Multicenter evaluation of complex urinary diversion for renal transplantation: outcomes of complex surgical solutions.

PURPOSE: An abnormal lower urinary tract poses significant challenges for transplant surgeons. Besides the ureteral anastomosis to an ileal conduit, there are diverse complex reconstructive solutions. Due to its rarity, standardization and teaching of complex urinary diversion is extremely difficult. METHODS: The indications and outcomes of complex urinary diversions after kidney transplantation (KT) were retrospectively investigated at eight urologic transplant centers including a current follow-up. RESULTS: Of 37 patients with 21 (56%) males, vesicoureteral reflux (24%), spina bifida (22%), and glomerulonephritis (12%) were the most common causes of terminal renal failure. In 30 (81%) patients, urinary diversion was performed before KT, at a median of 107.5 (range, 10; 545) months before. Transplantations were held at a median patient age of 43 (10; 68) years, including six (16%) living donations. Urinary diversion was modified during 12 (32%) transplantations. After KT, the ileal conduit was the most common incontinent urinary diversion in 25 (67%) patients; a Mainz pouch I and bladder augmentation were the most frequent continent diversions (each n = 3). At a median follow-up of 120 months (range 0; 444), 12 (32%) patients had a graft failure with a 5-year graft survival of 79% (95%CI 61; 90). The median overall survival was 227 months (168; 286) and the 5-year overall survival 89% (69.3; 96.4). CONCLUSION: The mid-term kidney transplant function with complex urinary diversion appears to be comparable to transplants with regular urinary diversions. Hence, complex urinary diversion should always be considered as a surgical option, even during transplantation, if necessary.

DEGUM Recommendations on Infection Prevention in Ultrasound and Endoscopic Ultrasound.

Microbial contamination of ultrasound probes for percutaneous or endoscopic use is common. However, infectious diseases caused by transmission of microorganisms by US procedures have rarely been reported. In Germany, legal regulations address hygiene in ultrasound procedures. Based on these regulations and the available literature, an expert panel of the German Society of Ultrasound in Medicine (DEGUM) has formulated sophisticated recommendations on hygienic measures in percutaneous and endoscopic US, including US-guided interventions.

Prospective follow-up of female sexual function after vaginal surgery for pelvic organ prolapse using transobturator mesh implants.

INTRODUCTION: Although the use of transobturator mesh implants for pelvic organ prolapse repair has been shown to be safe and effective, concern exists that the presence of prosthetic material in the vagina may adversely affect sexual function. AIM: To evaluate the impact of transobturator mesh implantation on sexual function using validated questionnaire. MAIN OUTCOME MEASURES: Female Sexual Function Index (FSFI), a validated 19-item questionnaire that assesses six domains of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and pain), was used. The questionnaire was administered preoperatively, and at 3, 6, 12, and 24 months postoperatively. Clinical data were also recorded at each time point. METHODS: Prospective nonrandomized study including 96 women with pelvic organ prolapse (cystocele, rectocele, vault prolapse). Transvaginal anterior or posterior wall repair using transobturator mesh implants with or without concomitant transobturator sling procedure. RESULTS: Mean age was 51.4 ± 5.2 years. Mean operating time was 47.6 ± 23.4 minutes, and the mean hospitalization period was 3.8 ± 1.6 days. After initial decrease during the first 3 months, patients experienced a steady improvement in their sexual function. At 24 months postoperatively, the total mean FSFI score reached significantly higher values compared to the baseline (P = 0.023). Furthermore, pain-free intercourse improved during the follow-up reaching mean score of 4.27 ± 0.79 (P < 0.05) after 2 years. Pelvic floor examination at 2 years follow-up showed excellent surgical results with only 3.1% of the patients presenting with stage II vaginal wall prolapse. CONCLUSIONS: Surgical repair of symptomatic pelvic organ prolapse using mesh implants results in improvement of major parameters of sexual function. A worsening in pain with intercourse during the initial months postoperatively lessens after 3 months as healing is completed.

Pelvic organ prolapse management in female kidney transplant recipients.

PURPOSE: Pelvic organ prolapse in female postmenopausal kidney transplant recipients may be complicated by adverse events affecting graft function. We describe our experience with pelvic reconstructive surgery in renal transplant recipients. MATERIALS AND METHODS: Pelvic reconstructive surgery was done in 16 female renal transplant recipients with pelvic organ prolapse with or without stress urinary incontinence. Intraoperative and postoperative data were recorded prospectively, including medical and surgical history, pelvic organ prolapse quantification measurement, 24-hour pad count, quality of life measurements and graft outcome. Patients were followed up to 12 months. RESULTS: Mean +/- SD age at surgery was 58.3 +/- 7.7 years (range 50 to 66). Mean time to renal transplantation was 54.2 +/- 15.1 months (range 38 to 123). A total of 12 anterior and 4 combined anterior/posterior colporrhaphies were done. A concomitant suburethral single incision transobturator sling procedure was performed in 8 women. We noted no bladder or rectal injury, bleeding necessitating transfusion or infection. Pelvic floor testing at 12-month followup showed stage I vaginal wall prolapse in only 4 patients (25%). No patient had evidence of de novo incontinence, synthetic sling infection, erosion or rejection. All women reported improved quality of life on the SF-36 questionnaire. Renal graft function remained stable in all patients. CONCLUSIONS: Pelvic reconstructive surgery is feasible for pelvic organ prolapse in patients with a kidney allograft on immunosuppression. However, concern about impaired graft function, infection and wound healing remains important.

Management of localized prostate cancer by retropubic radical prostatectomy in patients after renal transplantation.

BACKGROUND: The study aimed to report our experience with retropubic radical prostatectomy (RRP) for treatment of localized prostate cancer in renal transplant recipients (RTR). METHODS: Data of 16 RTR who had an RRP between 2001 and 2007 were retrospectively analysed and compared to the data of 294 non-transplanted patients who were operated for RRP during the same period. Diagnostic work-up consisted of digital rectal examination, serum prostate specific antigene levels, as well as Transrectal Ultrasonography (TRUS)-guided prostate biopsy. Follow-up was obtained in all patients with a mean follow-up time of 2.1 years in RTR. RESULTS: Mean time distance to the renal transplantation at the time of RRP was 81.2 ± 19.1 months. RRP was successfully performed and tolerated in all RTR without pelvic lymph node dissection. No major complications occurred during or after the operation. There were two minor complications in transplant group (prolonged haematuria and urinary leakage). Mean operative time was 108.3 ± 3.9 min in transplant group, which was significantly longer as in non-transplanted group (89.1 ± 4.1, P < 0.05). Mean estimated intra-operative blood loss was significantly lower in transplant group (P < 0.05). In RTR, one case of positive surgical margins was present (R(1): 6.2 vs. 12.3% in non-transplanted group, P < 0.05). None of the RTR had impairment of graft function. At follow-up, no case of biochemical recurrence was observed in RTR. CONCLUSIONS: RRP is safe and feasible for management of localized prostate cancer in patients with kidney allograft being under immunosuppression. However, concern about impairment of graft function, infection and wound healing remains important.

Detection of circulating tumor cells from renal carcinoma patients: experiences of a two-center study.

Approximately 30-40% of primary and localized renal cell carcinoma (RCC) will eventually become metastatic disease. Therefore, the detection and molecular characterization of circulating tumor cells (CTC) in RCC may have important prognostic and therapeutic implications. Venous blood samples were obtained from a total of 214 RCC patients before and after nephrectomy or during adjuvant immune chemotherapy in two urological centers. After density gradient centrifugation, the CD45-negative cell population was isolated from peripheral blood samples (BS) by a semi-automated immunomagnetic depletion procedure using the MACS technology. Enriched cell populations potentially containing CTC were stained for cytokeratin and evaluated by a trained pathologist. CTC were found in 105 out of 363 BS (29%) originating from 80 out of 214 patients (37%). The median tumor cell number was five (range 1-51) per BS, i.e. approximately one CTC was detectable per 2-3 ml peripheral blood after tumor cell enrichment. For a subpopulation, follow-up data indicate that 62% of the patients with CTC detection in the blood developed progressive disease with single or multiple distant metastases or died because of RCC within two years. Here we show that the standardized immunomagnetic depletion protocol is a powerful tool for detecting and isolating intact RCC-derived CTC. The occurrence and the quantity of CTC in RCC patients is an early disease event. Furthermore, the occurrence of CTC is correlated with an advanced tumor stage and seems to be associated with a more aggressive tumor phenotype.

Is intensive multimodality therapy the best treatment for fournier gangrene? Evaluation of clinical outcome and survival rate of 41 patients.

BACKGROUND: To evaluate the effect of surgical wound debridement, antibiotics, and hyperbaric oxygen (HBO) in the treatment of Fournier gangrene (FG). METHODS: Forty-one patients with a mean age of 54.3±14.6 years were referred to our department with a diagnosis of FG. To calculate a Fourier Gangrene Severity Index (FGSI), nine factors were assessed (temperature; heart rate; ventilatory rate; serum sodium, potassium, creatinine, and bicarbonate concentrations; hematocrit; and leukocyte count). After clinical stabilization, extensive debridement of the necrotic tissue was performed, and a surgical vacuum-assisted closure (V.A.C.®) device was applied. Hyperbaric oxygen was administered; medical therapy consisted of intravenous antibiotics, electrolyte replacement, and parenteral nutrition. RESULTS: Intraoperative cultures revealed Escherichia coli in 27 patients (66%), Pseudomonas aeruginosa in 28 (68%), gram-positive cocci in 24 (59%), and mixed flora (aerobic and anaerobic bacteria) in 39 (95%). One month after primary debridement, wound granulation was sufficient for plastic surgical reconstruction in all patients. CONCLUSION: Because of the rapid worsening of FG, early diagnosis and immediate, aggressive multi-modality therapy with surgical debridement and broad-spectrum empiric antibiotics is crucial. The utility of HBO remains unproved.

Right-sided transperitoneal hand-assisted laparoscopic donor nephrectomy: is there an issue with the renal vessels?

OBJECTIVE: Short right renal vessels might complicate kidney transplantation, thus causing traction and difficulties during anastomosis. Single-center prospective comparison of right- and left-sided transperitoneal hand-assisted laparoscopic donor nephrectomy (HALDN) is presented. PATIENTS AND METHODS: Eighty-two living kidney donors underwent HALDN between 2003 and 2008. Right-sided HALDN was performed in 46 living kidney donors. The operative technique of right-sided HALDN was modified to obtain the maximum length of right renal vessels. Outcome data in donors including quality of life as well as graft outcome in recipients were prospectively collected. RESULTS: All procedures were laparoscopically completed with no conversion. Mean operative time was 127 minutes (vs. 138 minutes in left HALDN, p = 0.08). The mean warm ischemia time was 41 seconds (vs. 39 seconds in left HALDN, p = 0.23). There was no renal artery or vein thrombosis in any of the grafts. Mean blood loss was 81 mL (vs. 92 mL in left HALDN, p = 0.09). Hospital discharge was on an average of 3.6 days postoperative. Delayed graft function occurred in two recipients: one in the left group and the other in the right group. One-year graft survival rate was 95% in the left group versus 96.9% in the right group (p = 0.08). Further, no statistically significant difference in serum levels of creatinine was seen between the groups 1 year after the transplantation. CONCLUSIONS: Right HALDN is technically safe and feasible and results in convenient extension of right renal vessels to full length with no increased incidence of vascular thrombosis.

The role of surgery in clinical management of patients with metastatic papillary renal cell carcinoma.

OBJECTIVES: Patients with metastatic papillary renal cell carcinoma (RCC) show special clinical behavior compared to patients with other histologic subtypes of RCC. This study aimed to assess the relevance of surgical and systemic options used in treatment of these patients prior to the recent era of targeted therapies. METHODS: Retrospectively, we assessed clinical data of 61 patients with metastatic papillary RCC who were treated at eight centers in Germany. RESULTS: Median follow-up was 20 (range 1-114) months and median age at time of diagnosis was 62 (range 24-85) years. Men were affected predominantly (50/61; 82%). Twenty-one patients (34%) showed metastases at time of diagnosis. In the remaining 40 patients, median time to development of metastases was 30.4 (range 3-143; mean 16.5) months. Sites of metastases were lung (37; 61%), bone (24; 38%), liver (20; 33%), lymph nodes (24; 38%), and local recurrence (17; 28%). Others sites of disease were brain metastases (6 patients/10%), peritoneal carcinosis (5 patients/8%), and others. A surgical approach with potentially curative intention was performed primarily in 11 patients (18%). 31 patients received an immuno- (interferon-alpha +/- interleukin-2) or immunochemotherapy as first line treatment for metastatic disease. Overall, 42/61 patients (69%) received systemic therapy. Supportive care only was performed in 12 patients (20%) because of poor performance status. Median overall survival after diagnosis of metastatic disease was longer than 48 months in patients with tumor resection (n = 11) compared to 13.0 +/- 4.3 months 95% CI 4.5-21.5 (n = 42) months in patients without surgical approach. CONCLUSIONS: Complete resection of metastases represents a valid option in management of patients with relapsing or metastatic papillary RCC.

Detection of circulating tumor cells in peripheral blood of patients with renal cell carcinoma correlates with prognosis.

PURPOSE: The aim of this study was to evaluate the clinical relevance of the presence of disseminated tumor cells in peripheral blood (so-called circulating tumor cells) for renal cell carcinoma patients. METHODS: Two hundred thirty-three peripheral blood samples from 154 renal cell carcinoma patients were investigated for the presence of disseminated tumor cells by autoMACS technique and immunocytochemical staining of cytokeratin. The frequency of circulating tumor cells was analyzed statistically for correlation with relevant clinical data. RESULTS: Two kinds of tumor cells were detected: those with expression of cytokeratin 8/18 (CK+) and cells without a detectable cytokeratin expression, which we called large blue-stained cells with a tumorlike morphology. After following the CD45 autoMACS depletion protocol, we identified circulating tumor cells in 96 (41%) of 233 peripheral blood samples, which originated from 81 (53%) of 154 renal cell carcinoma patients. A significant correlation between the detection of circulating tumor cells and positive lymph node status (P < 0.001; chi(2) test) and the presence of synchronous metastases at the time of primary tumor resection (P = 0.014; chi(2) test) was found. In a multivariate Cox's regression hazard model, presence of CK+ circulating tumor cells was significantly correlated with poor overall survival for renal cell carcinoma patients (relative risk, 2.3; P = 0.048). CONCLUSIONS: The presence of circulating tumor cells correlated to lymph node status and presence of synchronous metastases in renal cell carcinoma. It is important to evaluate CK+ and blue-stained tumor cells together to determine the role of circulating tumor cells in tumor behavior and disease progression. Detection of CK+ circulating tumor cells in peripheral blood is a significant and independent prognostic factor for renal cell carcinoma.