Outcomes after 20 years of experience in minimally invasive living-donor nephrectomy.

INTRODUCTION: The transperitoneal laparoscopic approach is considered the gold standard technique for living kidney donation. Other accepted laparoscopic techniques include the retroperitoneal approach, natural orifice transluminal endoscopic surgery (NOTES)-assisted, laparo-endoscopic single-site surgery (LESS), with excellent results in the donor and graft. Many studies have compared these techniques with open ones. Our objective is to describe our experience and results in minimally invasive living-donor nephrectomies (MILDN): laparoscopic, NOTES-assisted, and LESS since their introduction in March 2002. MATERIALS AND METHODS: We conducted a retrospective observational study of donors undergoing MILDN between March 2002 and March 2020. RESULTS: A total of 714 MILDNs were performed at our centre. All were completed, except for one, because of recipient death. The conventional laparoscopic approach was used in 541 cases (75.88%), NOTES in 116 (16.9%), LESS in 55 (7.7%), and one mini open (0.14%). Two-thirds of the donors were females (478 cases). The mean donor age was 52.87 years (SD 10.93). Six donors (0.8%) were diagnosed beforehand with a small renal mass, which was removed before transplantation in bench surgery. The right kidney was removed in 17.8% of cases. Warm ischaemia time was higher in the NOTES and LESS groups. We had eight conversions. The global intraoperative and postoperative complication rates were 6.8% and 4.9%, respectively. None of the donors developed renal disease during follow-up (mean 3.68 years). Five-year recipient and graft survival rates were 98.8% and 96.8%, respectively. CONCLUSIONS: MILDN techniques are safe for donors and grafts, with low complication.

[Orthotopic renal allograft transplant. State of the art.] / Trasplante renal ortotópico. Estado actual.

Kidney transplantation is the treatment of choice for patients with end-stage renal disease (ESRD)as it has shown a better quality of life and longer survival compared to dialysis. Patients with ESRD have associated vascular pathology in a significant percentage, with abundant calcifications at the level of the aorto-iliac axis.The survival of transplanted patients has also increased so an important number of patients have multiple transplants,patients with an indication for a third, fourth and even fifth transplant.In these cases, in which the iliac fossa is no longer practicable(atheromatosis, vascular abnormalities, occupied iliac fossae for previous kidney transplant…), orthotopic kidney transplantation offers a viable option with good results.

El trasplante renal es el tratamiento de elección para pacientes con insuficiencia renal crónica terminal (IRCT) ya que ha demostrado una mejor calidadd e vida y mayor supervivencia en comparación ala diálisis. Los pacientes con IRCT tienen asociada patología vascular en un importante porcentaje, con abundantes calcificaciones a nivel del eje aorto-ilíaco. La supervivencia de los pacientes trasplantados también se ha incrementado por lo que cada vez más nos encontramos con pluritrasplantados, pacientes con indicación de tercer, cuarto e incluso quinto trasplante.En estos casos en los que la fosa ilíaca ya no es practicable (ateromatosis, malformaciones vasculares, ocupación de fosas ilíacas por trasplantes renales previos…),el trasplante renal ortotópico ofrece una opción viable con buenos resultados.

Orthotopic Renal Transplantation: Indication, Technique and Outcomes.

PURPOSE OF REVIEW: Nowadays many ESRD patients awaiting kidney transplantation have known unsuitable iliac vessels for vascular anastomosis, due to severe atheromatosis, occupied iliac fossa, or other uncommon vascular abnormalities. In these cases, orthotopic kidney transplantation (OKT) could be the solution. RECENT FINDINGS: Since the update on OKT published in 2010, no more large series have been reported. Some small series or case reports being described in the literature. The orthotopic position has shown good recipient and graft results with acceptable complication rate in selected patients. This technique permits the possibility of kidney transplantation, in patients unfit for heterotopic kidney transplantation (HKT), and consequently the avoidance of the dialysis treatment. In this paper, we review what is new in the literature, analyzing indications, technique, and results of this surgical approach.

The evolution of CT diagnosed papillae tip microcalcifications: can we predict the development of stones?

OBJECTIVES: To determine the incidence of computed tomography (CT) identifiable Randall plaques in a CT explored population; to determine the clinical relevance of this radiological finding by a 7-year follow-up; to determine a cut point to identify a population with high risk of developing calcium stone disease (SD). MATERIALS AND METHODS: Retrospective study of all patients explored by abdominal CT in our center between January and March 2005. INCLUSION CRITERIA: age 30-60 years and no SD. Papillae attenuation was measured on nonenhanced CT in Hounsfield units (HU) and the mean of all papillae was calculated. Patients were re-evaluated after 7 years to identify calcium stone formers. Anamnesis and already available CT, ultrasound, kidney, ureter, and bladder radiograph (KUB) or intravenous urography (IVU) images performed as part of their follow-up were used. In patients with no follow-up, ultrasound and KUB were to be performed. Pearson correlation, Student t-test, and the receiver operator curve were used for statistical analysis. RESULTS: A total of 362 patients fulfilled the inclusion criteria and were analyzed; 12 developed calcium SD after 7 years. A significant difference was encountered between the papillae attenuation of stone formers (SF) versus non-SF (47.2HU vs. 35.5HU, p=0.001). There was good correlation between papillae attenuation and the possibility of developing SD (R=0.87). An optimal cut point of 43HU with a sensitivity of 81% and specificity of 97%, area under the curve 0.91, separated SF and non-SF. CONCLUSION: Patients with high papillae density have a higher risk of developing SD. A cut point of 43HU could accurately be used to identify a high-risk population.

[One-step reconstruction of penile urethral strictures. Indications and techniques]. / Reconstrucción de la estenosis de uretra peneana en un tiempo. Indicaciones y técnicas.

Penile urethra stenoses generally appear as a sequel after acute (sexually transmitted diseases) or chronic urethritis processes, associated with diseases such as lichen sclerosus or as a consequence of traumatism, iatrogeny and forced distention of the urethral lumen. One third of these lesions may be congenital and they usually present in the youngest patients. When there is indication for surgical urethral reconstruction there are multiple surgical techniques and different tissues. The selection of the best technique depends on the availability of different tissue sources, the knowledge of the various technical options, and being familiar or having personal experience with the surgical techniques. This chapter aims to review the various technical options of more frequent use for urethral lumen reconstruction, to offer the greatest number of resources to solve a medical problem of complex solution.

Abdominal computed tomography--a new tool for predicting recurrent stone disease.

PURPOSE: To evaluate whether CT-identified Randall plaques can be used to foresee the recurrence of stone disease (SD); to define a cut point that could identify a high-risk population. MATERIALS AND METHODS: A retrospective study of patients attended for SD from January 2004 to December 2009 was conducted. Study population was patients with a first episode of calcium SD that was diagnosed by abdominal CT. Papillae tip attenuation was measured in Hounsfield units (HU) on unenhanced abdominal CT images. Patients with recurrent SD were identified; t test, Pearson correlation, and receiver operating characteristic (ROC) curve analysis were used. RESULTS: A total of 543 patients were evaluated; 187 fulfilled the criteria and were included, and 49 (26.2%) had recurrent SD. Mean follow-up: 5 years (3-7 years). Papillae tip attenuation was significantly higher in the recurrent group (46.2 HU vs 40.1 HU, P=0.01) and correlated well with the possibility of developing SD (R=0.83). Attenuation >43 HU showed a ROC curve area under the curve=0.87 with sensitivity=77% and specificity=84% separating patients with a RR=8.7 of development of recurrent SD. The number of papillae >43 HU correlated with recurrent SD (RR=11.2 for ≥3 papillae vs <3 papillae with density >43 HU). CONCLUSIONS: The presence of the Randall plaques can be used as a marker for predicting SD recurrence. A cut point of 43 HU could be used to identify a high-risk population.

Low testosterone levels are related to poor prognosis factors in men with prostate cancer prior to treatment.

UNLABELLED: What's known on the subject? and What does the study add? Prostate growth is ruled by testosterone. Nevertheless, the paradigm that high testosterone levels induce prostate cancer development or lead to a poor prognosis in prostate cancer is not supported by evidence. A growing number of studies suggest that, on the contrary, low testosterone levels are related to poor prognosis features in prostate cancer such as higher prostate-specific antigen or higher Gleason score. Our experience shows that testosterone levels are related to risk of progression of prostate cancer - those men with lower testosterone levels are at higher risk of progression of their prostate cancer after treatment delivery. OBJECTIVES: • Low testosterone levels have been related to a higher diagnosis of prostate cancer (PCa). Hormonal levels have been related to poor prognosis factors in men with PCa, mainly after radical prostatectomy. • Our aim was to determine the relationship between hormonal levels and PCa prognosis factors in men with PCa prior to the onset of treatment. PATIENTS AND METHODS: • We prospectively analysed 137 males diagnosed in our centre with PCa with 5+5 core prostate biopsies from February 2007 to December 2009. • As part of our clinical protocol, we performed hormonal determination (testosterone and sex hormone binding globulin) following International Society of Andrology, International Society for the Study of the Aging Male and European Association of Urology recommendations. • Free testosterone and bioavailable testosterone were calculated using Vermeulen's formula. • Age, prostate-specific antigen (PSA), free to total PSA, PSA density, number of previous biopsies, digital rectal examination staging, Gleason score, percentage of tumour in the biopsy sample, bilaterality of the tumour and risk of progression group were prospectively recorded. RESULTS: • Higher testosterone levels were related to lower digital rectal examination staging (P= 0.02) and lower PSA level (P= 0.05). Higher testosterone was not related to lower Gleason score (P= 0.08). • Testosterone was inversely related to PCa bilaterality (P < 0.01) and percentage of tumour in the biopsy (P < 0.01). • High testosterone levels were found in patients allocated to the low risk of progression group and inversely (P= 0.03). • In multivariate analysis, higher age and lower testosterone were related to higher D'Amico risk of progression. CONCLUSION: • Patients with PCa and lower testosterone levels have poor prognosis factors and higher tumour burden before treatment onset. These findings reinforce the idea that low testosterone levels pretreatment are related to a poor prognosis in PCa.

Low testosterone bioavailability is related to prostate cancer diagnose in patients submitted to prostate biopsy.

INTRODUCTION: Relationship between prostate cancer (PCa) and testosterone (T) is controversial. Conflicting evidence has been published about T levels and development of PCa. AIM: (1) To determine the relationship between hormone levels and the diagnosis of PCa. (2) To specifically focus on the relationship between PCa and T in men classified as biochemically hypogonadal. MATERIALS AND METHODS: Prospective analysis of 1,000 transrectal ultrasound guided prostate biopsies (5 + 5 cores biopsies) between September 2007 and January 2010 in one center. Indication for prostate biopsy was suspicion of PCa on the basis of elevated prostate-specific antigen (PSA) and/or digital rectal examination (DRE). Serum testosterone and sex hormones binding globulin (SHBG) were determined in these patients. Of 557 men, the data were sufficient for further analysis. Age, body mass index (BMI), smoking/drinking habits, PSA, free PSA, PSA density, prostate volume, number of previous biopsies, DRE, and hormone levels were prospectively recorded. RESULTS: No relationship was found between T and PCa (449 ± 167 ng/dL in PCa versus 437 ± 169 ng/dL in non-PCa). SHBG was significantly higher in patients with PCa (51 ± 27 ng/dL in PCa vs. 44 ± 18 ng/dL in non-PCa). In hypogonadal men, T levels correlated with the PCa (235 ± 95 ng/dL in men with PCa versus 270 ± 58 ng/dL in men without PCa, P = 0.004). CONCLUSIONS: T levels were comparable in men with and without PCa, but SHBG levels were significantly higher in men with PCa. In men with low T, the men with PCa had a lower serum T levels and a lower prostate volume than the men without PCa.

Feasibility of transvaginal natural orifice transluminal endoscopic surgery-assisted living donor nephrectomy: is kidney vaginal delivery the approach of the future?

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) uses natural orifices to access the abdominal cavity. We adapted NOTES to perform transvaginal NOTES-assisted laparoscopic nephrectomy in living donors. OBJECTIVE: To assess the feasibility and reproducibility of this procedure and compare it with conventional laparoscopic living donor nephrectomy (LLDN). DESIGN, SETTING, AND PARTICIPANTS: From July 2009 to October 2010, 20 women underwent transvaginal NOTES-assisted living donor nephrectomy (LDN) in our centre. We compared the prospectively collected clinical data of each donor with those of a contemporaneous matched pair of conventional LLDNs (40 donors). SURGICAL PROCEDURE: The procedure was performed using three abdominal trocars and one trocar through the vaginal wall. MEASUREMENTS: Variables evaluated for donors were procedure length, blood loss, warm ischaemia time (WIT), complications, hospital stay, and first-month creatinine nadir. In the transvaginal LDN group, sexual function was assessed with the Female Sexual Function Index questionnaire before and after surgery. Variables evaluated for recipients were complications, graft function, and creatinine evolution. RESULTS AND LIMITATIONS: The procedure was completed in all cases. Operative variables were similar for both groups except for WIT, which was longer in the transvaginal LDN group (p<0.001) without consequences for graft functioning. One transvaginal LDN case had postoperative bleeding requiring immediate open surgery. All transvaginal LDN donors reported unaltered sexual function after surgery and satisfaction with the results. All recipients had immediate urine output, and all had a functioning graft at last follow-up except for one recipient of the transvaginal LDN group who required transplantectomy. Despite promising results, randomised controlled studies with longer follow-up are warranted to further elucidate the potential of this novel technique. CONCLUSIONS: Transvaginal NOTES-assisted LDN appears to be a feasible and reproducible surgical technique. The WIT was longer in the transvaginal group, and there was no effect on graft function after the short follow-up.

Orthotopic kidney transplantation: an alternative surgical technique in selected patients.

BACKGROUND: A renal transplant is the treatment of choice for patients with end-stage renal disease due to its superior short- and long-term survival benefits compared with dialysis treatment. A common trend for kidney transplantation in developed countries is an increasing acceptance of older patients, patients with comorbidities, and patients with vascular problems (eg, atheromatosis, venous thrombosis). For those patients, an orthotopic kidney transplant (OKT) is an option. OBJECTIVE: Our aim was to analyze the results of the largest OKT series in the world (surgical technique, complications, and outcomes) and to compare indications, surgical techniques, and long-term results from two different periods (before and after February 1987). DESIGN, SETTINGS, AND PARTICIPANTS: Between April 1978 and September 2009, 223 OKT were performed. We compared the results of transplants performed in two different periods: from April 1978 to January 1987 with 139 patients and from February 1987 to September 2009 with 84 patients. INTERVENTION: OKT were performed in all cases as described in the first report published in 1989 by Gil-Vernet et al. MEASUREMENTS: The clinical data, surgical reports, and complications rate of all patients were reviewed retrospectively. From a database maintained prospectively, two different periods were described, and the long-term results of the OKT were compared. Graft and patient survival in orthotopic versus heterotopic transplants from the same period were also compared. RESULTS AND LIMITATIONS: During the second period an important decrease in the number of OKT was observed due to the change in indication for this specific technique. No important differences between periods were noted in terms of surgical technique. The rate of urinary complications rate was similar in both periods. No differences in graft survival between series have been observed (p=0.22), but a higher mortality rate was seen in the second period mostly due to an older unfit population (p=0.031). No differences were observed in overall graft and patient survival between orthotopic and heterotopic kidney transplants performed during the same period. CONCLUSIONS: OKT is a good alternative with acceptable rates of urologic and vascular complications for those patients for whom heterotopic transplant is considered unsuitable.

[Evolution of living donor kidney transplantation: historic, statistical, national and own experience data]. / Evolución del trasplante renal de donante vivo: datos históricos, estadísticos, nacionales y propios.

Despite representing a small percentage of the transplant activity in our country, living donor kidney transplantation is a good alternative for the future because the needs exceed the offer of cadaver donor organs. We present the evolution of living donor kidney transplantation in Spain from the beginning in accordance to the ONT (Organización Nacional de trasplantes), and our current situation in comparison with other countries, as well as data obtained from the experience in our hospital which began in 1965.

[Renal transplantation in patients with HIV infection]. / Trasplante renal en pacientes infectados por el VIH.

The prevalence of human immunodeficience virus (HIV) infection among patients under renal replacement therapy varies, with estimates of 1% for Europe and 1.5% for the United States. Survival in HIV infected individuals receiving renal replacement therapy has improved since the introduction of high activity antiretroviral therapy (HAART). Current experience in renal transplantation in HIV-infected patients in the United States indicates that the three-year survival rate is similar to that of HIV-negative transplant recipients, with virological and immunological control of the infection by HAART and no increase in the number of opportunistic infections or tumors. The criteria for selecting renal transplantation candidates in this population are the following: no aids-defining events, CD4 cells > 200 cells/.l and undetectable viral load under HAART. In Spain, where most of these patients are former drug abusers, a two-year period of abstinence from cocaine and heroine abuse is also required, although patients can be participating in the methadone program. The main problems in the post-transplantation period have been interactions between HAART and immunosuppressive drugs, management of hepatitis C virus (HCV) coinfection and the high rate of acute rejection. To date, seven such renal transplantations have been performed in Spain, with favorable patient and graft survival and no progression to aids.

Transrectal prostatic ultrasonography in acute bacterial prostatitis: findings and clinical implications.

To evaluate the role of transrectal ultrasonography (TRUS) in the diagnosis of acute bacterial prostatitis (ABP) and to analyse the possible relationship between sonographic findings and clinical presentation and evolution, a prospective study using TRUS in patients with ABP was conducted. 45 patients (aged 58.2 +/- 14.6 y; mean +/- SD) with a clinical diagnosis of ABP admitted to a university hospital were studied prospectively. Clinical, analytical and microbiological data were recorded. TRUS was performed on admission and after 1 month of antibiotic therapy. Findings were correlated with clinical and evolutive data. The mean prostatic volume on admission was 40.5 +/- 17.9 ml. 21 patients (46.6%) had sonographically demonstrable lesions in peripheral prostatic lobules. One month later, when treatment had ended, lesions had disappeared or improved in 61.1% of patients, and the mean prostatic volume was 24.3 +/- 10.5 ml (p < 0.0005). Clinical, analytical and microbiological data and evolution of ABP were not significantly different in patients with or without sonographically demonstrable lesions. TRUS does not need to be performed in every patient with suspicion of ABP; the only indication for TRUS in ABP is the exclusion of prostatic abscess.