Preoperative Cylex assay predicts rejection risk in patients with kidney transplant.

INTRODUCTION AND OBJECTIVES: The ImmuKnow assay measures cell-mediated immunity by quantifying ATP release from CD4+ T-cells in peripheral blood. Herein, we hypothesized that this assay could predict complications associated with over-/under-immunosuppression in patients with kidney transplant (KT). METHODS: Sixty-seven patients undergoing KT were recruited prospectively and had ATP levels measured preoperatively, and at specified intervals over two months. Clinicians were blinded to ATP levels. Clinical events including rejection and infection/cancer were documented with a median follow-up of 21 months. Parameters including absolute ATP levels and changes in ATP patterns (slopes, delta) were analyzed. Association between ATP parameters and clinical outcomes was compared using the likelihood-ratio test and Kaplan-Meier curves. RESULTS: Absolute ATP values postoperatively had poor predictive value with regard to rejection or infection/malignancy. As well, changes in ATP values were poorly associated with complications. Importantly, patients with pre-transplant ATP values <300 ng/mL had significantly less rejection episodes vs. those with ATP values >300 ng/mL (p < 0.0001). CONCLUSIONS: For the first time, we have evidence that a preoperative ImmuKnow level can stratify patients with KT into low/high risk groups for rejection. Future studies used to assess the utility of this assay to design individualized immunosuppressive regimens are required.

A phase IIb randomized placebo-controlled trial testing the effect of MAG-EPA long-chain omega-3 fatty acid dietary supplement on prostate cancer proliferation.

BACKGROUND: High prostate eicosapentaenoic fatty acid (EPA) levels were associated with a significant reduction of upgrading to grade group (GG) ≥ 2 prostate cancer in men under active surveillance. We aimed to evaluate the effect of MAG-EPA long-chain omega-3 fatty acid dietary supplement on prostate cancer proliferation. METHODS: A phase II double-blind randomized placebo-controlled trial was conducted in 130 men diagnosed with GG ≥ 2 prostate cancer and undergoing radical prostatectomy between 2015-2017 (Clinicaltrials.gov: NCT02333435). Participants were randomized to receive 3 g daily of either MAG-EPA (n = 65) or placebo (n = 65) for 7 weeks (range 4-10) prior to radical prostatectomy. The primary outcome was the cancer proliferation index quantified by automated image analysis of tumor nuclear Ki-67 expression using standardized prostatectomy tissue microarrays. Additional planned outcomes at surgery are reported including plasma levels of 27 inflammatory cytokines and fatty acid profiles in circulating red blood cells membranes and prostate tissue. RESULTS: Cancer proliferation index measured by Ki-67 expression was not statistically different between the intervention (3.10%) and placebo (2.85%) groups (p = 0.64). In the per protocol analyses, the adjusted estimated effect of MAG-EPA was greater but remained non-significant. Secondary outcome was the changes in plasma levels of 27 cytokines, of which only IL-7 was higher in MAG-EPA group compared to placebo (p = 0.026). Men randomized to MAG-EPA prior to surgery had four-fold higher EPA levels in prostate tissue compared to those on placebo. CONCLUSIONS: This MAG-EPA intervention did not affect the primary outcome of prostate cancer proliferation according to nuclear Ki-67 expression. More studies are needed to decipher the effects of long-chain omega-3 fatty acid dietary supplementation in men with prostate cancer.

It is thought that our diet can impact our risk of cancer and affect outcomes in patients with cancer. Omega-3 fatty acids, mostly found in fatty fish, might be beneficial by protecting against prostate cancer and its adverse outcomes. We conducted a clinical trial to test the effects of an omega-3 dietary supplement (MAG-EPA) in men with prostate cancer. We randomly allocated 130 men to receive either MAG-EPA or a placebo for 7 weeks before their prostate cancer surgery. We measured a marker of how much tumor cells were proliferating (or growing in number) at the point of surgery, which might indicate how aggressive their disease was. However, the supplement did not affect tumor cell proliferation. The supplement was therefore not beneficial in this group of patients and further studies  are needed to test and confirm the effects of MAG-EPA on prostate cancer cells.

Impact of donor age on long-term outcomes after delayed graft function: 10-year follow-up.

Delayed graft function (DGF) has a negative impact on graft survival in donation after brain death (DBD) but not for donation after cardiac death (DCD) kidneys. However, older donor age is associated with graft loss in DCD transplants. We sought to examine the interaction between donor age and DGF in DBD kidneys. This is a single-center, retrospective review of 657 consecutive DBD recipients transplanted between 1990 and 2005. We stratified the cohort by decades of donor age and studied the association between DGF and graft failure using Cox models. The risk of graft loss associated with DGF was not significantly increased for donor age below 60 years (adjusted hazard ratio [aHR] 1.12, 1.51, and 0.90, respectively, for age <40, 41-50 and 51-60 years) but significantly increased after 60 years (aHR 2.67; P = 0.019). Analysis of death-censored graft failure yielded similar results for donor age below 60 years and showed a substantially increased risk with donors above 60 years (aHR 6.98, P = 0.002). This analysis reveals an unexpectedly high impact of older donor age on the association between DGF and renal transplant outcomes. Further research is needed to determine the best use of kidneys from donors above 60 years old, where DGF is expected.

Effects of omega-3 supplementation on psychological symptoms in men with prostate cancer: Secondary analysis of a double-blind placebo-controlled randomized trial.

BACKGROUND: In the general population, a higher omega-3 polyunsaturated fatty acids intake is associated with lower levels of several psychological symptoms, especially depression. However, the existing evidence in cancer is equivocal. METHODS: This phase IIB double-blind, placebo-controlled trial was aimed at comparing the effects of eicosapentaenoic acid monoacylglyceride (MAG-EPA) supplementation and high oleic acid sunflower oil (HOSO; placebo) on depression levels (primary outcome) and other symptoms (anxiety, fear of cancer recurrence, fatigue, insomnia, perceived cognitive impairments; secondary outcomes). Participants, recruited in a prostate cancer clinic, were randomized to MAG-EPA (3.75 g daily; n = 65) or HOSO (3.75 g daily; n = 65) for 1 year post-radical prostatectomy (RP), starting 4-10 weeks before surgery. Patients completed self-report scales at baseline (before RP) and 3, 6, 9, and 12 months after: Hospital Anxiety and Depression Scale (HADS), Fear of Cancer Recurrence Inventory (FCRI), Insomnia Severity Index (ISI), Fatigue Symptom Inventory (FSI), and Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog). RESULTS: Analyses showed significant reductions in HADS-depression, HADS-anxiety, FCRI, ISI, FSI-number of days, and FACT-Cog-impact scores over time. A significant group-by-time interaction was obtained on FACT-Cog-Impact scores only; yet, the temporal change was significant in HOSO patients only. CONCLUSIONS: Several symptoms significantly decreased over time, mainly within the first months of the study. However, MAG-EPA did not produce greater reductions than HOSO. Omega-3 supplementation does not seem to improve psychological symptoms of men treated with RP.

Effects of Concentrated Long-Chain Omega-3 Polyunsaturated Fatty Acid Supplementation on Quality of Life after Radical Prostatectomy: A Phase II Randomized Placebo-Controlled Trial (RCT-EPA).

Prostate cancer (PCa) and associated treatments incur symptoms that may impact patients' quality of life. Studies have shown beneficial relationships between diet, especially omega-3 fatty acids, and these symptoms. Unfortunately, only few data describing the relationship between long-chain omega-3 fatty acids (LCn3) and PCa-related symptoms in patients are available. The purpose of this study was to evaluate the effects of LCn3 supplementation on PCa-specific quality of life in 130 men treated by radical prostatectomy. Men were randomized to receive a daily dose of either 3.75 g of fish oil or a placebo starting 7 weeks before surgery and for up to one-year post-surgery. Quality of life was assessed using the validated EPIC-26 and IPSS questionnaires at randomization, at surgery, and every 3 months following surgery. Between-group differences were assessed using linear mixed models. Intention-to-treat analyses showed no significant difference between the two groups. However, at 12-month follow-up, per-protocol analyses showed a significantly greater increase in the urinary irritation function score (better urinary function) (MD = 5.5, p = 0.03) for the LCn3 group compared to placebo. These results suggest that LCn3 supplementation may improve the urinary irritation function in men with PCa treated by radical prostatectomy and support to conduct of larger-scale studies.

Opioid use after uro-oncologic surgeries in time of opioid crisis.

INTRODUCTION: Recent literature emphasizes how overprescription and lack of guidelines contribute to wide variation in opioid prescribing practices and opioid-related harms. We conducted a prospective, observational study to evaluate opioid prescriptions among uro-oncologic patients discharged following elective in-patient surgery. METHODS: Patients who underwent four surgeries were included: open retropubic radical prostatectomy, robot-assisted radical prostatectomy, laparoscopic radical nephrectomy, and laparoscopic partial nephrectomy. The primary outcome was the dose of opioids used after discharge (in oral morphine equivalents [MEq]). Secondary outcomes included: opioid requirements for 80% of the patients, management of unused opioids, opioid use three months postoperative, opioid prescription refills, and guidance about opioid disposal. RESULTS: Sixty patients were included for analysis. Patients used a mean of 30 MEq (95% confidence interval 17.8-42.2) at home and 80% of the patients used 50 MEq or less. A mean of 40.4 MEq per patient was overprescribed. Fifty percent of the patients kept the remaining opioids at home, with only 20.0% returning them to their pharmacy. After three months, 5.0% of the patients were using opioids at least occasionally. Three patients needed a new opioid prescription. Forty percent reported having received information regarding management of unused opioids. CONCLUSIONS: We found 60% of opioids prescribed were unused, with half of our patients keeping these unused tablets at home. Our results suggest appropriate opioid prescription amounts needed for urological cancer surgery, with 80% of the patients using 50 MEq or less of morphine equivalents.

Perception and satisfaction of patients after telemedicine urology consultations: A matched analysis with physicians' perspective.

INTRODUCTION: During the first regional COVID-19 lockdown in March 2020, we conducted a study aimed at evaluating completeness of telemedicine consultation in urology. Of 1679 consultations, 67% were considered completely managed by phone. The aim of the present study was to assess patients' experience and satisfaction with telemedicine and to compare them with urologists' perceptions about quality and completeness of the telemedicine consultation. METHODS: We contacted a randomly selected sample of patients (n=356) from our previous study to enquire about their experience. We used a home patient experience questionnaire, inspired by the Patient Experiences Questionnaire for Out-of-Hours Care (PEQOHC) and the Consumer Assessment Health Profile Survey (CAHPS). RESULTS: Of 356 patients contacted, 315 agreed to complete the questionnaire. Urological consultations were for non-oncological (104), oncological (121), cancer suspicion (41), and pediatric (49) indications. Mean patient satisfaction score after telemedicine consultation was 8.8/10 (median 9/10) and 86.3% of patients rated the quality of the consultation as either excellent (54.6%) or very good (31.7%). Consultations regarding cancer suspicion had the lowest score (8.3/10). Overall, 46.7% of all patients would have preferred an in-person visit outside of the pandemic situation. Among patients whose consultations were rated suboptimal by urologists, almost a third more (31.2%) would have preferred an in-person visit (p=0.03). CONCLUSIONS: Despite high reported patient satisfaction rates with telemedicine, it is noteworthy that nearly half of the patients would have preferred an in-person visit. Post-pandemic, it will be important to incorporate telemedicine as an alternative, while retaining and offering in-person visits.

Carbon monoxide-releasing molecules protect against ischemia-reperfusion injury during kidney transplantation.

Carbon monoxide (CO) can provide beneficial antiapoptotic and anti-inflammatory effects in the context of ischemia-reperfusion injury (IRI). Here we tested the ability of pretreating the kidney donor with carbon monoxide-releasing molecules (CORM) to prevent IRI in a transplant model. Isogeneic Brown Norway donor rats were pretreated with CORM-2 18 h before kidney retrieval. The kidneys were then cold-preserved for 26 h and transplanted into Lewis rat recipients that had undergone bilateral nephrectomy. Allografts from Brown Norway to Lewis rats were also performed after 6 h of cold ischemic time with low-dose tacrolimus treatment. All recipients receiving CORM-2-treated isografts survived the transplant process and had near-normal serum creatinine levels, whereas all control animals died of uremia by the third post-operative day. This beneficial effect was also seen in isografted Lewis recipients receiving kidneys perfused with CORM-3, indicating that CORMs have direct effects on the kidney. Pretreatment of human umbilical vein endothelial cells in culture with CORM-2 for 1 h significantly reduced cytokine-induced nicotinamide adenine dinucleotide phosphate-dependent production of superoxide, activation of the inflammation-relevant transcription factor nuclear factor-κB, upregulated expression of E-selectin and intercellular adhesion molecule-1 adhesion proteins, and leukocyte adhesion to the endothelial cells. Thus, CORM-2-derived CO protects renal transplants from IRI by modulating inflammation.

Three Weeks of Team-Based Leaning Do Not Overload Undergraduate Students.

CONTEXT: Team-based learning (TBL) is a flipped-classroom approach requiring students to study before class. Fully flipped curricula usually have fewer in-class hours. However, for practical reasons, several programs implement a few weeks of TBL without adjusting the semester timetable. Students fear that they will be overloaded by the individual and collaborative study hours needed to prepare for TBL. METHODS: We implemented three consecutive weeks of TBL in a 15-week lecture-based course on the renal system. In-class time and assessments were unchanged for all courses. Four hundred fifty-nine first-year undergraduate medical students (229 in 2018; 230 in 2019) were invited to complete weekly logs of their individual and collaborative study hours during lectures and TBL, along with questionnaires on cognitive load and perception of the course. Our program changed from A to E grading in 2018 to pass-fail grading in 2019. RESULTS: Participants (n = 324) spent a similar number of hours studying for TBL vs. lectures with a mean of 3.1 h/week. Collaborative study was minimal outside class (median 0.1 h/week). Results remained similar with pass-fail grading. If in-class time were reduced, 18% of participants said they would have used freed-up time to study for TBL. Studying for TBL generated similar extraneous cognitive load and lower intrinsic load compared to studying for lectures; students were less stressed, and maintained high levels of motivation and self-perceived learning. CONCLUSIONS: Three weeks of lectures were replaced by TBL without reducing in-class time. Students did not report overload in study hours or in cognitive load. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01314-x.

Kidney and liver transplants from donors after cardiac death: initial experience at the London Health Sciences Centre.

BACKGROUND: The disparity between the number of patients waiting for an organ transplant and availability of donor organs increases each year in Canada. Donation after cardiac death (DCD), following withdrawal of life support in patients with hopeless prognoses, is a means of addressing the shortage with the potential to increase the number of transplantable organs. METHODS: We conducted a retrospective, single-centre chart review of organs donated after cardiac death to the Multi-Organ Transplant Program at the London Health Sciences Centre between July 2006 and December 2007. In total, 34 solid organs (24 kidneys and 10 livers) were procured from 12 DCD donors. RESULTS: The mean age of the donors was 38 (range 18-59) years. The causes of death were craniocerebral trauma (n = 7), cerebrovascular accident (n = 4) and cerebral hypoxia (n = 1). All 10 livers were transplanted at our centre, as were 14 of the 24 kidneys; 10 kidneys were transplanted at other centres. The mean renal cold ischemia time was 6 (range 3-9.5) hours. Twelve of the 14 kidney recipients (86%) experienced delayed graft function, but all kidneys regained function. After 1-year follow-up, kidney function was good, with a mean serum creatinine level of 145 (range 107-220) micromol/L and a mean estimated creatinine clearance of 64 (range 41-96) mL/min. The mean liver cold ischemia time was 5.8 (range 5.5-8) hours. There was 1 case of primary nonfunction requiring retransplantation. The remaining 9 livers functioned well. One patient developed a biliary anastomotic stricture that resolved after endoscopic stenting. All liver recipients were alive after a mean follow-up of 11 (range 3-20) months. Since the inception of this DCD program, the number of donors referred to our centre has increased by 14%. CONCLUSION: Our initial results compare favourably with those from the transplantation of organs procured from donors after brain death. Donation after cardiac death can be an important means of increasing the number of organs available for transplant, and its widespread implementation in Canada should be encouraged.

A prospective, multisite study analyzing the percentage of urological cases that can be completely managed by telemedicine.

INTRODUCTION: The COVID-19 pandemic has accelerated the development of telemedicine due to confinement measures. However, the percentage of outpatient urological cases that could be managed completely by telemedicine outside of the COVID-19 pandemic remains to be determined. We conducted a prospective, multisite study involving all urologists working in the region of Quebec City. METHODS: During the first four weeks of the regional confinement, 18 pediatric and adult urologists were asked to determine, after each telemedicine appointment, if it translated into a complete (CCM), incomplete (ICM), or suboptimal case management (SCM, adequate only in the context of the pandemic). RESULTS: A total of 1679 appointments representing all urological areas were registered. Overall, 67.6% (95% confidence interval [CI] 65.3; 69.8), 27.1% (25.0; 29.3), and 4.3% (3.5; 5.4) were reported as CCM, SCM, and ICM, respectively. The CCM ratio varied according to the reason for consultation, with cancer suspicion (52.9% [42.9; 62.8]) and pediatric reasons (38.0% [30.0; 46.6]) showing the lowest CCM percentages. CCM percentages also varied significantly based on the setting where it was performed, ranging from 61.1% (private clinic) to 86.8% (endourology and general hospital). CONCLUSIONS: We show that two-thirds of all urological outpatient cases could be completely managed by telemedicine outside of the pandemic. After the pandemic, it will be important to incorporate telemedicine as an alternative for a patient's first or followup visit, especially those with geographical, pathological, and socioeconomic considerations.

Case report: technical and functional implications of hand-assisted laparoscopic partial nephrectomy in a patient with autosomal dominant polycystic kidney disease.

We describe laparoscopic partial nephrectomy in a patient with autosomal dominant polycystic kidney disease. Reconstruction was accomplished despite the abnormal quality of the renal tissue. In this patient, with borderline renal function, the warm-ischemia time (50 minutes) was longer than the normally accepted time and was poorly tolerated. In order to avoid the damaging effects of warm ischemia, alternatives to hilar clamping should be employed, and open partial nephrectomy should be considered.

High-flow priapism: An overview of diagnostic and therapeutic concepts.

We describe the case of a 23 year-old man with high-flow priapism following blunt perineal trauma. He was treated successfully with super-selective embolization with a resorbable material (gel foam). We will review the pathophysiology, etiology, and diagnosis and treatment approaches of high-flow priapism based on a review of the medical literature.

[Postoperative chylous ascites in urology]. / L'ascite chyleuse postopératoire en urologie.

Postoperative chylous ascites is a rare complication after retroperitoneal surgery. It is a complex problem associated with nutritionnal and immunological consequences. Urologists should be able to manage this complication linked to many urological procedures. Incidence of chylous ascites seems to increase with time probably because more complex surgical interventions. Diagnosis is usually suspected based on clinical abdominal symptoms. Diagnostic paracentesis shows milky fluid with high triglyceride and lymphocyte content. Treatment is classicaly based on dietary interventions with the goal to decrease fistula's lymph flow. Somatostatin analog is a very efficient adjuvant therapy and should be used early in the course of treatment. Surgery is usually attempted in patients who have failed conservative modalities. Because chylous ascites is rare, no clear management guidelines exist. Treatment should be individualized and tailored according to severity of lymphatic leakage, its consequences and the patient health status.

Donor-specific antibodies, C4d and their relationship with the prognosis of transplant glomerulopathy.

BACKGROUND: Transplant glomerulopathy (TG) is a diagnostic criterion for chronic active antibody-mediated rejection (CAABMR), with C4d, donor-specific antibodies (DSA) and other lesions of chronic tissue injury. However, TG often presents without C4d or DSA. Until recently, such cases were termed suspicious for CAABMR, and their prognosis remains unclear. METHODS: To better understand the contribution of TG, C4d, and DSA on outcomes, we retrospectively studied 61 patients with late TG for the composite endpoint of death-censored graft failure or doubling of serum creatinine. Cases were matched to controls based on age, year and number of transplant, type of donor, and the availability of an indication biopsy during the same time after transplantation. Analyses were performed using proportional hazards models. RESULTS: Compared to matched controls, patients with TG had a more than fivefold increased risk of reaching the endpoint (adjusted hazard ratio (aHR), 5.3; 95% confidence interval (95% CI), 1.5-18.4). The proportion of patients with isolated TG, TG suspicious for CAABMR (C4+/DSA- or C4d-/DSA+) and TG with definite CAABMR (C4d+/DSA+) were 63%, 20%, and 17%, respectively. Suspicious and definite CAABMR showed a similar prognosis, significantly worse than isolated TG (aHR, 4.5; 95% CI, 1.1-18.9 and aHR, 5.9, 95% CI, 1.1-31.3 respectively). CONCLUSION: Transplant glomerulopathy is associated with poor prognosis, independent of the level of graft dysfunction and other chronic histologic changes. This prognosis is similar whether there is evidence of tissue or peripheral alloantibody reactivity. These findings are relevant to the development of clinically meaningful criteria for CAABMR, for its clinical management, and in the future selection of population for clinical trials.

Cystatin C for early detection of acute kidney injury after laparoscopic partial nephrectomy.

INTRODUCTION AND OBJECTIVES: Mortality due to AKI has not changed significantly over the past 50 years. This is due in part to failure to detect early AKI and to initiate appropriate therapeutic measures. There is therefore a need to identify biomarkers that would improve the early detection of AKI. The objective of this study was to assess whether cystatin C levels obtained at specific timepoints during laparoscopic partial nephrectomy (PN) could be early predictors of AKI. MATERIALS AND METHODS: Twenty-five patients underwent laparoscopic PN for organ-confined tumors. All procedures were performed by two surgeons in a single institution. Plasma samples were collected preoperatively, and post-unclamping at 5, 20, 120 min and on the day following surgery. Plasma cystatin C was measured by enzyme-linked immunosorbent assay. Correlation between levels of cystatin C and other parameters of interest were assessed in order to define cystatin C ability to predict AKI and loss of renal function following laparoscopic PN. RESULTS: The mean baseline eGFR was 93 ml/min/1.73 m(2). Warm ischemia time varied between 16 and 44 min. Post-operative day 1 (POD1) cystatin C levels compared to baseline were increased in 13 (52%) of the patients. There was a high correlation between the difference of POD 1 and baseline value, and eGFR in the immediate postoperative period (r = -0.681; P = 0.0002) and at 12-month follow-up (r = -0.460, P = 0.048). However, the variation in cystatin C levels at earlier timepoints were not associated to AKI nor renal function. CONCLUSIONS: High increase in POD 1 cystatin C levels from baseline may help identify patients with AKI and those at higher risk of chronic kidney disease, following laparoscopic PN.

Extracapsular versus intracapsular allograft nephrectomy: impact on allosensitization and surgical outcomes.

INTRODUCTION: Our objective was to compare the impact of extra-capsular (ECAN) versus intracapsular allograft nephrectomy (ICAN) on allosensitization and surgical outcomes. METHODS: Between 1990 and 2004, 96 allograft nephrectomies were performed at our institution. Of these, 29 procedures were performed within 1 month of the transplant and were therefore omitted from analysis. Overall, the results of 44 ECAN and 23 ICAN were reviewed. RESULTS: The mean operative times were 110.9 versus 130.4 min for ICAN versus ECAN (p = 0.02) and the estimated blood loss was 226 mL for ICAN versus 483 mL for ECAN (p = 0.004). Intraoperative and postoperative complications were low using either technique and differences were not statistically significant. Overall, the preoperative to postoperative change in the percentage of panel reactive antibody was +2.1% for ICAN versus +1.2% for ECAN (NS) at 3 to 12 months postoperatively, respectively (NS). The percentage of patients relisted was 33.3% versus 54.3% (NS), and the percentage of patients re-transplanted once relisted was also very similar: 63.2% for ECAN versus 66.7% for ICAN (NS), after a mean follow-up of 4.5 and 8.4 years, respectively. CONCLUSIONS: ICAN can be performed with shorter operative times and less blood loss versus the extracapsular approach. As well, this operative approach does not appear to affect allosensitization and the ability to re-transplant patients.

A pioneer of urologic surgery from a small town in Ontario, Canada: A tribute to Abraham Groves (1847-1935).

BACKGROUND: Abraham Groves worked as a general practitioner and surgeon in the small town of Fergus, Ontario, Canada. Several priority claims have been attributed to Groves' life in surgery, including aseptic surgery (1874), appendectomy (1883) and the use of surgical gloves (1885). He was also an early practitioner of urological surgery. OBJECTIVE: The purpose of this paper is to describe and objectively assess his contributions as a pioneer in urological surgery. METHODS: A systematic search of contemporary journals was made for articles by or about Groves. These articles and his 1934 autobiography were reviewed. The information was assessed not only for priority, but also for the development of organized surgical principles and thought. RESULTS: Groves published frequently throughout his career; up to this point, 36 papers have been identified. Groves' claims are verifiable for aseptic surgery, which were the result of logical surgical thought and was practiced throughout his career. Contemporary publications support his early use of suprapubic lithotomy (1875), prostatotomy (1887), bladder repair (1892), urethral repair (1903), renal decapsulation (1905) and prostatectomy (1911). CONCLUSIONS: Despite his isolation, Abraham Groves independently developed a full range of surgical techniques and principles relevant to modern-day urology. His impact was reduced by the nature of the environment in which he worked and by the limited circulation of the journals in which he chose to publish.

Robot-assisted pyeloplasty: follow-up of first Canadian experience with comparison of outcomes between experienced and trainee surgeons.

BACKGROUND AND PURPOSE: Robot-assisted pyeloplasty (RAP) has been established recently as an option in the management of ureteropelvic junction obstruction (UPJO). We present the first Canadian experience with RAP with respect to operative results and outcomes. We compare the surgical outcomes between experienced and trainee surgeons, with respect to operating room times and success rates. PATIENTS AND METHODS: Eighty-eight patients underwent transperitoneal RAP for UPJO using the da Vinci robotic platform. Two surgeons performed Anderson-Hynes dismembered pyeloplasty in 85 cases and YV-plasty in 5 cases. Five patients had RAP for secondary UPJO after failure of other treatments. Diuretic renography was performed at 6 weeks, and 6, 12, 18, 24, and 36 months postpyeloplasty. The mean follow-up was 14.1 ± 8.5 months. RESULTS: The mean operative time was 167.7 ± 43.2 minutes, and the mean anastomotic time was 41.9 ± 14.1 minutes. The mean operative duration significantly decreased with time (P < 0.05). Ten patients needed simultaneous nephroscopic stone management via the pyelotomy incision. The mean blood loss was 56.6 ± 55.4 mL, and the mean hospital stay was 2.5 ± 0.5 days. There were five major postoperative (stent migration, urinoma) and three minor complications that were associated with the RAP procedures. Postoperative renal scintigraphy demonstrated only four cases with persistent obstruction. Eighty-three (94.3%) patients experienced improvement of symptoms whereas 5 continued to be symptomatic. Two patients needed secondary procedures to relieve persisting obstruction. There were no statistical differences in outcomes between the experienced surgeons and trainees (P = 0.28). CONCLUSIONS: In the first large case series of RAP from Canada, we demonstrate that RAP can be performed with relatively short operative times and is safe and effective, achieving similar long-term results with standard open repair. We show that robot-assisted surgery can be safely transitioned to surgical trainees. With its cost and availability, its role in the Canadian system needs further study.

Dual-kidney transplants as an alternative for very marginal donors: long-term follow-up in 63 patients.

BACKGROUND: Organ shortage has led to the use of dual-kidney transplant (DKT) of very marginal donors into a single recipient to increase the use of marginal organs. To date, few data are available about the long-term outcome of DKT and its usefulness to increase the pool of available organ. METHODS: We conducted a single-center cohort study of DKTs with longitudinal follow-up over an 8-year period. Between 1999 and 2007, 63 DKTs were performed. All kidneys from donors younger than 75 years refused by all centers for single transplantation, and kidneys from donors aged 75 years or older were routinely evaluated based on preimplantation glomerulosclerosis. Renal function, patient or graft survival, and perioperative complications were compared with 66 single kidneys from expanded criteria donors (ECD) and 63 ideal kidney donors. RESULTS: After a median follow-up of 56 months, patient or graft survival was similar between the three groups. Twelve-, 36-, and 84-month creatinine clearance were similar for DKT and ECD (12 months: 58 and 59 mL/min; 36 months: 54 and 60 mL/min; and 84 months: 62 and 51 mL/min, respectively). For the study period, the routine evaluation of very marginal kidneys for DKT in our center has led to an increase of 47% in the transplants from donors aged 50 years or older, which represent 12% at the level of our organ procurement organization. CONCLUSIONS: DKT patients can expect long-term results comparable with single kidney ECD. The implementation of a DKT program in our unit safely increased the pool of organs from marginal donors.