Technical refinement of mini-laparoscopic hernia repair in infants and children.

BACKGROUND: In large, long-term series of laparoscopic pediatric groin hernia repairs, the recurrence rate is commonly higher compared with the open herniotomy. Thus, we refined our laparoscopic technique from a simple hernia sac ligation into combined posterior wall repair for pediatric groin hernias. METHODS: Between March 2010 and March 2013, 41 consecutive infants and children with primary inguinal hernia were treated surgically with our refined mini-laparoscopic hernia technique. The mean patient age was 4.5 years. Before hernia repair, there were synchronous bilateral hernias in 4 (9.7 %), left inguinal hernias in 14 (34.2 %) and right inguinal hernias in 23 (56.1 %). The mini-laparoscopic hernia repair was carried out with three 3.5 mm trocar ports including 3 mm telescope and 3 mm instruments. RESULTS: Totally 61 repairs were performed. The mean follow-up period was 12 months. The mean operation time was 45 min. None of the repaired groin hernias had a recurrence or procedure-related complication during the period of follow-up. None of them experienced a chronic pain postoperatively. To date there was no scrotal or testicular complication detected by regular ultrasonographic follow-up. CONCLUSIONS: Our refined laparoscopic technique is a safe and effective method in the management of groin hernias in infants and children with a minimal early recurrence rate.

An audit of nephroureterectomy for upper tract urothelial carcinoma.

BACKGROUND: The boundary of nephroureterctomy has been revisited and lymph node dissection has been recommended recently. We investigated the role of synchronous ipsilateral adrenalectomy in treating patients with upper tract urothelial carcinoma. METHODS: 110 patients with clinically localized upper tract urothelial carcinoma treated by nephroureterectomy and bladder cuff resection were retrospectively evaluated. 70 patients underwent nephroureterectomy without concomitant ipsilateral adrenalectomy, whereas nephroureterectomy and ipsilateral adrenalectomy was performed in other 40 patients. Cancer specific, metastasis and local recurrence free survival during a follow-up of median 46 months were analyzed. RESULTS: No patient had adrenal metastasis among the 40 adrenalectomized patients. A total of 4 patients developed local recurrences; including 1 of the 70 adrenalectomy-sparing and 3 of the 40 adrenalectomized patients (p = 0.102, chi-square test). Five patients with adrenalectomy and four without adrenalectomy had distant metastases (p = 0.212, chi-square test). The five-year local recurrence free survival (p = 0.09, log-rank test), metastasis-free survival (p = 0.292, log-rank test), and cancer-specific survival (p = 0.117, log-rank test) did not have significant difference between both groups. CONCLUSIONS: This is the only study in recent 2 decades to evaluate the necessity of synchronous adrenalectomy in treating localized upper tract urothelial carcinoma. Adrenal-sparing nephroureterectomy seems justified for clinically localized upper tract urothelial carcinoma.

Urachal adenocarcinoma following kidney transplantation: the first case report.

A 53-year-old man who underwent successful kidney transplantation for stage 5 chronic kidney disease presented to our clinic with intermittent painless gross hematuria. Urachal adenocarcinoma, stage III A by Sheldon system, was diagnosed after serial histopathologic and radiological studies. The patient was treated with extended partial cystectomy, en bloc resection of urachus and umbilicus, pelvic lymphadenectomy, and ileocystoplasty. There were no complications seen in this patient. Neither urachal adenocarcinoma recurrence, metastasis, nor de novo uroileal cancer developed during 48-month follow-up. His reconstructed bladder functioned efficiently, without compromising the transplanted kidney function. Our case demonstrated that conservative surgery and augmentation ileocystoplasty could be offered to kidney transplant recipients with localized urachal carcinoma.

Optimal C2 concentration of cyclosporin corrected with good efficacy and safety in Asian kidney transplant recipients.

INTRODUCTION: Calcineurin inhibitors (CNI) are known for their renal toxicity. Lower CNI exposure is a reasonable option to mitigate potential CNI-induced renal toxicity. Herein we have presented our long-term results after lower cyclosporine (CsA) exposure in the first year. MATERIALS AND METHODS: Between 1997 and 2004, 63 renal transplant recipients received CsA-based immunosuppression. CsA dosing was adjusted according to the 2-hour whole blood concentration (C2) level. We retrospectively reviewed acute rejection and graft survivals rates, as well as whole blood C2 levels. RESULTS: Review of serial mean C2 concentrations at 1, 2, 3, 6, and 12 months after transplantation were 1341, 1241, 1191, 1059, and 927 ng/mL, respectively. These levels were slightly lower than those suggested by the Consensus for C2 levels by Levy et al in 2002, namely, 1600 to 2000 ng/mL (mean, 1700); 1400 to 1600 ng/mL (mean, 1500); 1200 to 1400 ng/mL (mean, 1300); 1000 to 1200 ng/mL (mean, 1100), and 800 to 1000 ng/mL (mean, 900), respectively. Acute rejection rate at 3 months and 1 year are 17.5% and 23.8%. Graft survival at 1 year was 97% and at 5 years, 89%. Two patient were lost to fulminant hepatitis and acute myocardial infarction during the first year, which were not associated with underimmunosuppression. CONCLUSION: Appropriate CsA C2 levels may be lower among Taiwanese. Our C2 dosing strategy resulted in good outcomes with acceptable side effects in our single-center experience. Appropriate CsA C2 levels for Asians deserve more attention in trials of larger scale; most reference levels are presently concluded from studies of Caucasians.

Sirolimus does not absolutely abolish the occurrence/recurrence of urothelial carcinoma in renal transplant recipients.

OBJECTIVE: Sirolimus (SRL), an immunosuppressant shown to possess anti-proliferative properties, was hypothesized to mitigate the occurrence of posttransplantation malignancy. We examined its effect on posttransplantation urothelial carcinoma (UC). METHODS: This retrospective case analysis included renal allograft recipients with UC treated with SRL in a single institute. RESULTS: Among 90 renal recipients treated with SRL, 6 had previous/new-onset UC in the native kidney/ureter or bladder: at a mean period of 28 months (range, 7-49) of administering SRL for these recipients, UC occurred/recurred in 4 of the 6 patients. Individual cases are presented in detail. CONCLUSION: SRL does not absolutely abolish the occurrence/recurrence of UC among renal transplant recipients. Its potency as an anti-cancerous immunosuppressant for transplant recipients with UC deserves to be further defined in larger studies, probably by controlling SRL blood levels at lower or much higher ranges than used herein.

Acute lobar nephronia in a renal allograft: a case report and literature review.

We report a diabetic renal transplant recipient who presented with fever and right lower quadrant abdominal pain. Acute appendicitis was considered initially and she underwent emergent appendectomy. However, persistent symptoms postoperatively made us perform an imaging study to identify the problems. Abdominal and pelvic computed tomography disclosed several focal wedge-shaped lesions of low attenuation in the renal allograft. Acute lobar nephronia was successfully managed with parenteral antibiotics. The patient recovered without any sequela. A renal allograft in the right iliac fossa complicates the diagnosis among acute renal infection, malignancy, acute rejection, and even acute appendicitis. Biopsy of the renal allograft is sometimes needed due to clinically ambiguous imaging results. In this report, we not only detail the clinical course of such a rare case, but also review the previous 3 cases of acute lobar nephronia in renal allografts in the literature.

Bilateral aldosterone-producing adenomas: differentiation from bilateral adrenal hyperplasia.

BACKGROUND: Primary aldosteronism (PA) is a common curable disease of secondary hypertension. Most such patients have either idiopathic bilateral adrenal hyperplasia (BAH) or unilateral aldosterone-producing adenoma (APA). Bilateral APAs are reportedly extremely rare. AIM: To compare the distinctive characteristics, clinical course, and outcomes of bilateral APA vs. BAH. DESIGN: Retrospective record review. METHODS: From July 1994 to Jan 2007, 190 patients diagnosed with PA underwent surgical intervention at our hospital. Bilateral APA was diagnosed in 7/164 patients with histologically-proven APA. Twenty-one patients diagnosed as BAH, and 21 randomly selected of unilateral APA patients, matched by age and sex served as controls. RESULTS: Patients with bilateral APA had similar blood pressure, arterial blood gas analysis, spot urinary potassium to creatinine ratio and clinical symptoms to those with BAH, but lower serum potassium levels (p = 0.027), lower plasma renin activity (p = 0.037), and higher plasma aldosterone concentrations (p = 0.029). Aldosterone-renin ratio (ARR) after administration of 50 mg captopril was higher in bilateral APA than in BAH patients (p = 0.023), but not different between unilateral APA and BAH (p = 0.218). A cut-off of ARR >100 ng/dl per ng/ml/h and plasma aldosterone >20 ng/dl after captopril significantly differentiated bilateral APA from BAH. Bilateral subtotal adrenalectomy normalized blood pressure and biochemistry in all patients with bilateral APA. DISCUSSION: Bilateral APA, presenting simultaneously or sequentially, may not be a rare disease, accounting for 4.3% of APA in this sample. The clinical presentations of bilateral functional adenoma are not different from BAH, but patients with low serum potassium and ARR >100 after captopril should be carefully evaluated for bilateral adenoma.

Use of Hem-o-lok clips effectively lengthens renal vein during laparoscopic live donor nephrectomy.

We retrospectively reviewed our last 12 laparoscopic donor nephrectomies (LDNs) in which both the renal artery and the renal vein were controlled using 2 Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC, United States) on the proximal sides and the vessels were divided without securing the graft-side vessels (group 1). We compared the results with our 12 immediately preceding LDN donors in whom the arteries were controlled with 3 endoclips and the veins were controlled with staplers (group 2). The length of the vein was significantly longer (approximately 4 mm difference) in group 1, mainly due to trimmed staples from the graft vessels. Both cohorts of donors had uneventful surgery with no complications, and all the recipients recovered smoothly without any delayed graft function. Average operation time and warm ischemia time were similar among both groups (189 vs 207 minutes; 168 vs 149 seconds, respectively; both P > .1). We conclude that the use of Hem-o-lok effectively lengthens graft renal veins and is less costly during LDN.

Solitary port-site metastasis after laparoscopic bilateral nephroureterctomy for transitional cell carcinoma in a renal transplant recipient.

A renal transplant recipient with upper tract transitional cell carcinoma developed a solitary port-tract recurrence 8 months after a hand-assisted laparoscopic bilateral nephroureterectomy and was successfully managed by a local wide excision and adjuvant radiotherapy. Follow-up for 3 years after the salvage therapy showed no evidence of local recurrence or distant metastasis. This patient is the first one in the literature to have a solitary port-site metastasis of transitional cell carcinoma in renal transplant recipients.

Pharmacokinetic variability of sirolimus in Taiwanese renal transplant recipients.

To evaluate the pharmacokinetic variability of sirolimus (Rapamycin, SRL) in our renal transplant (RTx) recipients, dose-normalized trough concentration (C(0)) of SRL, and their intrasubject coefficients of variation (%CV) were analyzed. Thirty-eight patients were enrolled in regimens containing SRL. Concomitant immunosuppression included steroids (n = 38), cyclosporine (n = 33), tacrolimus (n = 3), and mycophenolate mofetil (n = 7). The mean dose-normalized C(0) was 2.13 +/- 0.91 ng/mL/mg. The intrasubject %CV of the dose-normalized C(0) ranged from 14% to 88% and averaged 42% in our series. The mean dose-normalized C(0) of SRL in our RTx recipients was much lower than that reported in Phase III trials. The intrasubject variation of dose-normalized C(0), even after administrating SRL for 6 months, could still be quite prominent. Thus, we suggest that, to maintain adequate therapeutic concentrations, periodic (monthly or bimonthly) SRL C(0) measurement is necessary in Taiwanese (Oriental) patients receiving SRL.

Use of simulect can reduce the incidence of acute rejection and demonstrates with superior 3-year patient and graft survival rates in renal transplantation.

BACKGROUND: Acute rejection is a major cause of graft loss in renal transplantation. Because the highest risk for acute rejection is in the first month posttransplantation, improved prophylaxis could be most beneficial in this period. Simulect administration provides 30 to 45 days of immunoprophylaxis against acute rejection during the critical period after transplantation. OBJECTIVES: We sought to assess the incidence of acute rejection episodes and the safety and tolerability of Simulect plus Neoral immunosuppression. Patient and graft survival rates up to 3 years posttransplantation were evaluated. METHOD: Forty-one transplant recipients received Simulect by intravenous infusion of an initial 20-mg dose on the day of renal transplantation and a second 20-mg dose on day 4 posttransplant. All renal recipients received immunosuppression with Neoral and steroid. RESULTS: There were eight cases (19.5%) of acute rejection within 1 year. The rejection episodes were easily reversed with steroid pulse therapy in seven patients except for graft loss. The 1-, 2-, and 3-year graft survival rates were 95%, 93%, and 88%, respectively. Overall, the 3-year patient survival rate was 100%. CONCLUSIONS: Simulect in combination with Neoral and steroid-reduced the incidence of acute rejection without an increase in adverse events. The low incidence and severity of acute rejection may have led to the superior 3-year patient and graft survival rates in renal transplantation.

Transitional cell carcinoma in renal transplant recipients.

We describe our experience in managing transitional cell carcinoma (TCC) in renal transplant (RTx) recipients. Nineteen RTx recipients (7 men; 12 women) presented with hematuria or hydronephrosis of native kidneys and were suspected with TCC were reviewed retrospectively; 17 of them proved to have TCC. The mean interval of the occurrence of TCC was 58.7 months (range, 3-144 months) after RTx. The patients with suspected upper tract lesions received bilateral nephroureterectomies (BNU) and bladder cuff resection. Transurethral resection of the bladder tumor (TUR-BT) was performed in patients with concomitant or solitary superficial bladder lesions. Of the 15 patients with upper tract TCC, 8 had bilateral lesions pathologically, but only 2 of them were suspected preoperatively on image study. With a mean follow-up of 28 months (range, 1-57 months) both the overall graft and patient survival rates were 76%; 4 patients with advanced diseases at presentation died. Bladder recurrence was noted in 6 patients (35%). Transplant patients with hematuria warrant detailed study of the whole urinary system and periodic ultrasonography of the native kidneys is recommended in all RTx recipients. Simultaneous BNU for the native kidneys is mandatory if there is any evidence of TCC in either renal/ureteral unit.

The utility of resistance index of distal interlobular arteries in evaluating renal graft function.

The correlations of the mean values of resistance index (RI) of the distal interlobular, arcuate, and interlobal arteries of the kidneys were evaluated with HDI 5000 ultrasonographic system using a 2- to 5-mHz scan probe under the power Doppler detection mode in 60 patients with various native renal conditions and 70 renal allografts. The mean values of RIs of the distal interlobular arteries and those of the interlobal arteries in the renal allografts were significantly correlated with the recipients' renal functions (P = .015 and .030, respectively), whereas those of arcuate arteries were not.