A systematic review of kidney transplantation outcomes in patients with end-stage renal disease due to childhood lower urinary tract malformations.

PURPOSE: Patients with lower urinary tract malformations (LUTM) were suspended from kidney transplantation (KT) programs in the past due to various concerns. Consequently, only a limited number of studies have explored this topic at hand. In this study, our objective was to perform a systematic review (SR) to evaluate the current evidence regarding KT outcomes as well as patient survival (PS), postoperative complications and urinary tract infections (UTI) in individuals with childhood LUTM. METHODS: The search encompassed databases of Web of Science, Medline (via PubMed), and Embase (via Scopus) to identify all studies reporting outcomes on KT for patients with LUTM. The research included articles published in English from January 1995 till September 2023. RESULTS: Of the 2634 yielded articles, 15 met the inclusion criteria, enrolling a total of 284,866 KT patients. There was significantly better 5-year graft survival (GS) in recipients with LUTM compared to the control group (RR, 1.04; 95% CI 1.02-1.06); while GS at 1-year and 10-year, and PS at 1-year, 5-year and 10-year were similar between groups. On the other hand, the postoperative UTI rate was significantly higher in the LUTM group (RR: 4.46; 95% CI 1.89-10.51). However, data on serum creatinine and estimated glomerular filtration rate on follow-up were insufficient. CONCLUSION: GS and PS rates appear to be similar in patients with childhood LUTM and those with normal lower urinary tract functions. Despite a higher postoperative UTI rate within this patient group, it appears that this has no effect on GS rates.

Proposal of a standardized training curriculum for open and robot-assisted kidney transplantation.

Standardized training programs for open (OKT) and robot-assisted kidney transplantation (RAKT) remain unmet clinical needs. To fill this gap, we designed a modified Delphi Consensus aiming to propose the first structured surgical curricula for both OKT and RAKT, involving a multispecialty international panel of experts. Two web-based surveys were built drafting two separate series of statements (for OKT and RAKT, respectively). The two surveys were delivered to a panel of 63 experts (for OKT) and 21 experts (for RAKT), selected considering their experience, academic profile and involvement in international associations. Consensus was defined as ≥75% agreement between the responders. Overall, 25/63 (40%) and 14/21 (67%) participated in the first round of the Delphi Consensus for the development of the structured curriculum for OKT and RAKT, respectively. During the second round, the experts reached consensus on all statements, as well as on the domains composing the structure of the training pathway: 1) eligibility criteria for trainees and host centres; 2) theoretical training; 3) simulation; 4) real case observation; and 5) modular training in the operating theatre. To the best of our knowledge, this is the first proposal of a dedicated curriculum for OKT and RAKT grounded on insights from international experts of different specialties. Our proposed curriculum provides the foundation to standardize the education and training in KT across Europe and beyond.

Graft survival and postoperative complications following orthotopic renal transplantation.

The iliac fossa is the most commonly used site to place the graft in renal transplantation in adults. However, iliac fossa may not be used in various conditions. Thus, orthotopic renal transplantation becomes a viable alternative for these selected patients. Given the technically challenging surgery and limited number of patients, data on the long-term outcomes on this regard are scarce. This narrative review serves as an update on the clinical outcomes after orthotopic renal transplantation, focusing on overall recipient survival and renal graft survival, as well as postoperative complications. We found that studies to date showed a comparable survival rate in both recipients and renal grafts in the postoperative follow-up period after orthotopic renal transplantation with a lower complication rate compared to the published data on heterotopic renal transplantation. The results of our review may encourage transplant centers to reevaluate their policies to consider orthotopic renal transplantation as an alternative technique in cases where heterotopic kidney transplantation is not possible.

Undescended testis: A roundtable discussion based on clinical scenarios - Part 1.

Undescended testis (UDT, cryptorchidism) is the most common congenital anomaly of the genital tract. Despite its high incidence, the management of UDT varies between specialties (urology, pediatric surgery, pediatric urology, pediatric endocrinology). Therefore, as the European Association of Urology - Young Academic Urologists Pediatric Urology Working Group, we requested experts around the world to express their own personal approaches against various case scenarios of UDT in order to explore their individual reasoning. We intended to broaden the perspectives of our colleagues who deal with the treatment of this frequent genital malformation.

Robot-Assisted Radical Prostatectomy in Renal Transplant Recipients: A Systematic Review.

Robot-assisted radical prostatectomy (RARP) has been shown to achieve excellent oncological outcomes with a low rate of complications in patients with prostate cancer. However, data on RARP in renal transplant recipients (RT) are dispersed. A literature search was conducted through April 2023 using PubMed/Medline, Embase and Web of Science databases. The primary aim was to evaluate the safety, oncologic and clinical outcomes of RARP in RT recipients. The secondary aim was to identify surgical technique modifications required to avoid iatrogenic damage to the transplanted kidney. A total of 18 studies comprising 186 patients met the inclusion criteria. Age at the time of treatment ranged 43-79 years. Biopsy results showed a high prevalence of low- and intermediate-risk disease. Operative time ranged between 108.3 and 400 mins, while estimated blood loss ranged from 30 to 630 mL. Length of hospital stay ranged from 3 to 6 days whereas duration of catheterization was between 5 and 18 days. Perioperative complication rate was 17.1%. Overall positive surgical margin rate was 24.19%, while biochemical recurrence was observed in 10.21% (19/186 patients). Modifications to the standard surgical technique were described in 13/18 studies. Modifications in port placement were described in 7/13 studies and performed in 19/88 (21.6%) patients. Surgical technique for the development of the Retzius space was reported in 13/18 studies. Data on lymphadenectomy were reported in 15/18 studies. Bilateral lymphadenectomy was described in 3/18 studies and performed in 4/89 (4.5%) patients; contralateral lymphadenectomy was reported in 7/18 studies and performed in 41/125 (32.8%) patients. RARP in RTRs can be considered relatively safe and feasible. Oncological results yielded significantly worse outcomes in terms of PSM and BCR rate compared to the data available in the published studies, with an overall complication rate highly variable among the studies included. On the other hand, low graft damage during the procedure was observed. Main criticisms came from different tumor screening protocols and scarce information about lymphadenectomy techniques and outcomes among the included studies.

Primum Non Discernere: Glass Ceilings and Female Representation at the European Association of Urology and European Society for Paediatric Urology Annual Meetings, 2012-2022.

Background: The term glass ceiling coined by Loden in 1978 is commonly used to describe difficulties faced by minorities and women when trying to move into senior roles. Objective: To analyse trends and patterns for female representation at the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) annual general meetings over the past decade. Design setting and participants: We used objective data on female representation in the roles of chairs, moderators, and lecture speakers at the EAU and ESPU meetings from 2012 to 2022. Outcome measurements and statistical analysis: We evaluated gender based representation in paediatric urology sessions at the EAU and ESPU meetings, collecting data on the overall number of sessions, lectures, symposiums, abstract/poster sessions, and courses, and analysed the male/female ratio. Data were derived from printed and digital programmes for the relevant meetings. Results and limitations: During the period from 2012 to 2022, the percentage female representation varied from 0% (2012) to a maximum of 35% (2022) at EUA paediatric urology sessions, and from 13.5% (2014) to a maximum of 32% (2022) at ESPU meetings. Both associations show clear progression towards equality. Conclusions: Female representation at EAU and ESPU meetings has risen over the years, reaching 35% and 32%, respectively, in 2022, which is in line with the number of female members. We hope that this motivates a move towards the equality objectives for 2030. A clear and fundamental societal change is needed, with fair and more consistent institutional policies and framework commitments in the areas of science, medicine, and global health. Gender equality and diversity taskforces are essential to achieve these goals. Patient summary: We analysed the male/female ratio for participants in annual meetings held by the European Association of Urology and the European Society for Paediatric Urology. From a low level in 2012, the ratio increased to over 30% in 2022, in line with the female membership of the societies. Focus on fair and consistent policies is needed to ensure that women are well represented in medicine.

Introducing a New Technique for Fascial Closure to Avoid Renal Allograft Compartment Syndrome in Pediatric Recipients: The Use of Tutoplast® Fascia Lata.

Introduction: Renal allograft compartment syndrome (RACS) is a complication that infrequently occurs after renal transplantation. Tight muscle closure may lead to RACS due to compression of renal parenchyma or kinking of the renal vessels. Many techniques have been proposed in an attempt to achieve tension-free closure, which can be specially challenging in child recipients. We present our experience with Tutoplast® Fascia Lata (RTI Surgical Tutogen Medical GmbH Industriestrasse 6, 91077 Neunkirchen am Brand, Germany) closure. Methods: All pediatric patients who underwent renal transplantation in our center between 2012 and 2021 were reviewed. Eight patients with Tutoplast® Fascia Lata placed at the time of initial transplantation were identified. Donor and recipient characteristics, Doppler ultrasound findings, and overall patient and graft survival rates were analyzed. Results: Doppler ultrasound was performed intra-operatively after abdominal wall closure. If any sign of vascular compromise was seen, the abdominal wall was opened and the graft was revised. The Tutoplast® Fascia Lata implant was used to perform tension-free fascia closure and, afterwards, a Doppler ultrasound was performed to confirm the optimal renal artery perfusion and venous patency. Three of the renal transplantations were from a cadaver donor, with two of them en bloc. Living donor transplantation was performed in four cases. Among which, there was a case of auto-transplantation due to bilateral renal artery stenosis. None of the patients presented any complications of either short or long term that was derived from the abdominal closure with Tutoplast® Fascia Lata. There was also no record of graft failure till datum. Conclusions: Restricted volume of the recipient pelvic cavity and the size discrepancy between the recipient pelvic cavity space and the donor adult kidney may lead to RACS. Other situations that occur more infrequently, i.e., as en bloc or auto-transplantation, are prone to suffer the same problem. Tutoplast® Fascia Lata is a safe option for these patients.

Pediatric Kidney Transplantation: Frameshift in Medical and Surgical Management. Does the Perioperative Setting Have an Impact on Transplant Outcome? A Single-Center Experience.

Introduction: Frameshift in medical management as well as in surgical thinking is putting the patient as a whole is the focus, rather than just the disease. To optimize the treatment of our pediatric transplant patients in our institution, we changed in 2013 the transplant program setting, treating, and operating all patients with pediatric transplant exclusively in a pediatric environment. The aim of this study was to analyze whether or not this change had an impact on patients safety, patient population, and patients and transplant outcome. Methods: In the retrospective analysis, we compared transplant outcome of two eras. Era1 (2008-2012) solely included patients treated in the adult facilities, era 2 (2013-2017) patients were exclusively treated in the pediatric environment. Results: There were 53 patients with renal transplant, with era 1 (28 patients) and era 2 (25 patients). Overall mortality was 5.6%. Median recipient age at transplantation was 13.2 years in era 1 and 8.59 years in era 2, median recipient weight at transplantation was 41.7 kg in era 1 vs. 26 kg in era 2, median size 149. 5 cm (era 1) vs. 123 cm in era2 (p = 0.05). The direct recipient/donor weight ratio remained stable in both eras, for recipients below 20 kg we saw a larger weight mismatch in era 1 (0.84 vs. 0.66). In the subgroup of patients with congenital anomalies of the kidney and urinary tract (CAKUT) those were significantly younger at onset of dialysis (p < 0.001) and at time of transplantation (p < 0.001), also they were less in body weight (p < 0.01), and body size (p < 0.001), this subgroup was larger in era 2. HLA mismatch data, serum creatinine, and GFR yield comparable results in both groups. Median time to detection of DSA was 46.2 month (3.8 years). Conclusion: Since children with ESRD at the time of transplant trend to be younger and smaller, it is crucial to ensure a medical environment that is able to address their particular challenges. Even in this recipient cohort, renal transplantation can be performed safely as outlined by our data.

Guideline Adherence of Paediatric Urolithiasis: An EAU Members' Survey and Expert Panel Roundtable Discussion.

Background: Paediatric nephrolithiasis has increased globally, requiring standardized recommendations. This study aims to assess the paediatric urolithiasis care between EAU members along with the statements of three experts in this field. Methods: The results of an electronic survey among EAU members comparing the guideline recommendations to their current practice managing paediatric nephrolithiasis in 74 centres are contrasted with insights from an expert-panel. The survey consisted of 20 questions in four main sections: demographics, instrument availability, surgical preferences and follow-up preferences. Experts were asked to give insights on the same topics. Results: A total of 74 responses were received. Computerised Tomography was predominantly used as the main imaging modality over ultrasound. Lack of gonadal protection during operations was identified as an issue. Adult instruments were used frequently instead of paediatric instruments. Stone and metabolic analysis were performed by 83% and 63% of the respondents respectively. Conclusions: Percutaneous Nephrolithotomy is the recommended standard treatment for stones > 20 mm, 12% of respondents were still performing shockwave lithotripsy despite PNL, mini and micro-PNL being available. Children have a high risk for recurrence yet stone and metabolic analysis was not performed in all patients. Expert recommendations may guide clinicians towards best practice.

Immunological Risk Factors in Paediatric Kidney Transplantation.

PURPOSE: The aim of this study was to identify factors impacting recipient sensitization rates and paediatric renal transplant patient outcomes. PATIENTS AND METHODS: For this purpose, a retrospective analysis of 143 paediatric renal transplants was carried out. This included the evaluation of patient's and donor's demographic data, HLA mismatches, immunosuppressive therapy, rejection episodes, panel reactive antibody (PRA) and post-transplant lymphoproliferative disease (PTLD). RESULTS: The mean patient age at the point of transplant receival was 11.5 years with a mean follow up time of 9.33±5.05 years. It was noted that graft survival rates for donors over 59 years had the worst outcome. HLA match did not show statistically significant influence on graft outcome. Graft survival for more than one biopsy-proven rejection was also significantly shorter (p=0.008). PRA were found in 28% of the recipient's post-transplantation and showed association with lower graft survival rates (p<0.001). In the present study, 22.7% (5/22) of the patients with EBV infections presented a PTLD. CONCLUSION: In conclusion, good graft survival with reduced sensitization for future transplantations and minimize the risk of PTLD, can be ensured through a balance between donor age, HLA match and condition of the recipient should be sought. Furthermore, paediatric patients should preferably receive organs from donors between the age of 10 and 59. EBV infection could be a relevant factor for developing PTLD.

Sexual function in adult patients who have undergone augmentation surgery in childhood: what is really important?

Problems relating to the development of a healthy approach to sex and intimacy during puberty, after augmentation cystoplasty, are scarcely discussed in literature. Therefore, this may suggest that such issues are insufficiently addressed by pediatric urologists. We gathered four experts in the field as well as an experienced leader of a patient group and mother of a girl with spina bifida and asked questions relevant to the following areas of care: (a) diversion, urinary incontinence, and sexual life; (b) impact of a stoma on body image perception and self-esteem; (c) specific female concerns with regard to fertility and recurrent urinary infections; (d) specific male concerns on anejaculation and erectile dysfunction. Their answers are discussed in view of the available literature. All experts and the patient group representative agreed that most of these patients will experience: lack of self-confidence as the most frequent obstacle to starting a relationship and incontinence as a barrier to sexual activity. The cosmesis of the stoma and abdominal scars might influence self-esteem and therefore the sexual activity, however it appears to be a less common concern in males than females. Our results outline the importance and influence that the body image, self-esteem, and confidence present for the individual expectations of the patients related to sex life and sexual activity. Physicians should be encouraged to ask all postpubertal patients about their sexual concerns at every visit. Further studies and exchange of information between clinicians are needed to provide meaningful and analyzable patient-related outcome measures (PROMs).

Circumcision in childhood and male sexual function: a blessing or a curse?

Male circumcision (MC) is the first planned surgical procedure ever performed. Nowadays many of these procedures are not necessarily carried out in a medical environment, therefore the real number remains unknown but it is estimated that one third of the men are circumcised. Some authors argue the negative impact of MC on men psychology and sexual life, but objective data are lacking. The purpose of this review is to summarize in the best possible way the literature to clarify this matter. A non-systematic narrative review was performed including articles between 1986 and 2019. The search for literature was carried out between July 2019 to October 2019 and any updates as of March 30, 2020. Although many authors support the hypothesis that circumcision status has an impact on sexual functioning, a negative outcome has not yet been entirely proven. Circumcision might affect how men perceive their body image, and consequently affect their sexual life. We should consider this when analysing the literature about MC and sexual dysfunction, as many of the results are based on specific populations with different attitudes towards this procedure. Sexual function consists of many elements that not only relate to measurable facts such as anatomy, somatosensory and histology. An objective evaluation of the impact of circumcision on sexuality is still challenging, as it affects a wide variety of people that confront sexuality differently due to their sociocultural and historical background. Therefore, individuals can either perceive their circumcision status as a blessing or a curse depending on the values and preferences of the different communities or social environments where they belong.

Transperitoneal Mini-Laparoscopic Pyeloplasty in Flank Position: A Safe Method for Infants and Young Adults.

INTRODUCTION AND OBJECTIVES: Open dismembered pyeloplasty has been the gold standard treatment for ureteropelvic junction obstruction in children. Laparoscopic pyeloplasty (LP) is becoming a standard procedure, but its acceptance is slow. We report our method for minilaparoscopy (MLP) in children using a tansperitoneal approach with the patient in the lateral flank decubitus which we found technically advantageous. MATERIALS AND METHODS: Retrospective review of the records of 52 children and adolescents up to 18 years of age who underwent transperitoneal MLP at our institution during March 2012-October 2017 A 5 mm trocar is placed for the camera at the site of the umblicus by open technique, two 3 mm trocars placed in the upper and lower quadrants of the abdomen. No additional ports were necessary. 20cm long, 3-mm-diameter instruments are used. Few cases needed percutaneous fixation of the pelvis. The anastomosis is performed with 5-0 or 6-0 Polyglecaprone 25 (Monocryl®) with 13 mm half circle needle (TF plus) suture cut to 12-14 cm length and introduced through the 5-mm port. Needles are removed through the 3-mm port under direct vision. RESULTS: Fifty-two children (53 renal units) with a mean age of 82 months (range 3.5-204), a mean weight of 24,35 kg (range 7-57), and a mean follow-up of 20,44 months (6-60). Nine children were younger than 12 months, and 14 were ≤10kg. Six patients were >50kg. The mean of preoperative grade of dilatation was III (SFU scale) and postoperatively improved to SFU 0,60 (0-2). In 50 (94,3%) of the cases, there was complete resolution of hydronephrosis. There was no conversions to open surgery. Three patients suffered complications Clavien-Dindo Classification IIIb, 2 omental prolapses through a port site in two children which required general anaesthesia and one percutaneous drainage due to a leakage. No reinterventions related to stent complications or obstruction were found. Mean hospital stay was 4,69 (3-14) days. CONCLUSIONS: The method of mini LP described here has proven efficient and safe. Weight appeared not to be limitation for both groups ≤10 and >50 kg.

Long-Term Follow-Up after Paediatric Kidney Transplantation and Influence Factors on Graft Survival: A Single-Centre Experience of 16 years.

INTRODUCTION: To evaluate graft- and patient survival after paediatric kidney transplantation and detecting influence factors, which affect the post-transplant time. MATERIALS AND METHODS: We analysed long-term survival rates and complications after paediatric kidney transplantation and searched for predictive parameters for graft function. RESULTS: In 132 patients, 143 kidney transplantations were performed. Graft failure occurred in 25%. Chronic rejections were the leading cause of graft loss (42.9%). Graft survival rates were 92.2% after 1 year, 85.5% after 5 years, 71.1% after 10 years and 62.1% after 15 years. The following parameters strongly influenced graft survival: number of transplants (p = 0.014), year of transplant (p < 0.0001 for 1997-2005), Epo-therapy post-transplant (p = 0.001), hypotension donor (p = 0.027), cold ischemia time (p = 0.023), anastomosis time >50 min (p = 0.008), delayed graft function (p = 0.003) and deceased donation (p = 0.039). The percentage of patients who died was 5.6%. Overall patient survival rates were 99.3% after 1 year, 95.2% after 5 years, 94.2% after 10 years and 90.7% after 15 years. Various types of infections (42.9%) were the main causes of death. CONCLUSIONS: The main causes of death after kidney transplantations in paediatric recipients are malignancy and infections. To avoid vascular complications especially in young recipients (<9 years), the cold ischemia time should be as short as possible.

[Evolution of the clinical presentation of renal cancer. Fifteen years experience]. / Evolución de las manifestaciones clínicas del cáncer renal. Experiencia de 15 años.

OBJECTIVE: To evaluate the evolution of the clinical presentation of this malignancy over time, and its possible prognostic repercussions. METHODS: A retrospective study of 538 patients subjected to surgery due to renal cancer in our hospital during the period 1995-2011. An analysis was made of the evolution of the clinical manifestations at the time of diagnosis, stratifying the results by years during four time periods. RESULTS: At the time of diagnosis, 53,4% of the patients were asymptomatic for 1995-1999 and 72% in the period 2008-2011. Pain is the symptom that occurs most frequently (18.8%) followed by hematuria (15.4% ). The proportion of symptomatic patients increases in relation to stage and histopathological grade. CONCLUSIONS: The clinical presentation of renal cancer has evolved over the years, not in terms of symptoms, which when present are still similar, but in terms of their incidence.

Evolución de las manifestaciones clínicas del cáncer renal. Experiencia de 15 años / Evolution of the clinical presentation of renal cancer: Fifteen years experience

OBJETIVO: Análisis del cambio de presentación clínica del tumor renal con el paso del tiempo y su posible repercusión pronóstica. MÉTODOS: Estudio retrospectivo de 538 pacientes intervenidos quirúrgicamente por esta patológica en nuestro hospital entre 1995 y 2011. Analizamos la evolución de las manifestaciones clínicas al diagnóstico estratificando los resultados por años divididos en cuatro periodos. RESULTADOS: Se observa un porcentaje significativamente creciente de diagnóstico en pacientes asintomáticos con el paso del tiempo siendo del 53.4% en el periodo 1995-1999 y del 72 % en 2008-2011. El dolor es el síntoma que se presenta con mayor frecuencia (18.8%) seguido de la hematuria (15.4%). El porcentaje de pacientes sintomáticos aumenta con el estadio y el grado tumoral. CONCLUSIÓN: Las manifestaciones clínicas del tumor renal han evolucionado con el tiempo, no en cuanto a los síntomas que cuando están presentes son similares, sino en cuanto a su incidencia (AU)

OBJECTIVE: To evaluate the evolution of the clinical presentation of this malignancy over time, and its possible prognostic repercussions. METHODS: A retrospective study of 538 patients subjected to surgery due to renal cancer in our hospital during the period 1995-2011. An analysis was made of the evolution of the clinical manifestations at the time of diagnosis, stratifying the results by years during four time periods. RESULTS: At the time of diagnosis, 53,4% of the patients were asymptomatic for 1995-1999 and 72% in the period 2008-2011. Pain is the symptom that occurs most frequently (18.8%) followed by hematuria (15.4%). The proportion of symptomatic patients increases in relation to stage and histopathological grade. CONCLUSIONS: The clinical presentation of renal cancer has evolved over the years, not in terms of symptoms, which when present are still similar, but in terms of their incidence (AU)