[Kidney transplant future developments.] / Futuro del trasplante renal.

OBJECTIVE: Kidney transplantation process involves a series of challenges such as the shortage of organs worldwide for a population waiting for a first and subsequent kidney transplants and the search forthe most appropriate graft for each recipient, optimizing the ischemia time as much as possible, minimizing the impact of surgery and subsequent immunosuppressive therapy. METHODS: We carry out a review of the different advances and lines of research in the different areas involved in the kidney transplantation process from strategies focused on increasing the donor pool, enabling the expansion of living donor programs as well as orga preservation strategies previous to transplantation surgery.The arrival of robotic surgery in the field of kidney transplantation has been an important milestone in the last decade, showing improvements compared to traditional open surgery, maintaining satisfactory functional results, although its implementation is currently reduced with technical limitations in the extension to any type of recipient. New immunosuppressive agents that minimize potential side effects or reduce anticalcineurinic drugsdoses are also important lines of research. CONCLUSIONS: The future of kidney transplantation involves the search for increasingly global strategies to improve the supply of organs, improvements in the conditioning and preservation of grafts or the global development of minimally invasive surgery in the different areas of kidney transplantation. The weight of biotechnology and gene therapies represent promising tools in the field of tissue generation or targeted immunosuppressive therapies.

OBJETIVO: El proceso del trasplante renal conlleva una serie de retos como son la escasez de órganos para una población a la espera de un primery sucesivos trasplantes renales y la búsqueda del injertomás apropiado para cada receptor optimizando al máximo el tiempo de isquemia, minimizando el impactode la cirugía y posterior terapia inmunosupresora.MÉTODOS: Realizamos una revisión de los diferentes avances y líneas de investigación en las diferentes etapas que conlleva el proceso del trasplante renal desdelas estrategias centradas a incrementar el pool de donantes,posibilitar la expansión de programas de donante vivo así como las estrategias de preservación del órgano previamente a la cirugía del implante.El desembarco de la cirugía robótica en el campo del trasplante renal ha sido un hito importante en la últimadécada, arrojando mejoras frente a la tradicional cirugía abierta manteniendo unos resultados funcionalessatisfactorios aunque su implantación es reducida en la actualidad con limitaciones técnicas en la extensión a cualquier tipo de receptor. Nuevos agentes inmunosupresores que minimicen los potenciales efectos secundarios o consigan reducir las dosis de anticalcineurínicos son también líneas importantes de investigación. CONCLUSIONES: El futuro del trasplante renal pasa por la búsqueda de estrategias cada vez más globales para mejorar la oferta de órganos, mejoras en el acondicionamiento y preservación de los injertos o el desarrollo a escala global de la cirugía mínimamente invasiva en los diferentes ámbitos del trasplante renal. El peso de las biotecnologías y terapias génicas suponen herramientas prometedoras en el campo de la generación de tejidos o terapias inmunosupresoras dirigidas.

[Renal transplantation during COVID-19 period in Spain.] / Trasplante renal en época COVID-19 en España.

INTRODUCTION: The COVID-19 pandemic poses significant challenges in the area of kidney donation and transplantation. The objective of this article is to establish general recommendations for surgical teams to manage the kidney transplant program duringthe COVID-19 era. MATERIAL AND METHODS: This document is based on the scientific evidence available on the infection caused by SARS-CoV-2 and the experience of authors during the COVID-19 pandemic. A web and Pubmed search was performed using the keywords "SARS-CoV-2"," COVID-19", "COVID Urology", "COVID-19 surgery", and "kidney transplantation." A modified nominal group technique was used. RESULTS: When health system saturation occurs, kidney transplants should be deferred, except in patients with low transplant possibilities and an optimal kidney available, combined transplants or life-threatening situations. Screening for the SARS-CoV-2 virus should be done in all those donors and recipients with clinical symptoms consistent with COVID-19, who have visited or live inhigh-risk areas, or who have been in close contact with confirmed cases of COVID-19. Donation and transplantation will not proceed in confirmed cases of COVID-19. Surgeries should be based on general recommendations in the COVID-19 era and will be efficient, short, and focused on those with the shortest hospital stay. In emergencies, protective measures will be taken with persona lprotection equipment. Surgical staff will be only the strictly necessary, and permanence in the OR should be minimized. Transplant urology consultations will be conducted by teleconsultation when possible. CONCLUSION: The safety of potential donors and recipients must be guaranteed, adopting individual protection measures and screening for SARS-CoV-2. Kidney transplant surgery must be efficient in terms of health, human resources, and clinical benefit. All non-urgent transplant activities should be delayed until the improvement of the local condition of each center.

INTRODUCCIÓN: La epidemia de COVID-19 plantea importantes retos en el ámbito de la donación y el trasplante renal. El objetivo de este artículo es establecer unas recomendaciones generales dirigidas a los equipos quirúrgicos de trasplante renal durante la era COVID-19. MATERIAL Y MÉTODOS: El documento se basa en la evidencia científica disponible sobre la infección causada por SARS-CoV-2 y la experiencia de los autores en la pandemia COVID-19. Se realizó una búsqueda web y en PubMed utilizando las palabras clave "SARSCoV-2", "COVID-19", "COVID Urology", "COVID-19 surgery" y "kidney transplantation". Se ha utilizado una técnica de grupo nominal modificada.RESULTADOS: En momentos de saturación del sistema sanitario, se deberán diferir los trasplantes renales, salvo en pacientes con bajas posibilidades de trasplante y un riñón óptimo disponible, trasplantes combinados o pacientes en situación de urgencia vital. Se deberá hacer cribado del virus SARS-CoV-2 en todos aquellos donantes y receptores que tengan sospecha clínica, hayan estado en zonas de alto riesgo o hayan compartido proximidad con casos confirmados de COVID-19. Nos e procederá con la donación ni con el trasplante en casos confirmados de COVID-19. Las cirugías deberáns er eficientes, cortas y centradas en las que menor estancia hospitalaria conlleven. En casos de urgencia, se extremarán las medidas de protección con equipos de protección individual. El personal quirúrgico será el menor posible y se minimizarán las estancias en quirófano. Las consultas urológicas de trasplante sin riesgo serán realizadas telemáticamente cuando sea posible. CONCLUSIÓN: La cirugía de trasplante renal debe ser eficiente en cuanto a recursos sanitarios, humano sy beneficio clínico. Se debe garantizar la seguridad de los potenciales donantes y receptores, adoptando medidas de protección individual y realizando cribado para SARS-CoV-2.

[Metastasis of a renal cell carcinoma in the corpora cavernosum of the penis. Case report and bibliographic review]. / Metastasis de carcinoma renal en cuerpo cavernoso, a propósito de un caso y revisión de la literatura.

OBJECTIVE: We describe a rare case, the metastasis of a renal clear cell carcinoma in the corpora cavernosum of the penis. METHODS: 53-year-old patient presenting with a painful, hard tumor in the penis three months after right radical nephrectomy with cavotomy and thrombus excision. RESULTS/CONCLUSIONS: Imaging tests and biopsy led to the diagnosis of metastasis of a renal carcinoma in the corpus cavernosum, which was confirmed on the pathologic study of the specimen after penectomy. The appearance of renal carcinoma metastases in the penis is generally associated with advanced tumor stage, therefore associated with bad prognosis as in the reported case.

[Clinical-pathological study of incidental renal cell carcinoma]. / Estudio clinico-patologico de los adenocarcinomas renales incidentales.

OBJECTIVES: To determine the percentage of renal cell carcinomas incidentally diagnosed (IRCC) and to compare their clinical and pathological characteristics with symptomatic or non-incidentally diagnosed tumors (SRCC). METHODS: We retrospectively study 189 patients who were diagnosed of renal carcinoma between 1990 and 1999. 166 underwent surgery (149 radical nephrectomy; 17 nephron-sparing surgery). We determine the percentage of IRCC detected by radiological tests and compare them with the SRCC diagnosed after presenting with some of the classic symptoms or metastasis, with special focus on tumor size, pathology stage, tumor recurrence, progression and evolution. RESULTS: 87 SRCC (46%); 102 SRCC (54%). There are not differences in terms of age, gender, side, and postoperative hospital stay. Tumor size was higher in the SRCC (mean 8.5 cm) than in the IRCC (6.3 cm). SRCC tumor stage was: pT1 27.3%, pT2 27.3%, pT3a 23.8%, pT3b 16.6%, pT3c 2.3%, and pT4 2.3%; IRCC stage was: pT1 51.3%, pT2 25.6%, pT3a 10.9%, pT3b 10.9%, pT3c 1.2%, and no pT4. The percentage of patients with lymph node involvement was higher (p = 0.02) in the SRCC (15%) than in the IRCC (4.8%). The percentage of patients with metastasis at the time of diagnosis was higher in the SRCC group (26%) than in the IRCC (9.2%). Recurrences were more frequent in the SRCC Group (8.3%) than in the IRCC (1.2%) (p = 0.07). Tumor progression was more frequent in the SRCC group (34%) than in the IRCC (7.3%) (p<0.01). 76% of the patients undergoing nephron sparing surgery were IRCC. CONCLUSIONS: Currently, there is a high percentage of IRCC (46% in our series from 1990-99). Renal tumors presenting as IRCC have better prognosis, since they have significantly smaller size, lower stage, less advanced disease, less recurrences, and less progression than SRCC.

[Cutaneous metastasis of a renal carcinoma: case report and review]. / Metastasis cutánea del cáncer renal: caso clínico y revisión.

OBJECTIVES: To report another rare case of skin metastasis from a renal adenocarcinoma, analyzing the prognostic significance, response to therapy, and clinical presentation after a bibliographic review. METHODS/RESULTS: We report the case of a 65-year-old male with a cutaneous metastasis in the root of his inferior left extremity one year after right nephrectomy for a clear cell adenocarcinoma. CONCLUSIONS: Skin metastases usually present as solitary cutaneous lesions of variable macroscopic features and rapid growing; the diagnosis is made by histological analysis, being excision the treatment of choice whenever possible. Prognosis is better for solitary lesions appearing asynchronously with the primary tumor, and among them the longer the time after diagnosis of initial lesion they appear the better the prognosis.