Ricardo Alvarez-Vijande

Feasibility of transvaginal natural orifice transluminal endoscopic surgery-assisted living donor nephrectomy: is kidney vaginal delivery the approach of the future?

BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) uses natural orifices to access the abdominal cavity. We adapted NOTES to perform transvaginal NOTES-assisted laparoscopic nephrectomy in living donors. OBJECTIVE To assess the feasibility and reproducibility of this procedure and compare it with conventional laparoscopic living donor nephrectomy (LLDN). DESIGN, SETTING, AND PARTICIPANTS From July 2009 to October 2010, 20 women underwent transvaginal NOTES-assisted living donor nephrectomy (LDN) in our centre. We compared the prospectively collected clinical data of each donor with those of a contemporaneous matched pair of conventional LLDNs (40 donors). SURGICAL PROCEDURE The procedure was performed using three abdominal trocars and one trocar through the vaginal wall. MEASUREMENTS Variables evaluated for donors were procedure length, blood loss, warm ischaemia time (WIT), complications, hospital stay, and first-month creatinine nadir. In the transvaginal LDN group, sexual function was assessed with the Female Sexual Function Index questionnaire before and after surgery. Variables evaluated for recipients were complications, graft function, and creatinine evolution. RESULTS AND LIMITATIONS The procedure was completed in all cases. Operative variables were similar for both groups except for WIT, which was longer in the transvaginal LDN group (p<0.001) without consequences for graft functioning. One transvaginal LDN case had postoperative bleeding requiring immediate open surgery. All transvaginal LDN donors reported unaltered sexual function after surgery and satisfaction with the results. All recipients had immediate urine output, and all had a functioning graft at last follow-up except for one recipient of the transvaginal LDN group who required transplantectomy. Despite promising results, randomised controlled studies with longer follow-up are warranted to further elucidate the potential of this novel technique. CONCLUSIONS Transvaginal NOTES-assisted LDN appears to be a feasible and reproducible surgical technique. The WIT was longer in the transvaginal group, and there was no effect on graft function after the short follow-up.

Low testosterone levels are related to poor prognosis factors in men with prostate cancer prior to treatment

Study Type – Prognosis (case series)

Orthotopic Kidney Transplantation: An Alternative Surgical Technique in Selected Patients

BACKGROUND A renal transplant is the treatment of choice for patients with end-stage renal disease due to its superior short- and long-term survival benefits compared with dialysis treatment. A common trend for kidney transplantation in developed countries is an increasing acceptance of older patients, patients with comorbidities, and patients with vascular problems (eg, atheromatosis, venous thrombosis). For those patients, an orthotopic kidney transplant (OKT) is an option. OBJECTIVE Our aim was to analyze the results of the largest OKT series in the world (surgical technique, complications, and outcomes) and to compare indications, surgical techniques, and long-term results from two different periods (before and after February 1987). DESIGN, SETTINGS, AND PARTICIPANTS Between April 1978 and September 2009, 223 OKT were performed. We compared the results of transplants performed in two different periods: from April 1978 to January 1987 with 139 patients and from February 1987 to September 2009 with 84 patients. INTERVENTION OKT were performed in all cases as described in the first report published in 1989 by Gil-Vernet et al. MEASUREMENTS The clinical data, surgical reports, and complications rate of all patients were reviewed retrospectively. From a database maintained prospectively, two different periods were described, and the long-term results of the OKT were compared. Graft and patient survival in orthotopic versus heterotopic transplants from the same period were also compared. RESULTS AND LIMITATIONS During the second period an important decrease in the number of OKT was observed due to the change in indication for this specific technique. No important differences between periods were noted in terms of surgical technique. The rate of urinary complications rate was similar in both periods. No differences in graft survival between series have been observed (p=0.22), but a higher mortality rate was seen in the second period mostly due to an older unfit population (p=0.031). No differences were observed in overall graft and patient survival between orthotopic and heterotopic kidney transplants performed during the same period. CONCLUSIONS OKT is a good alternative with acceptable rates of urologic and vascular complications for those patients for whom heterotopic transplant is considered unsuitable.

Trasplante renal en pacientes infectados por el VIH

La prevalencia de la infeccion por el virus de la inmunodeficiencia humana (VIH) en pacientes en terapia renal sustitutiva (TRS) es muy variable, pero de forma global se estima que en Europa es del 1% y en Estados Unidos del 1,5%. La supervivencia de estos pacientes en TRS tambien ha mejorado notablemente con la introduccion de tratamiento antirretroviral de gran actividad (TARGA). La experiencia acumulada en la era del TARGA en trasplante renal en pacientes infectados por el VIH en Estados Unidos indica que la supervivencia a los 3 anos es similar a la de los pacientes sin infeccion por el VIH, con un buen control virologico e inmunologico de la infeccion por el VIH bajo TARGA y sin presentar mayor numero de infecciones oportunistas y/o tumores. Los criterios de seleccion de pacientes infectados por el VIH que han utilizado los diferentes grupos de trasplante han sido: ausencia de manifestaciones oportunistas previas, tener una cifra de linfocitos CD41 superior a 200 cel./µl y una carga viral del VIH suprimible con TARGA. En Espana, donde la mayoria de pacientes eran antiguos drogadictos, para el trasplante hepatico se exigiria ademas una abstinencia de heroina y cocaina de 2 anos de duracion, y el paciente podia estar en el programa de metadona. Los principales problemas detectados en el periodo postrasplante son las interacciones farmacocineticas y farmacodinamicas entre los antirretrovirales y los inmunosupresores, el manejo de la coinfeccion por el virus de la hepatitis C y la elevada tasa de rechazo. En Espana se han realizado hasta la fecha siete trasplantes renales, con buena evolucion del paciente y del injerto y sin progresion de la infeccion por el VIH

Numeric Alterations in Chromosomes 7 and 8 Detected by Fluorescent in situ Hybridization Correlate with High-Grade Localized Prostate Cancer

Objective: To compare the ability of flow cytometry (FCM) and fluorescent in situ hybridization (FISH), using a small set of 4 enumeration chromosome probes to detect aneuploidy in prostate tumors, and to correlate it with histological grade and pathological stage. Methods: Among 28 suitable cases, 21 could be analyzed by FISH and FCM techniques. DNA centromeric probes were used in FISH analysis to enumerate chromosomes 7, 8, 10 and 12. Results: (a) Of the 21 cases studied by FISH, 5 were diploid, 14 aneuploid and 2 were tetraploid. When studied by FCM, these tumors were: 14 diploid, 6 aneuploid, and 1 tetraploid. FISH proved to have a higher ability for detecting DNA aneuploidy than FCM while been equally specific, since all tumors aneuploid by FCM were also found to be aneuploid by FISH. (b) Of the 14 aneuploid tumors, 12 were of high histological grade, while only 2 of the 7 nonaneuploid were of high grade. A statistically significant association was observed between high histological grade and FISH aneuploidy (p = 0.033). (c) All the aneuploid tumors showed chromosome 7 and/or 8 aneusomy. Trisomy 7 and monosomy 8 were the most frequent alterations present in 56 and 42% of the aneuploid tumors, respectively. Conclusion: FISH analysis of chromosome 7 and 8 alterations proved to be more sensitive than FCM in the detection of aneuploid prostate tumors. This aneuploidy was significantly associated with a poor pathological prognosis.

Cystic pyeloureteritis: Review of 34 cases. Radiologic aspects and differential diagnosis

OBJECTIVES To refine the clinical and radiologic description of an unusual benign disease, cystic pyeloureteritis (CPU), consisting of the appearance of suburothelial cysts that raise the mucosa layer of the urothelium. We also studied its relationship with various types of inflammation, including chronic infection, that may be the stimulus for the appearance of CPU. METHODS We compiled 34 cases of CPU covering the period 1976 to 1994, analyzing the clinical manifestations, diagnostic procedures, differential diagnosis, and evolution. RESULTS There are no specific symptoms associated with the presence of cysts. The average age of the patients was 59 years (range 30 to 77). Urinary tract infection was detected in 18 (53%). The pyeloureteritis was unilateral in 27 (79%) and bilateral in 7 (21%) of the patients. The location of the cysts was as follows: 1 pyelic (3%); 6 pyeloureteral (18%); and 27 (79%) ureteral. Resolution of the radiologic alterations depends on the resolution of the associated pathology: infections, lithiasis, and obstruction. CONCLUSIONS We conclude that CPU is a benign pathology with indolent evolution and variable duration; it is not associated with sequelae. Diagnosis is made on the basis of radiologic findings, mainly intravenous urography; in view of the minor entity of the pathology, biopsy is not advisable if the radiologic findings are conclusive.

Third and Fourth Kidney Transplant: Still a Reasonable Option

INTRODUCTION At present, a second kidney transplant is considered an established therapeutic option for patients who have lost a previous graft. Second transplants show similar graft survival as first transplants. A debate exists about the benefit of submitting the patient to a third or fourth renal transplant, or to maintain dialysis. OBJECTIVE We sought to analyze graft and patient survivals as well as associated variables and surgical complications of third and fourth transplantations. MATERIAL AND METHODS From July 1985 to December 2008, we performed 74 third and 8 fourth transplantations among 2763 cases. We prospectively collected the variables of age, gender, graft origin, hyperimmunization, time on dialysis, location, bench surgery, acute rejection episodes, graft survival, and operative complications. RESULTS Third and fourth trasplantations were performed in 49 men and 33 women, with an overall mean age of 40.26 years who were on dialysis for an average of 126.89 months before transplantation. Mean graft survivals of their first and second grafts were 35.6 and 50.1 months, respectively. Acute or chronic rejection was reason for renal failure in 71% and 75% of cases, respectively. Patient survivals at 1 and 5 years were 92.7% and 90.6%, for third and both 85.7% for the fourth transplantation. The third and fourth transplantations showed 1- and 5-year graft survivals of 88% and 76.4% and 71.4% and 42.9%, respectively. Sixty-eight cases underwent cadaveric donor and 14 living donor (mean age, 42.1 years) transplantations. Nine patients were hyperimmunized. In 60 cases, we used the left kidney. Orthotopic kidney transplantation was performed in 15 cases; heterotopic transplant to the right iliac fossa in 40 and in the left iliac fossa in 17 cases. Arterial bench surgery was necessary in 6 cases and venous in 3. We performed 3 hepatorenal and 1 cardiorenal transplantation. The complications included 29 cases (35.4%) of postoperative acute tubular necrosis, 14 of acute rejection episodes (17.1%); 12 of perirenal hematoma (14.6%); 1 urinary fistula (1.2%); 4 lymphocele (4.9%); 2 ureteral stenosis (2.4%); variables arterial kink requiring surgery (1.2%), and 1 venous thrombosis with graft loss (1.2%). The 4 patients who died in the perioperative period succumbed to intravascular disseminated coagulation (n = 1) cardiac failure (n = 2), and septic shock (n = 1). Induction antibody therapy, hyperimmunized status, or operative complications were not independent prognostic factors for patient or graft survival. CONCLUSIONS Third or fourth renal transplantations constitute a valid therapeutic option with reasonable short- and long-term patient and graft survivals. Although orthotopic kidney transplantation was used in selected patients, we preferred an iliac fossa approach for most.

Audit of an initial 100 cases of laparoscopic live donor nephrectomy.

BACKGROUND The objective of this study was to analyze variables related to the surgical technique and postoperative evolution of kidney donors. MATERIALS AND METHODS This retrospective analysis describes 100 laparoscopic nephrectomies from living donors performed in our hospital between February 2002 and July 2007. The variables were age, family relationship, surgical time, warm ischemia time, hospital stay, oral feeding resumption, morphine use, return to work, and complications. RESULTS The average age of the donors was 49.5 years and their male:female ratio was 1:2. The left kidney was extracted from 82% of patients. The warm ischemia time was 2.5 minutes (range = 1.09-5.10). There was only one case of multiple vessels. The surgical time was 149.5 minutes (range = 80-255). The mean hospital stay was 4.8 days (range = 1-18). Food intake was resumed after 24 hours, with morphine needed for 0.9 days. The time to return to work was 39 days (range = 7-120). The complications included kidney rupture (n = 1), liver tear (n = 1), hematoma (n = 6), including four requiring blood transfusions; fever and leukocytosis (n = 5) and one collection. No patients died as a result of the surgery. CONCLUSIONS Living-donor laparoscopic nephrectomy constitutes the gold standard among surgical options.

A simple method for the removal of indwelling ureteral stents in women

A new method for transurethral removal of an indwelling ureteral stent has been developed. The 8-inch instrument has a thread-like element at an acting end, which forms a loop that is used to snare and extract the stent from the bladder. This device does not require endoscopic methods, is safe and easy to learn, and requires no specific equipment or facilities.

Vesical tumors in patients under 25 years of age

Behavior of transitional cell carcinoma of the bladder during the third decade of life remains a controversial subject. During the period 1980-1988, we treated 7 patients (4 male and 3 female), 25 years of age or less (mean age 19.3, range 14-25), with transitional cell carcinoma of the bladder. Until now, all patients are alive and without disease during 12-50 months after surgery. In 6 of the 7 patients, endoscopic resection was the choice treatment for superficial stage A/O. The seventh patient underwent a partial cystectomy for a B1 Jewet stage cell carcinoma. We conclude that transitional cell carcinoma of the bladder in patients under 25 years of age has a less aggressive biological behavior. Therefore, ultrasonographic examinations and serial urine cytology represent the elective test for follow-up. Cystoscopy would only be performed in doubtful cases.