. Of the patients that developed infections we looked at gender, race, ethnicity, preoperative GU anatomic anomalies, and postoperative complications and whether these variables had any significance in the development of postoperative multidrug resistant UTI. Stents were removed at 3 weeks posttransplant. Comparisons of variables between the two cohorts were evaluated using the SAS statistical software. T-test and Chi square were utilized to compare the 2 cohorts with p 0.05 considered significant. RESULTS: Our data analysis found that there was no significant difference in the development of a multidrug resistant UTI in stented versus non-stented patients. Factors having significance in posttransplant multidrug resistant UTI development were female gender (p 0.02) and postoperative complications (p 0.001). Patients with prior GU abnormalities had an increased incidence of postoperative UTI however this did not reach statistical significance. There was no significant difference by race or age. The graft function was the same whether patients had a stent or no stent. CONCLUSIONS: Our data shows that the risk of development of a multidrug resistant UTI was not increased by the use of a stent at the time of transplant. The risk of multidrug resistant UTI is increased if the patient is female, has had prior GU anomalies, or had postoperative complications.