RESUMO
INTRODUCTION: Indication for percutaneous-ablation (PA) is gradually expanding to renal tumors T1b (4-7cm). Few data exist on the alteration of renal functional volume (RFV) post-PA. Yet, it is a surrogate marker of post partial-nephrectomy (PN) glomerular filtration rate (GFR) impairment. The objective was to compare RFV and GFR at 1-year post-PN or PA, in this T1b population. METHODS: Patients with unifocal renal tumor≥4cm treated between 2014 and 2019 were included. Tumor, homolateral (RFVh), contralateral RFV, and total volumes were assessed by manual segmentation (3D Slicer) before and at 1 year of treatment, as was GFR. The loss of RFV, contralateral hypertrophy, and preservation of GFR were compared between both groups (PN vs. PA). RESULTS: 144 patients were included (87PN, 57PA). Preoperatively, PA group was older (74 vs. 59 years; P<0.0001), had more impaired GFR (73 vs. 85mL/min; P=0.0026) and smaller tumor volume(31.1 vs. 55.9cm3; P=0.0007) compared to PN group. At 1 year, the PN group had significantly more homolateral RFV loss (-19 vs. -14%; P=0.002), and contralateral compensatory hypertrophy (+4% vs. +1,8%; P=0.02, respectively). Total-RFV loss was similar between both (-21.7 vs. -19cm3; P=0.07). GFR preservation was better in the PN group (95.9 vs. 90.7%; P=0.03). In multivariate analysis, age and tumor size were associated with loss of RFVh. CONCLUSION: For renal tumors T1b, PN is associated with superior compensatory hypertrophy compared with PA, compensating for the higher RFVh loss, resulting in similar ΔRFV-total between both groups. The superior post-PN GFR preservation suggests that the preserved quantitative RFV factor is insufficient. Therefore, the underlying quality of the parenchyma would play a major role in postoperative GFR.
Assuntos
Neoplasias Renais , Humanos , Neoplasias Renais/cirurgia , Nefrectomia , Rim/cirurgia , Taxa de Filtração Glomerular , HipertrofiaRESUMO
PURPOSE: Robot-assisted partial nephrectomy (RAPN) for posterior renal tumors may be performed through anterior (transperitoneal) or posterior (retroperitoneal) approach depending on surgeon's expertise. We propose herein a surgical artifice using daVinci Xi system to combine advantages of both approaches. MATERIALS AND METHODS: From November 2019 to November 2020, patients with posterior renal mass, candidate for RAPN were prospectively included after informed consent. After positioning patient in lateral position, daVinci Xi system was docked on tumor side, to initiate transperitoneal procedure. Posterolateral dissection of perinephric space along fascia retrorenalis was conducted until psoas major muscle was exposed. Three additional robotic ports were then inserted in lumbar space, and RAPN was resumed after rotating daVinci Xi boom. Demographics, tumor characteristics, perioperative outcomes, estimated glomerular filtration rate (eGFR) and follow-up data were analyzed. RESULTS: Ten consecutive patients underwent RAPN with the modified technique. All cases were performed robotically, without modification of port placement. Median (range) tumor diameter was 37 (21-48mm) with median RENAL score of 8 (4-10) Median operative time and warm ischemia time were respectively 128min (70-180min) and 19min (14-22). One patient had a Clavien-Dindo grade II complication. At median follow-up of 13 months (6-18), all patients had eGFR comparable to baseline. CONCLUSIONS: We report the feasibility and safety of a new hybrid posterior transperitoneal approach for RAPN using daVinci Xi system. Limitations include the absence of RENAL score>10 and pT2 tumors. Greater experience is needed to assess learning curve for surgeons untrained to robotic lomboscopy.
Assuntos
Neoplasias Renais , Procedimentos Cirúrgicos Robóticos , Robótica , Estudos de Viabilidade , Humanos , Neoplasias Renais/patologia , Nefrectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Robótica/métodos , Resultado do TratamentoRESUMO
OBJECTIF: Evaluate kidney autotransplantation (KAT) and ileal ureter substitution (IUS) practice and outcome as alternatives to indwelling ureteral stents for the management of long ureteral stenosis (US). MATERIAL: We included all patients treated for US with KAT or IUS in 5 French university urology centers between 2010 and 2018. We excluded US due to urothelial carcinoma. Primary endpoint was the preservation of ipsilateral kidney and renal function without any urinary diversion. RESULTS: 22 patients were treated with KAT (n=8, 36.4%) and IUS (n=14, 63.6%). Mean US length was 4.6cm and 6cm (P=0.52) in KAT and IUS groups respectively. US etiologies were lithiasis, iatrogenic, retroperitoneal fibrosis or extrinsic compression. US level was varied. The surgery was described as difficult because of peritoneal adhesions or major peri-ureteral fibrosis. Mean operating time and hospital stay were 336 and 346minutes (P=0.87) and 8 and 15 days respectively (P=0.001). Postoperative complications were mostly Clavien ≤2 (n=17, 77.3%). Revision surgery was required in the KAT group in 3 cases (37.5%), for textiles, renal vein thrombosis and anastomotic leak, none in the IUS group. The mean follow-up was 15.7 months. All but one (in the KAT group) ipsilateral kidneys were preserved, without renal function impairment (Δcreat +2.1 vs. +2.4µmol/l respectively, P=0.67), nor urinary diversion. CONCLUSION: KAT and IUS are safe alternatives whose indication depends on surgeons expertise. Our study pointed out the scarcity of this practice suggesting the need to refer patients to expert centers. LEVEL OF EVIDENCE: 3.
Assuntos
Carcinoma de Células de Transição , Ureter , Neoplasias da Bexiga Urinária , Constrição Patológica , Humanos , Estudos Retrospectivos , Stents , Ureter/cirurgiaRESUMO
INTRODUCTION: Neoadjuvant chemotherapy (NAC) is now recommended to treat muscle-invasive bladder cancer (MIBC) but is not always executed in real life. This study aims to evaluate the proportion of patients with MIBC who receive an optimal NAC, and to present the predictive factors of its achievement. METHODS: This monocenter retrospective study included all the patients who underwent radical cystectomy for≥pT2NxM0 MIBC between 2013, January and 2018, December. NAC consisted in 4-6 cycles of MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) or 4 cycles of GC (gemcitabin, and carboplatin). Demographic (sex, age, ECOG-PS, glomerular filtration rate [GFR], and cN stage), surgical (urinary derivation, time of surgery, blood loss, and complications), and oncological characteristics were analyzed. Multivariate analysis are made to find predictors of administration of NAC. RESULTS: One hundred and twenty-seven patients were included. Thirty received CNA (24%). Patients who underwent CNA were younger, with better ECOG and better GFR. Multivariate analysis showed that cN+ stage and better GFR were significantly associated to administration of NAC. Eight patients (27%) couldn't receive an optimal treatment due to toxicity. Perioperative complication rates were similar, with or without NAC. Patients who underwent NAC had a worse GFR after treatment (-17 versus +5mL/min, P<0.01). CONCLUSION: Due to the risks of toxicity, NAC can only be proposed to selected population, which is not the current patients. Immunotherapy could allow to treat more patients because of better tolerance. LEVEL OF EVIDENCE: 3.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Bexiga Urinária/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Quimioterapia Adjuvante , Feminino , Humanos , Masculino , Terapia Neoadjuvante , Invasividade Neoplásica , Padrões de Prática Médica , Estudos Retrospectivos , Resultado do Tratamento , Neoplasias da Bexiga Urinária/patologia , UrologiaRESUMO
OBJECTIVE: To propose recommendations for the management of renal cell carcinomas (RCC) of the renal transplant. METHOD: Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU to evaluate prevalence, diagnosis and management of RCC arousing in the renal transplant. References were assessed according to a predefined process to propose recommendations with levels of evidence. RESULTS: Renal cell carcinomas of the renal transplant affect approximately 0.2% of recipients. Mostly asymptomatic, these tumors are mainly diagnosed on a routine imaging of the renal transplant. Predominant pathology is clear cell carcinomas but papillary carcinomas are more frequent than in general population (up to 40-50%). RCC of the renal transplant is often localized, of low stage and low grade. According to tumor characteristics and renal function, preferred treatment is radical (transplantectomy) or nephron sparing through partial nephrectomy (open or minimally invasive approach) or thermoablation after percutaneous biopsy. Although no robust data support a switch of immunosuppressive regimen, some authors suggest to favor the use of mTOR inhibitors. CTAFU does not recommend a mandatory waiting time after transplantectomy for RCC in candidates for a subsequent renal tranplantation when tumor stageAssuntos
Carcinoma de Células Renais/terapia
, Neoplasias Renais/terapia
, Transplante de Rim
, Complicações Pós-Operatórias/terapia
, Humanos
RESUMO
OBJECTIVE: To define guidelines for the management of renal cell carcinoma of the native kidney (NKRCC) in kidney transplant (KTx) recipients and renal cell carcinoma (RCC) in end-stage renal disease (ESRD) patients candidates for renal transplantation. METHOD: A review of the literature following a systematic approach (Medline) was conducted by the CTAFU to report renal cell carcinoma epidemiology, screening, diagnosis and management in KTx candidates and recipients. References were assessed according to a predefined process to propose recommendations with the corresponding levels of evidence. RESULTS: ESRD patients are at higher risk of RCC with a standardized incidence ratio of approximately 4,5 as compared with general population. NKRCC tumors occur in 1 to 3 % of KTx recipients with a 10 to 15-fold increased risk as compared with general population, especially in patients with acquired multicystic kidney disease. Most authors suggest yearly monitoring of the native kidneys using ultrasound imaging. Radical nephrectomy (either open or laparoscopic approach) is the preferred treatment of NKRCC in KTx recipients and RCC in ESRD. Surveillance in a valid option in small or cystic renal masses. In the localized setting, change in immunosuppressive therapy is not recommended besides perioperative avoidance of mTOR inhibitor to limit morbidity. CTAFU does not recommend a mandatory waiting time after nephrectomy for RCC in ESRD patients candidates for renal tranplantation when tumor stageAssuntos
Carcinoma de Células Renais/diagnóstico
, Carcinoma de Células Renais/cirurgia
, Falência Renal Crônica/cirurgia
, Neoplasias Renais/diagnóstico
, Neoplasias Renais/cirurgia
, Transplante de Rim
, Complicações Pós-Operatórias/diagnóstico
, Complicações Pós-Operatórias/cirurgia
, Carcinoma de Células Renais/complicações
, Humanos
, Falência Renal Crônica/complicações
, Neoplasias Renais/complicações
RESUMO
OBJECTIVE: To propose surgical recommendations for urothelial carcinoma management in kidney transplant recipients and candidates. METHOD: A review of the literature (Medline) following a systematic approcah was conducted by the CTAFU regarding the epidemiology, screening, diagnosis and treatment of urothelial carcinoma in kidney transplant recipients and candidates for renal transplantation. References were assessed according to a predefined process to propose recommendations with levels of evidence. RESULTS: Urothelial carcinomas occur in the renal transplant recipient population with a 3-fold increased incidence as compared with general population. While major risk factors for urothelial carcinomas are similar to those in the general population, aristolochic acid nephropathy and BK virus infection are more frequent risk factors in renal transplant recipients. As compared with general population, NMIBC in the renal transplant recipients are associated with earlier and higher recurrence rate. The safety and efficacy of adjuvant intravesical therapies have been reported in retrospective series. Treatment for localized MIBC in renal transplant recipients is based on radical cystectomy. In the candidate for a kidney transplant with a history of urothelial tumor, it is imperative to perform follow-up cystoscopies according to the recommended frequency, depending on the risk of recurrence and progression of NMIBC and to maintain this follow-up at least every six months up to transplantation whatever the level of risk of recurrence and progression. Based on current data, the present recommendations propose guidelines for waiting period before active wait-listing renal transplant candidates with a history of urothelial carcinoma. CONCLUSION: The french recommendations from CTAFU should contribute to improve the management of urothelial carcinoma in renal transplant patients and renal transplant candidates by integrating both oncologic objectives and access to transplantation.
Assuntos
Carcinoma de Células de Transição/diagnóstico , Carcinoma de Células de Transição/terapia , Falência Renal Crônica/cirurgia , Transplante de Rim , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Neoplasias Urológicas/terapia , Carcinoma de Células de Transição/complicações , Humanos , Falência Renal Crônica/complicações , Neoplasias Urológicas/complicaçõesRESUMO
OBJECTIVE: To define guidelines for the use of antiplatelet therapy (AT) and direct oral anticoagulants (DOAC) in candidates for kidney allotransplantation. METHOD: A review of the medical literature following a systematic approach was conducted by the CTAFU to report the use of AT and DOAC before major surgery and in the setting of advanced chronic kidney disease, defining their managment prior to kidney transplantation with the corresponding level of evidence. RESULTS: DOAC are not recommended in patients under dialysis. Aspirin therapy, but not anti-P2Y12 and DOAC, may be maintained during renal transplantation. Anti-P2Y12 and DOAC should not be use in patients awaiting a kidney transplant, except when a living donor is scheduled, therefore authorizing treatment interruption in optimal conditions. Further data regarding DOAC reversion and monitoring may improve their use in this setting. Global level of evidence is weak. CONCLUSION: These French recommendations should contribute to improve surgical management of kidney transplant candidates exposed to AT or DOA.
Assuntos
Inibidores do Fator Xa/uso terapêutico , Transplante de Rim , Inibidores da Agregação Plaquetária/uso terapêutico , Humanos , Período Pré-OperatórioRESUMO
OBJECTIVE: To define guidelines for the management of localized prostate cancer (PCa) in kidney transplant (KTx) candidates and recipients. METHOD: A systematic review (Medline) of the literature was conducted by the CTAFU to report prostate cancer epidemiology, screening, diagnosis and management in KTx candidates and recipients with the corresponding level of evidence. RESULTS: KTx recipients are at similar risk for PCa as general population. Thus, PCa screening in this setting is defined according to global French guidelines from CCAFU. Systematic screening is proposed in candidates for renal transplant over 50 y-o. PCa diagnosis is based on prostate biopsies performed after multiparametric MRI and preventive antibiotics. CCAFU guidelines remain applicable for PCa treatment in KTx recipients with some specificities, especially regarding lymph nodes management. Treatment options in candidates for KTx need to integrate waiting time and access to transplantation. Current data allows the CTAFU to propose mandatory waiting times after PCa treatment in KTx candidates with a weak level of evidence. CONCLUSION: These French recommendations should contribute to improve PCa management in KTx recipients and candidates, integrating oncological objectives with access to transplantation.
Assuntos
Falência Renal Crônica/cirurgia , Transplante de Rim , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/terapia , Humanos , Falência Renal Crônica/complicações , Masculino , Neoplasias da Próstata/complicaçõesRESUMO
OBJECTIVE: To propose surgical recommendations for the management of lower urinary tract symptoms (LUTS) and urinary incontinence in kidney transplant recipients and candidates. METHOD: Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU focusing on medical and surgical treatment of LUTS and urinary incontinence in kidney transplant recipients and candidates. References were assessed according to a predefined process to propose recommendations with levels of evidence. RESULTS: Functional bladder capacity and bladder compliance are impaired during dialysis. LUTS, related to pre-kidney transplantion alterations, frequently improve spontaneously after kidney transplantation. LUTS secondary to benign prostatic hyperplasia (BPH) may be underestimated before kidney transplantation due to oliguria, low bladder compliance and low bladder capacity. In LUTS associated with BPH, anticholinergics require dosage adjustment with creatinine clearance. If surgery is indicated after kidney transplantation, procedure can be safely performed in the early post-transplant course after removal of ureteral stent. Surgical management of urinary incontinence does not seem to be associated with an icreased risk for infectious complications in kidney transplant recipients. Particular attention should be paid to the management of postvoid residual and bladder pressures in case of neurological bladder disease. Optimal care of neurological bladder should be provided prior to transplantation: with a cautious management, and despite an increased occurrence of febrile urinary tract infections, transplant survival is not compromised. CONCLUSION: These recommendations must contribute to improve the management of lower urinary tract symptoms and urinary incontinence in kidney transplant patients and kidney transplant candidates.
Assuntos
Transplante de Rim , Sintomas do Trato Urinário Inferior/complicações , Sintomas do Trato Urinário Inferior/cirurgia , Complicações Pós-Operatórias/cirurgia , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/cirurgia , Incontinência Urinária/complicações , Incontinência Urinária/cirurgia , HumanosRESUMO
OBJECTIVE: To propose surgical recommendations for living donor nephrectomy. METHOD: Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU regarding functional and anatomical assessment of kidney donors, including which side the kidney should be harvested from. Distinct surgical techniques and approaches were evaluated. References were considered with a predefined process to propose recommendations with the corresponding levels of evidence. RESULTS: The recommendations clarify the legal and regulatory framework for kidney donation in France. A rigorous assessment of the donor is one of the essential prerequisites for donor safety. The impact of nephrectomy on kidney function needs to be anticipated. In case of modal vascularization of both kidneys without a relative difference in function or urologic abnormality, removal of the left kidney is the preferred choice to favor a longer vein. Mini-invasive approaches for nephrectomy provide faster donor recovery, less donor pain and shorter hospital stay than open surgery. CONCLUSION: These French recommendations must contribute to improving surgical management of candidates for kidney donation.
Assuntos
Doadores Vivos , Nefrectomia/normas , França , Humanos , Obtenção de Tecidos e ÓrgãosRESUMO
INTRODUCTION: In front of a very calcified aortoiliac axis, renal transplantation with implantation of the artery on vascular prosthesis can be proposed. This rare intervention is considered difficult and morbid. The main objective of this work was to evaluate the overall and specific survival of the transplant in this situation. The secondary objective was the study of the complications and the evolution of the transplant's renal function. MATERIAL AND METHODS: From a multicenter retrospective data collection of the DIVAT cohort (6 centers) added with data from 4 other transplant centers, we studied transplants with prosthetic arterial anastomosis. RESULTS: Thirty four patients was included. The median duration of follow-up was 2.5 years. 4 patients died in the month following transplantation, 16 were hemodialysis and 9 were transfused. The median survival of the transplant was 212 days. Functional arrests of the transplant were mostly associated with nephrological degradation and return to dialysis (about 80%) while 10% were related to a death of the recipient directly attributable to renal transplantation. The surgical complications of the transplantation were marked by one arterial stenosis, one fistula and 4 urinary stenoses. CONCLUSION: Thus, renal transplantation with arterial anastomosis on vascular prosthesis, on selected patients, offers an alternative to dialysis. A national compendium of transplanted patients on vascular prosthesis would allow a long-term follow-up of transplant's survival and define selection criteria prior to this kind of surgery. LEVEL OF EVIDENCE: 3.
Assuntos
Prótese Vascular , Transplante de Rim/métodos , Adulto , Idoso , Anastomose Cirúrgica , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos VascularesRESUMO
INTRODUCTION: Partial nephrectomy (PN) is the gold standard treatment for renal cell carcinomas under 4cm. No robust data exists to recommend PN for tumours>7cm (cT2). The objective of this work is to evaluate the results of PN for cT2 tumours. PATIENTS AND METHODS: All patients who underwent PN or radical nephrectomy (RN) for cT2 tumours between 2000 and 2013 at our institution have been included. Patient demographics, postoperative data including renal function, morbidity, mortality and oncologic outcomes were reviewed retrospectively and compared using χ2 test, Mann-Whitney test, Kaplan-Meier method and log rank test. RESULTS: We included 130 patients, 49 (38%) in the PN group and 81 (62%) in the RN group, with a median follow-up of 42 months [19-69]. Variation of postoperative renal function at day 5 and last recorded value was significantly different between the groups (P=0.03 and P<0.001). The PN group had a significantly higher complication rate as compared with RN group (37% versus 14%, P=0.002). There were no significant differences between the two groups for overall, recurrence free and specific survival (P=0.55, P=0.55, P=0.24, respectively). In univariate analysis, the type of surgery (PN versus RN) was not associated with a significant difference of oncologic outcome (margins, survival). CONCLUSION: PN can be offered for cT2 tumours with oncological outcomes similar to RN. Despite an increased morbidity, it remains acceptable with the demonstrated advantage of preservation of renal function. LEVEL OF EVIDENCE: 4.
Assuntos
Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Néfrons/cirurgia , Tratamentos com Preservação do Órgão/métodos , Carga Tumoral/fisiologia , Adulto , Idoso , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/fisiopatologia , Feminino , Seguimentos , Humanos , Testes de Função Renal , Neoplasias Renais/patologia , Neoplasias Renais/fisiopatologia , Masculino , Pessoa de Meia-Idade , Néfrons/patologia , Néfrons/fisiopatologia , Estudos RetrospectivosRESUMO
INTRODUCTION: Elderly patients represent a growing part of our society for who treatment strategy for localized renal tumors has to be chosen knowing iatrogen effects and renal function morbidity. The aim was to analyze oncological and functional results of nephron sparing surgery (PN) versus radiofrequency ablation (RFA). MATERIALS AND METHODS: All patients aged more than 75 treated by partial nephrectomy or radiofrequency ablation between 2007 and 2014 in our centre were included. Patient and tumors data were compared and these criteria were analyzed: survival (overall and without recurrence) and loss of renal function (pre- and postoperative MDRD). RESULTS: In total, 100 patients were included (26 partial nephrectomies, group 1 and 74 radiofrequency ablation, group 2) with a 32-months medium follow-up. Medium age and tumor size were significantly different (respectively, 78 versus 81 years old, P=0.001, 38mm versus 29mm, P=0.003). Perioperative results showed no differences in complications. Transfusion rate and duration of hospital stay were significantly higher in the PN group. Median overall survival were 45 vs. 27 months (P=0.23) for PN and RFA and median recurrence-free survival were 28 vs. 10 months (P=0.34). On a multivariate analysis, operative technique (PN or RFA) were not significantly linked to survival (HR 2.37 [95% CI: 0.66-8.5]), P=0.19. Loss of renal function were 1.5±14mL/min/1.73m2 for PN and 3±14mL/min/1.73m2 for RFA (P=0.69). CONCLUSION: Our study showed better perioperative results for RFA than for PN, without significant different survival. Loss of renal function were little and similar. LEVEL OF EVIDENCE: 4.
Assuntos
Ablação por Cateter , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: The epidemiology of kidney cancer is evolving with a net increase in the incidence of renal tumors, globally, and in young people in particular. OBJECTIVE: To evaluate the incidence and clinical and pathological characteristics of sporadic renal tumors in young subjects and their risk factors. MATERIAL AND METHODS: A retrospective study aimed at collecting clinical, epidemiological and anatomopathological information from the 118 patients aged 18 to 40 treated for a sporadic kidney tumor in two Parisian university hospital centers between 2003 and 2013. RESULTS: Our study showed a very significant increase in the incidence of renal tumors in our 11 years of decline (P=6.10-15). The mode of discovery also seems to have evolved with a majority of tumors (67 %), due to the considerable growth of imaging in recent decades. We also showed a different pathological distribution compared to the literature with a significant increase in the number of papillary tumors (16.9 %) and chromophobes (15.2 %), in addition to a decrease in the number of carcinomas (43.2 %) as well as the appearance of a new pathological entity of particular clinical severity: renal carcinoma related to translocation Xp11.2 (15.3 %) (P<10-5). Among the risk factors, hypertension seems to be a definite risk factor while tobacco and obesity do not have a significant influence. CONCLUSION: Our study showed a marked increase in the incidence of renal tumors with specific clinical and epidemiological features in a population of young subjects. The role and importance of oncogenetic management as well as the study of environmental factors could lead to the identification of new risk factors and corollary to their prevention. LEVEL OF EVIDENCE: 4.
Assuntos
Neoplasias Renais/epidemiologia , Neoplasias Renais/patologia , Adolescente , Adulto , Fatores Etários , Feminino , Humanos , Incidência , Masculino , Estudos Retrospectivos , Adulto JovemRESUMO
INTRODUCTION: Compare three morphometrics scores of the kidney on the reproductibility and the predictability of complications per- and post-partial nephrectomy. MATERIALS AND METHODS: This comparative study analyzed a monocentric retrospective cohort of 47 patients affected by a unique renal tumor and operated by partial nephrectomy by lumbotomy excluding the genetic diseases from January till December, 2014. The preoperative scanners were reviewed in double-blind by a radiologist and an internal surgeon who classified each tumor according to the three classifications: R.E.N.A.L. score, score in 12 segments and the University Paris Renal Cancer Classification (UPRCC). The judging criteria were the operative and ischemic duration, the blood loss, the preoperative injuries, the length of the hospital stay, the postoperative complications according to the Clavien-Dindo classification. The Cohen's kappa coefficient and the one-way analysis of variance were used respectively to compare the inter-observer reproducibility and the predictability of the complications for each classification. RESULTS: Forty-four tumors of which 30 (64%) were on the left kidney, with an average size of 55.19mm with 17 (39%) on the upper pole, 12 (27%) on the lower pole and 15 (34%) medio-renal. The UPRCC was the most reproductible classification with 90% inter-observer concordance against 84% for the R.E.N.A.L. score and 72% for the score in 12 segments. The most predictable classification of complications was the score in 12 segments in particular thanks to the subgroup including the number of segments reached which allows to predict significantly the risk of a duration of intervention, prolonged ischemia and the risk of blood loss (P=0.03, 0.06 and <0.001). CONCLUSION: The main result of this study is that, as in the majority of the previous studies on morphometrics scores, no score allows to predict the postoperative complications. LEVEL OF EVIDENCE: 4.
Assuntos
Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
OBJECTIVE: To report the nature, incidence, diagnosis and treatment options of surgical complications after renal transplantation. MATERIAL AND METHODS: Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov/) and Embase (http://www.embase.com/) database from 1960 to 2016 using the following keywords "fistula; lymphocele; stricture; thrombosis", in association with "renal transplantation" in Title/Abstract field. Articles were selected according to methods, language of publication and relevance. A total of 7618 articles were identified including specifically 981 for vascular complications, 1016 for urologic complications and 239 for lymphocele; after careful selection 190 publications were eligible for our review. RESULTS: Surgical complications occur in 1 to 30% of renal transplantations while being incompletely reported without consensual management. Angioplasty techniques led to a significant improvement of short- and long-term vascular complications outcome. Risk factors for transplant thrombosis are a right allotransplant, multiple renal arteries or vasculopathy in the donor, diabetes, arterial disease or thrombophilia in the recipient and hemodynamic changes during procedure. Urinary complications and lymphocele significantly impair overall outcome and recipients quality of life with no demonstrated impact on allotransplant survival. Immediate or salvage pelvi-ureterostomy is a main treatment option for ureteral strictures and fistula. CONCLUSION: Prevention of surgical complications following renal transplantation relies on careful allotransplant preparation and strict respect of surgical best practices. Increasing comorbidities in recipients as well as marginal donors are significant limits for the improvement of post-transplant surgical outcome.
Assuntos
Transplante de Rim/efeitos adversos , Complicações Pós-Operatórias/etiologia , Árvores de Decisões , Humanos , Linfocele/diagnóstico , Linfocele/etiologia , Linfocele/terapia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Doadores de Tecidos , Doenças Urológicas/diagnóstico , Doenças Urológicas/etiologia , Doenças Urológicas/terapia , Doenças Vasculares/diagnóstico , Doenças Vasculares/etiologia , Doenças Vasculares/terapiaRESUMO
OBJECTIVES: To review epidemiologic data's and medical results of deceased donation in renal transplantation. MATERIAL AND METHODS: Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association, "brain death; cardiac arrest; deceased donation; organ procurement; transplantation". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and recommendations were selected. In addition, French national transplant and health agencies (http://www.agence-biomedecine.fr and http://www.has-sante.fr) databases were screened using identical keywords. A total of 2498 articles, 8 official reports and 17 newspaper articles were identified; after careful selection 157 publications were eligible for our review. RESULTS: Deceased donation may involve either brain death or non-heartbeating donors (NHBD). Organ shortage led to the procurement of organs from expanded-criteria donors, with an increased age at donation and extended vascular disease, leading to inferior results after transplantation and underlining the need for careful donor management during brain death or cardiac arrest. Evolution of French legislation covering bioethics allowed procurement from Maastricht categories II and recently III non-heartbeating donors. CONCLUSION: The increase of organ shortage emphasizes the need for a rigorous surgical technique during procurement to avoid loss of transplants. A history or current neoplasm in deceased-donors, requires attention to increase the pool of organs without putting the recipients at risk for cancer transmission. French NHBD program, especially from Maastricht category III, may stand for a potential source of valuable organs.
Assuntos
Transplante de Rim , Doadores de Tecidos , Obtenção de Tecidos e Órgãos , Algoritmos , Morte Encefálica , Protocolos Clínicos , Seleção do Doador/métodos , Seleção do Doador/normas , Parada Cardíaca , Humanos , Transplante de Rim/métodos , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Doadores de Tecidos/legislação & jurisprudência , Doadores de Tecidos/estatística & dados numéricos , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos/legislação & jurisprudência , Obtenção de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/normasRESUMO
OBJECTIVES: To describe lower urinary tract symptoms (LUTS) and their management in renal transplant candidates and recipients. MATERIAL AND METHODS: Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association: "transplantation", "prostate hyperplasia", "transurethral resection of prostate", "urinary incontinence", "LUTS", "pelvic floor dysfunction". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and case reports were selected. In addition, French national transplant and health agencies (http://www.agence-biomedecine.fr and http://www.has-sante.fr) databases were screened using identical keywords. A total of 991 articles were analyzed and after careful selection, 47 publications were eligible for our review. RESULTS: Reduction of bladder capacity, due to dialysis and anuria, is correlated with dialysis duration. This reduction is reversible after renal transplantation and does not seem to put renal transplant recipients at risk for medical complications. Transplant procedure generally allows restoration of bladder maximal output, normal bladder capacity and compliance. Medical treatment of LUTS related to prostate hyperplasia (BPH) includes alpha-blockers and finasteride. Silodosin and dutasteride have not been evaluated in that setting. Antimuscarinics may be used with caution, and favor the use of solifenacin at 5mg per day. Surgical treatment of BPH requires a preserved urine output, otherwise must be delayed after transplantation; it may thus be performed safely in the early postoperative course. Botulinum toxin injections and surgical treatment of stress incontinence and prolapse are barely reported in this population. CONCLUSION: Precise assessment and optimal management of LUTS in renal transplant candidates and recipients are critical to improve quality of life and to preserve allotransplant function. Literature data lack evidence to propose robust recommendations. However, knowledge of reported specificities in this peculiar setting is mandatory for urologists to provide patients with finest options and optimal treatment timing.
Assuntos
Falência Renal Crônica/complicações , Falência Renal Crônica/cirurgia , Transplante de Rim , Sintomas do Trato Urinário Inferior/complicações , Distúrbios do Assoalho Pélvico/complicações , Complicações Pós-Operatórias/etiologia , Humanos , Sintomas do Trato Urinário Inferior/diagnóstico , Sintomas do Trato Urinário Inferior/fisiopatologia , Sintomas do Trato Urinário Inferior/terapia , Masculino , Distúrbios do Assoalho Pélvico/diagnóstico , Distúrbios do Assoalho Pélvico/fisiopatologia , Distúrbios do Assoalho Pélvico/terapia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Hiperplasia Prostática/complicações , UrodinâmicaRESUMO
OBJECTIVES: To describe kidney transplantation surgical techniques and to propose strategies in high-risk recipients. MATERIAL AND METHODS: Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov/) and Embase (http://www.embase.com/) database using the following keywords, alone or in association, "renal transplantation; peripheral arterial disease; obesity; third and fourth transplantation; robotic-assisted kidney transplant; anticoagulant therapy; dual kidney transplant". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and case-reports were selected. A total of 1949 articles were analyzed for arterial disease and anticoagulant therapy, 1083 for obesity, 663 for dual kidney transplants, 458 for third and subsequent procedures and 84 for robotic-assisted kidney transplantation. After careful selection, 304 publications were eligible for our review. RESULTS: Surgical assessment of future recipients is a pivotal step to anticipate technical difficulties, to interrupt clopidogrel or direct oral anticoagulants and to propose a revascularization procedure when necessary. Lack of data regarding obese recipients does not allow us to conclude about best surgical care or optimal timing but suggest that an early global management of obesity in chronic kidney disease patients is mandatory to improve access to a successful transplantation. In neurologic bladder and congenital anomalies, urodynamics and bladder function must be assessed prior to the onset of oliguria to intend an early treatment. Urinary diversion may be performed prior to or after transplantation with similar survival outcome and comparable rates of infections. Because of a rigorous selection of donors, the French dual kidney transplant program provides satisfactory outcomes, but fails in convincing surgical teams nationwide. Third and subsequent transplant procedures remain a surgical and immunological challenge, with an increased morbidity and a moderate decline in transplant survival only when donors are extended criteria' with extensive duration of waiting time between procedures. Robotic-assisted kidney transplantation is a recent technique requiring methodical evaluation. CONCLUSION: Kidney transplantation in challenging recipients implies a global understanding of patients' prognosis and benefits versus dialysis, in the context of the attribution of a valuable resource awaited by other patients on waiting list.