Kidney transplantation of living unrelated and ABO-incompatible donor-recipient combinations.

INTRODUCTION: In Japan, ABO-incompatible (ABO-IC) living kidney transplantation (LKT) has been performed among more than 2000 patients between 1989 and 2010 seeking to compensate for the shortage of donor organs. In addition, many patients lack a genetically living related donor (LRD); therefore, volunteer spouses (unrelated, LURD) have been considered since about 1990. PATIENTS AND METHODS: We performed 112 LKT between April 2003 and March 2011, including 44 (39%) spousal and two other LURD. The other 66 cases received LRD kidneys. We divided patients into two groups: 44 patients (group 1) received a kidney from a spouse (LURD) and 66 (group 2) from LRD. During the induction phase, tacrolimus or cyclosporine, mycophenolate mofetil, and methylprednisolone were prescribed for immunosuppression. Basiliximab was administered on postoperative days 0 and 4. For ABO-IC LKT, plasmapheresis was performed to remove anti-AB antibodies prior to LKT. Splenectomy was performed at the time of or before LKT. Since March 2010, rituximab administration was performed before transplantation instead of splenectomy. RESULTS: Death-censored graft survival rates were 97.7% in group 1 and 98.5% in group 2, respectively. The incidences of acute rejection episodes were 31.8% and 24.2% in groups 1 and 2, respectively. There were three cases of antibody-mediated rejection in group 1. No patient experienced a lethal infectious complication. CONCLUSIONS: Our results demonstrated that spousal LKT (LURD) was equivalent to LRD. In response to the shortage of deceased donors and genetically LRD, LKT between married couples or from ABO-IC donors will spread in Japan.

Kidney transplantation in patients with long-term (more than 15 years) prior dialysis therapy.

OBJECTIVE: The number of kidney transplantations (KTx) among patients on long-term hemodialysis (HD) is increasing due to the donor shortage in Japan. We investigated the outcomes of KTx among long-term (more than 15 years) patients on HD. METHODS: We performed 103 KTx between April 2003 and April 2010 including seven patients (one living and six deceased donor grafts), who had been treated with HD for more than 15 years (group 1) compared with 96 patients (94 living and two deceased donor grafts) treated for less than 15 years (group 2) before KTx. We examined the differences in patient and graft survivals and complication rates between the groups. RESULTS: Acute rejection episodes (ARE) occurred in 2 (29%) group 1 and 22 (22%) group 2 subjects. Urinary tract infections were diagnosed in 1 (14%) group 1 versus 8 (8%) group 2 cases. The incidence of perioperative complications, such as delayed graft function, cytomegalovirus infection, and surgical complications was higher among group 1. The serum creatinine at 1 year after KTx was the same (1.3 mg/dL). The patient/graft survivals were 100%/100% at 1 and 3 years in group 1 versus 100%/100% at 1 and 99%/98% at 3 years in group 2. CONCLUSION: The outcomes of KTx among long-term dialysis patients were similar to those in short-term dialysis patients.

Kidney transplantation of living unrelated donor-recipient combinations.

INTRODUCTION: According to the Japanese renal transplant registry in 2009, there were 1123 living kidney transplantations (LKT), including 35% from spouses (husband/wife). Up to the present in Japan, biologically living unrelated donors (LURD) are most frequently spouses. This study summarized our experience with LURD, especially spousal, kidney transplantation. PATIENTS AND METHODS: We performed 112 cases of LKT between April 2003 and March 2011, including 44 (39%) from spouses and two from other LURD. The other 66 cases received kidneys from living related donors (LRD). We divided the patients into two groups: 44 patients (group 1) received kidneys from spouses (LURD) and 66 (group 2) from LRD. During the induction phase, tacrolimus or cyclosporine, mycophenolate mofetil, and methylprednisolone were prescribed for immunosuppression. Basiliximab was administered on postoperative days 0 and 4. In ABO-incompatible LKT, plasmapheresis was performed to remove anti-AB antibodies prior to LKT; splenectomy or rituximab administration, at the time of or before LKT. RESULTS: Among group 1, one patient died with a functioning graft and one lost her graft. Among group 2, one patient died with a functioning graft and one lost his graft. The incidences of an acute rejection episode were 31.8% and 24.2% in groups 1 and 2, respectively. There were three cases of antibody-mediated rejection in group 1. No patient experienced a lethal infectious complication. CONCLUSIONS: Our results demonstrated that spousal LKT (LURD) was equivalent to LKT from LRD. In response to the shortage of deceased donors, LKT between married couples and from ABO-incompatible donors will spread in Japan.

Acceptable residual renal function after retroperitoneoscopic kidney donation in elderly donors.

Recent studies suggest that the overall survival and risk of end-stage renal disease among renal transplant donors are similar to those of the general population, but few studies focused on elderly donors. Among 88 donors who underwent retroperitoneoscopic live donor nephrectomies; 20 (22.7%) were elderly, namely, older than 65 years. Perioperative characteristics, such as sex, donor kidney side (left or right), body mass index, operative time, blood loss, and complication rate were not significantly different among groups classified by age: young (<50), middle (50-65), or elderly (>65). One month after kidney donation, the serum, creatinine values in the young, middle, and elderly groups increased to 1.05 ± 0.25, 0.96 ± 0.24, and 1.06 ± 0.15 mg/dL (P = .103) and the estimated glomerular filtration rate (eGFR) decrease to 63 ± 10, 63 ± 14, 56 ± 8 mL/min/1.73 m(2), respectively (P = .037). At three months and at three years after donation these parameters showed the same degree of improvement in all groups. Percentage of eGFR (% eGFR) of its pre-donation value in the young and middle groups improved up to 21% and up to 9%, respectively, until four years after donation, whereas that of the elderly group remained unchanged below 1%. In conclusion residual renal function after retroperitoneoscopic kidney donation in elderly donors was stable and acceptable during mid-term observation. Our retroperitoneoscopic approach was safe.

Strategic hand assistance for effective and safe retroperitoneoscopic live donor nephrectomy.

Hand-assisted laparoscopic live donor nephrectomy has been widely applied, because it enables safe dissection of the renal vessels, reducing warm ischemia time (WIT) during rapid extraction of the kidney. In the method described in the current series, the hand-port device was placed after the kidney was mostly mobilized using a pure retroperitoneoscopic procedure. After placement of the hand port, the ureter was completely dissected by an open procedure. Finally, the renal vessels were dissected and transected under the hand-assisted retroperitoneoscopic procedure, and the kidney removed through the hand port. We performed 66 retroperitoneoscopic live donor nephrectomies, including 14 right-sided and 52 left-sided procedures, with this original method of hand assistance. The mean operative time, WIT, blood loss, and renal vein length were 246 +/- 43 minutes, 209 +/- 124 seconds, 202 +/- 180 mL, and 17.4 +/- 6.4 mm, respectively. Comparison of the operative data between the initial 30 cases and the recent 36 cases using the established method showed significant differences in blood loss and WIT that approached statistical significance. No delayed graft function was observed in the current series. The technical and functional outcomes were acceptable. The site and timing of hand assistance minimize the disadvantage of a small working space during the retroperitoneoscopic procedure, making surgery easier and safer.

Transplantation of ABO-incompatible and living unrelated donor-recipient combinations.

INTRODUCTION: According to the Japanese renal transplant registry 2005, 834 transplantations were performed using living donors. Among them 199 (23.9%) kidneys were donated from spouses (husband/wife) and 174 (20.9%) from ABO-incompatible donors. This study summarized our experience of ABO-incompatible and living unrelated, especially spousal kidney transplantation. PATIENTS AND METHODS: We performed 44 cases of living donor kidney transplantation (LKT) between April 2003 and July 2007, including 14 (31.8%) from spouses (unrelated donor) who were divided into two groups: six patients (group 1; G1) from ABO-incompatible donors and eight patients (group 2; G2) from ABO-compatible donors. During the induction phase, tacrolimus or cyclosporine, mycophenolate mofetil, and methylprednisolone were used for immunosuppression. Basiliximab was administered on postoperative days 0 and 4. In all G1 patients plasmapheresis was performed to remove anti-AB antibodies prior to LKT, and splenectomy performed at the time of or before LKT. RESULTS: Among G1, no patient died. Among G2, one patient died with a functioning graft due to a traumatic subdural hematoma. Graft survival rate was 100% in both groups. The incidence of acute rejection was 33.3% and 25.0% in G1 and G2, respectively. No patient experienced a lethal infectious complication. CONCLUSIONS: Our results demonstrated that transplantation from an ABO-incompatible spousal donor was equivalent to transplantation from an ABO-compatible spousal donor. In response to the shortage of deceased donors, LKT between married couples and from ABO-incompatible donors will spread in Japan.

Preemptive kidney transplantation of living related or unrelated donor-recipient combinations.

INTRODUCTION: According to the Japanese renal transplant registry 2005, 834 transplantations were performed using living donors. Among them 112 (13.4%) patients were transplanted from living donors before the initiation of maintenance dialysis. Preemptive kidney transplantation (PreKTx) has been associated with improved allograft and patient survival rates compared to non-PreKTx. This study was designed to summarize our experience with PreKTx. PATIENTS AND METHODS: From April 2003 to July 2007, 44 living kidney transplantations were performed at our institution. We divided these 44 patients into two groups: 5 (11.4%) patients (group 1; G1) who underwent PreKTx and the other 39 patients (group 2; G2) who received kidneys after the institution of maintenance dialysis. Living unrelated donors were mostly spouses. During the induction phase, tacrolimus or cyclosporine, mycophenolate mofetil, and methylprednisolone were used for immunosuppression. In ABO-incompatible cases, plasmapheresis was performed to remove anti-AB antibodies prior to transplantation and splenectomy at the time of or before transplantation. RESULTS: Among G1, no patient died. Among G2, two patients died with functioning grafts, one due to a traumatic subdural hematoma and another due to malignant B cell lymphoma. Death-censored graft survival rates were 100% in both groups. The incidence of acute rejection was 20.0% and 20.5% in G1 and G2, respectively. CONCLUSIONS: Our results demonstrated that PreKTx from a living donor was equivalent to the non-PreKTx. However, there were also potential benefits to PreKTx in the long-term outcome, including avoidance of morbidity associated with dialysis and access procedures, as well as reduced cost. In response to the shortage of deceased donors, PreKTx from living donors will spread in Japan.

Retroperitoneoscopic living donor nephrectomy: a safe and minimally invasive procedure for the donor.

A living kidney donor surgery must be safe and minimally invasive. In addition the removed kidney must be in good condition. Retroperitoneoscopic nephrectomy has the advantage that it does not risk intra-abdominal organ injuries and provides direct access to the renal artery/vein despite the small working space. An abdominal wall-lifting method combined with the pneumoretroperitoneum provides sufficient space to use a hand skillfully in retroperitoneoscopic surgery. Introduction of hand-assisted retroperitoneoscopic living donor nephrectomy with the abdominal wall-lifting method yielded safer and easier operations as well as shorter warm ischemia (mean: 3 minutes; 7 seconds) and operative times (mean: 3 hours; 28 minutes) in the current 10 cases. The procedure is a useful alternative to procure a kidney graft.

Lower ureteral replacement using a tubularized gastric segment.

OBJECTIVES: To review our early experience with the use of a gastric segment for lower ureteral replacement in patients with bilateral ureteral stenosis after pelvic radiotherapy. METHODS: Four adult patients (three women and one man) underwent bilateral ureteral substitution using stomach. All patients received whole pelvic irradiation for malignant disease and had undergone bilateral nephrostomy because of severe bilateral ureteral stenosis. The postoperative follow-up period was 11 to 50 months. RESULTS: No major complication was recognized, and the bilateral nephrostomy tubes were removed in all patients. Three female patients could void urethrally without incontinence, and the male patient needed regular self-catheterization. The three women were alive with normal renal function at a follow-up of 11 to 50 months. The man had a vesicorectal fistula 8 months postoperatively, and colostomy was performed. He died of a cause unrelated to the operation 11 months after surgery. CONCLUSIONS: Stomach has not been used commonly for ureteral replacement. In patients with bilateral severe ureteral stenosis after pelvic radiotherapy, ureteral substitution with a gastric segment can be safely performed and will increase the patient's quality of life.

[A case of giant small cell carcinoma of the prostate].

A 64-year-old man having backbone pain was referred to our institute, and laboratory examinations revealed that he was suffering from severe renal failure. Abdomino-pelvic CT revealed bilateral hydronephrosis, a giant prostate over 500 g in weight, and multiple para-aortic lymph node metastasis. Histological diagnosis of the prostate was small cell neuroendocrine carcinoma. Serum neuron-specific enolase (NSE) level was slightly high reflecting the positive immunohistochemical staining, but serum PSA remained within normal limits. The patient was treated with hormone-chemotherapy after successful treatment of the renal failure, but he died on the 74th hospital day. Small cell carcinoma is known to have a high rate of malignancy and metastasis from an early stage. Several giant prostatic tumors have been reported previously, but this case is considered to be the second gigantic small cell carcinoma in the Japanese literature.

Leiomyoma of the ureter.

We report a case of leiomyoma of the ureter, and the patient underwent partial ureteral resection. This is the 8th case reported after 1955, and the clinical features of ureteral leiomyomas of these 8 cases are discussed.

[Gastrocystoplasty for severely contracted bladder following high dose pelvic irradiation: a case report].

A 24-year-old female who had received hysterectomy and adnexectomy of bilateral appendages for yolk sac tumor at the age of 12 years, followed by repeated surgery and pelvic irradiation over a total of 100 Gy for relapse of tumor, suffered from a severely contracted bladder and renal dysfunction of serum creatinine level over 2.0 mg/dl. The diagnosis was radiation-induced contracted bladder with renal dysfunction due to vesicoureteral reflux. Since the small intestine was not considered suitable after high dose irradiation, the stomach was used to reconstruct the bladder. The vesical pressure, which was 70 cmH2O at the capacity of 30 ml, was decreased to 22 cmH2O at the capacity of 100 ml, 5 weeks after surgery. The renal function was stable with a serum creatinine level below 1.4 mg/dl and the bladder capacity was 200 ml, 15 months after surgery. This method using the stomach was considered valuable for bladder reconstruction after large dose pelvic irradiation.

Gastrocystoplasty in a woman with radiation-induced ureteral obstruction and low-compliance bladder.

A 56-year-old woman presented with bilateral hydronephrosis and moderate renal insufficiency. A diagnosis of bilateral ureteral obstruction and low-compliance bladder following pelvic irradiation was made by urological examinations. She underwent gastrocystoplasty to facilitate bilateral ureteral reimplantation with an uneventful postoperative course. We consider that the use of the stomach to reconstruct the urinary tract injured by pelvic irradiation is valuable to avoid an abdominal urinary stoma.

[A case of colo-vesico-vaginal fistula caused by sigmoid colon diverticulitis].

A 74-year-old woman was referred to our hospital with the chief complaints of pneumaturia, fecaluria and discharge of feces and urine from vagina. Fistulography on the vaginal side showed the presence of contrast medium both in the sigmoid colon and bladder. Colonoscopy revealed multiple diverticulosis of the sigmoid colon. Under diagnosis of colo-vesico-vaginal fistula due to sigmoid colon diverticulitis, a one-stage operation removing sigmoid colon, uterus-vaginal wall and urinary bladder wall including the fistula and careful reconstruction was performed. Postoperatively, urinary leakage from vagina in large amounts continued due to the recurrence of vesico-vaginal fistula. An attempt to use human fibrin glue in the recurrent fistula was successful, and the patient was asymptomatic at 21 months of follow-up. Colovesical fistula has been reported in about 10-20% of patients undergoing surgery for complicated diverticulitis, but a combined fistula is a rare condition. Furthermore, we recommend the use of human fibrin glue for a recurrent fistula.