Urological complications following unstented pediatric renal transplantation.

Urological complications which develop post-renal transplantation can be associated with significant morbidity especially in children. We evaluated the occurrence and management of all urological complications in a series of unstented pediatric renal transplants in a tertiary pediatric hospital. We reviewed the medical records of children who underwent unstented renal transplant between January 1996 and December 2014. Postoperative urological complications and the outcomes of their management were analyzed. A total of 160 unstented renal transplants were performed, and 32 urological complications were noted in 29 transplants (18%). There were 20 boys and nine girls with an age range of 2.5 years to 18.4 years. Nine (31%) of these patients had LUTD. The most common complication was VUR occurring in 17 patients (10.6%). Urine leaks occurred in six patients (3.8%) and ureteric obstruction in six patients (3.8%), and three patients (1.9%) had unexplained hydronephrosis. Loss of graft occurred in three patients (1.9%), and one patient died from sepsis post-uretero-ureterostomy. Patients with LUTD had more urological complications (P = .037). Unstenting is feasible in most pediatric renal transplants. LUTD is associated with a higher incidence of urological complications, especially VUR.

Urological aspects of HIV and AIDS.

The use of highly active antiretroviral therapy (HAART) in HIV-infected people has led to a dramatic decrease in the incidence of opportunistic infections and virus-related malignancies such as non-Hodgkin lymphoma and Kaposi sarcoma, but not cervical or anal cancer. Advanced-stage cervical cancer is associated with a high incidence of urological complications such as hydronephrosis, renal failure, and vesicovaginal fistula. Adult male circumcison can significantly reduce the risk of male HIV acquisition. Although HAART does not completely eradicate HIV, compliance with medication increases life expectancy. HIV infection or treatment can result in renal failure, which can be managed with dialysis and transplantation (as for HIV-negative patients). Although treatment for erectile dysfunction--including phosphodiesterase 5 inhibitors, intracavernosal injection therapy, and penile prosthesis--can increase the risk of HIV transmission, treatment decisions for men with erectile dysfunction should not be determined by HIV status. The challenges faced when administering chemotherapy to HIV-infected patients with cancer include late presentation, immunodeficiency, drug interactions, and adverse effects associated with compounded medications. Nonetheless, HIV-infected patients should receive the same cancer treatment as HIV-negative patients. The urologist is increasingly likely to encounter HIV-positive patients who present with the same urological problems as the general population, because HAART confers a prolonged life expectancy. Performing surgery in an HIV-infected individual raises safety issues for both the patient (if severely immunocompromised) and the surgeon, but the risk of HIV transmission from patients on fully suppressive HAART is small.

Outcome of dual flange metallic urethral stents in the treatment of neuropathic bladder dysfunction after spinal cord injury.

PURPOSE: To review the results of metallic urethral stents used in patients with neuropathic bladder dysfunction after spinal cord injury (SCI). PATIENTS AND METHODS: In a rehabilitation unit for SCI and stroke in Cape Town, South Africa, we performed a case note review of dual flange Memokath stents placed from March 2008 until October 2011. Stents were placed rather than performing an external sphincterotomy in selected patients. With the patient under deep general anesthesia, a thermosensitive expandable metallic stent was positioned over the internal and external urethral sphincters. RESULTS: In total, 33 stents were placed in 28 male patients. SCI was cervical in 23 patients and thoracic in 5. Average follow-up was 18 months (range 1-40 months, median 18 months). The most common indications were repeated catheter blockage in eight patients and urinary tract infection in six. The average time from SCI to stent insertion was 79 months (range 1-468 months, median 21 months). Severe autonomic dysreflexia was present in 17 cases before stent placement and in 7 after stents were placed (P=0.003). Stents failed in 15 patients (45%) and were removed. The most common reason for failure was stone formation. Comparing the group of patients with stents lasting >20 months (n=11) to the group with stent removal before 20 months (n=10), the mean time between SCI and stent placement was 31 vs 119 months (P=0.057). Medium term results (up to 27 months) were significantly influenced by earlier stent placement (P=0.0484). One major complication was stent migration that caused an urethrocutaneous fistula.

Inflammatory myofibroblastic tumor of the bladder in a 3-year-old boy.

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm with unknown malignant potential that has been described in most organ systems. We present the case of a 3-year-old boy who was referred with lower urinary tract symptoms and macroscopic hematuria. An IMT was suspected after clinical, radiological, and surgical work-up, and the diagnosis was confirmed after a partial cystectomy was performed. A bladder-preserving approach is the treatment of choice, but close clinical follow-up is recommended because of the unknown biological behavior of these tumors.

Management of radiation cystitis.

Acute radiation cystitis occurs during or soon after radiation treatment. It is usually self-limiting, and is generally managed conservatively. Late radiation cystitis, on the other hand, can develop from 6 months to 20 years after radiation therapy. The main presenting symptom is hematuria, which may vary from mild to severe, life-threatening hemorrhage. Initial management includes intravenous fluid replacement, blood transfusion if indicated and transurethral catheterization with bladder washout and irrigation. Oral or parenteral agents that can be used to control hematuria include conjugated estrogens, pentosan polysulfate or WF10. Cystoscopy with laser fulguration or electrocoagulation of bleeding points is sometimes effective. Injection of botulinum toxin A in the bladder wall may relieve irritative bladder symptoms. Intravesical instillation of aluminum, placental extract, prostaglandins or formalin can also be effective. More-aggressive treatment options include selective embolization or ligation of the internal iliac arteries. Surgical options include urinary diversion by percutaneous nephrostomy or intestinal conduit, with or without cystectomy. Hyperbaric oxygen therapy (HBOT) involves the administration of 100% oxygen at higher than atmospheric pressure. The reported success rate of HBOT for radiation cystitis varies from 60% to 92%. An important multicenter, double-blind, randomized, sham-controlled trial to evaluate the effectiveness of HBOT for refractory radiation cystitis is currently being conducted.

Evaluation of a hemostatic sponge (TachoSil) for sealing of the renal collecting system in a porcine laparoscopic partial nephrectomy survival model.

OBJECTIVE: The objective of this study was to evaluate the efficacy of TachoSil (Nycomed UK, Oxford, Buckinghamshire, UK), a hemostatic sponge, to seal major collecting system injuries (in addition to providing an adjunct to hemostasis) after partial nephrectomy in a porcine chronic survival model. MATERIALS AND METHODS: Laparoscopic upper-pole partial nephrectomies were performed in 10 farm pigs (>40 kg). After hilar clamping, an energyless incision was made at a point halfway between the hilum and the upper pole of the kidney and the collecting system was opened widely. TachoSil was applied to cover the defect; 15 to 20 minutes after the application of TachoSil, the hilar clamp was removed, hemostasis confirmed, and the pig survived. Assessment was made for hematoma and urinoma. Four weeks postoperatively, the pigs were euthanized. Ex-vivo retrograde studies were performed to assess collecting system leak. Weight, blood pressure, estimated blood loss, the weight of the partial and completion nephrectomy specimen, presence/absence of urinary leak on retrograde study, histopathologic findings, and complications were recorded. RESULTS: All pigs survived. Mean warm ischemia time was 18 minutes, mean blood loss was 90 mL, and mean resected weight was 13.7 g. There was no evidence of leak on retrograde study. Histologically, nonspecific changes were noted in all specimens, which included dystrophic calcification, scarring, and areas of fibrosis at the partial nephrectomy surgical margin. CONCLUSION: TachoSil seals the collecting system after partial nephrectomy on a porcine chronic survival model, in addition to providing an adjunct to hemostasis. More studies, including human trials, are warranted to evaluate this observation further.