Hideki Kanashiro

Radical Retropubic Prostatectomy for Localized Prostate Cancer in Renal Transplant Patients

OBJECTIVE To investigate the feasibility of radical retropubic prostatectomy (RRP) in renal transplant recipients with clinically localized prostate cancer. METHODS A prospective protocol was established between August 2004 and November 2007. In that period, 8 patients diagnosed with localized prostate cancer were submitted to RRP, and their clinicopathologic data were reviewed. RESULTS The mean age (+/- standard deviation) at surgery was 59.6 +/- 6.7 years (range, 49-67 years). All patients had T1C tumors, except for 1 with a T2A tumor. The mean preoperative prostate-specific antigen value was 4.5 +/- 1.8 ng/mL (range, 1.6-7.0 ng/mL). The mean interval between renal transplantation and RRP was 89.9 +/- 65.1 months (range, 40-209 months). The procedure was well tolerated without major complications, and all patients were discharged on the fifth postoperative day. There was no impairment to bladder descent caused by the presence of the allograft or the ureteroneocystostomy. Urethrovesical anastomosis was easily performed in all cases in the standard manner. Blood transfusion was needed in 2 patients (1 received 2 U and another 5 U of blood). The mean operative duration was 183 +/- 29.7 minutes (range, 150-240 minutes), the mean estimated blood loss was 656 +/- 576 mL (range, 100-2000 mL), and no deterioration of graft function was observed. All patients were followed, and the mean follow-up was 10.5 months (range, 2-30 months). Prostate-specific antigen was undetectable in all cases during this time frame. CONCLUSIONS Radical retropubic prostatectomy in renal transplant patients is safe, effective, and can be easily performed in the same manner as described by Walsh, regardless of the presence of the allograft. The only necessary technical modification is the avoidance of ipsilateral lymphadenectomy to prevent damage to the transplanted organ.

Endoscopic treatment of vesical and urethral perforations after tension-free vaginal tape (TVT) procedure for female stress urinary incontinence.

UNLABELLED Stress urinary incontinence is a problem that is prevalent in women, and its treatment with minimally invasive techniques using synthetic materials has increased recently, although the procedure has also brought increased occurrence of specific complications such as vesical and urethral perforations. We describe 11 cases of endoscopic correction of vesical and urethral perforations due to the use of synthetic material for the treatment of stress urinary incontinence. MATERIALS AND METHOD Eleven patients were treated for complications after undergoing the TVT(R) (tension-free vaginal tape) procedure; 6 of them had the polypropylene tape inside the bladder, and 5 had erosion of the urethra. Endoscopic resection of the polypropylene tapes was performed on all patients. RESULTS A 6-month follow-up with cystoscopic control showed that the procedures were successful with complete relief of the symptoms except for 1 patient who persisted with the polypropylene tape in the bladder. This patient underwent a new endoscopic resection, and the cystoscopic control exam was normal 3 months later. CONCLUSION Endoscopic resection of intravesical and intraurethral synthetic tapes can be considered a good alternative for the treatment of complications resulting from the TVT procedure.

C4d staining in post-reperfusion renal biopsy is not useful for the early detection of antibody-mediated rejection when CDC crossmatching is negative

BACKGROUND Sensitized patients (pts) may develop acute antibody-mediated rejection (AMR) due to preformed donor-specific antibodies, undetected by pre-transplant complement-dependent cytotoxicity (CDC) crossmatch (XM). We hypothesized that C4d staining in 1-h post-reperfusion biopsies (1-h Bx) could detect early complement activation in the renal allograft due to preformed donor-specific antibodies. METHODS To test this hypothesis, renal transplants (n = 229) performed between June 2005 and December 2007 were entered into a prospective study of 1-h Bx and stained for C4d by immunofluorescence. Transplants were performed against a negative T-cell CDC-XM with the exception of three cases with a positive B-cell XM. RESULTS All 229 1-h Bx stained negative for C4d. Fourteen pts (6%) developed AMR. None of the 14 protocol 1-h Bx stained positive for C4d in peritubular capillaries (PTC). However, all indication biopsies-that diagnosed AMR-performed at a median of 8 days after transplantation stained for C4d in PTC. CONCLUSIONS These data show that C4d staining in 1-h Bx is, in general, not useful for the early detection of AMR when CDC-XM is negative.

Revascularization of Living-Donor Kidney Transplant With Multiple Arteries: Long-term Outcomes Using the Inferior Epigastric Artery

OBJECTIVE To study the safety and long-term outcomes of use of the inferior epigastric artery (IEA) for revascularization of small accessory kidney arteries (3 mm or less). MATERIALS AND METHODS Data of 602 living-donor kidney transplants were reviewed. Age was 37.4 ± 15 years (range, 3-78 years). Multiple arteries were present in 98 kidneys (16.3%); of these, 83 (84.7%) had 2 and arteries and 15 (15.3%) had 3 arteries. In 21 kidneys (21.4%) with multiple arteries (group I [GI]), the IEA was used for reconstruction. Four (14.3%) had 3 arteries, and 17 (85.7%) had 2 arteries. In 77 patients (group II [GII]), the inferior accessory renal artery was reconstructed with a side-to-side or an end-to-side anastomosis to the main renal artery. Follow-up was 43.8 ± 38.1 months (range, 1-124 months). The Fisher exact test and the 2-tailed t test were used for statistical analysis. RESULTS Delayed graft function occurred in 1 GI patient (4.8%) and in 5 GII patients (6.5%; P >.05). One partial renal infarction occurred in each group (4.8% vs 1.3%; P >.05). There was 1 urinary fistula in GI and 3 urinary fistulas and 1 ureteral stenosis in GII (P >.05). One graft (4.8%) lost function in GI and 5 (6.5%) in GII (P >.05). Eleven patients (53.4%) were hypertensive in GI and 53 (68.8%) in GII (P >.05). CONCLUSION The use of the IEA for revascularization of a living-donor kidney transplant with multiple arteries is safe and effective, yielding similar long-term outcomes compared with the standard technique. Use of the IEA avoids the risks of manipulation of the main renal artery.

Transurethral injection therapy with carbon-coated beads (Durasphere®) for treatment of recurrent pyelonephritis in kidney transplant patients with vesico-ureteral reflux to the allograft

Antonopoulos IM, Piovesan AC, Falci R Jr, Kanashiro H, Saito FJA, Nahas WC. Transurethral injection therapy with carbon‐coated beads (Durasphere®) for treatment of recurrent pyelonephritis in kidney transplant patients with vesico‐ureteral reflux to the allograft. 
Clin Transplant 2011: 25: 329–333.

Renal cell carcinoma presenting as a cervical mass

The authors report a case of a 60-year-old woman presenting with a renal cell carcinoma in which the first sign leading to its diagnosis was a cervical metastasis, an uncommon site of distant disease in renal neoplasms. The patient had an 18-month history of a progressively enlarging cervical mass at the anterior aspect of the neck. After laboratory and radiological evaluation, the cervical mass was excised, and the microscopic and immunohistochemical patterns suggested the possibility of a metastatic renal cell carcinoma. Computerized tomography of the abdomen showed a solid, 4 cm left renal mass. A radical left nephrectomy was performed, and the histology confirmed the suspected diagnosis. The patient received immunotherapy, and in a follow-up period of 9 months, there was no evidence of recurrent disease. It seems that head and neck metastasis of renal cell carcinoma should preferentially be treated with surgical excision because of the associated morbidity and quality-of-life issues.

Histologic Inflammatory Changes on the Prostatic Gland Due to Immunosuppression for Kidney Transplantation

OBJECTIVE To determine the incidence of type IV prostatitis in patients with kidney transplantation receiving an immunosuppression regimen and to compare it with that of a nonimmunosuppressed control group. METHODS We retrospectively reviewed 216 electronic charts of patients who had undergone surgical treatment for benign prostatic hyperplasia from August 2000 to January 2006. Of the 216 patients, 183 did not receive immunosuppressive therapy and were included in the control group (group 1). The other 33 patients had undergone kidney transplantation and were included in the study group (group 2). The patient data were accessed for age at surgery, International Prostate Symptom Score, prostate volume, preoperative serum prostate-specific antigen level, history of acute urinary retention, and surgical approach (open vs transurethral resection of prostate). Histologic findings from the surgical specimens were also recorded. RESULTS The mean age at surgery, mean serum prostate-specific antigen level, mean prostate volume, and mean International Prostate Symptom Score were not significantly different between both groups. However, histologic evidence of chronic prostatitis was obtained in 145 surgical specimens (78%) from group 1 and in just 3 specimens from group 2 (9%; P < .001). Moreover, nonimmunosuppressed patients had a 38.2 times greater risk of presenting with prostatitis than did the immunosuppressed patients. CONCLUSION Immunosuppression therapy in kidney transplantation has a protective factor in the prostatitis incidence.

Current outcome of prioritized patients for kidney transplantation

PURPOSE To analyze the outcome of deceased donor recipients given priority in allocation due to lack of access for dialysis and compare this data to the one obtained from non-prioritized deceased donor kidney transplant recipients. MATERIALS AND METHODS we reviewed electronic charts of 31 patients submitted to kidney transplantation that were given priority in transplantation program due to lack of access for dialysis from January 2005 to December 2008. Immunological and surgical complications rates, and grafts and patients survival rates were analyzed. These data were compared to those obtained from 100 regular patients who underwent kidney transplantation without allocation priority during the same period. RESULTS Overall surgical complication rate was 25.8 % and 27 % in the patients with priority in allocation and in the non-prioritized patients, respectively. There was no statistical significant difference for surgical complications (p = 1.0), immunological complications (p = 0.21) and graft survival (p = 0.19) rates between the groups. However, patient survival rate was statistically significant worse in prioritized patients (p = 0.05). CONCLUSIONS patients given priority in allocation owing to lack of access for dialysis have higher mortality rate when compared to those non-prioritized.

Comparison between laparoscopic and subcostal mini-incision for live donor nephrectomy

OBJECTIVES The aim of this study was to compare the results of laparoscopic donor nephrectomy with open donor nephrectomy. METHODS A non-randomized prospective analysis was conducted of living donor kidney transplantations (118 open donor nephrectomies; 57 laparoscopic donor nephrectomies) between January 2005 and December 2007 in the Kidney Transplantation Unit of Hospital das Clínicas of Faculdade de Medicina of the Universidade de São Paulo. RESULTS Mean donor operative time, mean donor hospital stay, mean postoperative creatinine values, and rates of complications and graft survival were similar for both groups. A significant statistical difference in warm ischemia time was observed between the open donor nephrectomy and laparoscopic donor nephrectomy groups (p < 0.001). There was only one conversion in the laparoscopic donor nephrectomy group. CONCLUSIONS Laparoscopic donor nephrectomy is a safe procedure for a donor nephrectomy, comparable to an open procedure with similar results despite a longer warm ischemia time.

Subcostal mini incision: a good option for donor nephrectomy

OBJECTIVES We describe the results of over one hundred nephrectomies performed using a subcostal mini incision. INTRODUCTION A major effort has been undertaken to encourage living donor renal transplantation. New techniques that use minimally invasive approaches to perform donor nephrectomy have been progressively accepted. Among these new procedures is the mini-incision approach. METHODS We prospectively analyzed one hundred and seventeen consecutive donors that were subjected to subcostal mini-incision nephrectomy at a single center. Surgical time, warm and cold ischemia time, intraoperative complications, time until hospital discharge, presence of infection, bleeding, the need for a second operation, and death were analyzed. Eventual loss of donor renal function was indicated by increases in serum creatinine and proteinuria. RESULTS The mean time of surgery was 180.5 ± 26.2 minutes. The mean warm ischemia time was 93 ±8.3 seconds, while the mean cold ischemia time was 85.9 (±23.5) minutes. We had one case with an intraoperative complication, and only two patients required another operation. An intra-abdominal abscess occurred in one patient (0.85%), proteinuria occurred in one patient (0.85%), and a transitory increase of creatinine levels occurred in two patients (1.7%). DISCUSSION Reducing the length of the abdominal incision did not influence surgical time or result in an increase in intraoperative complications relative to our historical data or literature reports. Organ preparation was accomplished successfully with a brief warm ischemia time. Additionally, the mean hospital stay was short, and few surgical complications occurred. CONCLUSION The use of a subcostal mini incision is both safe and similar to conventional techniques previously described in the literature.