Partial Nephrectomy of Transplanted Kidney with Calyceal Fistula.

Kidney transplant is the established treatment for patients with chronic kidney disease but is associated with complications due to the complexity of the procedure. Calyceal fistulas are rare urological complications in transplants caused by arterial occlusion with segmental infarction of the graft. Treatment is based on the extension of the affected area and the clinical status of the patient. For extensive infarctions treated surgically, a total nephrectomy of the transplanted kidney is generally performed. We present a case of a transplanted kidney with polar necrosis and calyceal fistula treated with partial nephrectomy of the affected area, maintaining the graft and preserving kidney function.

Colorenal fistula and urinary tract infection in a pediatric patient with acute lymphoblastic leukemia. / Fístula colorrenal e infección de vías urinarias en paciente pediátrico con leucemia linfoide aguda.

INTRODUCTION: Colorenal fistula is rare in the pediatric population. It may occur at any segment involved by ischemia, chronic inflammation, or necrosis. It is typically associated with a preliminary renal lesion that may arise as a result of interventional procedures, inflammatory conditions, colon tumor, and xanthogranulomatous pyelonephritis, among others. CASE REPORT: 15-year-old female patient diagnosed with acute lymphoblastic leukemia admitted at our institution for baseline condition management. During her stay, she experienced gastrointestinal and urinary infectious events. In the assessment and management of those, a left colorenal fistula was found. Surgical treatment was decided upon. DISCUSSION: Colorenal fistula typically occurs secondary to renal inflammation or infection. Clinical signs are highly variable, and treatment is surgical, with the fistulous tract being resected in all cases.

INTRODUCCION: Las fístulas colorrenales son infrecuentes en la población pediátrica. Pueden desarrollarse en cualquier segmento afectado por isquemia, inflamación crónica o necrosis. Suelen estar asociadas a una lesión primitiva en el riñón que puede producirse por procedimientos intervencionistas, enfermedades inflamatorias, tumorales del colon, pielonefritis xantogranulomatosa, entre otras. CASO CLINICO: Paciente femenina de 15 años, con diagnóstico de leucemia linfoide aguda, ingresa a la institución para recibir manejo de su enfermedad de base. Durante su evolución, desarrolla eventos infecciosos (gastrointestinales y urinarios), y en evaluación y manejo de estos se documenta fístula colorrenal izquierda, motivo por el cual se da un enfoque de tratamiento quirúrgico. COMENTARIOS: La fístula renocólica generalmente se presenta secundaria a procesos inflamatorios o infecciosos renales; su presentación clínica es muy variada, y el tratamiento es quirúrgico, incluyendo siempre la resección del trayecto fistuloso.

Urorectal fistula repair using different approaches: operative results and quality of life issues

ABSTRACT Purpose: To evaluate efficacy of urorectal fistula (URF) repair using different approaches and the clinical factor determinant of success, and also the morbidity associated to the procedure and health-related quality of life (HRQoL) in male survivors of pelvic malignancies. Material and Methods: Retrospective evaluation of 39 patients with URF primarily intervened in three institutions using different surgical approaches. Success was defined as effective fistula closure. Variables evaluated included demographics, previous treatments, surgical approach, ancillary surgeries, complications and HRQoL by using a standardized non-validated specific questionnaire. Median follow-up from surgery to interview was 55 months (interquartile range 49, range 4-112). Factors determinant of success were investigated using logistic regression. Safety of the procedure was evaluated by Clavien-Dindo scale. Deterioration of continence and erectile function and other HRQoL issues were evaluated. Results: Prostate cancer treatment was the predominant etiology. The success rate for fistula repair was 89.5%. The surgical approach was not related to failed repair (p=0.35) or complications (p=0.29). Factors associated with failure were complications (p=0.025), radiotherapy (p=0.03), fistula location (p=0.04) and fistula size (p=0.007). Multivariate analysis revealed fistula size was the only independent determinant of failure (OR 6.904, 1.01-47.75). Complications occurred in 46.2% and severe complications in 12.8%. The mortality related to the procedure was 2.6%. Urinary incontinence was present before repair in 26.3% and erectile dysfunction in 89.5%. Fistula repair caused de novo urinary incontinence in 7.9% and deterioration of erectile status in 44.7%. Globally 79% were satisfied after repair and only 7.9% rated HRQoL as unhappy. Trans-sphincteric approach was related to less deterioration of erectile function (p=0.003), and higher perceived satisfaction in QoL (p=0.04). Conclusions: The surgical approach elected to correct URF is not determinant of success nor of complications. Fistula size appears as independent determinant for failure. Transsphincteric approach could be advantageous over other procedures regarding HRQoL issues.

Urorectal fistula repair using different approaches: operative results and quality of life issues.

PURPOSE: To evaluate efficacy of urorectal fistula (URF) repair using different approaches and the clinical factor determinant of success, and also the morbidity associated to the procedure and health-related quality of life (HRQoL) in male survivors of pelvic malignancies. MATERIAL AND METHODS: Retrospective evaluation of 39 patients with URF primarily intervened in three institutions using different surgical approaches. Success was defined as effective fistula closure. Variables evaluated included demographics, previous treatments, surgical approach, ancillary surgeries, complications and HRQoL by using a standardized non-validated specific questionnaire. Median follow-up from surgery to interview was 55 months (interquartile range 49, range 4-112). Factors determinant of success were investigated using logistic regression. Safety of the procedure was evaluated by Clavien-Dindo scale. Deterioration of continence and erectile function and other HRQoL issues were evaluated. RESULTS: Prostate cancer treatment was the predominant etiology. The success rate for fistula repair was 89.5%. The surgical approach was not related to failed repair (p=0.35) or complications (p=0.29). Factors associated with failure were complications (p=0.025), radiotherapy (p=0.03), fistula location (p=0.04) and fistula size (p=0.007). Multivariate analysis revealed fistula size was the only independent determinant of failure (OR 6.904, 1.01-47.75). Complications occurred in 46.2% and severe complications in 12.8%. The mortality related to the procedure was 2.6%. Urinary incontinence was present before repair in 26.3% and erectile dysfunction in 89.5%. Fistula repair caused de novo urinary incontinence in 7.9% and deterioration of erectile status in 44.7%. Globally 79% were satisfied after repair and only 7.9% rated HRQoL as unhappy. Trans-sphincteric approach was related to less deterioration of erectile function (p=0.003), and higher perceived satisfaction in QoL (p=0.04). CONCLUSIONS: The surgical approach elected to correct URF is not determinant of success nor of complications. Fistula size appears as independent determinant for failure. Trans-sphincteric approach could be advantageous over other procedures regarding HRQoL issues.

Can regional anesthesia have an effect on surgical outcomes in patients undergoing distal hypospadia surgery?

BACKGROUND: Caudal and penile blocks are the most popular regional anesthetic techniques used in infants and children undergoing urological surgery. A recent report has suggested that penile venous pooling resulting from caudal blocks could affect surgical outcomes after hypospadias operations. OBJECTIVE: The aim was to report our experience in patients with distal hypospadias undergoing repair with caudal versus penile block. STUDY DESIGN: A retrospective clinical database was constructed for patients who underwent distal hypospadias repair by a single surgeon (M.P.B.) at our sponsoring institutions for the time period 2008-2013 (n = 192). Collected data included hypospadias classification (glanular, coronal, subcoronal), chordee status, perioperative anesthesia (caudal vs. penile), and assessment of postoperative complications (fistula and meatal stenosis). RESULTS: Risk ratio (RR) analysis for all distal hypospadias cases revealed that there is a higher risk of developing complications in patients who underwent caudal anesthesia than in patients who underwent penile block RR for a complication was 3.70 (95% CI 1.05-13.03; p < 0.04) (Figure). DISCUSSION: Similar to other papers in the literature, we found that patients who underwent caudal anesthesia had more complications than those who underwent penile block. The limitations of this study include not adjusting the results according to the severity of hypospadias. CONCLUSION: The main goal of this study was accomplished by demonstrating that, in our series, caudal anesthesia is associated with a higher risk of fistula formation after undergoing distal hypospadias repair than penile block.

Can a graft be placed over a flap in complex hypospadias surgery? An experimental study in rabbits

ABSTRACT Purpose: To develop a rabbit experimental study to test the hypothesis that surgical repair of hypospadias with severe ventral curvatures might be completed in one stage, if a graft, such as buccal mucosa, could be placed over the tunica vaginalis flap used in corporoplasty for ventral lengthening, with the addition of an onlay preputial island flap to complete the urethroplasty. Materials and methods: The experimental procedure with rabbits included a tunica vaginalis flap for reconstruction of the corpora after corporotomy, simulating a ventral lengthening operation. A buccal mucosa graft was placed directly on top of the flap, and the urethroplasty was completed with an onlay preputial island flap. Eight rabbits were divided into 4 groups, sacrificed at 2, 4, 8 and 12 weeks postoperatively, and submitted to histological evaluation. Results: We observed a large number of complications, such as fistula (75%), urinary retention (50%) and stenosis (50%). There were two deaths related to the procedure. Histological evaluation demonstrated a severe and persistent inflammatory reaction. No viable tunica vaginalis or buccal mucosa was identified. Conclusions: In this animal model, the association of a buccal mucosa graft over the tunica vaginalis flap was not successful, and resulted in complete loss of both tissues.

Can a graft be placed over a flap in complex hypospadias surgery? An experimental study in rabbits.

PURPOSE: To develop a rabbit experimental study to test the hypothesis that surgical repair of hypospadias with severe ventral curvatures might be completed in one stage, if a graft, such as buccal mucosa, could be placed over the tunica vaginalis flap used in corporoplasty for ventral lengthening, with the addition of an onlay preputial island. flap to complete the urethroplasty. MATERIALS AND METHODS: The experimental procedure with rabbits included a tunica vaginalis flap for reconstruction of the corpora after corporotomy, simulating a ventral lengthening operation. A buccal mucosa graft was placed directly on top of the flap, and the urethroplasty was completed with an onlay preputial island flap. Eight rabbits were divided into 4 groups, sacrificed at 2, 4, 8 and 12 weeks postoperatively, and submitted to histological evaluation. RESULTS: We observed a large number of complications, such as fistula (75%), urinary retention (50%) and stenosis (50%). There were two deaths related to the procedure. Histological evaluation demonstrated a severe and persistent inflammatory reaction. No viable tunica vaginalis or buccal mucosa was identified. CONCLUSIONS: In this animal model, the association of a buccal mucosa graft over the tunica vaginalis flap was not successful, and resulted in complete loss of both tissues.

Urological complications, vesicoureteral reflux, and long-term graft survival rate after pediatric kidney transplantation.

To describe a single-center experience with kidney transplantation and then study some donor and recipient features that may impact on graft survival and urological complication rates. We reviewed our database searching for pediatric patients who underwent kidney transplantation from August 1985 through November 2012. Preoperative data and postoperative complications were recorded. Graft survival rates were analyzed and compared based on the type of donor, donor's age from deceased donors, and recipients' ESRD cause. Kaplan-Meier curves with log rank and Wilcoxon tests were used to perform the comparisons. There were 305 pediatric kidney transplants. The mean recipient's age was 11.7 yr. The mean follow-up was 11.0 yr. Arterial and venous thrombosis rates were 1.6% and 2.3%, respectively, while urinary fistula and symptomatic vesicoureteral reflux were diagnosed in 2.9% and 3.6% of cases, respectively. Deceased kidney transplantation had a lower graft survival rate than living kidney transplantation (log rank, p = 0.005). Donor's age (p = 0.420) and ESRD cause (p = 0.679) were not significantly related to graft survival rate. In long-term follow-up, type of donor, but not donor's age, impacts on graft survival rate. ESRD cause has no impact on graft survival rate, showing that well-evaluated recipients may have good outcomes.

Late complication of a renal calculus: fistulisation to the psoas muscle, skin and bronchi.

Kidney disease presenting with cutaneous fistula is a rare condition. We present a case of a 90-year-old woman with dementia who had no prior urological problems and had a cutaneous fistula in the left lumbar region. A fistulogram and computer tomography examination revealed a large staghorn calculus with signs of xanthogranulomatous pyelonephritis in the left kidney and renal fistulisation to the psoas muscle, skin and bronchi. To our knowledge this is the first report in the literature of coexisting renal fistulisation to the psoas major muscle, skin and bronchi. This report illustrates how computed tomography in combination with fistulography can resolve the diagnostic dilemma that pertains to the complex spread of the disease in cases involving nephrocutaneous fistula. Furthermore, the report shows how a renal calculus, even asymptomatic, can cause a serious medical condition, and highlights the importance of early medical intervention.

Late complication of a renal calculus: fistulisation to the psoas muscle, skin and bronchi

ABSTRACTKidney disease presenting with cutaneous fistula is a rare condition. We present a case of a 90-year-old woman with dementia who had no prior urological problems and had a cutaneous fistula in the left lumbar region. A fistulogram and computer tomography examination revealed a large staghorn calculus with signs of xanthogranulomatous pyelonephritis in the left kidney and renal fistulisation to the psoas muscle, skin and bronchi. To our knowledge this is the first report in the literature of coexisting renal fistulisation to the psoas major muscle, skin and bronchi. This report illustrates how computed tomography in combination with fistulography can resolve the diagnostic dilemma that pertains to the complex spread of the disease in cases involving nephrocutaneous fistula. Furthermore, the report shows how a renal calculus, even asymptomatic, can cause a serious medical condition, and highlights the importance of early medical intervention.

Peripyelitis: A risk factor for urinary fistula after tubeless PCNL.

A 43 years-old man presented to our stone clinic complaining of back pain for the last 3 months. He had significant past medical history for nephrolithiasis: he had undergone unsuccessful SWL for left renal calculi five years ago and also presented with several episodes of pyelonephritis in the last months, requiring hospitalization for intravenous antibiotics. Initial laboratory work-up revealed normal serum creatinine (0.92 mg/dL) and hemoglobin levels (15.3 g/dL); urine culture was negative. Abdominal computed tomography (CT) revealed a 140 mm2 stone in the left renal pelvis with 1500 Hounsfield Units (Figure-1a); thickening of the urothelium surrounding the stone was suspected after contrast infusion (Figure-1b) and confirmed in the excretory phase (Figure-1c).

Urological fistulas after fetal cystoscopic laser ablation of posterior urethral valves: surgical technical aspects.

OBJECTIVE: To describe the surgical technical aspects associated with the development of urological fistulas after fetal antegrade cystoscopic laser fulguration of the posterior urethral valves (PUV). METHODS: The perioperative data for all fetal cystoscopies performed between January 2004 and August 2013 at three institutions in the USA, France and Brazil were reviewed, with particular emphasis on surgical technical aspects of the procedure and the complications encountered. RESULTS: A total of 40 fetal cystoscopies were performed at the three institutions. Laser fulguration of the PUV was performed in 23 of these cases, with a survival rate of 60.9% (14/23) and normal renal function in 85.7% (12/14) of these infants. Urological fistulas were diagnosed postnatally in four (10%) newborns. The presence of fistulas was associated with a higher gestational age at diagnosis of PUV (P < 0.01) and with the use of semi-curved rather than curved sheaths (P < 0.01), the use of a diode laser (P < 0.01) and the use of higher laser power and energy (P < 0.01 and P < 0.01, respectively), as well as with less operator experience (P < 0.01) and with absence of fetal anesthesia/immobilization (P = 0.02). CONCLUSION: Urological fistulas are a severe complication of fetal cystoscopic laser fulguration of PUV and are associated with type, energy and power settings of the laser and instrumentation. The use of appropriate technique and proper training of the operator are necessary to perform this fetal intervention safely.

Identifying unrecognized collecting system entry and the integrity of repair during open partial nephrectomy: comparison of two techniques.

PURPOSE: To compare retrograde dye injection through an externalized ureteral catheter with direct needle injection of dye into proximal ureter for identification of unrecognized collecting system disruption and integrity of subsequent repair during open partial nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the records of 259 consecutive patients who underwent open partial nephrectomy. Externalized ureteral catheters were placed preoperatively in 110 patients (Group 1); needle injection of methylene blue directly into proximal ureter was used in 120 patients (Group 2). No assessment of the collecting system was performed in 29 patients (Group 3). We compared intraoperative parameters, tumor characteristics, collecting system entry and incidence of urine leaks among the three groups. RESULTS: The mean tumor diameter was 3.1 cm in Group 1, 3.6cm in Group 2, and 3.8 cm in Group 3 (p = 0.04); mean EBL 320cc, 351 cc and 376cc (p = 0.5); mean operative time 193.5 minutes, 221 minutes and 290 minutes (p < 0.001). Collecting system entry was recognized in 63%, 76% and 38% of cases in Groups 1, 2 and 3 respectively. (p = 0.07). Postoperative urine leaks requiring some form of management occurred in 11 patients from group 1 and 6 from group 2. (p = 0.2). No patient in Group 3 developed a urinary leak. CONCLUSIONS: Identification of unrecognized collecting system disruption as well as postoperative urine leak rate in patients undergoing partial nephrectomy were not influenced by the intraoperative technique of identifying unrecognized collecting system entry. Postoperative urine leaks are uncommon despite recognized collecting system disruption in the majority of patients.

[Surgical treatment of hypospadias and complications in relation to the child's age]. / Tratamiento quirúrgico del hipospadias y sus complicaciones en relación con la edad del niño.

BACKGROUND: Hypospadias is one of the most common congenital malformations. Few studies have explored the association of age at time of surgery and the occurrence of complications after hypospadias repair. OBJECTIVE: Determine whether age at hypospadias repair is a risk factor for development of complications. METHODS: Retrospective cohort of patients with hypospadias repair in one surgical time. The data included: age, type of hypospadias, surgical technique and complications presented. The monitoring was conducted for six months after the surgery. Patients were classified according to age group A less than 24 months, group B from 24 to 48 months and group C over 48 months. We calculated the relative risk and confidence intervals of 95%. RESULTS: 170 patients were included in the analysis. The incidence of complications was 24.1%, the most frequent complication was urethrocutaneous fistula (52.2%). The median age in months of the complication group was 40.8 (6-196), whereas in the group without complications was 37.5 (6-196). Age was not associated with an increased risk for complications, group B (RR= 0.975 [95% CI 0.374-2.547]), and group C (RR= 0.966 [95% CI 0.386-2.416]) when compared with group A. CONCLUSIONS: Age at time of surgery for hypospadias correction in one phase is not associated with complications.

Antecedentes: el hipospadias es una de las malformaciones congénitas más comunes. Pocos estudios han explorado la asociación de la edad al momento de la cirugía y las complicaciones. Objetivo: determinar si la edad al momento de la corrección del hipospadias es un factor de riesgo de complicaciones. Material y métodos: estudio de cohorte retrospectiva de pacientes con reparación del hipospadias en un tiempo quirúrgico. Los datos incluyeron: edad, tipo de hipospadias, técnica quirúrgica y complicaciones. El seguimiento se efectuó incluso seis meses después de la cirugía. Los pacientes se clasificaron según su edad: el grupo A menores de 24 meses, grupo B de 24 a 48 meses y el grupo C mayores de 48 meses. Se calculó el riesgo relativo y los intervalos de confianza de 95%. Resultados: se analizaron los expedientes de 170 pacientes. La incidencia de complicaciones fue de 24.1%, la más frecuente fue la fistula uretrocutánea (52.2%). La mediana de edad en meses del grupo con complicación fue: 40.8 (6-196), mientras que en el grupo sin complicación fue: 37.5 (6-196). La edad no se asoció con mayor riesgo de complicaciones, grupo B (RR= 0.975 [IC 95% 0.374-2.547]); y el grupo C (RR= 0.966 [IC 95% 0.386-2.416]) al compararla con el grupo A. Conclusiones: la edad al momento de la corrección del hipospadias en un tiempo quirúrgico no se asocia con complicaciones quirúrgicas.