Acute testicular infarction in the setting of SARS-CoV-2 infection and diabetic vasculopathy.

Acute testicular pain with no arterial flow on Doppler ultrasonography is highly consistent with testicular torsion. In adults, there are rare etiologies of testicular infarction other than torsion, including infection, vasculitis, and trauma. We describe a 41-year-old man with type 2 diabetes complicated by severe vasculopathy and positive SARS-CoV-2 status presenting with acute right testicular pain. Surgical exploration and pathology were concerning for arteriosclerosis and vasculitis. These observations suggest that medically complex patients presenting with acute testicular pain in the setting of COVID-19 infection could be at risk for ischemia; causes of testicular pain beyond torsion should be considered.

Microwave ablation of cT1a renal cell carcinoma: oncologic and functional outcomes at a single center.

PURPOSE: Percutaneous ablation is an established alternative to surgical intervention for small renal masses. Radiofrequency and cryoablation have been studied extensively in the literature. To date, series assessing the efficacy and safety of microwave ablation (MWA) are limited. We present a cohort of 110 renal tumors treated with MWA. METHODS: A review of the medical record between January 2015 and July 2019 was performed, retrospectively identifying 101 patients (110 tumors). All ablations were performed by a single board-certified urologist/interventional radiologist. Demographic information, intraoperative, postoperative, and follow-up surveillance data were recorded. RESULTS: Median (IQR) age was 69.7 years (60.8-77.0); 27 (24%) were female. Median (IQR) BMI was 27.0 (25.1-30.2) and Charleston Comorbidity Index was 5.0 (4.0-6.0). 82 tumors were biopsy-confirmed renal cell carcinoma/oncocytic neoplasms. Median (IQR) tumor size was 2.0 cm (1.5-2.6). Median (IQR) RENAL nephrometry score was 6.0 (5.0-8.0). Technical success was achieved in all patients and all but one patient were discharged on the same day. Median (IQR) eGFR at baseline and 1 year were 71.9 mL/min/1.73 m2 (56.5-82) and 63.0 mL/min/1.73 m2 (54.0-78.2); the difference was -5.3 (p = 0.12). Two Clavien-Dindo type-I complications, one type-II complication, and one type-III complication were experienced in this cohort. Median radiographic follow-up was 376.5 days with 2 tumors (2.4% of RCC/oncocytic neoplasms) having recurred to date. CONCLUSIONS: MWA is a safe and efficacious treatment option for small renal masses with minimal adverse events and low rates of recurrence in this cohort of 101 patients. Continued follow-up is needed to assess long-term outcomes.

Real-world comparative effectiveness of shockwave lithotripsy versus ureterorenoscopy for the treatment of urinary stones.

PURPOSE: To identify clinical and non-clinical predictors of treatment failure and perioperative complications following ureterorenoscopy versus shockwave lithotripsy. METHODS: The New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) database was used to identify 226,331 patients who underwent index ureteroscopy or shockwave lithotripsy for renal stones from 2000 to 2016. Propensity-matched generalized linear-mixed modeling was utilized to compare failure and complication rates between the two procedure groups. RESULTS: 219,383 individuals meeting inclusion criteria who underwent either ureterorenoscopy (n = 124,342) or shockwave lithotripsy (n = 95,041) in New York State between 2000 and 2016 were included in our analysis. After propensity score matching, patients undergoing shockwave lithotripsy were found to have decreased odds of experiencing any type of 30-day complication (P < 0.001 for all) but increased odds of treatment failure at both 90 (OR 1.70, 95% CI 1.64-1.77) and 180 (OR 1.83, 95% CI 1.76-1.89) days (P < 0.001 for both). CONCLUSION: Patients undergoing shockwave lithotripsy experienced significantly higher odds of treatment failure, although this undesirable outcome appears to be partially offset by lower 30-day complication rates.

Simultaneous Living Donor Kidney Transplant and Laparoscopic Native Nephrectomy: An Approach to Kidney Transplant Candidates with Suspected Renal-Cell Carcinoma.

Introduction: Kidney transplant candidates are occasionally found during the pre-transplant evaluation to have a suspicious mass in a native kidney. Further work-up and management of such a mass may delay transplantation for several months, which may create logistic barriers to transplant, particularly if there are timing constraints of the donor. In this study, we report our experience with simultaneous living donor kidney transplant and laparoscopic native nephrectomy, where the indication for nephrectomy was a suspicious lesion. Methods: We performed a retrospective review of patients who underwent simultaneous kidney transplant and native nephrectomy using prospectively collected data. We analyzed relevant patient characteristics, surgical details, pathologic results, and long-term follow-up. Results: We identified 16 patients who underwent simultaneous living donor kidney transplantation and laparoscopic native nephrectomy at our institution between 2013 and 2018. Ten (62.5%) patients were found to have renal-cell carcinoma (RCC) on the final pathology. No patients had recurrent RCC, at a median follow-up of 4 years. Conclusion: For patients who are planning to undergo a living donor kidney transplant and are found to have a small mass that is suspicious for RCC, a simultaneous living donor kidney transplant and laparoscopic native nephrectomy is a possible approach in selected patients.

Validation of risk factors for recurrence of renal cell carcinoma: Results from a large single-institution series.

PURPOSE: To validate prognostic factors and determine the impact of obesity, hypertension, smoking and diabetes mellitus (DM) on risk of recurrence after surgery in patients with localized renal cell carcinoma (RCC). MATERIALS AND METHODS: We performed a retrospective cohort study among patients that underwent partial or radical nephrectomy at Weill Cornell Medicine for RCC and collected preoperative information on RCC risk factors, as well as pathological data. Cases were reviewed for radiographic evidence of RCC recurrence. A Cox proportional-hazards model was developed to determine the contribution of RCC risk factors to recurrence risk. Disease-free survival and overall survival were analyzed using the Kaplan-Meier method and log-rank test. RESULTS: We identified 873 patients who underwent surgery for RCC between the years 2000-2015. In total 115 patients (13.2%) experienced a disease recurrence after a median follow up of 4.9 years. In multivariate analysis, increasing pathological T-stage (HR 1.429, 95% CI 1.265-1.614) and Nuclear grade (HR 2.376, 95% CI 1.734-3.255) were independently associated with RCC recurrence. In patients with T1-2 tumors, DM was identified as an additional independent risk factor for RCC recurrence (HR 2.744, 95% CI 1.343-5.605). Patients with DM had a significantly shorter median disease-free survival (1.5 years versus 2.6 years, p = 0.004), as well as median overall survival (4.1 years, versus 5.8 years, p<0.001). CONCLUSIONS: We validated high pathological T-stage and nuclear grade as independent risk factors for RCC recurrence following nephrectomy. DM is associated with an increased risk of recurrence among patients with early stage disease.

Minimally invasive vs open nephrectomy in the modern era: does approach matter?

PURPOSE: To evaluate if the widespread adoption of a minimally invasive approach to radical nephrectomy has affected short- and long-term patient outcomes in the modern era. METHODS: A retrospective cohort study of patients who underwent radical nephrectomy from 2001 to 2012 was conducted using the US National Cancer Institute Surveillance Epidemiology and End Results (SEER) Program and Medicare insurance program database. Patients who underwent open surgery were compared to those who underwent minimally invasive surgery using propensity score matching. RESULTS: 10,739 (85.9%) underwent open surgery and 1776 (14.1%) underwent minimally invasive surgery. Minimally invasive surgery increased from 18.4% from 2001-2004 to 43.5% from 2009 to 2012. After median follow-up of 57.1 months, minimally invasive radical nephrectomy conferred long-term oncologic efficacy in terms of overall (HR 0.84; 95% CI 0.75-0.95) survival and cancer-specific (HR 0.68; 95% CI 0.54-0.86) survival compared to open radical nephrectomy. Minimally invasive surgery was associated with lower risk of inpatient death [risk ratio (RR) 0.45 with 95% CI: (0.20-0.99), p = 0.04], deep vein thrombosis [RR: 0.35 (0.18-0.69), p = 0.002], respiratory complications [RR: 0.73 (0.60-0.89), p = 0.001], infectious complications [RR: 0.35 (0.14-0.90), p = 0.02], acute kidney injury [RR: 0.66 (0.52-0.84), p < 0.001], sepsis [RR: 0.55 (0.31-0.98), p = 0.04], prolonged length of stay (18.6 vs 30.0%, p < 0.001), and ICU admission (19.7 vs 26.3%, p < 0.001). Costs were similar between the two approaches (30-day costs $15,882 vs $15,564; p = 0.70). CONCLUSION: After widespread adoption of minimally invasive approaches to radical nephrectomy across the United States, oncologic standards remain preserved with improved perioperative outcomes at no additional cost burden.

Vouchers for Future Kidney Transplants to Overcome "Chronological Incompatibility" Between Living Donors and Recipients.

BACKGROUND: The waiting list for kidney transplantation is long. The creation of "vouchers" for future kidney transplants enables living donation to occur when optimal for the donor and transplantation to occur later, when and if needed by the recipient. METHODS: The donation of a kidney at a time that is optimal for the donor generates a "voucher" that only a specified recipient may redeem later when needed. The voucher provides the recipient with priority in being matched with a living donor from the end of a future transplantation chain. Besides its use in persons of advancing age with a limited window for donation, vouchers remove a disincentive to kidney donation, namely, a reluctance to donate now lest one's family member should need a transplant in the future. RESULTS: We describe the first three voucher cases, in which advancing age might otherwise have deprived the donors the opportunity to provide a kidney to a family member. These 3 voucher donations functioned in a nondirected fashion and triggered 25 transplants through kidney paired donation across the United States. CONCLUSIONS: The provision of a voucher to potential recipients whose need for a transplant makes them "chronologically incompatible" with their donors may increase the number of living donor transplants.

Adoption of Technology and Its Impact on Nephrectomy Outcomes, a U.S. Population-Based Analysis (2008-2012).

PURPOSE: Robot-assisted surgery has been touted as offering superior outcomes in various oncologic surgeries. We sought to evaluate the comparative effectiveness of robotic radical nephrectomy (RRN) compared with laparoscopic radical nephrectomy (LRN) in regard to hospital charges, complications, and survival. MATERIALS AND METHODS: Using the Surveillance Epidemiology and End Results (SEER) Program-Medicare linked database, we identified patients over the age of 65 who underwent radical nephrectomy (RN) for nonmetastatic renal-cell carcinoma from 2008 to 2012. Patients who underwent RRN were compared with those who underwent LRN. We used propensity scoring matching to compare perioperative and survival outcomes, including overall survival, cancer-specific survival, major adverse events, and healthcare charges. RESULTS: Two hundred forty-one patients underwent RRN, and 574 patients underwent LRN. After propensity score matching, the adverse events rate and length of stay were similar between two groups (Major Events: 5.7% vs 6.1%, p = 0.84; prolonged LOS: 17.8% vs 16.1%, p = 0.62). The inpatient charges following RRN were significantly higher than those of LRN ($53,681 vs $44,161, p < 0.01). The mean follow-up of the cohort was 3.2 years. Estimated overall survival (88.0% vs 87.9%, p = 0.90) and cancer-specific survival (98.1% vs 96.4%, p = 0.25) were similar between the two matched cohorts at 3 years. CONCLUSION: The robotic platform showed no benefit over standard laparoscopy for RN, as we found no difference in oncologic efficacy or adverse event rates.

Renal calculi: trends in the utilization of shockwave lithotripsy and ureteroscopy.

INTRODUCTION: To assess trends in the usage of extracorporeal shockwave lithotripsy (SWL) and ureteroscopy (URS) in the treatment of renal calculi. MATERIALS AND METHODS: An analysis of the 5% Medicare Public Use Files (years 2001, 2004, 2007 and 2010) was performed to evaluate changes in the use of SWL and URS to treat renal calculi. Patients were identified using ICD-9 (cm) and CPT codes. Statistical analyses, including the Fisher, 2 tests, and multivariate logistic regression analysis were performed using SAS 9.3 (SAS Institute Inc., Cary, NC, USA) and SPSS v20 (IBM Corp., Armonk, NY, USA). RESULTS: The absolute number of patients diagnosed with (+85.1%) and treated for (+31.5%) kidney calculi increased from 2001 to 2010. The ratio of diagnosed/treated patients declined from 15.2% in 2001 to 10.8% in 2010. Whites (OR = 1.27, p < 0.0001), patients in the South (OR = 1.16, p < 0.0001) and those ≤ 84 years of age were more likely to be treated. The utilization of SWL (84.7%) was greater than URS (15.3%), but the utilization of URS increased over time from 8.4% in 2001 to 20.6% of cases by 2010 (p < 0.0001). Treatment via URS was more likely in women (OR = 1.28, p < 0.0001), in patients living outside the South (OR = 1.29-1.45, p ≤ 0.006) and in later years of the study (OR = 2.87, p < 0.0001). CONCLUSIONS: Treatment patterns for renal calculi changed from 2001 to 2010. The usage of URS increased at the cost of SWL. Multiple sociodemographic factors correlated with the likelihood of being treated surgically as well as the choice of the surgical approach.

National Trends and Cost of Minimally Invasive Surgery in Urology.

INTRODUCTION: We determine national trends in costs of care as well as associated growth and adoption of minimally invasive surgery for major uro-oncology procedures. METHODS: Using a nationally representative sample we identified patients diagnosed with prostate, renal and bladder cancer who underwent prostatectomy, nephrectomy, partial nephrectomy and cystectomy from 2000 to 2011. Temporal trends in patient demographics, hospital and procedure related characteristics, surgical volume, minimally invasive surgery use and costs of hospitalization over the years were analyzed. Hierarchical linear regression was performed to evaluate the effects of hospital volume, time and surgery type on costs of hospitalization. RESULTS: Overall 836,563, 440,337 and 122,992 patients underwent prostatectomy, nephrectomy and cystectomy from 2000 to 2011, respectively. There was a 33.6%, 50.8% and 25.5% increase in annual surgical volume for these 3 surgeries during the 10 years, with the most prominent increase at high volume hospitals. The use of minimally invasive surgery increased 65.6% for prostatectomy, 22.0% for nephrectomy and 12.5% for cystectomy, and this increase was more prominent at high volume hospitals. For all 3 surgeries the hospital stay for minimally invasive surgery cases was more expensive than for open procedures, but decreased during the study period from $17,367 to $11,145 for prostatectomy and from $54,209 to $28,753 for cystectomy. CONCLUSIONS: High volume hospitals experienced greater growth in surgery caseloads and minimally invasive surgeries but this did not lead to higher costs of care. While minimally invasive surgery has consistently been more expensive than open surgery, the costs of minimally invasive prostatectomy and cystectomy have decreased in the last decade.

Laparoscopic renal cryoablation.

In light of evidence linking radical nephrectomy and consequent suboptimal renal function to adverse cardiovascular events and increased mortality, research into nephron-sparing techniques for renal masses widely expanded in the past two decades. The American Urological Association (AUA) guidelines now explicitly list partial nephrectomy as the standard of care for the management of T1a renal tumors. Because of the increasing utilization of cross-sectional imaging, up to 70% of newly detected renal masses are stage T1a, making them more amenable to minimally invasive nephron-sparing therapies including laparoscopic and robotic partial nephrectomy and ablative therapies. Cryosurgery has emerged as a leading option for renal ablation, and compared with surgical techniques it offers benefits in preserving renal function with fewer complications, shorter hospitalization times, and allows for quicker convalescence. A mature dataset exists at this time, with intermediate and long-term follow-up data available. Cryosurgical recommendations as a first-line therapy are made at this time in limited populations, including elderly patients, patients with multiple comorbidities, and those with a solitary kidney. As more data emerge on oncologic efficacy, and technical experience and the technology continue to improve, the application of this modality will likely be extended in future treatment guidelines.

Trends and inequalities in the surgical management of ureteric calculi in the USA.

OBJECTIVE: To assess trends in the surgical management of ureteric calculi over a 10-year period. MATERIALS AND METHODS: An analysis of the 5% Medicare Public Use Files, from 2001, 2004, 2007 and 2010, was performed to assess the use of ureteroscopy (URS), extracorporal shockwave lithotripsy (ESWL) and ureterolithotomy (UL) in treating ureteric calculi. Patients were identified using International Classification of Diseases 9th edition (Clinical Modification) and Current Procedure Terminology codes. Statistical analyses using the Fisher and chi-squared tests, and multivariate logistic regression analysis (dependent variables: URS, ESWL, UL, treatment, no treatment; independent variables: age, gender, ethnicity, geography and year of treatment) were performed. RESULTS: A total of 299 920 patients with ureteric calculi were identified. Of these, 115 200 underwent surgery. Men (odds ratio [OR] = 1.15, P < 0.001) were more likely, while patients from ethnic minorities (OR = 0.84, P = 0.004) were less likely to be treated. Patients in the West of the USA were also less likely to be treated (OR = 0.76, P < 0.001) as were patients aged <65 or >84 years old (P = 0.29). The predominant surgical approach was URS (65.2%), followed by ESWL (33.6%) and UL (1.2%). The use of URS increased over time, while the use of ESWL and UL declined. Women (OR = 1.25, P < 0.001) were more likely to undergo URS. Patients in the South of the USA (OR = 1.51, P < 0.001) and patients from ethnic minorities were more likely to undergo ESWL (OR = 1.23, P = 0.03). CONCLUSIONS: The surgical treatment of ureteric calculi changed significantly between 2001 and 2010. The use of URS expanded at the expense of ESWL and UL. Multiple inequalities existed in overall surgical treatment rates and in the choice of treatment; age, gender, ethnicity and geography influenced both whether patients underwent surgical intervention and the type of surgical approach used.

Trends in the utilization of percutaneous and open nephrolithotomy in the treatment of renal calculi.

PURPOSE: To evaluate trends in the use of percutaneous nephrolithotomy (PCNL) and nephrolithotomy (NL) in patients with renal pelvis calculi. MATERIALS AND METHODS: An analysis of the 5% Medicare Public Use Files (years 2001, 2004, 2007, and 2010) was performed to assess changes in the use of PCNL and NL over a 10-year period. Patients were identified using the International Classification of Diseases-9 (cm) and Current Procedure Terminology codes. Statistical analyses, including the Fisher and chi-square tests and multivariate regression analyses, were performed using SAS 9.3 (SAS Institute Inc, Cary, NC) and SPSS v20 (IBM Corp., Armonk, NY). RESULTS: A total of 26,100 patients underwent either PCNL or NL. Use of PCNL and NL decreased from 3.1% to 2.5% in patients with a diagnosis of stones (P<0.0001). Women (odds ration [OR]=1.19, P=0.003) were more likely to undergo surgery. Patients aged ≥65 years were less likely to be treated (OR=0.65-0.71, P<0.05). Patients treated after 2004 were less likely to undergo surgery (OR=0.77-0.84, P<0.05). The use of PCNL exceeded NL at a stable 10:1 ratio. CONCLUSIONS: The use of PCNL and NL for treatment of patients with stone disease slightly decreased from 2001 to 2010, although the number of patients with renal calculi increased. The use of PCNL vs NL was unchanged during this period. Multiple inequalities existed in overall surgical treatment rates and were influenced by sociodemographic factors such as age and sex.

Laparoendoscopic single-site radical nephrectomy for large renal masses.

PURPOSE: To report our operative experience and short-term outcomes for the laparoendoscopic single-site (LESS) management of large renal tumors and tumors of advanced stage. PATIENTS AND METHODS: Ten consecutive patients underwent LESS-radical nephrectomy (RN) for large (≥ 7 cm) and/or locally advanced tumors (>T(2)). Intraoperative, postoperative, and short-term follow-up data were analyzed. RESULTS: Median surgical time was 146 minutes (range 73-164 min), and median estimated blood loss was 100 mL (range 25-400 mL). No procedure needed conversion to open RN or hand-assisted laparoscopic RN. The median hospital stay was 47 hours (range 42 hours-12 days). One (10%) patient had a minor complication (postoperative fever treated with antibiotics) and one (10%) patient had a major complication (small bowel obstruction necessitating reoperation). Of the 10 tumors, 2 were pathologic stage T(1b), 4 were pathologic stage T(2), and 4 were stage T(3a). At a median follow-up of 12.3 months (range 1-16 mos), six (60%) patients were alive without evidence of recurrence, and 4 (40%) patients were alive with disease. Of those four patients, all four had known metastatic disease before surgery. CONCLUSION: LESS-RN for large or advanced stage renal masses is a technically challenging operation. In experienced hands, however, it is a safe and feasible therapeutic option for the management of these tumors.

Preoperative radiographic parameters predict long-term renal impairment following partial nephrectomy.

PURPOSE: We analyzed radiographic parameters describing anatomic features of renal tumors to identify preoperative characteristics that could help predict long-term decline in renal function following partial nephrectomy. METHODS: We retrospectively reviewed the records of 194 consecutive patients who underwent partial nephrectomy from January 2006 to March 2009 and analyzed a cohort of 53 patients for whom complete clinical, radiographic, and operative information was available. Computed tomography images were reviewed by a single radiologist. Radiographic criteria for describing renal tumor size and location included diameter, volume, endophytic properties, proximity to collecting system, anterior/posterior location, location relative to polar lines, and R.E.N.A.L. nephrometry score. Postoperative estimated glomerular filtration rate was calculated using the MDRD study group equation with serum creatinine at last follow-up. RESULTS: The median preoperative and postoperative GFR values were 75 (IQR 65-97) and 66 (IQR 55-84) mL/min/1.73 m(2), respectively. At a median follow-up of 38 months, the median percentage decrease in GFR was 12%. On univariate analyses, tumor diameter (P = 0.002), tumor volume (P < 0.0001), nearness of tumor to collecting system (P = 0.017), and location relative to polar lines (P = 0.017) were associated with percentage decrease in GFR. Furthermore, higher R.E.N.A.L. nephrometry score was also associated with poorer renal functional outcomes following partial nephrectomy (P = 0.019). CONCLUSIONS: Anatomic features of renal tumors defined by preoperative radiographic characteristics correlate with the degree of renal functional decline after partial nephrectomy. Identification of these parameters may assist in patient counseling and clinical decision making following partial nephrectomy. Validation in larger prospective studies is necessary.

Early corticosteroid withdrawal in recipients of renal allografts: a single-center report of ethnically diverse recipients and recipients of marginal deceased-donor kidneys.

BACKGROUND: Candidacy for kidney transplantation is being progressively liberalized, and the safety and efficacy of early withdrawal of corticosteroids in high-risk patients have not been fully characterized. METHODS: We analyzed the safety and efficacy of an early corticosteroid withdrawal regimen of rabbit antithymocyte globulin induction, tacrolimus, mycophenolate mofetil, and steroid withdrawal by day 5 after transplantation in our study cohort of 634 kidney transplant recipients that included 27% African American and 18% Hispanic recipients. Fifty-five percent of the recipients were recipients of deceased-donor kidneys, and 46% of deceased-donor kidneys were kidneys from expanded criteria donors. RESULTS: Kaplan-Meier patient survival at 1, 3, and 5 years after transplantation was 98.6%, 94.6%, and 90.2%, and death-censored graft survival was 96.2%, 91.9%, and 87.6%, respectively. During a mean follow-up of 57 months, 89.3% of patients remained off of corticosteroids, and the incidence of acute rejection including subclinical rejection identified by protocol biopsy was 12.0%. Multivariable analysis identified age older than 60 years as protective against (P=0.01) and the African American ethnicity as a risk factor for (P=0.03) rejection. Delayed graft function (P<0.0001), rejection (P<0.0001), and transplant panel reactive antibody 20% or more (P=0.03) were risk factors for graft loss. Opportunistic infections included viral in 15.3%, fungal in 1.6%, and parasitic in 0.6% of the patients. Posttransplantation malignancy occurred in 9.1% of patients. CONCLUSIONS: An early corticosteroid withdrawal regimen of rabbit antithymocyte globulin induction, tacrolimus, and mycophenolate mofetil is associated with excellent patient and kidney graft survival in an ethnically diverse population with risk factors for poor outcomes.

Kidneys from older living donors provide excellent intermediate-term outcomes after transplantation.

BACKGROUND: Despite the increasing use of older living donors in kidney transplantation, intermediate-term donor and recipient outcomes are poorly characterized. METHODS: We retrospectively compared 143 recipients from donors older than 50 years (older) to 319 recipients from donors 50 years or younger (younger). RESULTS: Mean older donor age (years) was 58; younger age was 37 (P<0.001). One-year, three-year, and five-year patient survival was 99.3%, 94.1%, and 91.3% in recipients of older donors and 99.7%, 98.7%, and 95.4% in recipients of younger donors respectively (P=not significant). One-year, three-year, and five-year death-censored graft survival was 99.2%, 95.0%, and 93.7% in older recipients and 99.7%, 96.7%, and 95.4% in younger recipients respectively (P=not significant). Older and younger recipients demonstrated equivalent rates of vascular complications (2.7% vs. 1.2%, P=not significant) and acute rejection (7.7% vs. 9%, P=not significant). Recipients from donors aged 51 to 59 (n=95), 60 to 69 (n=42), and older than 70 years (n=6) had diminished graft function (eGFR=46±13, 44.9±16, 32.2±18.6 mL/min/1.73m(2) at 5 years respectively) compared with younger donor recipients (58.4±20.0 mL/min/1.73m(2), P<0.001). Older donors had decreased baseline renal function compared with younger donors (eGFR of 82.5±35.12 and 105.3±46.7 mL/min/1.73m(2), respectively). No progressive decline in renal function was observed in older donors (3 years after donation). CONCLUSION: Older living donor kidneys can be transplanted with low perioperative risk without compromising recipient 5-year patient or graft survival or donor renal function. Younger donor kidneys have superior graft function 5 years after transplantation, highlighting the need for appropriate donor/recipient matching.

Living donor kidney paired donation transplantation: experience as a founding member center of the National Kidney Registry.

Kidney paired donation (KPD) is a safe and effective means of transplantation for transplant candidates with willing but incompatible donors. We report our single-center experience with KPD through participation in the National Kidney Registry. Patient demographics, transplant rates, and clinical outcomes including delayed graft function (DGF), rejection, and survival were analyzed. We also review strategies employed by our center to maximize living donor transplantation through KPD. We entered 44 incompatible donor/recipient pairs into KPD from 9/2007 to 1/2011, enabling 50 transplants. Incompatibility was attributable to blood type (54.4%) and donor-specific sensitization (43.2%). Thirty-six candidates (81.8%) were transplanted after 157 d (median), enabling pre-emptive transplantation in eight patients. Fourteen candidates on the deceased donor waiting list also received transplants. More than 50% of kidneys were received from other transplant centers. DGF occurred in 6%; one-yr rejection rate was 9.1%. One-yr patient and graft survival was 98.0% and 94.8%. KPD involving participation of multiple transplant centers can provide opportunities for transplantation, with potential to expand the donor pool, minimize waiting times, and enable pre-emptive transplantation. Our experience demonstrates promising short-term outcomes; however, longer follow-up is needed to assess the impact of KPD on the shortage of organs available for transplantation.

Laparoscopic and open partial nephrectomy: complication comparison using the Clavien system.

BACKGROUND AND OBJECTIVES: To compare postoperative complications in patients undergoing laparoscopic and open partial nephrectomy using a standardized complication-reporting system and a standardized tumor-scoring system. METHODS: We conducted a retrospective analysis of 189 consecutive patients with nephrometry scores available who underwent elective partial nephrectomy for renal masses. Demographic, perioperative, and complication data were recorded. By using the modified Clavien scale, we graded 30- and 90-day complication rates. RESULTS: 107 patients underwent laparoscopic partial nephrectomy and 82 underwent open partial nephrectomy (N=189). Open partial nephrectomy patients had higher nephrometry scores than laparoscopic patients had (7.1±2.4 vs. 5.6±1.8, P<.001). Surgical and hospitalization times were shorter, and estimated blood loss was lower in the laparoscopic group (P<.001). At 30 days, there were more overall complications in the open group, but more major complications in the laparoscopic group (P>.05). After multivariable logistic regression analysis, only higher body mass index and higher estimated blood loss were predictors of more overall complications. CONCLUSIONS: Laparoscopic partial nephrectomy has the advantages of decreased operative time, lower blood loss, and shorter hospital stay. The complication rate in the laparoscopic group is similar to that in the open group, despite favorable tumor characteristics in the laparoscopic group.