Intraoperative placing of drains decreases the incidence of lymphocele and deep vein thrombosis after renal transplantation.

OBJECTIVE: To investigate the effect of placing a prophylactic drain during renal transplantation on the incidence of lymphocele, wound complication and deep venous thrombosis (DVT) in renal transplant recipients induced with sirolimus vs calcineurin inhibitors (CNI), as sirolimus-based immunosuppression is a risk factor for the formation of fluid collections after transplantation. PATIENTS AND METHODS: We analysed 165 consecutive adult renal transplant patients at our institution between January 2004 and February 2005. Group 1 (84) did not receive an intraoperative drain and group 2 (81) did. Recipients were analysed within each group based on immunosuppression (sirolimus or CNI) and whether they had wound complication, fluid collection, lymphocele treatment, or DVT. RESULTS: In group 1 and 2, respectively, the wound complication rate was 22.6% vs 13.6% (P = 0.134), the fluid collection rate 45.2% vs 16.% (P < 0.001), the lymphocele treatment rate 19.0% vs 2.5% (P = 0.001) the DVT rate 14.3% vs 4.9% (P = 0.043) the fluid collection rate (for CNI) 26.5% vs 16.0% (P = 0.246), the lymphocele treatment rate (for CNI) 5.9% vs 0% (P = 0.084), the fluid collection rate (sirolimus) 58.0% vs 16.1% (P < 0.001) and lymphocele treatment rate (sirolimus) 28% vs 6.5% (P = 0.018). Multivariate analysis of risk factors for fluid collection showed significance for no drain (odds ratio 3.30, P = 0.002), associated wound complication (2.41, P = 0.041) and sirolimus (2.48, P = 0.015). CONCLUSIONS: Placing a drain during transplantation decreased the incidence of fluid collection, lymphocele treatment and DVT. The reduction of fluid collection and lymphocele were significant for patients treated with sirolimus. We recommend placing a drain in patients undergoing induction with sirolimus-based immunosuppression.

Posttransplant diabetes mellitus in kidney transplant recipients receiving calcineurin or mTOR inhibitor drugs.

BACKGROUND: The aim of this study was to evaluate the incidence and risk factors for posttransplant diabetes mellitus (PTDM; defined as new insulin use and/or new hyperglycemia) in 528 kidney recipients using different immunosuppressive agents. METHODS: Maintenance therapy included mycophenolate mofetil or azathioprine plus glucocorticoids in combination with Group I cyclosporine (263); Group II tacrolimus (60); or Group III sirolimus (205). RESULTS: The mean follow-up was 39.2 (range 9.0-103.8) months. Overall, the number of patients needing insulin was 7.4% (39/528). The incidences for Groups I, II, and III of 7.6%, 11.7%, and 5.9%, respectively, were not statistically different. Characteristics of patients with PTDM included older age (P=0.007); greater body weight (kg) at transplant, 6 months, and 12 months, respectively (P<0.001); greater BMI (kg/m2) at transplant, 6 months, and 12 months, respectively (P<0.001); more acute rejection episodes 28.2% vs. 13.5% (P=0.012); and increased incidence in African Americans (P=0.03). Multivariable analysis demonstrated increased risk for PTDM (defined as new insulin use) for tacrolimus, (hazard ratio [HR] 3.794, P=0.007); treated rejections (HR 2.491, P=0.0115); age (HR 1.407, P=0.0116); and BMI (HR 1.153, P<0.0001). New insulin use occurred sooner and with less total glucocorticoid dose for tacrolimus patients. If PTDM is defined as all cases of new hyperglycemia, then no immunosuppressive drug group demonstrated an increased risk. CONCLUSION.: The risk for developing PTDM is greatest among older recipients, and those obese at the time of transplant; those given steroid pulse therapy were at exceptionally high-risk. PTDM risk reduction should focus on weight loss in the obese end-stage renal disease population prior to transplant.

Non-small cell lung carcinoma metastatic to the kidney.

INTRODUCTION: Renal metastasis by non-small cell lung cancer is uncommon and usually described at autopsy. CASE PRESENTATION: We report the rare case of a 77-year-old man with localized non-small cell lung carcinoma who underwent extirpative surgery and 2 years later presented with gross hematuria and was noted to have a large infiltrating renal mass on computed tomography. CONCLUSIONS: In patients with a prior history of resected localized non-small cell lung carcinoma, presence of a renal lesion should prompt the clinician to consider the possibility of metastasis. Further evaluation should consider this scenario.

Simultaneous vs. sequential laparoscopic bilateral native nephrectomy and renal transplantation.

We reviewed our experience with simultaneous single incision bilateral native nephrectomy and renal transplantation in 11 patients (Group 1), compared to seven recipients who underwent staged laparoscopic bilateral nephrectomy followed by kidney transplantation (Group 2). Mean age, donor source, sex, cause of ESRD, and specimen size were similar in both groups (P=0.1). All Group 2 patients and 9 of 11 Group 1 patients had autosomal-dominant polycystic kidney disease. Perioperative Group 1 complications included: bowel injury, transplant urine leak, necrotic pancreatitis, delayed bowel movement, and severe shoulder pain secondary to diaphragmatic irritation. Seven (63.6%) Group 1 patients required an additional surgical procedure: midline incisional hernia, repair ureteral fistula, and repair enterocutaneous fistula. One Group 1 patient lost his graft secondary to bowel injury and intra-abdominal sepsis. No major complications, reoperations, or graft loss occurred in Group 2. For simultaneous bilateral native nephrectomy and kidney transplantation, over 60% of patients required an additional surgical procedure. Laparoscopic bilateral nephrectomy followed by kidney transplantation is a safe and feasible alternative.

Partial penile disassembly for isolated epispadias repair.

OBJECTIVES: Isolated male epispadias defect is present in 10% of cases of epispadias-exstrophy complex. Surgical repair of epispadias malformation remains debatable as evident by the different techniques adopted. The current study presents our experience in partial penile disassembly for isolated epispadias repair. METHODS: Epispadias repair was performed on 11 male patients aged 4 to 13 years. Two were penopubic, 6 penile, and 3 glanular. All cases were fresh. Extensive disassembly of penile components was performed to the corporal attachments down to the horizontal branches of pubic bones. The corporal bodies were separated with the urethral plate left attached to 1 corpus to preserve its blood supply. Urethral plate was tubularized and then transported from dorsal to ventral position by using corporal rotation technique. Glanuloplasty was then performed. Patients were followed up for 6 to 12 months. RESULTS: The penis had a satisfactory cosmetic appearance with no significant dorsal chordee. Two cases were transformed to subcoronal hypospadias, as it was difficult to bring the urethral plate to the tip of the glans because of its shortening. One child had a minute penopubic fistula that was repaired at a later stage. CONCLUSION: Partial penile disassembly technique restores the anatomic relationship of the penile components. Our repair of partial penile disassembly is a simple modification of the Mitchell technique for isolated epispadias repair.

The predictive value of helical computed tomography for collecting-system entry during nephron-sparing surgery.

OBJECTIVES: To assess the ability of helical computed tomography (CT) including multiplanar reformatting and volume rendering (3D CT) to predict collecting system entry at surgery, as helical CT can be used to delineate renal tumour and normal renal anatomy before nephron-sparing surgery (NSS). PATIENTS AND METHODS: Knowledge of the possibility of collecting system entry during surgery might either dissuade some surgeons from NSS in elective situations or influence the operative approach or ablative technology in cases where NSS is imperative, or prepare the surgeon for the possibility of collecting system repair. We reviewed all 3D CT (349 scans) obtained before NSS at our institution over three consecutive years. Tumour size, central tumour extension, and presence of calyceal involvement were prospectively recorded at the time of 3D rendering. Collecting system entry was analysed for these three CT variables, and for three clinical variables (tumour side, size and surgical approach) collected retrospectively from the medical records. Multivariate logistic regression was used to assess the sensitivity, specificity, and positive and negative predictive values. RESULTS: Of 344 patients, 170 had collecting system entry reported at surgery. There were statistically significant associations between collecting system entry and central tumour location by CT (sensitivity 58.8%, specificity 80.5%, P < 0.001), calyceal involvement at CT (sensitivity 53.5%, specificity 78.2%, P < 0.001), and tumour size on CT of > 4 cm (sensitivity 39.4%, specificity 74.7%, P = 0.005). There were no significant associations with side or type of surgery (P > 0.83). CONCLUSION: Helical CT is a reliable predictor of calyceal entry at surgery.