Kidney transplantation from expanded criteria donors: an increased risk of urinary complications - the UriNary Complications Of Renal Transplant (UNyCORT) study.

OBJECTIVES: To assess the impact of expanded criteria donors (ECD) on urinary complications in kidney transplantation. PATIENTS AND METHODS: The UriNary Complications Of Renal Transplant (UNyCORT) is a cohort study based on the French prospective Données Informatisées et VAlidées en Transplantation/Computerized and VAlidated Data in Transplantation (DIVAT) cohort. Data were extracted between 1 January 2002 and 1 January 2018 with 1-year minimum follow-up, in relation to 44 pre- and postoperative variables. ECD status was included according to United Network for Organ Sharing (UNOS) definition. The primary outcome of the UNyCORT study was the association between the donor's ECD/standard criteria donors (SCD) status and urinary complications at 1 year in uni- and multivariate analysis. Sub-group analysis, stratified analysis on ECD/SCD donor's status and transplant failure analysis were then conducted. RESULTS: Between 1 January 2002 and 1 January 2018, 10 279 kidney transplants in adult recipients were recorded within the DIVAT network. A total of 8559 (83.4%) donors were deceased donors and 1699 (16.6%) were living donors (LD). Among donation after circulatory death (DCD) donors, 224 (2.85%) were uncontrolled DCD and 93 (1.09%) were controlled DCD donors. A total of 3617 (43.9%) deceased donors were ECD. The overall urological complication rate was 16.26%. The donor's ECD status was significantly associated with an increased risk of urological complications at 1 year in multivariate analysis (odds ratio: 1.50, 95% CI 1.31-1.71; P < 0.001) and especially with stenosis and ureteric fistulae at 1 year. There is no association with LD, uncontrolled and controlled DCD. The placement of an endo-ureteric stent was beneficial in preventing urinary complications in all donors and particularly in ECD donors. CONCLUSION: The donor's ECD status is associated with a higher likelihood of stenosis and ureteric fistulae at 1 year. Recipients of grafts from ECD donors should probably be considered for closer urological monitoring and systematic preventive measures.

Comparison of the outcomes of the pediatric kidney transplantation between recipients below and above 15 kg: a single center retrospective study.

BACKGROUND: The renal transplantation is the best treatment for end-stage renal disease in children. We present the findings of an analysis of our institution's paediatric transplant outcomes comparing recipients under 15 kg, who represent this potentially higher risk group, to those above 15 kg. METHODS: We retrospectively identified consecutive paediatric kidney transplants from a prospectively collected database for analysis. We included all recipients under the age of 18 years at the time of transplant between 2006 and 2018 without any exclusion criteria. The primary outcome was death-censored graft survival at 1 year, 5 years and 10 years. RESULTS: 109 paediatric kidney transplants were performed in 100 children. Graft survival in the all population was 98%, 96% and 76% at 1 year, 5 years and 10 years, respectively. Recipient weight below 15 kg was not found to be a risk factor of graft loss. Overall, we found no individual factor to be statistically significantly associated with renal graft lost. The overall complication rate was 16% (18/109) with 12 early complications (11%) and 6 late ones (5%). CONCLUSION: Kidney transplantation in children weighing < 15 kg seems safe and offers the same patient and graft survival outcomes as in other (> 15 kg) pediatric recipients with equally low complication rates.

Right Kidney Mini-Invasive Living Donor Nephrectomy: A Safe and Efficient Alternative.

INTRODUCTION: Right kidney living donor transplantation is considered more difficult and associated with more complications. The objective was to evaluate donor safety and graft function of right hand-assisted laparoscopic donor nephrectomy (HALDN). METHODS: A total of 270 consecutive HALDN procedures have been performed in our institution up to April 2017. We retrospectively compared the outcomes of right-sided nephrectomy (R-HALDN) to left-sided nephrectomy (L-HALDN) to evaluate donor safety and graft function of R-HALDN. RESULTS: Sixty-seven right kidneys were removed for functional asymmetry in favour of left kidney (35/67) or left kidney multiple arteries (28/67). Among the donors, neither conversion to open surgery nor preoperative blood transfusion was necessary. There was no significant difference in operative time, compared to L-HALDN group (170 ± 37 min vs. 171 ± 32 min; p value = 0.182). Warm ischaemia time was significantly longer for R-HALDN (4.0 ± 1.6 min vs. 3.0 ± 1.7 min; p < 0.001). There was no significant difference in terms of post-operative complications and serum Cr levels. Among the recipients, there were no graft venous thrombosis. There was no significant difference in delayed graft function (3 for R-HALDN group and 8 for L-HALDN group; p value = 0.847), serum Cr levels, and graft survival. CONCLUSION: R-HALDN is a safe procedure for kidney donors, with excellent graft function for the recipients, compared to L-HALDN.

Benign Prostatic Hyperplasia Endoscopic Surgical Procedures in Kidney Transplant Recipients: A Comparison Between Holmium Laser Enucleation of the Prostate, GreenLight Photoselective Vaporization of the Prostate, and Transurethral Resection of the Prostate.

Purpose: The main objective of this multicentric retrospective pilot study was to evaluate the 1-year follow-up safety (i.e., minor [Clavien-Dindo I-II] and major [Clavien-Dindo ≥III] complications) of holmium laser enucleation of the prostate (HoLEP), GreenLight photoselective vaporization of the prostate (GL PVP), and transurethral resection of the prostate (TURP) performed after kidney transplantation (KT). The secondary objectives were to evaluate the efficacy and to assess the impact of these procedures on graft function. Materials and Methods: We retrospectively included all KT recipients who underwent a HoLEP or GL PVP or TURP for benign prostatic hyperplasia (BPH) in three French university centers. Results: From January 2013 to April 2018, 60 BPH endoscopic surgical procedures in KT recipients were performed: 17 HoLEP (HoLEP group), 9 GL PVP (GL PVP group), and 34 TURP (TURP group). Age, body mass index, preoperative serum creatinine, preoperative International Prostatic Symptom Score, preoperative Qmax, preoperative prostate-specific antigen, medical history of acute urinary retention (AUR), urinary tract infection (UTI), and indwelling urethral catheter were similar in all study groups. Mean preoperative prostate volume was higher in HoLEP group. The rate of overall postoperative complications was statistically higher in the HoLEP group (11/17 [64.7%] vs 1/9 [11.1%] vs 12/34 [35.3%] in HoLEP group, GL PVP group, and TURP group, respectively, p = 0.02), with higher rate of long-term UTI and AUR. Qmax improved in all groups after operation. Delta postoperative month 12-preoperative serum creatinine was similar in the all groups. Conclusions: Although our study is underpowered, the rate of postoperative complications is higher with HoLEP procedure, in comparison with GL PVP, for the treatment of BPH after KT. One-year efficacy is similar in HoLEP, GL PVP, and TURP groups. Further prospective randomized controlled trials are needed to confirm our results.

Technical feasibility of robot-assisted laparoscopic radical prostatectomy in renal transplant recipients: Results of a series of 12 consecutive cases.

INTRODUCTION: We evaluate the technical feasibility of robotic prostatectomy in renal transplant recipients. METHODS: We retrospectively analyzed preoperative and perioperative settings, as well as functional and oncologic results of 12 patients operated on between 2009 and 2013. Prostatectomy was performed via a transperitoneal approach without any changing in the ports position. The average age was 61.92 ± 2.98 years. The period between transplant and the diagnosis of adenocarcinoma was 79.7 months. The mean PSA was 7.34 ng/mL (range: 4.9-11). RESULTS: The operative time was 241.3 ± 35.6 minutes with only one conversion and one transfusion. The intervention was difficult due to adhesions on the side of the graft in 50% of cases. There was a case of obstructive acute renal failure resulting from a hematoma of the Retzius treated by percutaneous nephrostomy at D20. There was a majority of pT2c (72.7%), including 3 positive margins (27.3%) and 2 biochemical relapses treated with radiotherapy and hormonotherapy, respectively. The end point prostate-specific antigen was undetectable. There was no significant difference between preoperative and J7 creatinine (p = 0. 22). CONCLUSIONS: Robotic prostatectomy in renal transplant recipients is a safe technique with no serious effects on the allograft.

An unexpected etiology of priapism: infection-related anti-protein s antibodies.

INTRODUCTION: In adolescents, the occurrence of priapism is commonly related to sickle cell disease and rarely to other causes. We hereby report a case of priapism due to an acquired protein S (PS) deficiency. AIM: The aim of this study was to describe a young man who developed a priapism with a thrombosis of the corpora cavernosa associated with an anti-PS antibody (anti-PS Ab). METHODS: One week after the onset of an influenza-like illness, a young male developed multiple extensive venous thromboses including a thrombosis of the corpora cavernosa causing painful partial priapism. These thromboses along with purpuric lesions with necrotic vesicles of the feet skin were linked to an acquired PS deficiency due to an anti-PS Ab. The optimal treatment of anti-PS Ab-associated thrombosis is debated but we chose to initiate (i) heparin; (ii) corticosteroids; and (iii) plasmapheresis. RESULTS: Even if priapism lasted more than 4 days, a full recovery of erectile function was observed within 3 months. As compared with priapism due to sickle cell disease, which is commonly associated with definitive erectile dysfunction, this favorable outcome is noteworthy. The skin healing was complete only 6 months later. CONCLUSION: Acquired PS deficiency complicating an infectious disease is a rare, life-threatening condition, associated with substantial morbidity related to amputations of limbs or digits. This is the first report of priapism due to acquired PS deficiency.

The artificial bowel sphincter: a single institution experience over a decade.

OBJECTIVE: A report on the long-term results of a consecutive series of patients implanted with the Acticon Neosphincter. METHOD: Data were reviewed from a prospective database. From May 1996 to Jan 2010, 52 patients (46 women), mean age 51.5 ± 14.8 years, with severe fecal incontinence for a mean of 10.6 ± 10.5 years, were implanted with 85 devices. All patients had failed conservative management, including 13 with unsuccessful prior surgical treatments. Indications for implantation were sphincter destruction (45), pudendal neuropathy (12), congenital malformation (7), and perineal colostomy (4). Preoperative assessment included anal endosonography, anorectal manometry, and electrophysiologic testing. Incontinence (Wexner) and Quality of Life scores were recorded prior to the procedure and at each follow-up visit, together with annual anal physiology assessments. Cumulative risks of device revision and explantation were evaluated using Kaplan-Meier survival curves. RESULTS: Mean follow-up was 64.3 ± 46.5 months (range, 2-169); 26 patients (50%) required revisions after a mean of 57.7 ± 35.0 months, with 73.1% due to a leaking cuff from a microperforation; 14 patients (26.9%) required definitive explantation after a mean of 14.6 ± 7.9 months, with the majority (42.9%) due to infection; and 9 patients were lost to follow-up. In 35 patients (67.3%) with an activated device, there were significant improvements in both median Wexner (P < 0.0001) and Quality-of-life scores (P = 0.0286). There was a significant difference between preoperative resting anal pressures and closed pressures at activation (P < 0.0001) and latest follow-up (P < 0.0001). CONCLUSION: With careful patient selection, meticulous surgical technique, and dedicated surveillance, favorable long-term results can be achieved with acceptable rates of revision and explantation.

Female urinary incontinence and artificial urinary sphincter: study of efficacy and risk factors for failure and complications.

BACKGROUND: The artificial urinary sphincter (AUS) has become a commonly used therapy for severe urinary incontinence (UI) due to intrinsic sphincter deficiency (ISD). OBJECTIVE: To evaluate retrospectively the efficacy and risk factors for failure and complications of AUS implantation in women with nonneurologic UI. DESIGN, SETTING, AND PARTICIPANTS: From May 1987 to December 2009, 215 women with ISD were treated by AUS implantation, with a mean age of 62.8 yr and a mean follow-up of 6 yr (standard deviation: 5.6 yr). Previous surgical procedures to treat incontinence had been performed in 88.8% of the patients. Urodynamic assessment was required. Patients using only 0 or 1 pad at the end of follow-up were considered continent. The patient's level of satisfaction was evaluated by a global analogue scale and clinical interview. INTERVENTION: All women had AUS implantation. MEASUREMENTS: Patients were evaluated for continence rate, risk factors for failures, and complications. RESULTS AND LIMITATIONS: At the end of follow-up, 158 patients (73.5%) were continent, and 170 (79%) were satisfied. The redo rate was 15.3% after a mean interval of 8.47 yr for the first redo procedure. Fifteen explantations (7%) were performed. The only risk factor for intraoperative complications (10.7%) was smoking (p<0.004). Six patients (2.8%) were lost to follow-up. AUS failed to treat incontinence in 51 patients (23.7%) due to defective manipulation in 27.4% of the cases. On multivariate analysis, risk factors for failure were age >70 yr (odds ratio [OR]: 2.46), a history of the Burch procedure (OR: 2.28), or pelvic radiotherapy (OR: 4.37) (p<0.05). CONCLUSIONS: The place for this safe and long-lasting effective technique in the treatment of UI due to recurrent sphincter deficiency is confirmed. Screening for these risk factors should allow better patient selection.

Functional results after tape removal for chronic pelvic pain following tension-free vaginal tape or transobturator tape.

PURPOSE: The incidence of pelvic pain after placement of a suburethral sling for incontinence ranges between 0% and 30%. The management of this chronic pain after suburethral sling placement is complex and to our knowledge no consensus has been reached. We evaluated the functional results after removal of the suburethral tape responsible for chronic pelvic pain. MATERIALS AND METHODS: From November 2004 to August 2009, 32 patients undergoing removal of suburethral tape causing chronic pelvic and perineal pain at our department were prospectively followed. Patients were divided according to the type of suburethral sling into the transobturator tape group (15 patients) and the tension-free vaginal (retropubic) tape group (17 patients). In the TVT group tape removal was performed using transperitoneal laparoscopy in every patient. In the TOT group tape removal was performed via a transvaginal approach possibly associated with a unilateral or bilateral incision in the proximal part of the thigh. Pain was evaluated by a visual analogue scale from 0-no pain to 10-maximal pain. RESULTS: The surgical exploration of suburethral tape responsible for chronic, treatment refractory pelvic pain revealed in most cases an abnormal tape position or excessive tape traction. In the overall population tape removal provided improvement of pain (at least 50% improvement of the visual analogue scale score) in 68% with a mean followup of 10 months. Mean visual analogue scale score was 7.3 +/- 1.5 before surgery and 3.4 +/- 3 after surgery. However, recurrence of incontinence was observed in 22% of cases. No significant difference was demonstrated in terms of functional results according to the type of tape insertion. CONCLUSIONS: The surgical removal of suburethral tape improved pain in 68% of patients but with a risk of recurrence of urinary incontinence in 22%.

[Identification of lithogenic risk factors by a simplified first-line laboratory assessment in urinary calculi patients]. / Recherche de facteurs lithogènes par le bilan biologique simplifié de premiere intention chez le lithiasique, en urologie.

INTRODUCTION: A simplified first-line laboratory assessment is recommended by the Stones Committee of the Association Française d'Urologie (CLAFU) right from the first episode of renal stones to detect any lithogenic risk factors. This study was designed to evaluate the feasibility of this assessment in urology, to specify the frequency of risk factors and to compare the results between first stone formers and recurrent stone formers. MATERIAL AND METHODS: This prospective study included patients with a first stone or recurrent stones with no previous laboratory assessment. Known cases of secondary stones were excluded. The stone or fragments had to be analysed by infrared spectrophotometry. In addition to the usual assessment, the first-line laboratory assessment was performed two to three months after the acute episode with a blood test (calcium, phosphorus, uric acid and creatinine), 24-hour urine collection (volume, calcium, uric acid, urea, creatinine, sodium) and first morning urine sample (pH, density, crystals). RESULTS: The results are based on 115 of the 204 patients included (69 first stones, 46 recurrent stones). The assessment was performed and interpreted easily, except for collection of stone fragments. Infrared spectrophotometry was performed in only 49 patients. Whewellite was the most frequent crystalline structure. No patients presented hyperparathyroidism or renal failure. In 69% of cases, the urinary assessment identified one or several risk factors, with insufficient diuresis (42%), hypercalciuria (29%), hypernatriuria (41%), high urinary urea (29%), and hyperuricuria (20%). 25% of patients had a single abnormality, 20% had two abnormalities, the most frequent combination being hypercalciuria-hypernatriuria, and 11% had 4 or more abnormalities. Comparison of first stone formers and recurrent stone formers did not reveal any difference in the frequency of lithogenic risk factors. CONCLUSION: This easy to perform assessment identified lithogenic risk factors in many cases, in both first stone formers and recurrent stone formers, that can guide the prevention of recurrent stones.

[Oncological results of renal cancer with inferior vena cava thrombosis after nephrectomy]. / Résultats de la néphrectomie pour cancer du rein avec avec thrombus tumoral dans la veine cave inférieure.

OBJECTIVE: The objective of this study was to evaluate survival and risk of recurrence in patients undergoing nephrectomy with resection of inferior vena cava tumour thrombus in our department. MATERIAL AND METHODS: From June 1991 to March 2003, 40 patients underwent radical nephrectomy with resection of inferior vena cava tumour thrombus. The upper limit of the tumour thrombus was below the hepatic veins in 21 cases (52.5%) and above the hepatic veins in 19 cases (47.5%), with thrombus in the right atrium in 6 cases (15%). Cardiopulmonary bypass (CPB) was used in 12 patients (30%) RESULTS: With a mean follow-up of 28.5 +/- 36.8 months (range: 0-150), 22 patients (55%) have died. The 2- and 5-year overall survival rates were 45.2% and 38. 7%, respectively. Local and/or metastatic recurrence was observed in 28 patients (70%) after a mean interval of 18 +/- 22.9 months (range: 1-104). Patients with tumour thrombus derived from the left kidney had a higher local recurrence rate than patients with thrombus derived from the right kidney (p = 0.0194). The 2- and 5-year recurrence-free survival rates were 28.3% and 8.9%, respectively. Only stage pN had a statistically significant prognostic value on overall survival, but not on recurrence-free survival. At the end of the study, only 1 patient (2.5%) can be considered to be cured with no disease progression with a sufficient follow-up (52 months) after nephrectomy. CONCLUSION: Nephrectomy with resection of tumour thrombus from the inferior vena cava provides a gain in terms of medium-term survival, but the majority of patients are not cured by this major surgery. Only lymph node status has a prognostic value.

[Morbidity and mortality of renal cancer with inferior vena cava extention according to various types of surgical management]. / Morbidité et mortalité des cancers du rein avec thrombus tumoral dans la veine cave inférieure en fonction du type de la prise en charge chirurgicale.

OBJECTIVE: The objective of this study was to evaluate the mortality and morbidity of patients operated for renal cancer with inferior vena cava extension according to the surgical management and the upper limit of the tumour thrombus. underwent radical nephrectomy with resection of neoplastic venous thrombus extending into the inferior vena cava. The upper limit of the tumour thrombus was below the hepatic veins in 21 cases (52.5%) and above the hepatic veins in 19 cases (47.50%) with invasion of the right atrium in 6 cases (150). RESULTS: Cardiopulmonary bypass (CPB) was used in 12 patients (30%). The transfusion rate was 87.5%. In the group of 19 patients with thrombus extending above the hepatic veins, the transfusion rate was lower in patients operated by CPB (p=0.008). Intraoperative embolism occurred in 3 patients (7.5%): 2 cases of thrombotic embolism and 1 case of gas embolism, always in patients operated without CPB. The early mortality was 7.5% from haemorrhagic complications. The early morbidity was 47.5%. No significant difference was observed between groups of patients operated with or without CPB in terms of morbidity (p=0.836) or mortality (p=0.896). CONCLUSION: The management of patients with renal cancer and inferior vena cava extension is complicated and requires a multidisciplinary approach. Patients operated under CPB for tumours extending above the hepatic veins have a lower transfusion rate and a lower embolic complication rate with no increase of mortality and morbidity.

Surgical care, morbidity, mortality and follow-up after nephrectomy for renal cancer with extension of tumor thrombus into the inferior vena cava: retrospective study since 1990s.

OBJECTIVES: The aim of our survey was to evaluate surgical care, morbidity, mortality and follow-up of patients who had undergone surgical exeresis of a renal cancer with extension of tumor thrombus into the inferior vena cava. PATIENTS AND METHODS: Between June 1991 and March 2003, 40 (5.4%) patients were operated on for an enlarged nephrectomy with thrombectomy. The upper limit of the tumor thrombus was below the sus-hepatic veins in 21 (52.5%) patients and above the sus-hepatic veins in 19 (47.5%) patients with six (15%) located in the right atrium. RESULTS: Cardiopulmonary bypass (CPB) was used for 12 patients (30%). A per-operative embolism was noted for three (7.5%) patients: two cases of cruoric embolism and one case of gaseous embolism, systematically occurring in patients operated on without CPB. Early mortality was 7.5% (three patients) attributable to hemorrhagic complications. Overall survival at 2 and 5 years was 45.2% and 38.7%, respectively. Disease-free survival at 2 and 5 years was 28.3% and 8.9% respectively. Only the pN stage had a statistically significant prognosis value for overall survival but not for disease-free survival. At the end of the study, only one (2.5%) patient could be considered free of the disease with sufficient follow-up after the surgery. CONCLUSION: Patients with renal cancer and tumor extension in the inferior vena cava need multidisciplinary cooperation to adapt a good surgical strategy, particularly with the use of CPB. However, the rate of patients free of disease after such surgery was low.

[Predisposing factors for ureteric strictures in renal transplantation]. / Facteurs favorisant les sténoses urétérales en transplantation rénale.

OBJECTIVE: Renal transplantation is a well defined surgical procedure, but it nevertheless remains associated with a risk of medical and surgical complications. Ureteric strictures, with an incidence ranging from 2% to 7.5% according to the series, are the most frequent urological complication. The objective of this study was to determine the incidence of ureteric strictures and the existence of risk factors predisposing to the development of ureteric strictures and to evaluate their consequences on patient and graft survival, based on a single-centre retrospective series of renal transplantations. PATIENTS AND METHODS: From January 1990 to December 2002, 1787 renal transplantations were performed consecutively in our centre. Graft, donor and recipient characteristics were extracted from a computerized database and validated by an independent observer. The parameters studied included donor's age and recipient's age, donor's haemodynamic status and serum creatinine at the time of harvesting, cause of death, graft weight and number of graft arteries, cold ischaemia and reperfusion times, number of HLA incompatibilities and percentage anti-HLA immunization, time to return of graft function, acute rejection, presence or absence of a double J stent, episodes of acute pyelonephritis, CMV infection and patient and graft survival according to the Kaplan-Meier method. RESULTS: Ureteric stricture was observed in 74 patients (4.1% of cases) and a donor age greater than 65 years (p < 0.0001), the presence of more than 2 arteries on the graft (p = 0.03) and recipients with an anti-HLA immunization less than 25% (p = 0.037) were identified as independent risk factors. Furthermore, grafts complicated by ureteric stricture resumed function later (p = 0.001). The development of ureteric stricture did not have an unfavourable impact on the 10-year recipient and graft survival rates.

[Therapeutic management of ureteric strictures in renal transplantation]. / Prise en charge thérapeutique des sténoses urétérales en transplantation rénale.

OBJECTIVE: Ureteric strictures, with a reported incidence ranging from 2% to 7.5%, are the most frequent urological complication of renal transplantation. This article reports the results of open surgery and percutaneous or endoscopic techniques used to treat these strictures, based on a single-centre retrospective series of renal transplantations. PATIENTS AND METHODS: From January 1990 to December 2002, in a series of 1787 consecutive renal transplantations performed in our centre, 74 were complicated by ureteric stricture (4.1% of cases). Strictures occurred at the ureterovesical implantation in 82.4% of cases and during the first year in 88% of cases. The mean time to management of the stricture after transplantation was 9 months (range: 6 days-120 months). Criteria of success were defined by regression or even resolution of ultrasound signs of dilatation associated with stabilization of serum creatinine obtained by the external urinary diversion. Surgical or percutaneous revisions (particularly repeated changes of double J stents) were considered to be treatment failures. RESULTS: 44 strictures (59.5% of cases) were treated by open surgery and 30 (40.5%) were treated by a first-line endoscopic or percutaneous technique. In our hands, open surgical techniques (ureteropelvic anastomosis: 80% of success (n=5), ureterovesical reimplantation: 82% of success (n=11), ureteroureteric anastomosis: 100% of success (n=4)) gave better results than endourological techniques (endoscopic electrical incision: 61.5% of success (n=13), double J stent: 61.5% of success (n=13), balloon catheter dilatation: no success (n=4)). CONCLUSION: Classical open surgical revision remains the reference treatment for ureteric strictures in renal transplantation for our team.

[Complications of Bricker ileal conduit urinary diversion: analysis of a series of 246 patients]. / Complications des urétérostomies cutanées trans-iléales selon Bricker. Analyse d'une série de 246 patients.

OBJECTIVE: The objective of this retrospective study was to evaluate the mortality and early and late morbidities of Bricker ileal conduit urinary diversion. PATIENTS AND METHODS: Between January 1990 and December 2002, 246 Bricker ileal conduit urinary diversion was performed in our centre in 164 males (67%) and 82 females (33%) with a mean age of 64 years (range: 9 to 90 years). Bricker diversion was performed in 73.6% of cases for underlying tumour (prostate, bladder, cervical, colon cancer), and in 26.4% of cases for benign disease (neurogenic bladder radiation bladder bladder exstrophy, incrusting cystitis). Cystectomy was associated with Bricker diversion in 62.2% of cases. The mean follow-up was 24 months (range: 1 to 151 months). The following parameters were studied: mortality and early and late medical or surgical, urological and gastrointestinal complications. RESULTS: The postoperative mortality was 6.9% (17 deaths, 16 in patients in whom Bricker diversion was performed for cancer). The early morbidity was marked by gastrointestinal complications (ileus, fistula, evisceration) in 46 cases (1.7%), 25 of which required re-operation. A medical complication was observed in 41 patients (16.7% of the series), responsible for 60% of the postoperative mortality (10 of the 17 deaths). A urinary fistula was observed in 7 patients (2.8%). The late morbidity consisted of parietal complications (incisional hernia, peristomal hernia, stricture of the stoma) in 18.3% of cases. Urological complications consisted of acute pyelonephritis (11%), ureteroileal stricture (4.9%) and urinary stones (4.9%). CONCLUSION: Bricker ileal conduit urinary diversion is associated with considerable mortality, especially in cancer patients. Early complications are essentially gastrointestinal, while late complications tend to be parietal or urological.

Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation.

BACKGROUND: We assess that pudendal neuralgia is a tunnel syndrome due to a ligamentous entrapment of the pudendal nerve and have treated 400 patients surgically since 1987. We have had no major complication. We conducted a randomized controlled trial to evaluate our procedure. METHODS: A sequential, randomized controlled trial to compare decompression of the pudendal nerve with non-surgical treatment. Patients aged 18-70, had chronic, uni/bilateral perineal pain, positive temporary response to blocks at the ischial spine and in Alcock's canal. They were randomly assigned to surgery (n=16) and control (n=16) groups. Primary end point was improvement at 3 months following surgery or assignment to the non-surgery group. Secondary end points were improvement at 12 months and at 4 years following surgical intervention. RESULTS: A significantly higher proportion of the surgery group was improved at 3 months. On intention-to-treat analysis 50% of the surgery group reported improvement in pain at 3 months versus 6.2% of the non-surgery group (p=.0155); in the analysis by treatment protocol the figures were 57.1% versus 6.7% (p=.0052). At 12 months, 71.4% of the surgery group compared with 13.3% of the non-surgery group were improved, analyzing by treatment protocol (p=.0025). Only those randomized to surgery were evaluated at 4 years: 8 remained improved at 4 years. No complications were encountered. CONCLUSIONS: In this study we demonstrate that decompression of the pudendal nerve is an effective and safe treatment for cases of chronic pudendal neuralgia that have been unresponsive to analgesia and nerve blocks. Following surgery, other medical interventions may be necessary.

[Results and surgical complications of pancreas transplantation with enteric exocrine drainage]. / Résultats et complications chirurgicales de la transplantation pancréatique avec dérivation intestinale.

INTRODUCTION: The objective of this study was to evaluate the results and surgical complications of total pancreas transplantation with enteric exocrine drainage since the beginning of our experience with this type of transplantation. PATIENTS AND METHODS: From November 1999 to December 2002, 62 total pancreas transplantations were performed, consisting of 51 combined kidney-pancreas transplantations, 10 after renal transplantation and 1 pancreas-liver transplantation. Kidneys and pancreases were washed and stored in either Belzer solution or Celsior solution. Transplantation was performed via a midline transperitoneal incision with venous anastomosis at the root of the inferior vena cava (54 cases) or, more recently, in the superior mesenteric vein (8 cases). The arterial anastomosis was then performed in the right common iliac artery. Exocrine drainage was performed by side-to-side anastomosis between the donor duodenum and the recipient jejunum. The kidney was transplanted onto the left external iliac vessels and was extraperitonealised. RESULTS: The mean age of the recipients and donors was 41 +/- 9 years and 33 +/- 11 years, respectively. The mean cold ischaemia time was 14 +/- 5 hours. Four pancreases were lost due to venous thrombosis, 1 due to severe pancreatitis with haemodynamic collapse and venous thrombosis and another due to total necrosis of the duodenum. Seventeen patients (27%) were reoperated, including 10 during the first postoperative month and 7 during the first year. No cases of fistula of the gastrointestinal anastomosis were observed. All patients with a functional graft no longer required exogenous insulin. The actuarial patient and graft three-year survival was 96% and 86% respectively. CONCLUSION: Despite their high frequency, surgical complications did not have any harmful effects on either control of diabetes or graft and patient survival.

[Ureteric catheter nephrostomy: simple and effective drainage after percutaneous nephrolithotomy]. / Néphrostomie par sonde urétérale: un drainage simple et efficace après nephrolithotomies percutanées.

The authors describe an original technique of postoperative drainage of percutaneous nephrolithotomy consisting of leaving a 5 F ureteric catheter in place, which descends into the bladder and drains into a conventional 18 or 20 F nephrostomy drain. It ensures ureteric drainage while eliminating the need for a urethral catheter, protects the nephrostomy tunnel by maintaining the nephrostomy drain in place and maintains access to the caliceal group used for percutaneous nephrolithotomy.

[Percutaneous nephrolithotomy (PCNL) in subjects over the age of 70: a multicentre retrospective study of 210 cases]. / La néphrolithotomie percutanée (N.L.P.C.) chez le sujet âgé de 70 ans et plus: étude multicentrique de 210 cas.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) in subjects over the age of 70 is considered to be associated with a higher risk than extracorporeal shock-wave lithotripsy (ESWL). However this technique is sometimes necessary for very large or complex stones in patients with several comorbidities. STUDY OBJECTIVE: To evaluate the predictive factors of success and operative risks likely to influence the results of PCNL in a population of patients over the age of 70. MATERIAL AND METHOD: Retrospective study of 203 patients (110 males, 97 females) over the age of 70, in whom a total of 210 PCNL were performed over a 12-year period in ten referral centres for the treatment of stones. 68.5% of cases presented a comorbidity and the median ASA score was 2. The median stone dimensions were 24 x 15 mm. There were 67 solitary pelvic stones, 7 infrapelvic ureteric stones, 31 solitary inferior caliceal stones, 40 complex stones and 13 staghorn calculi. A standard one-stage operative technique was performed in 92% of cases; the nephrostomy tract was easily performed by the urologists themselves in 71.8% of cases. RESULTS: The overall stone-free (SF) rate was 70.8%. The patient's weight and height (p=0.03 and p=0.01), stone dimensions and their solitary nature were significant factors of success (p<0.00001 and p=0.01) with SF rates of 81.1% for pelvic stones and 90.3%for solitary inferior caliceal stones (p<0.003); the SF rate for complete staghorn calculi was only 30.8%. A history of stones (p=0.04) and diabetes (p=0.03) influenced the stone-free rate, but the other comorbidities, body mass index, and age did not influence the stone-free rate. There were two deaths (0.9% and haemostasis nephrectomy was performed in 2 ASA 3 subjects in renal failure. In the other patients, there was no difference between preoperative and postoperative serum creatinine and haemoglobin levels. The ease of nephrostomy, the rapidity of PCNL, the day of removal of the drainage nephrostomy, the mean hospital stay (median stay: 6 days), sterility of postoperative urine and at the 1-month visit were significantly correlated with the SF rate. CONCLUSIONS: PCNL in subjects over the age of 70 years is a safe and reliable technique that achieved a stone-free rate of 70.8% for all types of stones combined. The best results were obtained for solitary stones larger than 20 mm in the renal pelvis or inferior calyx. Apart from diabetes, which remains a risk factor, well controlled comorbidities do not increase the operative risk. PCNL did not affect haemodynamic parameters or renal function.