Pediatric KT in children up to 15 kg: A single-center experience.

BACKGROUND: KT is the preferred treatment for ESRD in pediatrics. However, it may be challenging in those weighing ≤15 kg with potential complications that impact on morbidity and graft loss. METHODS: This retrospective review reports our experience in KT in children, weighing ≤15 kg, and the strategies to reduce morbidity and mortality. RESULTS: All patients were on RRT prior to KT. Patients reached ESRD mainly due to urologic malformations (54.54%). LD was performed in 82% of patients. The recipient's median age was 2.83 years, and median weight 12.280 kg. Male sex was predominant (73%). All patients required transfusions of PRBCs. There was a high requirement for ventilated support in patients post-KT with no relation to weight, amount of resuscitation used intra-operatively or ml/kg of PRBCs. One patient presented with stenosis of the native renal artery. No patients presented DGF, graft thrombosis, or surgical complications. No association was found between cold ischemia and eGFR at 1 year (p = .12). In univariate analysis, eGFR at 1 year is related to AR. eGFR at 3 years is related to the number of UTI. Median follow-up was 1363 days. Patient and graft survival were 100%. CONCLUSIONS: KT in children ≤15 kg can be challenging and requires a meticulous perioperative management and surgical expertise. Patient and graft survival are excellent with low rate of complications.

Robotic surgery in public hospitals of Latin-America: a castle of sand?

INTRODUCTION: There is no information about the evolution of robotic programs in public hospitals of Latin-America. OBJECTIVE: To describe the current status and functioning of robotic programs in Latin-American public hospitals since their beginning to date. METHODS: We conducted a survey among leading urologists working at public hospitals of Latin-America who had acquired the Da Vinci laparoscopic-assisted robotic system. Questions included: date the program started, its utilization by other services, number and kind of surgeries, surgery paying system, surgery related deaths, occurrence and reasons of robotic program interruptions and its use for training purposes. Medians and 25-75 centiles (IQR) were estimated. RESULTS: Since 2009, there are ten public hospitals of four Latin-American countries that acquired the Da Vinci robotic system. The median number of months robotic programs has been functioning without considering transitory interruption: 43 (IQR 35, 55). Median number of urologic and total surgeries performed: 140 (IQR 94, 168) and 336 (IQR 292, 621), respectively. The corresponding median number of urologic and total surgeries performed per month: 3 (IQR 2, 5) and 8 (IQR 5, 11). Median number of total surgeries performed per year per institution was 94 (IQR 68,123). The median proportion of urologic cases was 40% (IQR 31, 48), ranging from 24 to 66%. Five of ten institutions had their urology programs transitory or definitively closed due to the high burden costs. CONCLUSION: Adoption and development of robotic surgery in some public hospitals of Latin-America have been hindered by high costs.

American Confederation of Urology (CAU) experience in minimally invasive partial nephrectomy.

PURPOSE: To describe the perioperative and oncology outcomes in a series of laparoscopic or robotic partial nephrectomies (PN) for renal tumors treated in diverse institutions of Hispanic America from the beginning of their minimally invasive (MI) PN experience through December 2014. METHODS: Seventeen institutions participated in the CAU generated a MI PN database. We estimated proportions, medians, 95 % confidence intervals, Kaplan-Meier curves, multivariate logistic and Cox regression analyses. Clavien-Dindo classification was used. RESULTS: We evaluated 1501 laparoscopic (98 %) or robotic (2 %) PNs. Median age: 58 years. Median surgical time, warm ischemia and intraoperative bleeding were 150, 20 min and 200 cc. 81 % of the lesions were malignant, with clear cell histology being 65 % of the total. Median maximum tumor diameter is 2.7 cm, positive margin is 8.2 %, and median hospitalization is 3 days. One or more postoperative complication was recorded in 19.8 % of the patients: Clavien 1: 5.6 %; Clavien 2: 8.4 %; Clavien 3A: 1.5 %; Clavien 3B: 3.2 %; Clavien 4A: 1 %; Clavien 4B: 0.1 %; Clavien 5: 0 %. Bleeding was the main cause of a reoperation (5.5 %), conversion to radical nephrectomy (3 %) or open partial nephrectomy (6 %). Transfusion rate is 10 %. In multivariate analysis, RENAL nephrometry score was the only variable associated with complications (OR 1.1; 95 % CI 1.02-1.2; p = 0.02). Nineteen patients presented disease progression or died of disease in a median follow-up of 1.37 years. The 5-year progression or kidney cancer mortality-free rate was 94 % (95 % CI 90, 97). Positive margins (HR 4.98; 95 % CI 1.3-19; p = 0.02) and females (HR 5.6; 95 % CI 1.7-19; p = 0.005) were associated with disease progression or kidney cancer mortality after adjusting for maximum tumor diameter. CONCLUSION: Laparoscopic PN in these centers of Hispanic America seem to have acceptable perioperative complications and short-term oncologic outcomes.

Laparoscopic resection of isolated fossa recurrence of renal cell carcinoma after open nephrectomy: report of 6 cases and literature review.

OBJECTIVES: Local recurrence after a correct surgical technique and absence of distant metastasis is a rare occurrence after radical nephrectomy. Surgical resection remains the standard management for this pathological setting. Nevertheless controversy persists over surgical approach and adjuvant treatments. METHODS: We report on perioperative outcomes of a small multi-institutional series of patients with fully laparoscopic management of isolated renal fossa recurrence following open radical nephrectomy. RESULTS: All patients underwent full laparoscopic surgery. Mean operative time was 140 minutes (range 75 to 240 minutes). Only one patient had a Clavien Grade IIIa complication. Mean hospital stay was 3 days (range 2 to 4 days). Out of the six patients, 5 had a mean follow-up of 20 months (range 9 to 32 months). Only one of these patients evolved with distant metastasis after surgery. CONCLUSIONS: Laparoscopic resection of local recurrence after open radical nephrectomy is a challenging but reproducible technique. There is still no consensus or an operative protocol for this clinical setting. However, as long as surgery is kept within the possibilities, a laparoscopic approach should be sought.

Nephron-sparing surgery: our experience in open and laparoscopic approach in 254 cases.

OBJECTIVES: The majority of renal cell carcinomas are now incidentally detected as small renal masses in asymptomatic patients due to the widespread use of ultrasound and new improved noninvasive abdominal imaging modalities. Nephron-sparing surgery is the treatment of choice for patients with small renal masses in presence of normal contralateral kidney or in presence of an anatomic or functional solitary kidney. We reviewed retrospectively our experience in open and laparoscopic partial nephrectomy. METHODS: The records for all patients who underwent nephron-sparing surgery for a renal mass since 1995 at British Hospital of Buenos Aires and Hospital Aleman and since 2000 at Hospital Universitario Austral were reviewed. The most relevant data of 246 patients were collected, with special focus on demographic data, operative details, pathology results, complications and outcome in cancer control. RESULTS: We have performed 254 nephron-sparing surgeries. Open partial nephrectomy was performed in 220 procedures and the laparoscopic partial nephrectomy since 2001 in 34 patients. The indication was elective or relative in 236 patients with 8 patients with bilateral tumors and 18 tumors in a solitary kidney. The pedicle was clamped in 168 procedures with hypothermia in 43 patients. Mean ischemia time was 24.7 minutes. Average tumor size was 3.49 cm. The pathologic findings demonstrate a carcinoma in 193 cases and benign lesions in 61 patients (24%). One patient presented a positive surgical margin in the pathologic examination, but subsequent nephrectomy was negative for residual tumor. One patient presented a pseudo-tumoral mass on follow-up on CT scan and MRI, but nephrectomy was negative for residual tumor. There were postoperative complications in 20 patients (7.9 %). Oncologic follow up was available in 84% of the patients for an average of 46.6 months showing progression with metastasis in 8 patients. Local recurrence was observed in 4 patients (2%). One patient developed a tumor in the contralateral kidney 20 months after partial nephrectomy and another one 10 years later. The cancer specific survival and overall survival rates were 98 % and 95% respectively. In the last year the laparoscopic approach duplicated the indications of all previous years. CONCLUSIONS: Open partial nephrectomy is considered nowadays the gold standard treatment of small renal masses, and in our experience it is a safe and effective technique of treatment of these tumors. The evolution of the technology and the acquirement of laparoscopic skills allow us in selected cases to duplicate the open approach in a laparoscopic way, obtaining similar results.

[Epidemiology, etiology and prevention of bladder cancer.] / Epidemiología, etiología, prevención del cáncer vesical.

Bladder cancer is the seventh most frequent cancer on male population and eleventh within the whole inhabitants. Differences in incidence and mortality between countries and regions exist. Those differences depend on variables including epidemiological data, social and cultural features and economics amongst the several populations that are exposed to different risk factors and treatment approaches. Smoking is the strongest risk factor for bladder cancer, representing approximately 50% of the cases. Its alternative, the electronic cigarette does not seem to providea decrease in risk of bladder cancer. Employment exposure to aromatic amines, aromatic polycyclic hydrocarbons and chlorate hydrocarbons, are still important risk factors. Water consumption with high levels of arsenic has also shown an increased risk of bladder cancer. Fast acetylators or genetic predisposition would be tentative risk factors. Some medical treatments with chemotherapy oradiation therapy increase bladder cancer risk. Identifying all these factors allows for progress in the field of prevention and early detection. The main objective is to decrease incidence and mortality related to bladder cancer.

El cáncer de vejiga (CV) es el séptimo cáncer más frecuente en la población masculina y el undécimo en frecuencia cuando se consideran ambos sexos. Existen diferencias de incidencia y mortalidad entre los países y regiones, en relación a una serie de variables que incluyen desde la recolección de los datos epidemiológicos, las características socioculturales y económicas de las distintas poblaciones hasta diferencias en la exposición a los factores de riesgo y formas de tratamiento. El tabaquismo es el factor de riesgo mejor establecido para el CV, representando aproximadamente el 50% de los casos; su alternativa, el cigarrillo electrónico, no parece ser menos riesgoso para la aparición de este tumor. La exposición ocupacional a aminas aromáticas, hidrocarburos aromáticos policíclicos e hidrocarburos clorados, pese a la prohibición de la utilización de determinadas sustancias, sigue siendo un factor de riesgo importante para CV. La ingesta de agua con niveles elevados de trihalometanoso arsénico han demostrado tener relación a un aumento de la incidencia del CV. Los acetiladores lentos o predisposiciones genéticas podrían ser de importancia en la potenciación de los factores de riesgo. Hay tratamientos médicos con quimioterapia o radioterapia que aumentan el riesgo de CV. La importancia del reconocimiento de todos éstos factores hace posible avanzarsobre el terreno de la prevención y la detección precoz,c on la intención de disminuir de la incidencia y mortalidad por CV.