Ureteral Stenosis and Fistula after Kidney Transplantation.

INTRODUCTION: Ureteral complications after kidney transplantation are frequent and may have a negative impact on morbidity and graft function. Treatment modalities include conservative, endourological, and surgical techniques, with variable outcomes. The purpose of this study was to report the incidence, characteristics, treatment, and outcomes of ureteral complications at our center. METHODS: Retrospective study of kidney transplants performed at our unit between 2015 and 2020, analyzing incidence, characteristics, treatment, and outcomes of ureteral stenoses and fistulas. RESULTS: Of 648 kidney transplants, we present 3.24% stenosis and 2.16% ureteral fistulas, with a mean time from transplantation of 101.4 and 24.4 days, respectively. Primary treatment was open surgical repair in 52.4% stenosis and 100% fistulas, with a success rate of 90.9% and 71.4%, respectively. Anterograde balloon dilatations were performed in 33.3% of stenosis with 40% success. Three patients required surgery as a secondary approach with 100% success. Major complications (Clavien-Dindo III) were observed in 18.5% following surgical repair. After a mean follow-up of 31.1 ± 20.9 months, we observe 88.6% of functioning grafts. We found no significant differences in graft survival between patients with or without ureteral complications (p 0.948). CONCLUSION: Surgical repair of ureteral complications offers satisfactory results with low associated morbidity. Endourological techniques are less effective and should be reserved for selected cases. With adequate management, there is no impact on graft survival.

[Late kidney transplant complications treatment.] / Tratamiento de las complicaciones tardías del trasplante renal.

OBJECTIVES: Late kidney transplant complication might compromise graft durability, thus the need for early detection and treatment. MATERIAL AND METHODS: A PubMed review including the following MeSH terms was included: kidney transplant¨, ¨complications¨, ¨vascular complications¨,¨transplant renal artery stenosis¨, ¨ureteral obstruction¨,¨urologic complications¨, ¨forgotten stent¨, ¨vesicoureteralreflux¨, ¨urinary lithiasis¨ e ¨incisional hernia¨. Metanalysis and systematic review in spanish and English were included from January 2015 till February 2021, as well as relevant selected manuscripts. RESULTS: We defined as late complications those appearing at 3 months from kidney transplant. Those include vascular complications (renal artery stricture), urinary tract (ureteral stricture, permanent double Js, pyelonephritis due to reflux, urinary stones) and abdominal wall (incisional hernia). CONCLUSIONS: Late kidney transplant complications remain high still with advancement on surgical technique and immunotherapy. Those complication might compromise the graft durability and so early detection is or primary importance.

OBJETIVO: Las complicaciones tardías del trasplante renal pueden comprometer de manera importante la viabilidad del injerto, por lo que debemos detectarlas y tratarlas de manera precoz.MATERIAL Y MÉTODOS: Realizamos una revisión bibliográfica en PubMed utilizando los términos MeSH ¨kidney transplant¨, ¨complications¨, ¨vascular complications¨, ¨transplant renal artery stenosis¨, ¨ureteralobstruction¨, ¨urologic complications¨, ¨forgotten stent¨,¨vesicoureteral reflux¨, ¨urinary lithiasis¨ e ¨incisionalhernia¨. Se incluyeron metaanálisis, revisiones y revisiones sistemáticas en inglés y español, desde enero de2015 hasta febrero de 2021, así como las referencias más relevantes incluidas en los artículos seleccionados. RESULTADOS: Definimos como complicaciones tardías aquellas que suelen aparecer a partir del tercer mes trasla realización del trasplante. Dentro de ellas se incluyen complicaciones vasculares (estenosis de la arteria renal), de la vía urinaria (estenosis ureteral, catéteres ureterales no retirados, pielonefritis secundarias a reflujovesico-ureteral y litiasis urinaria) y de pared (hernia incisional). CONCLUSIONES: A pesar de los avances, tanto médicos (inmunosupresión) como en la técnica quirúrgica, en el trasplante renal, todavía son frecuentes las complicaciones a largo plazo. Estas complicaciones pueden comprometer la viabilidad del injerto renal, lo que hace necesario que sean detectadas lo antes posible, y no demorar su tratamiento.

Tratamiento de las complicaciones tardías del trasplante renal / Treatment of late complications of renal transplantation

Objetivo: Las complicaciones tardíasdel trasplante renal pueden comprometer de maneraimportante la viabilidad del injerto, por lo que debemosdetectarlas y tratarlas de manera precoz.Materiales y métodos: Realizamos una revisión bibliográfica en PubMed utilizando los términos MeSH ̈kidney transplant ̈, ̈complications ̈, ̈vascular complications ̈, ̈transplant renal artery stenosis ̈, ̈ureteralobstruction ̈, ̈urologic complications ̈, ̈forgotten stent ̈, ̈vesicoureteral reflux ̈, ̈urinary lithiasis ̈ e ̈incisionalhernia ̈. Se incluyeron metaanálisis, revisiones y revisiones sistemáticas en inglés y español, desde enero de2015 hasta febrero de 2021, así como las referenciasmás relevantes incluidas en los artículos seleccionados. Resultados: Definimos como complicaciones tardíasaquellas que suelen aparecer a partir del tercer mes trasla realización del trasplante. Dentro de ellas se incluyen complicaciones vasculares (estenosis de la arteriarenal), de la vía urinaria (estenosis ureteral, catéteresureterales no retirados, pielonefritis secundarias a reflujo vesico-ureteral y litiasis urinaria) y de pared (herniaincisional).Conclusiones: A pesar de los avances, tanto médicos (inmunosupresión) como en la técnica quirúrgica,en el trasplante renal, todavía son frecuentes las complicaciones a largo plazo. Estas complicaciones puedencomprometer la viabilidad del injerto renal, lo que hacenecesario que sean detectadas lo antes posible, y nodemorar su tratamiento.(AU)

Objetives: Late kidney transplant complication might compromise graft durability, thus theneed for early detection and treatment.Material and methods: A PubMed review including the following MeSH terms was included: kidneytransplant ̈, ̈complications ̈, ̈vascular complications ̈, ̈transplant renal artery stenosis ̈, ̈ureteral obstruction ̈, ̈urologic complications ̈, ̈forgotten stent ̈, ̈vesicoureteral reflux ̈, ̈urinary lithiasis ̈ e ̈incisional hernia ̈. Metanalysis and systematic review in spanish and Englishwere included from January 2015 till February 2021,as well as relevant selected manuscripts. Results: We defined as late complications those ap-pearing at 3 months from kidney transplant. Those include vascular complications (renal artery stricture),urinary tract (ureteral stricture, permanent double Js, pyelonephritis due to reflux, urinary stones) and abdominalwall (incisional hernia).Conclusions: Late kidney transplant complicationsremain high still with advancement on surgical techniqueand immunotherapy. Those complication might compromise the graft durability and so early detection is or primary importance.(AU)

Iterative renal transplantation: our experience on third transplants.

PURPOSE: To report our experience on third kidney transplantation, analyzing the complications and graft survival rates as compared to previous transplants. METHODS: Retrospective study of third renal transplants performed at our center. Outcomes were compared with a cohort of first and second transplants. RESULTS: Of a total of 4143, we performed 72 third transplants in 46 men and 26 women with an average age of 46 years and mean time on dialysis of 70 months. Thirty-seven patients were hypersensitized [panel-reactive antibody (PRA) > 50%]. They were all from deceased donors, with a mean cold ischemia time of 19.2 h. The extraperitoneal heterotopic approach was used in 88.8%, transplantectomy was performed in 80.6% and vascular anastomoses were realized mostly to external iliac vessels, using the common iliac artery in 15 cases, and the inferior vena cava in 16. The main ureteral reimplantation technique was the Politano-Leadbetter (76.4%). Third transplantation reported a significantly higher incidence of lymphocele (13.9% vs. 3.2% in first and 4.5% in second transplants; p < 0.001), rejection (34.7% vs. 14.9% and 20.5%, p < 0.001) and urinary obstruction (11.1% vs. 3.6% and 6.3%, p 0.002). Graft survival rates for first, second and third transplants were 87%, 86% and 78% at 1 year, 83%, 82% and 74% at 3 years and 80%, 79% and 65% at 5 years, respectively. CONCLUSION: Iterative transplantation constitutes a valid therapeutic option with adequate surgical and survival results compared to previous transplants. It is a challenging procedure which must be performed by experienced surgeons.

Grade 3a Clavien grade complication following percutaneous nephrolithotomy. Related factors and review of the literature.

OBJECTIVE: We review the literature about bleeding complications of percutaneous nephrolithotomy (PCNL) and the application of the modified Clavien system classification. METHODS: We present a 38 year old man who underwent left PCNL with acute severe hematuria during the immediate postoperatory time. We review the literature and analyze the usefulness of the modified Clavien system to grade perioperative complications. RESULTS: Conservative management was insufficient so we had to perform arteriography and superselective embolization to solve the acute arterial bleeding. According to Clavien's classification, our case would be included within the grade 3a group complications. CONCLUSIONS: The complications following a PCNL are not uncommon. However most of them are not severe. The modified Clavien system, used for classifying complications after performing PCNL, can be useful for reporting results in an objective and replicable way.

Factores relacionados con una complicación grado IIIa de Clavien tras una nefrolitotomía percutánea. Revisión de la literatura / Grade 3a Clavien grade complication following percutaneous nephrolithotomy. Related factors and review of the literature

OBJETIVO: Revisamos la literatura a propósito de las complicaciones hemorragicas derivadas de una Nefrolitotomia Percutánea (NLP) y la aplicación del sistema modificado de Clavien para su clasificación. MÉTODOS: Presentamos el caso de un varón sometido a una NLP izquierda que presentó de forma aguda durante el postoperatorio inmediato una hematuria severa y anemizante secundaria a un sangrado arterial. Revisamos la literatura al respecto y analizamos la utilidad del sistema de clasificación de Clavien para las complicaciones quirúrgicas. RESULTADOS: Mediante arteriografía y embolización percutánea supraselectiva del vaso sangrante se consiguió el control definitivo del sangrado arterial. Representado así una complicación grado IIIa según el sistema de Clavien. CONCLUSIONES: Las complicaciones tras una NLP, en su mayoría leves, no son infrecuentes. El sistema modificado de Clavien adaptado para clasificar las complicaciones tras una NLP puede ser de utilidad para notificar resultados de forma objetiva y reproducible

OBJECTIVE: We review the literature about bleeding complications of percutaneous nephrolithotomy (PCNL) and the application of the modified Clavien system classification. METHODS: We present a 38 year old man who underwent left PCNL with acute severe hematuria during the immediate postoperatory time. We review the literature and analyze the usefulness of the modified Clavien system to grade perioperative complications. RESULTS: Conservative management was insufficient so we had to perform arteriography and superselective embolization to solve the acute arterial bleeding. According to Clavie's classification, our case would be included within the grade 3a group complications. CONCLUSIONS: The complications following a PCNL are not uncommon. However most of them are not severe. The modified Clavien system, used for classifying complications after performing PCNL, can be useful for reporting results in an objective and replicable way

[Radiological diagnosis: scrotal ultrasound and Doppler ultrasound in the diagnosis of male infertility]. / Diagnóstico por imagen: ecografía escrotal y eco doppler en el diagnóstico de la infertilidad masculina.

OBJECTIVES: To review the ultrasound technique, normal anatomy, bibliography, as well as the most frequent scrotal ultrasound findings in infertile patients studied in our center over the last five years, with special emphasis in the diagnosis of varicocele and its follow-up after surgical treatment or embolization. METHODS: We reviewed a total of 439 male patients with the diagnosis of infertility referred to our vascular ultrasound section between 1998 and 2004, and 101 patients referred for ultrasound control after treatment of varicocele (endovascular or surgical). RESULTS: The most frequent diagnosis associated with infertility were left varicocele (146 patients, 33.3%), right varicocele (39 patients, 8.9%) and intratesticular varicocele (1 patient, 0.2%). Only one patient had a right-side-only varicocele (0.2%), the rest of the cases of right varicocele having bilateral affectation (38 patients, 8.7%). Other relevant diagnoses found were testicular atrophy, epididymal lesions, microlithiasis, inguinal scrotal hernias, testicular tumors, and dilation of the rete testis. CONCLUSIONS: Testicular ultrasound should be performed in every patient with unexplained infertility and abnormal sperm analysis. It allows diagnosis of more pathologic conditions than physical examination. Besides a rapid varicocele screening, colour Doppler ultrasound allows us to evaluate its hemodynamic repercussion, by studying the spectral display, colour and response to Valsalva's. It also provides an exact measure of testicular volume, allows to detect the presence of dystrophic changes in the testicle, as well as anomalies of the epididymis and vas deferens, such as cystic dilations. It is also the test of choice to detect non descended testicles. Ultrasound may also detect non palpable testicular tumors which are more prevalent in this group of patients.

[The effect of seminal leukocytes on semen quality in subfertile males with and without varicocele]. / Efectos de la leucocitospermia sobre la calidad seminal en varones subfértiles con y sin varicocele.

OBJECTIVES: To compare the concentration of leukocytes and round cells in semen samples of subfertile males (SM), men with varicocele (VM), and fertile males (FM) to establish a possible relationship between leukocyte concentration, semen parameters (pH, concentration, mobility, spermatic morphology) and lipidic peroxidation of the spermatozoid. METHODS: We evaluated 298 semen samples from: 42 fertile males, 170 subfertile males, and 86 men with varicocele. Sperm tests were performed following WHO criteria. All samples with leukocyte counts higher than 1 million/ml were submitted for oxidative stress study (malonyldialdehyde in seminal plasma). RESULTS: Leukocyte concentration was higher in subfertile males and men with varicocele (2.5 +/- 2.1 x 10(6)/ml and 2.3 +/- 2.1 x 10(6)/ml) than in fertile males (1.1 +/- 0.1 x 10(6)/ml) (p 0.0001). In the same way concentration of round cells was higher in the SM group (6.5 +/- 0.3 x 10(6)/ml) and VM group (6.1 +/- 0.4 x 10(6)/ml) than in FM (4.5 +/- 0.4 x 10(6)/ml) (p 0.05). Spermatozoid concentration was lower in SM (42.1 +/- 2.4 x 10(6)/ml) and VM (9.9 +/- 3.5 x 10(6)/ml) than in FM (82.4 +/- 5.7 x 10(6)/ml) (p 0.0001). The percentage of spermatozoa with type "a" mobility was lower in the SM (14.1 +/- 0.9) and VM (19.9 +/- 1.4) groups than in the FM group (50.0 +/- 1.3) (p 0.0001). In the same way, "a + b" mobility was lower in the SF group (26.7 +/- 1.4) and VM group (34.1 +/- 1.9) than in the FM group (50.0 +/- 1.3) (p 0.0001). The SM group showed a lower percentage of normal forms (43.3 +/- 1.5) than the VM (50.0 +/- 1.6) and FM (60.6 +/- 1.3) groups (p 0.0001). When grouping by concentration of peroxidase positive cells, there were not statistical differences in the spermatic variables in SM, with the exception of progeny cells. Type "a" mobility in the VM group was lower in the peroxidase positive group than in the peroxidase negative group (p 0.005); "a + b" mobility was also lower in the peroxidase positive men than in peroxidase negative (p 0.01); in the progeny cells they were higher in the peroxidase positive males (4.2 +/- 0.4 x 10(6)/ml) than in peroxidase negative males (3.0 +/- 0.3 x 10(6)/ml). Malonyldialdehyde concentrations were significantly higher in seminal plasma of subfertile and varicocele males than in fertile males (p 0.006, and p 0.03). CONCLUSIONS: Increased number of semen lymphocytes is more frequent in subfertile and varicocele males than in fertile males. The increase of semen leukocytes is associated with deterioration of seminal parameters. Oxidative stress has a negative influence on seminal parameters in subfertile males of unknown etiology.

[Varicocele's radiological endovascular occlusion]. / Oclusión radiológica endovascular del varicocele.

OBJECTIVES: To report our experience on percutaneous treatment of male varicocele over the last 15 years. METHODS: 690 patients with left varicocele underwent percutaneous occlusion of the spermatic vein. Embolization was undertaken using various types of materials; the most frequently used association was coils and sclerosing substances. Thorough clinical control was carried out, including ultrasound and spermiogram when indicated. RESULTS: Initial success rate was 97.8% and complication rate was 6.2%. Varicocele persistence or relapse was found in 13.2% of the cases after embolization. In the group of patients with sperm tests on follow-up, sperm counts became normal in 46% of the patients, and "a + b" mobility in 35%. Post-treatment pregnancy rate was 20%. CONCLUSIONS: Percutaneous occlusion of the spermatic vein is a very extensively developed technique. Its efficacy and nearly null rate of severe complications, associated with its good results, make it the technique of choice in the treatment of male varicocele.

[The treatment of varicocele in the infertile male I: results on semen quality]. / Tratamiento del varicocele en el varón infértil I: resultados sobre la calidad seminal.

OBJECTIVES: To evaluate the effect of interventionist treatment of varicocele, either open surgery or endovascular radiological occlusion, on seminal parameters, and to identify which factors are associated with their normalization. METHODS: Between 1975 and 2000, 631 patients with the diagnosis of idiopathic varicocele were evaluated in our hospital; 238 of them were part of an infertile couple. Among them, finally, 183 underwent studies; they complied with the following criteria: 1) Infertility for more than one year; 2) seminal parameters below normality following WHO criteria (1992); 3) absence of other pathologies or diseases which could explain male infertility; and 4) absence of evident causes of male infertility. 131 patients were treated by radiological occlusion and 26 by conventional surgery. The remaining 26 patients did not undergo the treatment indicated. Two parameters were evaluated on follow-up: 1) achievement of pregnancy (these results will be analyzed in a next article), and 2) normalization of seminal parameters. RESULTS: 48% and 39% of the patients respectively achieved normalization of the number of spermatozoids per ml (=20 million spermatozoids per ml) and spermatic morbidity (=50%). The association between normalization of seminal parameters and age, clinical grade, or type of treatment was not demonstrated. Only baseline degree of severity in the alteration of seminal parameters showed statistically significant differences in the evaluation of semen quality after treatment of varicocele (p = 0.001 and p = 0.002). CONCLUSIONS: The degree of previous seminal alteration--oligospermia and asthenospermia--was the factor with greatest prognostic value in relation with normalization of seminal parameters.

[The treatment of varicocele in the infertile male II: results on fertility]. / Tratamiento del varicocele en el varón infértil II: resultados sobre la fertilidad.

OBJECTIVES: To analyze the efficacy of varicocele treatment, either surgical or endovoscular radiological occlusion, on pregnancy rates of infertile couples in which the male had clinically. patent left varicocele, and to identify which factors are associated with the probability of obtaining pregnancy in such cases. METHODS: This study is part of a more ample one described in previous article: "The treatment of varicocele in the infertile male I: Results on semen quality". Overall, 183 couples were included. 157 males received treatment (131 radiological occlusion and 26 open surgery), the remaining 26 did not received the treatment indicated. Couples underwent periodic follow-up during the first year, evaluating two parameters: 1) normalization of semen analysis parameters, and 2) pregnancy during the following 12 months after indication of treatment. RESULTS: Overall, 41 couples (22.4%) achieved pregnancy during first year, 35/157 (22%) in the group of treated patients, and 6/26 (23%) in the non treatment group. In the treatment group, surgical ligature achieved higher pregnancy rates than radiological occlusion (35% vs. 20%), but the difference was not statistically significant (p = 0.255). No association was demonstrated between male age, female age, varicocele clinical grade, degree of semen quality abnormalities, or duration of infertility and pregnancy rates. The FSH value was significantly lower (p 0.0006) in patients who achieved pregnancy. CONCLUSIONS: The degree of semen quality abnormality, which so closely correlated to normalization of seminal parameters, locked of prognostic significance in terms of achievement of pregnancy. The FSH value was the only factor with certain prognostic value, although it did not reach significance in logistic regression analysis.

Diagnóstico por imagen: ecografía escrotal y eco doppler en el diagnóstico de la infertilidad masculina / Radiological diagnosis: scrotal ultrasound and Doppler ultrasound in the diagnosis of male infertility

OBJETIVO: Revisión de la técnica ecográfica, de la anatomía normal, de la bibliografía así como de los hallazgos en ecografía escrotal mas frecuentes en los pacientes infértiles estudiados en nuestra institución en los últimos cinco años, con especial hincapié en el diagnóstico del varicocele y su seguimiento tras la terapéutica quirúrgica o embolizante. MÉTODOS: Se han revisado un total de 439 pacientes remitidos a nuestra sección de ecografía vascular con el diagnóstico de infertilidad entre los años 19982004 así como 101 pacientes remitidos a control ecográfico después de tratamiento de varicocele (endovascular o quirúrgico). RESULTADO: El diagnóstico más frecuente asociado a infertilidad ha sido el de varicocele izquierdo (146 pacientes, 33,3 por ciento), varicocele derecho (39 pacientes, 8,9 por ciento), y varicocele intratesticular (1 paciente, 0,2 por ciento).El varicocele fue exclusivamente derecho en 1 paciente (0,2 por ciento), siendo en el resto de los casos de varicocele derecho la afectación bilateral (38 pacientes, 8,7 por ciento). Otros diagnósticos relevantes encontrados fueron, la atrofia testicular, lesiones del epidídimo, microlitiasis, hernias inguinoescrotales, tumores testiculares y dilatación de la rete testis. CONCLUSIONES: La ecografía escrotal debería de realizarse en todos los pacientes con infertilidad no explicada y anomalías en el espermiograma. Permite la detección de más condiciones patológicas que las detectadas con la exploración clínica. Aparte de un despistaje rápido sobre la presencia o no de varicocele, el estudio con doppler color permite valorar la repercusión hemodinámica del mismo, mediante el estudio de la representación espectral, el color y su respuesta a la maniobra de Valsalva. Permite además un estudio exacto del volumen testicular, detectar la presencia de cambios distróficos en el testículo, así como de anormalidades del epidídimo y del conducto deferente como dilataciones quísticas. Es también la técnica de elección en la localización de testículos no descendidos. La ecografía puede detectar también tumores testiculares no detectados en la exploración física y que son mas prevalentes en este grupo de pacientes (AU)

Plasmocitoma renal. Presentación de un nuevo caso / Renal plasmacytoma: a case report

OBJETIVO: Presentamos un caso de plasmocitoma extramedular localizado en el riñón, describiendo su presentación clínica, pruebas diagnósticas empleadas y el tratamiento aplicado, así como la evolución del paciente. MÉTODOS/RESULTADOS: Se trata de un paciente de 59 años, que presenta una masa renal derecha acompañada de insuficiencia renal. En las pruebas complementarias realizadas se puso de manifiesto la presencia de una banda monoclonal lambda en sangre y orina, y en la biopsia del riñón izquierdo se objetivaron cambios compatibles con riñón de mieloma. El diagnóstico definitivo de plasmocitoma se llevó a cabo mediante biopsia renal abierta, ya que la PAAF era compatible con carcinoma. El tratamiento empleado fue la poliquimioterapia, falleciendo el paciente un año después del diagnóstico por rápida progresión de su discrasia de células plasmáticas. CONCLUSIONES: La presencia de un plasmocitoma en el riñón es excepcional, debiendo sospecharse ante la presencia de paraproteína en sangre u orina y cuando el paciente tiene antecedentes de discrasia de células plasmáticas. No hay un tratamiento establecido, pudiendo utilizarse la cirugía, la radioterapia o la quimioterapia, bien de forma aislada, o bien asociadas (AU)

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Nefroma mesoblástico del adulto: aportación de un nuevo caso / A case of adult mesoblastic nephroma

OBJETIVO: Presentamos un nuevo caso de nefroma mesoblástico en el adulto, describiendo la presentación clínica, tratamiento realizado, diagnóstico histológico y evolución de la paciente. METODOS/RESULTADOS: Se trata de una paciente de 68 años, diagnosticada mediante ecografía de masa renal, a la que se realizó una nefrectomía radical. El diagnóstico anatomopatológico fue de nefroma mesoblástico. La paciente no ha presentado recidiva tras Fig. 3: Infiltrado inflamatorio constituido por numerosas células espumosas (xantomatosas), acompañadas por linfocitos y células plasmáticas (hematoxilina-eosina. X400). un seguimiento de 3 años. CONCLUSIONES: El nefroma mesoblástico en el adulto tiene un comportamiento benigno, siendo excepcional la recidiva después de la cirugía (AU)

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