Perineal wound closure using gluteal turnover flap or primary closure after abdominoperineal resection for rectal cancer: study protocol of a randomised controlled multicentre trial (BIOPEX-2 study).

BACKGROUND: Abdominoperineal resection (APR) for rectal cancer is associated with high morbidity of the perineal wound, and controversy exists about the optimal closure technique. Primary perineal wound closure is still the standard of care in the Netherlands. Biological mesh closure did not improve wound healing in our previous randomised controlled trial (BIOPEX-study). It is suggested, based on meta-analysis of cohort studies, that filling of the perineal defect with well-vascularised tissue improves perineal wound healing. A gluteal turnover flap seems to be a promising method for this purpose, and with the advantage of not having a donor site scar. The aim of this study is to investigate whether a gluteal turnover flap improves the uncomplicated perineal wound healing after APR for rectal cancer. METHODS: Patients with primary or recurrent rectal cancer who are planned for APR will be considered eligible in this multicentre randomised controlled trial. Exclusion criteria are total exenteration, sacral resection above S4/S5, intersphincteric APR, biological mesh closure of the pelvic floor, collagen disorders, and severe systemic diseases. A total of 160 patients will be randomised between gluteal turnover flap (experimental arm) and primary closure (control arm). The total follow-up duration is 12 months, and outcome assessors and patients will be blinded for type of perineal wound closure. The primary outcome is the percentage of uncomplicated perineal wound healing on day 30, defined as a Southampton wound score of less than two. Secondary outcomes include time to perineal wound closure, incidence of perineal hernia, the number, duration and nature of the complications, re-interventions, quality of life and urogenital function. DISCUSSION: The uncomplicated perineal wound healing rate is expected to increase from 65 to 85% by using the gluteal turnover flap. With proven effectiveness, a quick implementation of this relatively simple surgical technique is expected to take place. TRIAL REGISTRATION: The trial was retrospectively registered at Clinicaltrials.gov NCT04004650 on July 2, 2019.

Internal or External Stenting of the Ureterovesical Anastomosis in Renal Transplantation.

BACKGROUND: Stenting of the ureterovesical anastomosis reduces the incidence of urological complications (UCs) after renal transplantation, but there are multiple stenting techniques, and there is no consensus regarding which technique is preferred. The aim of this study was to compare an internal versus an external stenting technique on the incidence of UCs. METHODS: This is a retrospective analysis of 419 deceased donor renal transplantations performed between January 2008 and December 2013. Until 2011, 183 patients received an external stent through the ureterovesical anastomosis placed by suprapubic bladder puncture (SP stent). From 2011, 236 recipients received an internal double-J (JJ) stent. RESULTS: The rate of UC was 3.8% in JJ stents, compared to 9.3% in SP stents (p = 0.021). No difference in surgical ureter revision rate was observed between the groups (2.1 vs. 5.5%; p = 0.068). Urinary tract infection (UTI) rate and graft function were comparable between both groups. CONCLUSIONS: Internal JJ stenting significantly decreased the incidence of UC compared to an external SP stent. There was no difference in surgical ureter revision rate, UTI or graft function.

Wound morbidity after kidney transplant.

CONTEXT: Wound morbidity is an important surgical complication after kidney transplant. OBJECTIVE: To assess risk factors for postoperative wound complications and the impact of such complications on outcomes of kidney transplant. DESIGN AND PATIENTS: Retrospectively, 108 consecutive kidney transplant patients between January 2010 and December 2010 were included in the analysis. Wound morbidity was defined as a surgical site infection or symptomatic lymphocele requiring intervention. Patient, donor, and surgical characteristics were reviewed. RESULTS: Eight lymphoceles and 5 surgical site infections occurred in 12 patients. Risk factors for wound complications were recipient's age (P<.01), body mass index (P=.01), urinary tract infection (P=.01), and prolonged postoperative wound drainage (P=.047). Wound morbidity did not increase the incidence of delayed graft function, acute rejection, graft failure, or mortality. Obesity, recipient's age, urinary tract infection, and prolonged wound drainage are risk factors for wound-related complications. Graft and patient survival rates are comparable between patients with and without wound-related complications.

Ureterovesical anastomotic techniques for kidney transplantation: a systematic review and meta-analysis.

No consensus exists about which ureterovesical anastomosis technique to use for kidney transplantation. The aim of this systematic review was to compare the existing techniques in relation to the risk of urological complications. All studies that compared ureterovesical anastomotic techniques in kidney transplantation were included. Study endpoints were urinary leakage, ureteral stricture, vesicoureteral reflux and hematuria. Subanalyses of stented and nonstented techniques were performed. Two randomized clinical trials and 24 observational studies were included. Meta-analyses were performed on the Lich-Gregoir (LG) versus Politano-Leadbetter (PL) techniques and LG versus U-stitch (U) techniques. Compared with the PL technique, the LG technique had a significantly lower prevalence of urinary leakage (risk ratio (RR): 0.47, 95% confidence interval (CI): 0.30 to 0.75) and a significantly lower prevalence of hematuria when compared with both PL and U techniques (RR: 0.28, 95% CI: 0.16 to 0.49 and RR: 0.23, 95% CI: 0.11 to 0.50, respectively), regardless of ureteral stenting. There was no difference in the prevalence of ureteral strictures or vesicoureteral reflux between the various techniques. Of the three most frequently used ureterovesical anastomotic techniques, the LG technique results in fewer urological complications than the PL and U techniques.

[Renal transplantation at night]. / Niertransplantaties in de nacht.

BACKGROUND: In renal transplantation, prolonged cold ischaemia time (CIT) increases the risk of delayed graft function, rejection and graft failure. To minimise CIT, renal transplantations are performed directly upon graft availability and often take place during the night. Night-time surgery is supposedly associated with an increased risk of surgical complications compared with daytime operations. The aim of this study was to assess the consequences of night-time renal transplantation on surgical complications and graft function. METHOD: 384 adult recipients of deceased-donor renal transplantations performed between January 2007 and June 2012 were retrospectively examined. Night-time renal transplantations were defined as surgery between 11 PM and 6 AM. The primary outcome was the occurrence of surgical complications. The secondary outcome was graft function. RESULTS: No differences in surgical complications or graft function were observed among daytime and night-time groups. CIT was significantly increased in night-time renal transplantation (p < 0.001). CONCLUSION: Night-time renal transplantation is not associated with an increased risk of surgical complications or graft failure, and can be considered a safe procedure. Given the need to minimise CIT, delaying the procedure until the morning is unjustified.

Effect of gentamicin-containing collagen sponges on surgical site infection after hand-assisted laparoscopic donor nephrectomy.

BACKGROUND: Postoperative surgical site infection (SSI) can be considered a frequent complication of hand-assisted laparoscopic donor nephrectomy (HALDN). Since 2007, our center used routinely a gentamicin-containing collagen sponge (GCCS) when closing the wound. The effect of GCCS on SSI is not elucidated clearly. In this retrospective cohort study, we assessed the effects of GCCS on SSI after HALDN. METHODS: Between December 2004 and November 2007, we treated 100 patients without GCCS, and from November 2007 to July 2010, there were 100 patients with GCCS placed after HALDN. A SSI was defined as an incisional infection that required an intervention such as opening of the site or antibiotic treatment within 90 days after surgery. RESULTS: Implantation of a GCCS resulted in a statistically significant reduction in the SSI rate, from 6% to 0 (p=0.01). All infections occurred in the Pfannenstiel incision site. There was no significant difference between the groups in the creatinine concentration after three months. CONCLUSIONS: The use of gentamicin-containing collagen sponges reduces the risk of SSI significantly after HALDN without compromising kidney function.

Transplant nephrectomy: what are the surgical risks?

BACKGROUND: Whether or not to remove a failed renal graft has been the subject of much debate. One reason for a cautious approach to graft removal is its high morbidity and mortality rates. We analyzed the morbidity, mortality, and risk factors of transplant nephrectomy at our center. MATERIAL AND METHODS: We included 157 cases of transplant nephrectomy in 143 patients, performed between January 2000 and May 2012 at the Academic Medical Center, Amsterdam. Patient data were collected retrospectively. RESULTS: A total of 32 surgical complications occurred after transplant nephrectomy (20%) and 16 patients needed surgical re-intervention (10%). Hemorrhage and infection are the most frequent causes of surgical complications (14%). The mortality rate was 3.2%. There were no significant differences in characteristics and timing of transplant nephrectomy between the group with surgical complications and the group without. A total of 59 re-transplantations were performed in 57 patients (38%). CONCLUSIONS: Transplant nephrectomy is associated with high morbidity and mortality rates. We found no significant risk factors for surgical complications following transplant nephrectomy and no significant association between timing of transplant nephrectomy and surgical complications. Steps to reduce these complications need further investigation.