M. Timsit

Complications urologiques de la transplantation rénale.

INTRODUCTION Urinary fistula and ureteral stenosis occur respectively in 2-5% and 2-7.5% after kidney transplantation. The aim of the study was to do an overview about the complex management of these complications. MATERIAL AND METHODS A bibliographical research in French and English language was carried out. Debates on the topic held within a meeting organized by the transplantation Committee of the French association of urology (CTAFU) have incremented the work. RESULTS Within the different causes of stenosis and fistula after kidney transplantation, ischemic diseases of the complex blood supply of the ureter are usually involved. The diagnosis is not always easy to establish. It is based on clinical assessment, blood and urinary biochemical exams, ultrasonography and CT-scan. Pyelography or retrograde ureteropyelography are essential in the management. Definitive treatment is surgical: uretero-vesical reimplatation, uretero-uretral anastomosis, pyelo-ureteral anastomosis. CONCLUSION Urologic complications of the kidney transplantation usually do not affect the transplant survival if treated accurately and on time. The surgical management remains complex.

Nephron sparing surgery in tumours greater than 7 cm

INTRODUCTION Partial nephrectomy (PN) is the gold standard treatment for renal cell carcinomas under 4cm. No robust data exists to recommend PN for tumours>7cm (cT2). The objective of this work is to evaluate the results of PN for cT2 tumours. PATIENTS AND METHODS All patients who underwent PN or radical nephrectomy (RN) for cT2 tumours between 2000 and 2013 at our institution have been included. Patient demographics, postoperative data including renal function, morbidity, mortality and oncologic outcomes were reviewed retrospectively and compared using χ2 test, Mann-Whitney test, Kaplan-Meier method and log rank test. RESULTS We included 130 patients, 49 (38%) in the PN group and 81 (62%) in the RN group, with a median follow-up of 42 months [19-69]. Variation of postoperative renal function at day 5 and last recorded value was significantly different between the groups (P=0.03 and P<0.001). The PN group had a significantly higher complication rate as compared with RN group (37% versus 14%, P=0.002). There were no significant differences between the two groups for overall, recurrence free and specific survival (P=0.55, P=0.55, P=0.24, respectively). In univariate analysis, the type of surgery (PN versus RN) was not associated with a significant difference of oncologic outcome (margins, survival). CONCLUSION PN can be offered for cT2 tumours with oncological outcomes similar to RN. Despite an increased morbidity, it remains acceptable with the demonstrated advantage of preservation of renal function. LEVEL OF EVIDENCE 4.

Comparaison des résultats opératoires et oncologiques de la néphrectomie partielle et de l’ablation par radiofréquence pour traitement des tumeurs rénales chez les patients de plus de 75 ans

INTRODUCTION Elderly patients represent a growing part of our society for who treatment strategy for localized renal tumors has to be chosen knowing iatrogen effects and renal function morbidity. The aim was to analyze oncological and functional results of nephron sparing surgery (PN) versus radiofrequency ablation (RFA). MATERIALS AND METHODS All patients aged more than 75 treated by partial nephrectomy or radiofrequency ablation between 2007 and 2014 in our centre were included. Patient and tumors data were compared and these criteria were analyzed: survival (overall and without recurrence) and loss of renal function (pre- and postoperative MDRD). RESULTS In total, 100 patients were included (26 partial nephrectomies, group 1 and 74 radiofrequency ablation, group 2) with a 32-months medium follow-up. Medium age and tumor size were significantly different (respectively, 78 versus 81 years old, P=0.001, 38mm versus 29mm, P=0.003). Perioperative results showed no differences in complications. Transfusion rate and duration of hospital stay were significantly higher in the PN group. Median overall survival were 45 vs. 27 months (P=0.23) for PN and RFA and median recurrence-free survival were 28 vs. 10 months (P=0.34). On a multivariate analysis, operative technique (PN or RFA) were not significantly linked to survival (HR 2.37 [95% CI: 0.66-8.5]), P=0.19. Loss of renal function were 1.5±14mL/min/1.73m2 for PN and 3±14mL/min/1.73m2 for RFA (P=0.69). CONCLUSION Our study showed better perioperative results for RFA than for PN, without significant different survival. Loss of renal function were little and similar. LEVEL OF EVIDENCE 4.

Histoire chirurgicale de la transplantation rénale

OBJECTIVES To perform a state of the art about the history of kidney transplantation. MATERIAL AND METHODS An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords (MESH): kidney transplantation, history, vascular anastomosis. RESULTS From the first vascular ligations to the discovery of ciclosporin, the history of organ transplantation was made of surgical bets and medical discoveries, such as blood group, HLA-system, immunity, etc. The audacity of some surgeons led to the onset of renal transplantation as the treatment of choice for end stage renal disease. CONCLUSION This article aims to describe the first surgical methods for vascular anastomosis and renal transplantation. Through a comprehensive search within the archives of the French National Library, the authors provide a precise description of the first renal transplantations performed, the technique that have been used and their authors.