Management of people with Type 2 diabetes shared between a specialized outpatient clinic and primary health care is noninferior to management in a specialized outpatient clinic: a randomized, noninferiority trial.

AIM: To evaluate whether management of people with Type 2 diabetes shared between a specialized outpatient clinic and primary health care has noninferior HbA1c outcomes compared with mono-sectorial management in a specialized outpatient clinic. METHODS: A randomized controlled, noninferiority study. People with moderate hyperglycaemia, hypertension and/or incipient complications were eligible for the study. All participants had annual comprehensive check-ups at the outpatient clinic. Quarterly check-ups were conducted by general practitioners (GPs) for the shared care group and by endocrinologists at the outpatient clinic for the control group. The primary outcome was the mean difference in HbA1c from baseline to 12 months of follow-up. The noninferiority margin for HbA1c was 4.4 mmol/mol. RESULTS: A total of 140 people were randomized [age 65.0 ± 0.9 years, HbA1c 52 ± 0.8 mmol/mol (6.9 ± 0.1%), systolic BP 135.6 ± 1.1 mmHg; all mean ± sem]. Peripheral neuropathy was present in 68% of participants and microalbuminuria in 19%; 15% had history of a previous major cardiovascular event. Among study completers (n = 133), HbA1c increased by 2.3 mmol/mol (0.2%) in the shared care group and by 1.0 mmol/mol (0.1%) in the control group, with a between-group difference of 1.3 mmol/mol [90% confidence interval (CI) -1.3, 3.9] (0.1%, 90% CI -0.1, 0.4). Noninferiority was confirmed in both per protocol and intention to treat analyses. CONCLUSION: We found that our shared care programme was noninferior to specialized outpatient management in maintaining glycaemic control in this group of people with Type 2 diabetes. Shared care should be considered for the future diabetes management of Type 2 diabetes.

Treatment of acute cellular rejection with T10B9.1A-31 or OKT3 in renal allograft recipients.

T10B9.1A-31, a nonmitogenic immunoglobulin Mk monoclonal antibody that detects an epitope on the alpha/beta chains of the T cell antigen receptor (TCR alpha/beta), or OKT3, an anti-CD3 mAb, was employed in a randomized double-blind phase II clinical trial to treat biopsy-proven acute cellular renal allograft rejection. Two of the 40 patients initially selected for the protocol were considered to be nonevaluable. Analysis of the remaining 38 patients receiving both living related and cadaveric donor allografts revealed a patient survival of 100% and a graft survival of 97%. Primary rejection reversal was achieved in 18/19 (95%) patients treated with T10B9.1A-31 and in 20/21 (95%) of patients receiving OKT3. The two patients who did not respond to the first mAb responded to the crossover mAb. Rerejection occurred in 3/18 (17%) of patients treated with T10B9.1A-31 and in 3/20 (15%) treated with OKT3. The mean day of rejection reversal was 1.9 +/- 0.7 with T10B9.1A-31 and 3.37 +/- 1.21 with OKT3 treatment. The rise in mean serum creatinine after mAb administration and the mean creatinine on days 1 through 6 were significantly less in patients treated with T10B9.1A-31. Biopsy specimens analyzed for rejection revealed no significant difference between the T10B9.1A-31 and OKT3 cohorts. The mean serum creatinines at 30, 60, 180, and 360 days posttransplantation were the same for both groups. Significantly fewer febrile, respiratory, and untoward effects followed the first dose (day 0) and fewer febrile, gastrointestinal, and neurological side effects occurred with subsequent doses (days 1-9) in patients treated with T10B9.1A-31. Infectious complications occurred in 3/13 patients treated only with T10B9.1A-31, in 9/17 OKT3-treated patients, and in 4/8 patients treated with both mAb. Analysis of human antimouse antibody (HAMA) revealed that the development of HAMA with T10B9.1A-31 was similar to that of OKT3.

Initial experience with retroperitoneoscopic nephroureterectomy: use of a double-balloon technique.

OBJECTIVES: To report the initial experience with retroperitoneoscopic nephroureterectomy for symptomatic, end-stage vesicoureteral reflux. METHODS: Two patients underwent a nephroureterectomy by a four-port retroperitoneal laparoscopic approach. In 1 patient, a double-balloon technique was used to dissect the pelvic extraperitoneal space and gain access to the juxtavesical ureter. In the second patient, the distal ureter was mobilized with routine laparoscopic dissection techniques. RESULTS: Operative time was 6 and 5.5 hours, respectively, and mean hospital stay was 4 days. Mean patient follow-up is 17.5 months. CONCLUSIONS: The technique of retroperitoneoscopic nephroureterectomy is in evolution; until now, a major concern has been the inadequate access to the distal ureter through a completely retroperitoneoscopic approach. Described herein is a double-balloon technique that significantly facilitates dissection of the juxtavesical ureter during a retroperitoneal laparoscopic nephroureterectomy.

Urolithiasis associated with the protease inhibitor indinavir.

OBJECTIVES: To report the association between the protease inhibitor indinavir and the development of urolithiasis. METHODS: Case reports of three adult patients infected with the human immunodeficiency virus who developed surgical renal stones while being treated with indinavir are presented. RESULTS: Of the 3 patients requiring surgical intervention, stone analyses were available in 2. One stone revealed an inner core of an unidentifiable crystal surrounded by calcium oxalate, and another was found to have indinavir components as determined by thin-layer chromatography and gas chromatography-mass spectrometry. Metabolic evaluation of all 3 patients identified significant hypocitraturia as an isolated finding. CONCLUSIONS: The widely used protease inhibitor indinavir is associated with the development of urolithiasis and may act as a nidus for heterogeneous nucleation leading to the development of mixed urinary stones. Surgical intervention may be necessary in some cases. Underlying metabolic abnormalities may contribute to the increased incidence of stone formation. Urologists and other health care providers should be aware of this association, as combined medical and surgical intervention may be necessary.

Laparoscopic complications in markedly obese urologic patients (a multi-institutional review)

OBJECTIVES: Significant obesity is considered to be a relative contraindication to laparoscopic surgery. This study reviews the complications encountered in massively obese patients undergoing urologic laparoscopic surgery. METHODS: Body mass index (BMI) was used as an objective index to indicate massive obesity. Eleven institutions compiled retrospective data on 125 patients having a BMI greater than 30. Procedures performed included 76 pelvic lymph node dissections, 14 nephrectomies, 7 bladder neck suspensions, and 28 miscellaneous procedures. RESULTS: For the group as a whole, the mean BMI was 35.1 (range 30.1 to 57.2). Mean operative time was 202 minutes (range 60 to 480). Conversion to open surgery occurred in 15 of the 125 patients (12%). Complication rates (minor and major) were 22% (27 occurrences in 125 patients) intraoperatively and 26% (33 occurrences in 125 patients) postoperatively. The major complications included 2 trocar injuries to abdominal wall vessels, 1 bladder injury, 3 peripheral nerve injuries, 1 dysrhythmia, 1 deep vein thrombosis, 1 wound seroma, 1 nephrocutaneous fistula, 1 incisional hernia, and 1 death. CONCLUSIONS: In this review, complication rates for urologic laparoscopic surgery on massively obese patients were higher than in the general population undergoing laparoscopic surgery (0.3% to 21%).

Adenocarcinoma of renal pelvis.

Adenocarcinoma accounts for a small percentage of neoplasms arising within the renal pelvis. We describe a mucinous adenocarcinoma of the renal pelvis that occurred in a 57-year-old woman. Investigation of the recent literature reveals an additional 12 cases of adenocarcinoma of the renal pelvis reported since 1980. These 13 cases are summarized in detail, for a total of 59 cases of adenocarcinoma of the renal pelvis documented in the English-language literature. These tumors can be subdivided into three major histologic types: tubulovillous, mucinous, and papillary non-intestinal. The tubulovillous and mucinous tumors are morphologically similar to intestinal tumors accounting for 71.5% and 21.5% of cases, respectively. They are believed to arise in foci of intestinal metaplasia. Only three cases (7%) were of the nonintestinal, nonmucinous, papillary subtype. These rare tumors are notable for their morphologic similarity to Bellini or collecting duct carcinoma, but a specific morphologic precursor has not been identified. Of the three subtypes, tumors of tubulovillous morphology confer the worst prognosis with 70% of patients dying within 5 years. Thirty-three percent of mucinous tumors and none of the papillary nonintestinal tumors were fatal.

Enlarged photon-deficient area in expected site of renal allograft on Tc-99m DTPA study. A sign of renal vein thrombosis.

Tc-99m DTPA renal imaging has been routinely used in postrenal transplant evaluation. A patient's Tc-99m DTPA studies after transplantation are presented, showing a large photon-deficient area in the region of the allograft on the third postoperative day. The photon-deficient area is two to three times larger than that seen in the original, functioning allograft on the first postoperative day. Enlarged to a weight of 530 g, the allograft on gross and microscopic examination confirmed renal vein thrombosis. Enlargement of the photon-deficient area at the anatomic site of the allograft indicates a scintigraphic pattern of renal vein occlusion incompatible with a viable allograft.

Using immersive VR as a tool for preoperative planning for minimally invasive donor nephrectomy.

For surgeons approaching minimally invasive donor nephrectomy it is important to identify variant anatomy preoperatively since this anatomy can vary significantly from patient to patient. The goal of this operation is to preserve the architecture and function of the organ so it can be transplanted and function successfully. The ability of the surgeon to navigate through an individual patient's anatomy in a virtual three-dimensional (3D) immersive environment augments understanding of anatomical relationships particular to that individual patient and facilitates conveying that information to other physicians and students. Utilizing automated 3D reconstruction of high contrast computed tomography (CT) scan files viewed in this way, surgeons reported a better preoperative understanding of the anatomical variations and encountered fewer surprises at the time of surgery.

Laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction.

The treatment of ureteropelvic junction (UPJ) obstruction has evolved over the past several years with the implementation of endopyelotomy techniques and, more recently, hot wire balloon incision of the stenotic UPJ. Nonetheless, the long-term results suggest, at least for primary treatment, that none of the new techniques provide the long-term outcomes achieved with traditional open pyeloplasty techniques. I describe the technique of laparoscopic dismembered pyeloplasty, a possible bridge between the open and endoscopic approaches. Difficulties associated with laparoscopic reconstructive procedures are discussed as well as innovative developments that may overcome these problems and truly allow laparoscopic procedures to assume a more prominent role in urologic surgery.

Use of a stockinette to minimize warm ischemia during renal transplant vascular anastomoses.

Prolonged warm ischemia during renal transplant vascular anastomosis may have a deleterious impact upon allograft function in the immediate post-transplant period. Placing the donor kidney and sterile ice slush in a cotton stockinette obviates renal rewarming during vascular anastomoses. We successfully used this technique in nearly 1,000 patients undergoing renal transplantation. The stockinette facilitates transplant vascular anastomoses by permitting easier handling of the kidney and eliminating warm ischemia during revascularization as documented by continuous core temperature monitoring.

Laparoscopic retroperitoneal partial nephrectomy.

To our knowledge we report the initial case of laparoscopic partial nephrectomy performed completely via the retroperitoneal approach. The retroperitoneal space was developed by inflating a balloon. Renal parenchymal hemostasis was obtained by a newly designed double loop apparatus and the argon beam coagulator. Convalescence was rapid and no complications have been noted during a followup of 7 months.