Management of renal transplant urolithiasis: a multicentre study by the French Urology Association Transplantation Committee.

PURPOSE: Urolithiasis is rare among renal transplant recipients and its management has not been clearly defined. METHODS: This multicentre retrospective study was organised by the Comité de Transplantation de l'Association Française d'Urologie (French Urology Association transplantation committee). Statistical analysis was performed with SPSS 19 software. RESULTS: Ninety-five patients were included in this study. Renal transplant urolithiasis was an incidental finding in 55% of cases, mostly on a routine follow-up ultrasound examination. One half of symptomatic stones were due to urinary tract infection and the other half were due to an episode of acute renal failure. The initial management following diagnosis of urolithiasis was double J stenting (27%), nephrostomy tube placement (21%), or watchful waiting (52%). Definitive management consisted of: watchful waiting (48%), extracorporeal lithotripsy (13%), rigid or flexible ureteroscopy (26%), percutaneous nephrolithotomy (11%) and surgical pyelotomy (2%). All transplants remained functional following treatment of the stone. The main limitation is the retrospective design. CONCLUSIONS: The incidence of lithiasis could be higher in kidney transplanted patients due to a possible anatomical or metabolical abnormalities. The therapeutic management of renal transplant urolithiasis appears to be comparable to that of native kidney urolithiasis.

[Anticoagulation impact on bleeding risk during HoLEP: Monocentric study of 156 patients]. / Impact des anticoagulants sur le risque hémorragique au cours de l'HoLEP : étude monocentrique de 156 patients.

OBJECTIVE: Compare the length of hospital stay and the complications after HoLEP between three groups of patients: a control group, a group with antiplatelet therapy, a group with anticoagulation therapy. MATERIALS: Retrospective cohort study that included all consecutive patients who underwent HoLEP for prostatic hyperplasia in our center from may 2013 to may 2016. Anticoagulated patients and patients under clopidogrel had respectively a relay with heparine and aspirine. Patients were seen after surgery at 1 and 3 months. RESULTS: A hundred and fifty six patients were analysed, mean age was 70.7 years (DS 6.8), mean prostate volume 88.8g (DS 34.1). 106 patients were in the control group, 34 had antiplatelet therapy and 16 had anticoagulation therapy. There were no difference between the 3 groups for mean age, mean prostatic volume, PSA. There was also no difference for length of intervention, irrigated volume and length of morcellation between the three groups. There were no difference between patients in the control group and patients with antiplatelet therapy for length of hospital stay (2.1 days vs 2.0 days), lenght of urethral catheterization (1.6 days vs 1.5 days). There was a statistical difference between patients in the control group and patients with anticoagulation therapy for lenght of hospital stay (2.0 days vs 4.4 days; P=0.01), length of bladder irrigation (0.9 day vs 1.8 days; P=0.01), lenght of urethral catheterization (1.6 days vs 3.5 days; P=0.01). Transfusion rate was 18.75% (n=3) for patients with anticoagulation, 2.9% (n=1) for patients under antiplatelet therapy and 0.9% (n=1) for patients in the control group. CONCLUSION: Anticoagulation during HoLEP is a valid option but need to be proceed with carefully management. LEVEL OF PROOF: 4.

[Simultaneous pancreas and kidney transplantation]. / Transplantation simultanée de rein et de pancréas.

OBJECTIVES: To perform a State of The Art about the different aspects of pancreas transplantation such as indications, technical features, immunosuppressive strategies and outcomes of simultaneous pancreas-kidney transplantation. MATERIAL AND METHODS: An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords (MESH) : « pancreas transplantation; kidney transplantation; simultaneous pancreas-kidney transplantation; immunosuppression ¼. Publications obtained were selected based on methodology, language, date of publication (last 20 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 2736 articles. After reading titles and abstracts, 23 were included in the text, based on their relevance. RESULTS: These last few years, considerable progresses were done in optimizing indication for pancreas transplantation, as well as surgical improvement and a better used of immunosuppression. In the first part of this article, demographics, indication and pre-transplant evaluation will be described. The different techniques of procurement, preparation and transplantation will then be discussed. Finally, the results and outcomes of pancreas transplantation will be reported. CONCLUSIONS: Despite its morbidity, pancreas transplantation is the optimal treatment of end stage renal disease in diabetic patients under 55. Long-term results and quality of life improvement after pancreas transplantation are excellent. LEVEL OF EVIDENCE: NA.

[Pediatric kidney transplantation]. / Transplantation rénale pédiatrique.

AIMS: To describe indications, surgical aspects, results and outcomes of kidney transplantation in children. MATERIAL AND METHODS: An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords (MESH): "kidney transplantation", "pediatric", "children", "outcomes". Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 2608 articles. After reading titles and abstracts, 18 were included in the text based on their relevance. RESULTS: Kidney transplantation is the gold-standard treatment for end stage renal kidney disease in children. The surgical procedure is well standardized with a retroperitoneal approach when child and kidney size allow it or a transperitoneal approach in child less than 15 kg and big size kidney graft. Anastomosis sites include iliac vessels in the retroperitoneal approach, and inferior vena cava and aorta in case of transperitoneal procedure. Ureteral reimplantation used most of the time a Campos Freire technique. Sometimes, particular conditions in the recipient (such as vena cava thrombosis) required procedure adaptation. CONCLUSION: Graft survival dramatically increased over the past few years and is now superior to those observed in adult kidney transplantation, particularly in experienced team with microsurgery skills. Immunosuppressive treatments are similar to adults. Viral infections and post-transplant lymphoproliferative disorder are the main complications of renal transplantation in children and may lead to lethal outcomes. An increase graft loss is observed during boyhood due to immunosuppressive drugs uncompliance.

[Ischemia-reperfusion. Preservation solution and hypothermic machine perfusion]. / Ischémie­reperfusion. Liquides de conservation et machines de perfusion en transplantation rénale.

AIMS: To describe ischemia-reperfusion mechanisms, the impact on kidney graft and strategies developed to minimize ischemia-reperfusion damages. MATERIAL AND METHODS: An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords: ischemia-reperfusion; organ preservation; hypothermic machine perfusion; renal transplantation. Publications obtained were selected based on methodology, language, date of publication and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 1293 articles. After reading titles and abstracts, 88 were included in the text, based on their relevance. RESULTS: Ischemia-reperfusion injuries occur when blood supply of an organ is interrupted or drastically reduced. Ischemic damages started immediately after arterial clamping in donor, persist during cold ischemia time, and are increased after reperfusion because of increased oxygen levels, organ warming and recipient cell infiltration. Besides metabolic and biologic impact, IR induced dramatic immunologic impact through immunologic cells activation. CONCLUSIONS: Knowledge of IR mechanisms is crucial to improve organ storage strategies and to decreased impact of IR on long-term graft and patient survival. Hypothermic machine perfusion was associated with prolonged graft survival versus cold storage. Principles and results of hypothermic machine perfusion will be reported.

Nephron sparing surgery for De Novo kidney graft tumor: results from a multicenter national study.

Nephron sparing surgery (NSS) results in the transplanted population remain unknown because they are only presented in small series or case reports. Our objective was to study renal sparing surgery for kidney graft renal cell carcinomas (RCC) in a multicenter cohort. Data were collected from 32 French transplantation centers. Cases of renal graft de novo tumors treated as RCC since the beginning of their transplantation activity were included. Seventy-nine allograft kidney de novo tumors were diagnosed. Forty-three patients (54.4%) underwent renal sparing surgery. Mean age of grafted kidneys at the time of diagnosis was 47.5 years old (26.1-72.6). The mean time between transplantation and tumor diagnosis was 142.6 months (12.2-300). Fifteen tumors were clear cell carcinomas (34.9%), and 25 (58.1%) were papillary carcinomas. Respectively, 10 (24.4%), 24 (58.3%) and 8 (19.5%) tumors were Fuhrman grade 1, 2 and 3. Nine patients had postoperative complications (20.9%) including four requiring surgery (Clavien IIIb). At the last follow-up, 41 patients had a functional kidney graft, without dialysis and no long-term complications. NSS is safe and appropriate for all small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis.

Polyethylene glycols and organ protection against I/R injury.

During the organ transplantation process, conservation solutions must address responses to the physiologic organ preservation and prevent ischemia-reperfusion injuries. The use of colloids seems beneficial especially for long ischemia time compared to the impermeant molecules used for short time. The colloids family includes molecules as hydroxyethyl starch (HES), albumin, dextran or polyethylene glycol (PEG). In this review, the authors describe the rational for PEG use, its potential immunomodulatory effect and the main results of its experimental and clinical use.

[New ultrasound navigational system in extracorporeal lithotripsy: decreased fluoroscopy and radiation]. / Nouveau repérage échographique en lithotritie extracorporelle: diminution des temps de scopie et de l'irradiation.

PURPOSE: Extracorporeal shock wave lithotripsy is the most common method of treatment for kidney stones. Both fluoroscopy and ultrasound imaging can be used to locate stones, but fluoroscopy is more frequently employed. Evaluation of a new stereotaxic navigational system: the stone was located using an ultrasound probe, and its 3D location was saved. The table automatically moved to position the stone at the focal point. A real-time follow-up was possible during treatment. Our objective was to demonstrate a decrease in the use of fluoroscopy to locate kidney stones for extracorporeal shock wave lithotripsy through the use of a 3D ultrasound stone locking system. PATIENTS AND METHODS: Prospective analysis of the case records of the 20 patients preceding and the 20 patients succeeding the arrival of the ultrasound stone locking system Visio-Track (EDAP-TMS). We used a Student test to compare age, BMI, kidney stone size, number of shock waves and administered energy. RESULTS: Patient characteristics were comparable. The average age was 55 years old and the average kidney stone size was 10.7 mm. Radiation duration was 174.8 seconds in the group without Visio-Track versus 57.1 seconds in the group with it (P<0.0001). A similar result was observed for radiation doses: 5197.25 mGy x cm2 for the group without versus 1987.6 mGy x cm2 for the group with Visio-Track (P=0.0033). CONCLUSION: The stone locking system Visio-Track reduced fluoroscopy in our first group of patients, which decreased the patient's individual absorbed irradiation dose.

Kidney graft outcome and quality (after transplantation) from uncontrolled deceased donors after cardiac arrest.

The use of uncontrolled deceased donors after cardiac arrest (uDDCA) has been developed in France to compensate for organ shortage. The quality of these kidneys remains unclear. We analyzed kidney graft function and histology from 27 uDDCA and compared them with kidneys from 30 extended criteria donors (ECD) and from 24 simultaneous pancreas kidney (SPK) donors as a control group of optimal deceased donors. Kidneys from ECD and SPK donors were preserved by static cold storage while kidneys from uDDCA were preserved by pulsatile perfusion. The uDDCA graft function at 3 years posttransplantation (estimated with MDRD and measured with inulin clearance) did not differ from that of the ECD group (eGFR 44.1 vs. 37.4 mL/min/1.73 m(2) , p = 0.13; mGFR 44.6 vs. 36.1 mL/min/1.73 m(2) , p = 0.07 in the uDDCA and ECD groups, respectively). The histological assessment of 3-month and 1-year protocol biopsies did not show differences for interstitial lesions between the uDDCA and ECD grafts (IF score at M3 was 30 vs. 28% and at M12 36 vs. 33%, p = NS). In conclusion, the results at 3 years with carefully selected and machine-perfused uDDCA kidneys have been comparable to ECD kidneys and encourage continuation of this program and development of similar programs.

De novo kidney graft tumors: results from a multicentric retrospective national study.

De novo tumors in renal allografts are rare and their prevalence is underestimated. We therefore analyzed renal cell carcinomas arising in renal allografts through a retrospective French renal transplant cohort. We performed a retrospective, multicentric survey by sending questionnaires to all French kidney transplantation centers. All graft tumors diagnosed after transplantation were considered as de novo tumors. Thirty-two centers participated in this study. Seventy-nine tumors were identified among 41 806 recipients (Incidence 0.19%). Patients were 54 men and 25 women with a mean age of 47 years old at the time of diagnosis. Mean tumor size was 27.8 mm. Seventy-four (93.6%), 53 (67%) and 44 tumors (55.6%) were organ confined (T1-2), low grade (G1-2) and papillary carcinomas, respectively. Four patients died of renal cell carcinomas (5%). The mean time lapse between transplantation and RCC diagnosis was 131.7 months. Thirty-five patients underwent conservative surgery by partial nephrectomy (n = 35, 44.3%) or radiofrequency (n = 5; 6.3%). The estimated 5 years cancer specific survival rate was 94%. Most of these tumors were small and incidental. Most tumors were papillary carcinoma, low stage and low grade carcinomas. Conservative treatment has been preferred each time it was feasible in order to avoid a return to dialysis.

[Treatment of stress urinary incontinence after prostate surgery: results of the artificial urinary sphincter after suburethral sling failure]. / Traitement de l'incontinence urinaire d'effort après prostatectomie : résultats du sphincter urinaire artificiel après échec de bandelette sous-urétrale.

OBJECTIVE: To determine whether the presence of a previously implanted suburethral sling for post-prostatic surgery incontinence influences the outcomes of subsequent AUS implantation. PATIENTS AND METHODS: A retrospective study comparing 15 patients who underwent AUS placement after suburethral sling failure between November 2004 and December 2009 to 15 patients who underwent AUS placement as first-line treatment during the same period. Demographic characteristics, preoperative assessment of urinary incontinence and technique of implantation of the AUS were similar in the both arms. A USP(®) continence questionnaire was sent to patients by mail. Success was defined as a subjective improvement of the incontinence in patients using less than one pad per day. RESULTS: No perioperative incidents were noted in either arm. Mean operative time, the size of implanted cuffs, duration of catheterisation, length of hospital stay and postoperative complication rate, as well as the rate of surgical revision, were similar in both arms. The follow-up was slightly lower in the first arm (21 vs. 28.8 months, P=0.83). Stress incontinence and bladder overactivity scores of the USP(®) questionnaire, as well as success rates (73.3 vs. 80%, P=0.67), were equivalent in both arms. CONCLUSION: The results associated with the AUS procedure were not significantly different between men who had a suburethral male sling implanted before and those who had the AUS implanted as a first-line treatment.

Evaluation of pulsatile perfusion machine RM3 for kidney preservation in a swine model of renal autotransplantation.

AIM: Transplantations of kidneys from non-heart-beating donors (NHBD) are intended to increase the donor pool by 20% to 30%. Nevertheless the rate of primary nonfunction and delayed graft function is generally higher among this group of donors. The goal of this study was to assess whether kidney preservation by a pulsatile perfusion machine was able to limit the renal lesions due to ischemia reperfusion injuries as compared with static incubation. We have used a model of an autotransplanted kidney exposed to controlled warm ischemia in the pig to mimic the clinical conditions of NHBD. MATERIAL AND METHODS: Left kidneys from 11 large white pigs aged 4 weeks were harvested after vascular clamping of the renal vessels for 1 hour. Kidneys were preserved for 22 hours. Two groups were studied: the MPS static group (static incubation with Belzer MPS; n = 6) versus the MPS RM group (renal perfusion with Belzer MPS; n = 5). Kidneys were then autotransplanted into pigs after a right nephrectomy. The primary end point was animal survival rate at 1 month. Secondary endpoints were evolution of the plasma creatinine values, proteinuria, tubular sodium reabsorption, and histological features at 1 month. RESULTS: For all biological parameters, the differences between the perfusion and the static incubation groups were significant, except creatinine, with favorable effects for the perfusion machine group. The histological data at 1 month showed recovery of the normal kidney architecture in the MPS RM group. CONCLUSION: In our pig experimental model that reproduced the clinical conditions of a NHBD, we demonstrated better kidney preservation when the pulsatile perfusion machine was used as compared with static conservation.