Gender equality challenges in orthopaedic surgery: a systematic review.

PURPOSE: Several studies have examined gender-equality challenges and ways to improve women's representation and management. Orthopaedic surgeons and patients are less gender equitable than them of other surgical disciplines. This systematic review summarizes these findings and highlights orthopaedic surgery gender inequality. METHODS: Search of the PubMed, Embase, and Cochrane databases was carried out to extract human studies investigating the gender gap in orthopaedics, trying to highlight the equality challenges orthopaedic surgery faces. Studies incorporating patients with comorbidities in which gender is a proven risk factor, and pregnant women were excluded. RESULTS: This systematic review included 59 studies involving 692,435 people (mean females/males ratio: 4.44), spanning the years 1987-2023. Regarding the targeted population, 35 (59.32%) studies focused on patients, while 24 (40.68%) on physicians. Orthopaedic surgery is described as an unfriendly career field for women as surgeons or sports leading physicians while women are generally under represented in the academic field of orthopaedics. Regarding patients, female gender consists both a risk and prognostic factor influencing the prevalence of degenerative disease and the outcome of the operative treatment in reconstructive orthopaedics. Female gender is a risk factor for multiple sports injuries and influences the pathogenetic mechanisms resulting in ACL reconstruction. Regarding spine surgery, women are less likely to have surgery suggested, and such suggestion underlines severe disease's progression. CONCLUSIONS: Gender differences affect orthopaedic patient-physician-healthcare system interactions. Recognizing biases and their patterns is useful to improve the actual situation. By preventing those an unbiased, tolerant, and egalitarian workplace for physicians and a healthcare system that provides the best treatment to patients could be created.

A distal anterior cerebral artery tripod branching to a bihemispheric pericallosal artery.

The anterior cerebral artery (ACA) branching pattern may be particularly complex and variant including bifurcations, trifurcations or quadrifurcations, thus leading to typical or atypical vessels. The bihemispheric ACA (BhACA) variant crosses the midline to supply the contralateral hemisphere. The current case highlights a left-sided ACA trifurcation into a bihemispheric pericallosal artery, and two ipsilateral atypical arteries: a callosomarginal artery of short course and a left-sided pericallosal artery of an aberrant course into the cingulate sulcus. The depicted trifurcation was characterized as a distal ACA tripod. The bihemispheric branch supplied the contralateral pericallosal area and coursed into the cingulate sulcus. Deviations from the typical ACA pattern, especially when they coexist are quite rare and may complicate neurosurgical approaches or raise diagnostic difficulties. The BhACA may be implicated in aneurysm formation and bilateral ischemia after its occlusion. Knowledge of such variants, as well as awareness of the complications they may be related to, is of great significance.

The left-sided aortic arch variants: prevalence meta-analysis of imaging studies.

PURPOSE: To estimate the prevalence of the left-sided aortic arch (LSAA) variants, and the effect of possible moderators on variants' detection. METHODS: A systematic online literature search was conducted. The pooled prevalence with 95% confidence intervals was estimated for the typical and atypical branching patterns to compare the overall proportions of different variants. Meta-regression analyses were performed to investigate the effect of the subjects' gender and geographical region, and the multidetector computed tomography (MDCT) scanner's technology on the estimated prevalence. RESULTS: In total, 18,075 cases from 23 imaging studies were included and 33 different LSAA variants were detected. The estimated heterogeneity was statistically significant. Based on the estimated prevalence, approximately 77% of the population is expected to have the typical branching anatomy with sequence brachiocephalic trunk-left common carotid artery-left subclavian artery, and 23% variant branching patterns. Approximately 71%, 23%, 2%, and 0.1% of the atypical populations are expected to have two, four, three, and five emerging branches, respectively. The meta-regression analyses showed that the number of detector rows of the MDCT scanner, and the subjects' geographical region are statistically significant moderators of the estimated prevalence. CONCLUSION: The current findings indicate that the prevalence of the LSAA variant branching anatomy is significantly affected by the subjects' geographical region and the MDCT scanner's technological improvement, with the advanced scanners to facilitate the detection of the aortic arch variants. However, due to the heterogeneity among studies, further research is required.

Students' perspective on the interactive online anatomy labs during the COVID-19 pandemic.

PURPOSE: New training methods sprung up using communication technologies after the suspension imposed on Greek Universities due to restrictive measures against the COVID-19 pandemic. The current questionnaire-based study evaluates the efficacy and utility of the interactive online anatomy labs (ONALs) in assisting the assimilation of anatomy and substituting dissection labs during the pandemic. METHODS: ONALs consisting of video recorded demonstrations of dissected cadavers were developed so that real-time dialogue and interaction between tutor and students was feasible. First- and second-year medical students who were taught neuroanatomy and splanchnology and first-year dental students who were taught head and neck anatomy evaluated the ONALs. RESULTS: One hundred and sixty students participated. The 61 students (38.13%) attended the splanchnology, 58 (36.25%) the neuroanatomy, and 41 (25.63%) the head and neck anatomy course. 86.9% of the participants found the ONALs beneficial for their study. The 75.5% with previous experience of a "face-to-face" dissection replied that the ONALs cannot substitute satisfactorily "face-to-face" dissections. 63.8% replied positively to the ONALs maintenance after the pandemic. CONCLUSIONS: The study's novelty is based on the maintenance of the greater possible interaction between tutors and students during the ONALs, in contrast to the previously described usage of dissection educational videos in anatomy. Our findings reinforce the established statement that "a teaching dissection is an irreplaceable tool in anatomy education". However, the ONALs were well-received by the students and can be kept on as a supplementary teaching modality and can be proven quite useful in Medical Schools that lack cadavers.

A systematic review of splenic artery variants based on cadaveric studies.

PURPOSE: The splenic artery (SA) is the largest and most tortuous branch of the celiac trunk with a wide spectrum of variants, particularly in its terminal branches. METHODS: The current study presents a systematic review of the English literature on the SA variations, with emphasis on its terminal branching patterns. RESULTS: Thirty cadaveric studies (3132 specimens) were included in the analysis. The SA originated from the celiac trunk in 97.2%, from the abdominal aorta in 2.1% and from the superior mesenteric or the common hepatic artery in 0.7% of cases. A suprapancreatic course was observed in 77.4%, retropancreatic course in 17.8%, anteropancreatic course in 3.4% and intrapancreatic course in 1.3%. In the majority of cases, the SA bifurcated into superior and inferior lobar arteries (83.4%), with trifurcation and quadrifurcation in 11.3% and 2.7%, respectively. Five or more lobar branches (1.4%) and a single lobar artery (1.2%) were rarely identified. The distributed branching pattern was found in 72.7%, whereas the magistral pattern in 26.9%. The inferior and superior polar arteries (IPA and SPA) were found in 47.7% and 41.7% of cases, respectively, while polar artery agenesis was recorded in 28.2%. The SPA usually originated from the SA main trunk (53.6%) or from the superior lobar artery (33.1%). The IPA emanated mainly from the left gastroepiploic artery (53%), from the SA (23.5%) or the inferior lobar artery (21.9%). Intersegmental anastomoses between adjacent arterial segments were identified in 14.2%. CONCLUSION: Knowledge of the SA aberrations is important for surgeons and radiologists involved in angiographic interventions.

B cell depletion treatment decreases CD4+IL4+ and CD4+CD40L+ T cells in patients with systemic sclerosis.

Recent data suggests that rituximab may favorably affect skin fibrosis and lung function in patients with systemic sclerosis. Based on experimental data suggesting a key role of B and T cells in scleroderma we aimed to explore the effect(s) of rituximab treatment on T cell subpopulations. Fifteen patients with scleroderma who received rituximab treatment and six who received standard treatment alone were recruited. Peripheral CD4+IL4+, CD4+INFγ+, CD4+IL17+ and CD4+CD40L+ T cells were assessed using flow cytometry. Using ELISA, serum levels of IL4 were assessed. Skin CD4+IL4+ T cells were assessed with confocal microscopy from skin biopsies. Following rituximab treatment skin CD4+IL4+ T cells obviously decreased as seen with confocal microscopy. Moreover, peripheral CD4+IL4+ T cells decreased significantly compared to those from patients who received standard treatment alone: median (IQR): 14.9 (22.63-12.88) vs 7.87 (12.81-4.9)%, p = 0.005 and 9.43 (19.53-7.50)% vs 14.86 (21.96-6.75)%, p = NS at baseline and 6 months later respectively, whereas there was no difference in serum IL4 levels. Peripheral CD4+CD40L+ T cells also decreased significantly following rituximab treatment compared to those from patients who received standard treatment alone: median (IQR): 17.78 (25.64-14.44)% vs 8.15 (22.85-3.08)%, p = 0.04 and 22.13 (58.77-8.20)% vs 72.11 (73.05-20.45)%, p = NS at baseline and 6 months later respectively. Furthermore, peripheral CD4+INFγ+ and CD4+IL17+ T cells revealed no differences following rituximab treatment. Our study demonstrates a link between rituximab treatment and CD4+IL4+ T cell decrease both in the skin and peripheral blood of patients with SSc.

Outcomes of endovascular treatment of renal arterial stenosis in transplanted kidneys.

OBJECTIVE: To evaluate the effectiveness and outcomes of endovascular treatment of TRAS with PTA. MATERIALS AND METHODS: We searched our prospectively collected database looking at cases of TRAS between January 2005-December 2011. CCT was the gold-standart for diagnosis of TRAS. Parameters analysed comprised technical aspects, arterial blood pressure variation, and renal function. A minimum follow-up of 24 months was considered. RESULTS: Of the 2221 renal transplants performed in the selected period, 22 (0.9%) patients were identifi ed with TRAS. Fourteen (63.6%) were male and mean age was 377±14.8years (12-69). Kidney graft was from deceased donnors in 20 (80%) cases. On doppler evaluation, mean blood fl ow speed after transplantation, at TRAS diagnosis and after TAP was 210.6±99.5, 417±122.7 and 182.5±81.6mL/sec, respectively (p<0.001). For SBP and DBP, there was a signifi cant difference between between preintervention and all post-treatment time points (p<0.001). After 1 month of the procedure, there was stabilization of the Cr level with a signifi cant difference between mean Cr levels along time (p<0.001). After a mean follow-up of 16±4.2 (3-24) months, overall success rate was 100%. CONCLUSIONS: Endovascular treatment with PTA/stenting is a safe and effective option for managing TRAS, ensuring the functionality of the graft and normalization of blood pressure and renal function.

Dickkopf-1 is downregulated early and universally in the skin of patients with systemic sclerosis despite normal circulating levels.

OBJECTIVES: The activity of the Wnt pathway, a critical mediator of fibrosis, is regulated by Dickkopf-1 (Dkk-1). Dkk-1 is absent from scleroderma skin in contrast to skin from healthy subjects where it is clearly expressed. There are no data on circulating levels and function of Dkk-1 in patients with systemic sclerosis (SSc). Our objectives are to assess: i) circulating and functional levels of Dkk-1 in patients with SSc and ii) whether the striking lack of Dkk-1 skin expression is also evident in a) clinically uninvolved skin from patients with SSc and b) very early disease prior to skin thickening. METHODS: Circulating Dkk-1 levels were measured in 50 patients with SSc and 50 controls. Skin biopsies were obtained from SSc patients from a) clinically involved skin b) clinically uninvolved skin, c) oedematous skin prior to skin thickening. RESULTS: Circulating and functional Dkk-1 levels were similar in patients with SSc and controls. Healthy skin displayed a high Dkk-1 immuno-expression in the epidermis and dermal fibroblasts in contrast to clinically involved scleroderma skin where Dkk-1 was totally absent. In all biopsies of clinically uninvolved skin Dkk-1 was only moderately expressed whereas skin from very early disease displayed only a weak Dkk-1 immunoreactivity. CONCLUSIONS: The downregulation of Dkk-1 at the oedematous phase of the disease indicates that the Wnt pathway is involved early in the disease process and may play a role in driving fibrosis. The decrease in Dkk-1 expression in clinically uninvolved scleroderma skin indicates that skin in SSc is universally affected.

Urological complications, vesicoureteral reflux, and long-term graft survival rate after pediatric kidney transplantation.

To describe a single-center experience with kidney transplantation and then study some donor and recipient features that may impact on graft survival and urological complication rates. We reviewed our database searching for pediatric patients who underwent kidney transplantation from August 1985 through November 2012. Preoperative data and postoperative complications were recorded. Graft survival rates were analyzed and compared based on the type of donor, donor's age from deceased donors, and recipients' ESRD cause. Kaplan-Meier curves with log rank and Wilcoxon tests were used to perform the comparisons. There were 305 pediatric kidney transplants. The mean recipient's age was 11.7 yr. The mean follow-up was 11.0 yr. Arterial and venous thrombosis rates were 1.6% and 2.3%, respectively, while urinary fistula and symptomatic vesicoureteral reflux were diagnosed in 2.9% and 3.6% of cases, respectively. Deceased kidney transplantation had a lower graft survival rate than living kidney transplantation (log rank, p = 0.005). Donor's age (p = 0.420) and ESRD cause (p = 0.679) were not significantly related to graft survival rate. In long-term follow-up, type of donor, but not donor's age, impacts on graft survival rate. ESRD cause has no impact on graft survival rate, showing that well-evaluated recipients may have good outcomes.

Aberrant accessory abductor digiti minimi manus muscle: a rare anatomical variation.

The hypothenar muscle with the greatest frequency of variations is the abductor digiti minimi manus. Except for morphological variations of this muscle, have also been reported cases of an extra wrist muscle, the accessory abductor digiti minimi manus muscle. This case report presents a rare case of an accessory abductor digiti minimi muscle characterized by an unusual origin from the tendons of the flexor digitorum superficialis. This anatomical variation was identified on a formalin - fixed male cadaver of Greek origin during routine dissection. This anatomical variation, which may result in Guyon's canal syndrome or complicate common wrist and hand surgical procedures such as the carpal tunnel release, should be known to orthopaedic surgeons and hand surgeons in particular.

George Sclavunos (1869-1954): Anatomical Insights and His Contribution into the "Magenstrasse of Waldeyer".

The purpose of this article is to present a well-known physician and highlight his contribution into an essential, but neglected anatomical feature. George Sclavunos (1869-1954) was a 20th century Greek physician, whose scientific work was a significant milestone in global medical knowledge. In 1899 he became Professor of Anatomy and Head Director of the Department of Anatomy. In 1906 Sclavunos G. published the first volume of the three volume book "Human Anatomy" (1906-1926), which is characterized by its unparalleled illustrations. For more than a century it was the most important book of medical literature in Greece. In 1926 he became a Full Member of the Academy of Athens and was named Life Partner of the International Anatomical Society. His interests included Anatomy, Physiology, Histology, as well as Osteology and Syndesmology. In his book "Human Anatomy", he described for first time the "Sialine Groove of the Stomach", which was described by Waldeyer-Hartz almost at the same time as the "Magenstrasse", a German word that means "stomach road". It is a ribbon-like path that extends along the lesser curvature of the stomach from the gastric cardia to the antrum and releases the gastric content directly into the small intestine. Its importance is confirmed by its association not only with drug delivery, but also with anti-obesity surgical techniques. The old German term has come back into common medical usage in view of the commonly performed Magenstrasse and Mill procedure, a form of bariatric surgery. CONCLUSION: Sclavunos G. managed to observe an anatomical structure that has remained of great importance until today.

A Simplified Three-Layered Suturing Training Pad for Undergraduate Medical Students: A Technical Note.

Surgical training is a long process that requires a lot of commitment and effort. Basic surgical techniques are the foundation of every procedure, with suturing being one of them. Hence, it is of great importance for aspiring young surgeons to practice and develop their suturing skills. Quite many kinds of suturing training models have been used and proposed worldwide, ranging from commercial silicone pads to meat leftovers and various fruits. We have developed our own, simplified, and low-cost suturing training pad that consists of three layers and is based on the combined use of silicone sponge sheet and polyurethane foam. It is quite durable and elastic and has been applied in three suturing training workshops so far. For this reason, we would like to present our experience of a low-cost but effective way of promoting and achieving further surgical excellence.

The Coexistence of an Incomplete Superficial Palmar Arch and a Berrettini Anastomosis: A Case Report.

OBJECTIVE: The aim of this study is to present a relatively rare case of the coexistence of an incomplete superficial palmar arch and a Berrettini anastomosis, identified in a cadaveric specimen, and further discuss the potential clinical implications of such anatomical variations. CASE REPORT: The variation was found in the left hand of a formalin-fixed male cadaver of Greek origin, that was dissected under an operating microscope (×4, ×10 magnification) in our Anatomy Department. In the specimen, we found an incomplete superficial palmar arch, formed only by the superficial branch of the ulnar artery, and a Type 1 Berrettini Anastomosis, originating from the ulnar nerve and joining a branch of the median nerve. CONCLUSION: To avoid iatrogenic damage and permanent loss of sensation, hand surgeons and microsurgeons should be aware of the presence of a BA, and the potential coexistence of this variation with vascular abnormalities in the hand that may complicate surgical procedures.

Anatomical Variations in the Celiac Trunk: A Short Review.

OBJECTIVE: The objective of the current study was the examination of possible variants of the celiac trunk. METHODS: An advanced review of the literature search was undertaken by means of the PubMed database and Google Scholar, searching for new studies published up to October 2022. Additional articles provided useful information in relation to the aim of this review. Hence, articles that met the inclusion criteria were included in this review and the collected data were organized into a table. RESULTS: The search of the literature retrieved 10 articles that referred to the anatomical variations of the celiac trunk. According to the available literature, the most common anatomical variations are: hepatosplenic trunk where the left gastric artery originates from the abdominal aorta, hepatosplenic trunk, where the left gastric artery originates from the splenic artery, and hepatogastric trunk and splenic artery origin from the superior mesenteric artery. Many other anatomical variations of the celiac trunk may exist, such as tetrafurcation, pentafurcation and hexafurcation, that refer to the division of the celiac trunk into four, five or six branches, respectively, and should be reported as they can affect surgical approaches and the development of the appropriate treatment strategy in patients. CONCLUSION: Every visceral surgeon, interventional radiologist and abdominal imager should be familiar with these variants.

Fusion of the Median and Musculocutaneous Nerves Masquerading as Biceps' Innervation from the Median Nerve.

Embryologically, the musculocutaneous nerve (MCN) comes from the lateral root of the median nerve, and thus numerous anatomical variations concerning the formation and branching pattern of these two nerves of the brachial plexus have been described. In this case study, we describe a relatively uncommon case of fusion of the median and MCNs that was identified during routine teaching dissection of a male human cadaver. The identification of this anatomical variation requires awareness of the embryological background, as it may be confused with biceps innervation from the median nerve or the existence of a communicating branch between the two nerves. In addition, awareness of such anatomical variations is of undisputable significance for the safety of surgical operations in the brachial plexus and the arm in general.

Variations of the Median Nerve and Carpal Tunnel Syndrome: a Systematic Review of the Literature.

Objectives:The purpose of this systematic review is to examine the different variations of the median nerve (MN) and the diagnostic methods used to identify carpal tunnel syndrome (CTS), a common neuropathy resulting from the entrapment of the MN within the carpal tunnel. Understanding the different variations of the MN is crucial in order to prevent injuries during surgical treatment of the syndrome. Materials and methods:Data were extracted from studies published in PubMed. A detailed search in PubMed was performed for studies that reviewed the variations of the MN and CTS. Results:There are two main classifications of the MN, known as the Lanz and Amadio categories. Lanz's classification is the one being mostly used in the surgical literature, with group 3 (Bifid MN) being the main cause of the CTS. Additionally, there are branches and anastomosis of the MN that do not fit into either category, with the third common digital branch being the most injured nerve during carpal tunnel release surgery. Diagnostic techniques for CTS include physical examination combined with NCS tests, magnetic resonance imaging (MRI), ultrasound, or elastography. While NCS has been previously the most commonly used diagnostic method, the recent literature suggests that ultrasound and elastography are the most accurate techniques. Conclusions:In order to minimize injuries during carpal tunnel release surgery, it is crucial to have knowledge on the different variations of the MN that cause CTS. Additionally, this review emphasizes the significance of the current diagnostic methods, which not only make CTS more affordable but also facilitate easier recognition of the condition.

Current outcome of prioritized patients for kidney transplantation.

PURPOSE: To analyze the outcome of deceased donor recipients given priority in allocation due to lack of access for dialysis and compare this data to the one obtained from non-prioritized deceased donor kidney transplant recipients. MATERIALS AND METHODS: we reviewed electronic charts of 31 patients submitted to kidney transplantation that were given priority in transplantation program due to lack of access for dialysis from January 2005 to December 2008. Immunological and surgical complications rates, and grafts and patients survival rates were analyzed. These data were compared to those obtained from 100 regular patients who underwent kidney transplantation without allocation priority during the same period. RESULTS: Overall surgical complication rate was 25.8 % and 27 % in the patients with priority in allocation and in the non-prioritized patients, respectively. There was no statistical significant difference for surgical complications (p = 1.0), immunological complications (p = 0.21) and graft survival (p = 0.19) rates between the groups. However, patient survival rate was statistically significant worse in prioritized patients (p = 0.05). CONCLUSIONS: patients given priority in allocation owing to lack of access for dialysis have higher mortality rate when compared to those non-prioritized.

Anxiety, Distress, and Depression in Elderly Rheumatoid Arthritis Patients.

Rheumatoid arthritis (RA) and affective disorders (anxiety/depression) constitute important pathologies in the elderly population, and their coexistence creates synergistically increased problems in functional ability and quality of life of the patients. Purpose: Evaluation of anxiety, distress, and depression in elderly (≥65 years old) patients with RA. Patients ­ methods: 114 patients from the cities of Patras, Arta and Ioannina (all located in Western Greece) were included. Demographics and medical information regarding RA were recorded, including disease duration, medication, previous treatments, disease activity measures, comorbidities etc. Patients answered the State-Trait Anxiety Inventory (STAI), General Health Questionnaire-28 (GHQ28) and Health Assessment Questionnaire -Disability Index (HAQ-DI) questionnaires, for evaluation of anxiety, general health and functional ability, respectively. Statistical analysis was made by using STATA. Results: 88 women (78.07%) and 25 men (21.93%) with median age 70 years and median disease duration 10 years were studied. Female patients, with longer disease duration and higher disease activity, had statistically significant higher levels of anxiety, worse general health and decreased functional ability. A strongly significant association was found between the levels of anxiety and distress, with disease activity and functional inability. Conclusions: Levels of anxiety and distress are strongly associated with disease activity and functional inability in elderly patients with RA. Women with longer disease have higher levels of anxiety and distress. Controlling disease activity is of upmost importance for improvement of anxiety and distress and functional ability. Larger studies are needed for evaluation of anxiety and distress in elderly patients with RA.

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.

INTRODUCTION AND OBJECTIVES: Recurrent transplant pyelonephritis (RTP) secondary to vesico-ureteral reflux (VUR) to the transplant kidney (KTx) remains a significant cause of infectious complications with impact on patient and graft outcomes. Our objective was to verify the safety and efficacy of transurethral injection of Durasphere(®) to relieve RTP secondary to VUR after renal transplantation. PATIENTS AND METHODS: Between June 2004 and July 2008, eight patients with RTP (defined as two or more episodes of pyelonephritis after transplantation) and VUR to the KTx were treated with subureteral injections of Durasphere(®). The mean age at surgery was 38.8 ± 13.8 yr (23-65). The patients were followed regularly every six months. The mean interval between the KTx and the treatment was 76 ± 74.1 (10-238 months). The mean follow-up was 22.3 ± 16.1 months (8-57 months). RESULTS: Six patients (75%) were free of pyelonephritis during a mean period of follow-up of 23.2 ± 17.1 months (8-57 months). Two of them had no VUR and four cases presented with G II VUR (pre-operative G IV three cases and one case G III). In one case, symptomatic recurrent cystitis made a second treatment necessary. This patient remained free of infections for three yr after the first treatment and for 18 months after the second treatment. Of the remaining two patients, one had six episodes of RTP before treatment in a period of three yr and only two episodes after treatment in two yr of follow-up. The last case had a new episode of pyelonephritis five months after treatment. CONCLUSIONS: Transurethral injection therapy with Durasphere(®) is a safe and effective minimally invasive treatment option for KTx patients with recurrent RTP. A second treatment seems to be necessary in some cases.