Renato Falci

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.

A better understanding of urogenital tuberculosis pathophysiology based on radiological findings

PURPOSE To assess the radiological findings of urogenital tuberculosis (UGT) in patients at different disease stages, for a better understanding of its pathophysiology. PATIENTS AND METHODS We retrospectively reviewed the radiological exams of 20 men (median age 41 years; range: 28-65) with urogenital tuberculosis diagnosis. The patients were classified in the following groups: (1) bilateral renal tuberculosis with predominantly parenchymatous involvement; (2) unilateral renal tuberculosis; (3) unilateral renal tuberculosis with bladder tuberculosis and (4) bilateral renal tuberculosis with bladder tuberculosis. RESULTS One AIDS patient had multiple bilateral renal tuberculosis abscesses (group 1). Six patients had unilateral renal tuberculosis with hydronephrosis due to stenosis and thickening of the collecting system, without involvement of the bladder or contralateral kidney (group 2). Six patients had bladder tuberculosis with diffuse thickening of the bladder wall, with one very low or no function kidney while the other kidney was normal (group 3). Seven patients had bladder tuberculosis associated to a very low or no function kidney with the other kidney with high-grade vesicoureteral reflux-associated ureterohydronephrosis (group 4). In two patients, sequential exams showed evolution of tuberculosis from a unilateral renal and ureteral lesion to contracted bladder and dilatation of the contralateral kidney secondary to high-grade reflux. CONCLUSIONS UGT may have variable radiological presentations. However, in two of our cases we have seen that tuberculosis involvement of the urinary tract may be sequential. Further evidences are necessary to confirm this hypothesis.

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.

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.

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.

MP30-07 BLADDER AUGMENTATION IN KIDNEY TRANSPLANT PATIENTS: COMPARISON BETWEEN TYPES OF LOWER URINARY RECONSTRUCTION.

INTRODUCTION AND OBJECTIVES: The aim of this study was to assess the results of kidney transplant(KT) in patients with bladder augmentation (BA) and compare results between enterocistoplasty and ureterocistoplasty. METHODS: Betwenn 1988 and 2015, 64 patients with BA underwent KT ( 3 after KT), due to significant lower urinary tract dysfunction. Ten second and 1 third KT were performed, comprising 75 KT in 64 patients The bowel segments used in the augmentation included ileum in 45(70.3%) patients, ileocecal in 3(4.7%) patients and sigmoid in 4(6.3%) patients. The ureter was used in 12 (18.8%) patients. Redo BA was performed in 4 patients after ureterocistoplasty (1 redo ureterocistoplasty, 3 redo ileocistoplasty); 2 redo BA were performed before the first KT. Mean age at first KT in Group 1(enterocistoplasty, n1⁄448) and Group 2(ureterocistoplasty, n1⁄412) was 24.28 and 15.06 years, respectively. Mean age at BA in Group 1 and 2 was 19.06 and 11.87 years, respectively. Redo KT was performed in 6 (11.3%) and 6 (50%) patients in Group 1 and 2, respectively. KT from deceased donor in Group 1 and 2 was 39.6% and 44.4%, respectively. KT from living donor in Group 1 and 2 was 60.4% and 55.6%, respectively. RESULTS: Mean follow-up after first BA was 188,8 118,9 (17522) months and 140,5 71,5 (16-224) months in Group 1 and 2, respectively. In group 1, overall patient survival after 10 years was 78.78% and actuarial graft survival at 1,3,5,7 and 10 years was 94.3%,92.2%,83.1%,70.1 and 63.1%, respectively. In group 2, overall patient survival after 10 years was 90.9% and actuarial graft survival at 1,3,5,7 and 10 years was 88.5%,76.7%,76.7%,68.2 and 34.1%, respectively. Forty (83.3%) and 8(66.7%) patients in Group 1 and 2 were in clean intermittent catheterism (CIC), respectively. Symptomatic or febrile urinary tract infection occurred at least 1 episode in 81.3% and 83.3% in group 1 and 2, respectively. CONCLUSIONS: Both enterocistoplasty and ureterocistoplasty are safe and effective methods of restoring lower urinary tract function in patients with end stage renal disease and a small, noncompliant bladder. CIC is safe in both groups. Graft survival rates are similar until 9 years, with a tendency of poor results after 10 years in ureterocistoplasty patients.

PD38-11 KIDNEY TRANSPLANTATION IN PATIENTS WITH BLADDER AUGMENTATION: LONG TERM OUTCOMES

INTRODUCTION AND OBJECTIVES: The aim of this study was to assess the results of kidney transplant (KT) in patients with bladder augmentation (BA). METHODS: Between 1988 and 2015, 64 patients with BA (3 after KT) underwent kidney transplantation, due to significant lower urinary tract dysfunction. There were 40 males and 24 females. Ten second and 1 third KT were performed, comprising 75 KT in 64 patients. 44 were from living donor and 31 from deceased donor. Mean age at first KT was 22.54 15.09 (3-64) years and mean age at first bladder augmentation was 18.31 13.83 (2-64) years. The etiology of bladder dysfunction was neurogenic bladder due to spina bifida (23 patients), posterior urethral valve (12 patients), vesico-urethral reflux (6 patients), tuberculosis (8 patients) and other causes (14 patients). The bowel segments used in the augmentation included ileum in 45(70.3%) patients, ileocecal in 3(4.7%) patients and sigmoid in 4(6.3%) patients. The ureter was used in 12 (18.8%) patients. Redo BA was performed in 4 patients (1 ureterocistoplasty and 3 ileocistoplasty), all after ureterocistoplasty. In 2 patients, it was performed before the first kidney transplant. RESULTS: Mean follow-up after first BA was 172.47 112,07 (11-522) months. Overall patient survival was 77.6% and actuarial graft survival at 1,2,5,7,9 and 10 years was 92%, 87.6%, 81.2%, 67.8%, 65.7% and 53.9%, respectively. Surgical complications included 1 vesicocutaneous fistula and 1 stenosis of ureteral reimplant. 51(79.7%) patients were in clean intermittent catheterization. Symptomatic or febrile urinary tract infections (UTI) occurred at least 1 episode in 79.3% of patients. Ten (62.5%) patients died of unrelated cause and 6 (37.5%) patients died due to related causes. The main cause of graft loss was chronic allograft nephropaty in 21 (77.7%) patients. CONCLUSIONS: Augmentation cystoplasty is a safe and effective treatment for lower urinary dysfunction. Patients must be followed up closely with special attention to UTIs. Survival graft after 10 years seems to similar to regular KT recipients.

Single Center Experience With Elective Surgical Patients as Living Kidney Donors

PURPOSE To report a single center experience with elective surgical patients as living kidney donors. METHODS We retrospectively analyzed a prospective database of 458 living kidney donors from September 2005 to May 2011. Fifteen (3.2%) of them were elective surgical patients simultaneously undergoing living donor nephrectomy. We reviewed age, gender, operative time, intraoperative blood transfusion, intra- and postoperative complications, as well as length of hospital stay. Recipients were evaluated for delayed graft function. Four hundred forty-three patients undergoing living donor nephrectomy alone composed the control group. RESULTS Among the elective surgical patients group, the mean (range) operative time was 155 (90 to 310) minutes and mean (range) length of hospital stay was 3 (2 to 9) days. One (6.7%) recipient displayed delayed graft function. Among the regular living kidney donors group, the mean (range) operative time was 100 (70 to 150) minutes, mean (range) length of hospital stay was 3 (2 to 5) days, and delayed graft function was observed in 5.6% of recipients. Only operative time (P = .03) was significantly different between the groups. CONCLUSIONS Elective surgical patients are potential donors who may be treated at the same time as the living donor nephrectomy.

2071 LONG TERM OUTCOMES OF THE INFERIOR EPIGASTRIC ARTERY IN THE REVASCULARIZATION OF LIVING DONOR KIDNEY TRANSPLANT WITH MULTIPLE ARTERIES

period to the evaluation of RAM atrophy by CT scan were investigated and a principal factor was calculated using a multivariate logistic regression model. RESULTS: Significantly lower RAM atrophy was observed in group A (17.2 %) compared with that in group B (62.0 %, p 0.01). In the multivariate analysis, preservation of iEGA was the independent factor which can reduce the incidence of lower RAM atrophy (p 0.005). CONCLUSIONS: Preservation of iEGA during kidney transplant can minimize atrophy of lower RAM morphologically. Functional expedient of this procedure should be determined.