Mahmoud Alameddine

Propensity matched comparative analysis of survival following chemoradiation or radical cystectomy for muscle-invasive bladder cancer

To compare survival outcome between chemoradiation therapy (CRT) and radical cystectomy (RC) for muscle‐invasive bladder cancer (MIBC).

Kidney Autotransplantation: Between the Past and the Future

Purpose of ReviewThe practice of kidney autotransplantation (KAT) has become an increasingly favorable approach in the treatment of certain renovascular, ureteral, and malignant pathologies. Current KAT literature describes conventional open procedures, which are associated with substantial risks. We sought to compare previously reported outcomes, evaluate common surgical indications, and assess associated risks and benefits of current KAT methods. A thorough evaluation and review of the literature was performed with the keywords “autologous transplantation” and “kidney.”Recent FindingsEarly outcomes of robotic KAT are encouraging and have been associated with fewer complications and shorter hospital stay, but require robotic technique proficiency.SummaryKAT is an important method to manage selected complex urological pathologies. Robotic KAT is promising. Nevertheless, future studies should utilize larger patient cohorts to better assess the risks and benefits of KAT and to further validate this approach.

Case series: Transplantation of kidneys from donors with renal artery aneurysm

INTRODUCTION With the present disparity between organ availability and recipient demands, we reported our experience in transplanting kidneys with renal artery aneurysm after back-table reconstruction. METHODS Four patients were identified. The repair consisted of excision of the aneurysm with ostial closure, and for one of the cases, an ovarian vein patch was used. We reviewed the safety and outcomes of this procedure. All donors were asymptomatic before surgery and were diagnosed incidentally during living donor evaluation. The nephrectomies performed were hand-assisted laparoscopic approaches. All recipients had followup renal function and ultrasound duplex of renal artery at six and 12 months and then annually. RESULTS The mean age of the recipients was 28.7 years (range 3-45). The mean size of the aneurysm was 7.4 ± 2.7 mm. All patients had immediate graft function with median serum creatinine of 1.9 ± 1.5 mg/dL at discharge. The average length of hospital stay was 6.25 ± 2.6 days. They also maintained good renal function with an average estimated glomerular filtration rate (eGFR) of 102.8 mL/min/1.73m2 (range 53.4-199 mL/min/1.73m2) and patent vessels at one year. One patient suffered from acute antibody-mediated rejection and lost his graft (medication non-compliance). One patient had two simultaneous benign renal cysts that were resected. Three of the kidneys were right-sided and one left. Mean cold ischemia time was 86 ± 18 minutes. No deaths have been recorded. CONCLUSIONS Transplanting kidneys with a renal artery aneurysm after ex-vivo repair is safe and the outcomes are encouraging. Also, it may play an important role in expanding the donor pool in the face of current organ shortage.

Indications, complications, and outcomes following surgical management of locally advanced and metastatic renal cell carcinoma

ABSTRACT Introduction: Surgery may set the basis for a potential cure or would provide the best achievable quality of life in locally advanced or metastatic renal cell carcinoma (mRCC). However, survival extension with this approach would be scarce and not exempt from adverse events, thus preventing its recommendation in an already frail patient. An evidence based analysis on the role of surgery in each of the possible clinical scenarios involved under this heading may provide a clear picture on this issue and would be of value in the decision making process. Areas covered: Current literature was queried in PubMed/Medline in a systematic fashion. Manuscripts included were selected according to the quality of the data provided. A narrative review strategy was adopted to summarize the evidence acquired. Expert commentary: A surgery-based multimodal treatment approach should be strongly considered after adequate counseling in locally advanced and mRCC, since it may provide for additional benefits in terms of survival. However, a critical reevaluation of its adequacy, optimal timing, and selection of ideal candidates is currently ongoing.

Trends in Utilization of Robotic and Open Partial Nephrectomy for Management of cT1 Renal Masses

BACKGROUND Partial nephrectomy is widely used for surgical management of small renal masses. Use of robotic (RPN) versus open partial nephrectomy (OPN) among various populations is not well characterized. OBJECTIVE To analyze trends in utilization of RPN and disparities that may be associated with this procedure for management of cT1 renal masses in the USA. DESIGN, SETTING, AND PARTICIPANTS Patients who underwent RPN or OPN for clinical stage T1N0M0 renal masses in the USA from 2010 to 2013 were identified in the National Cancer Data Base. A total of 23 154 patients fulfilled the inclusion criteria. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Univariable and multivariable logistic regression analyses were performed to evaluate differences in receiving RPN or OPN across various patient groups. RESULTS AND LIMITATIONS Utilization of RPN increased from 41% in 2010 to 63% in 2013. Black patients (adjusted odds ratio [aOR] 0.91, 95% confidence interval [CI] 0.84-0.98) and Hispanic patients (aOR 0.85, 95% CI 0.77-0.95) were less likely to undergo RPN. RPN was less likely to be performed in rural counties (aOR 0.80, 95% CI 0.66-0.98) and in patients with no insurance (aOR 0.52, 95% CI 0.44-0.61) or patients covered by Medicaid (aOR 0.81, 95% CI 0.73-0.90). There was no significant difference in RPN utilization between academic and non-academic facilities. Patients with higher clinical stage (aOR 0.58, 95% CI 0.55-0.62) and comorbidities (aOR 0.79, 95% CI 0.71-0.88) were also less likely to undergo RPN. CONCLUSIONS Utilization of RPN has continued to increase over time; however, there are significant disparities in its utilization according to race and socioeconomic status. Black and Hispanic patients and patients in rural communities and with limited insurance were more likely to be treated with OPN instead of RPN. PATIENT SUMMARY The use of robotic surgery in partial nephrectomy for management of small renal masses has increased over time. We found a significant disparity across different racial and socioeconomic groups in use of robotic partial nephrectomy compared to open surgery. Patients living in rural areas, with limited insurance, and multiple medical comorbidities were more likely to undergo open than robotic partial nephrectomy.

Never events and hospital-Acquired conditions after kidney transplant

INTRODUCTION Never events (NE) and hospital-acquired conditions (HAC) after surgery have been designated as quality metrics in health-care by the Centres for Medicare and Medicaid Services (CMS). METHODS The Nationwide Inpatient Sample (NIS) database 2002-2012 was used to identify patientswho underwent kidney transplant. Multivariate analysis using logistic regression was used to identify outcomes and risk factors of HAC and NE after transplantation; however, we were limited by using a retrospective database missing some important variables specified for the kidney transplant, such as some operative factors, donor factors, and cold and warm ischemia times. RESULTS Among 35 058 patients who underwent kidney transplant, there were 11 NEs, all of which were due to retained foreign bodies. Among HAC after surgery, falling was the most common (44.9%), followed by poor glycemic control (21.7%), vascular catheter-associated infection (21%), and catheter-associated urinary tract infection (8%). HAC and NE after surgery lead to a significant increase in mortality (adjusted odds ratio [AOR] 2.49; p=0.04), hospitalization length (13 vs. 7 days; p<0.01), and total hospital charges (

A successful case of salvage kidney transplantation using the recipient gonadal vein to bypass a major outflow obstruction

231 801 vs.

Lymph node yield as a predictor of overall survival following inguinal lymphadenectomy for penile cancer

146 717; p<0.01). A significantly higher risk of HAC or NE was seen for patients who had more loss of function before surgey (AOR 3.25; p<0.01) and patients expected to have higher postoperative mortality before operation (AOR 1.62; p=0.03). CONCLUSIONS Despite the limitations of the study, we found HAC and NE significantly increase mortality, hospitalization length, and total hospital charges of kidney transplant patients. Quality improvement initiatives should target HAC and NE in order to successfully reduce or prevent these events.

Effect of prescription medications on erectile dysfunction

Renal transplantation is the treatment of choice for chronic kidney disease and has been shown to have better outcomes than dialysis in multiple studies.1 In the standard procedure, the donor renal artery and vein are anastomosed to the external iliac vessels of the recipient. In cases of an unusable vein, such as thrombosis of the iliac vein or inferior vena cava (IVC), renal transplantation becomes extremely difficult. These issues were originally considered contraindications to renal transplant, but several case reports have demonstrated ways to circumvent the obstructed veins by using other systemic or portal veins in the area. We present an unusual case of kidney transplantation on a right external iliac vein (EIV) that contained a chronic thrombus extending to the common iliac vein (CIV) and infrarenal IVC, hence, partially obstructing the right EIV. It was identified intraoperatively after a standard initial anastomosis. The transplanted kidney was salvaged by utilizing the recipient right gonadal vein to bypass the iliac outflow obstruction.

Evolution of the Application of Techniques Derived from Abdominal Transplant Surgery in Urologic Oncology

OBJECTIVE To determine whether a specific lymph node yield (LNY) affects overall survival (OS) in patients with penile cancer. MATERIALS AND METHODS Using the National Cancer Database, we identified 364 men diagnosed with pSCC who underwent ILND between 2004 and 2013. Men diagnosed on autopsy or at the time of death, patients with preoperative chemotherapy or radiotherapy, M+ and N3 disease, or with less than 3-month of follow-up were excluded. Kaplan-Meier analysis was used to compare Overall Survival (OS). A multivariable Cox regression model was developed to assess predictors of OS. RESULTS The median number of LN retrieved was 16 (IQR: 9-23). There was no significant difference in race, stage, grade for men with LNY ≤15 vs. >15. However, men with LNY ≤15 were significantly older than those with LNY >15 (65 vs. 59 years, p<0.001). On multivariable analysis, radical surgery, age, N+ disease, and LNY ≤15 were independent predictors of worse OS. Patients with LNY ≤15 showed significantly worse 5-year OS versus those with LNY >15 (49% vs. 67%, p=0.008). Nodal density (ND) ≥12.5% was also associated with decreased 5-year OS versus ND <12.5% (31% vs. 70%, p<0.0001). CONCLUSIONS LNY following ILND for pSCC appears to be an independent predictor of OS. A total LNY of >15 following ILND may have a beneficial impact on OS and serve as the threshold for defining an adequate ILND.