Combined Liver, Pancreas-Duodenum, and Kidney Transplantation for Patients with Hepatitis B Cirrhosis, Uremia, and Insulin-Dependent Diabetes.

BACKGROUND Abdominal organ cluster transplantation for the treatment of upper abdominal end-stage diseases is a serious conundrum for surgeons. CASE REPORT We performed clinical assessment of quadruple organ transplantation (liver, pancreas, duodenum, and kidney) for a patient with end-stage liver disease, post-chronic hepatitis B cirrhosis, uremia, and insulin-dependent diabetes mellitus, and explored the optimal surgical procedure. Simultaneous classic orthotopic liver, pancreas-duodenum, and heterotopic renal transplantation was performed on a 46-year-old man. The process was an improvement of surgery implemented with a single vascular anastomosis (Y graft of the superior mesenteric artery and the celiac artery open together in the common iliac artery). The pancreatic secretions and bile were drained through a modified uncut jejunal loop anastomosis, and the donor's kidneys were placed in the right iliac fossa. The patient was prescribed basiliximab, glucocorticoid, tacrolimus, and mycophenolate mofetil for immunosuppression. The hepatic function recovered satisfactorily on postoperative day (POD) 3, and pancreatic function recovered satisfactorily in postoperative month (POM) 1. Hydronephrosis occurred in the transplanted kidney, with elevated creatinine on POD 15. Consequently, renal pelvic puncture and drainage were performed. His creatinine dropped to a normal level on POD 42. No allograft rejections or other complications, like pancreatic leakage, thrombosis, or localized infections, occurred. The patient had normal liver, renal, and pancreas functions with insulin-independent after POD 365. CONCLUSIONS Simultaneous classic orthotopic liver, pancreas-duodenum, and heterotopic renal transplantation is a promising therapeutic option for patients with insulin-dependent diabetes combined with end-stage hepatic and renal disease, and our center's experience can provide a reference for clinical multiorgan transplantation.

Inferior survival outcomes of pancreas transplant alone in uremic patients.

Theoretically, pancreas transplant alone in uremic (PTAU) patients could also be one of the options for those waiting for both pancreas and kidney grafts, but it has never been reported. There were 160 cases of pancreas transplant in this study, including 16% PTAU. The 5-year patient survival was 66.2% after PTAU, 94.5% after SPK, 95.8% after PAK, and 95.4% after PTA. Rejection of pancreas graft was significantly lower in PTAU group (3.8%), followed by 16.7% in pancreas after kidney transplant (PAK), 29.8% in simultaneous pancreas and kidney transplant (SPK) and 37.0% in pancreas transplant alone (PTA). Fasting blood sugar and serum HbA1c levels after PTAU were not significantly different from those by other subgroups. The 5-year death-censored pancreas graft survival was 100% after PTAU and PAK, and 97.0% after SPK and 77.9% after PTA. However, the 5-year death-uncensored pancreas graft survival was 67.0% after PTAU, 100% after PAK, 91.3% after SPK, and 74.0% after PTA. The superior graft survival in the PTAU group was achieved only if deaths with a functioning graft were censored. In conclusion, given the inferior patient survival outcome, PTAU is still not recommended unless SPK and PAK is not available. Although PTAU could be a treatment option for patients with diabetes complicated by end-stage renal disease (ESRD) in terms of surgical risks, endocrine function, and immunological and graft survival outcomes, modification of the organ allocation policies to prioritize SPK transplant in eligible patients should be the prime goal.

Challenges and controversies in the surgical management of uremic hyperparathyroidism: A systematic review.

BACKGROUND: Prevalence of uremic hyperparathyroidism (uHPT), secondary and tertiary, continues to rise. Historically, surgery was the only durable treatment for these conditions, but with the development of pharmacologic options, the treatment landscape has shifted predominantly towards medical management. Presently, there is a paucity of clear guidelines for surgical indications in the treatment of uHPT. In this review, we will discuss the risks and benefits associated with surgical management of uHPT and will evaluate recent evidence and controversies surrounding indications for parathyroidectomy (PTX) in uHPT. DATA SOURCES: A systematic review of the literature was performed, in accordance with PRISMA guidelines, resulting in the evaluation of 69 articles. CONCLUSIONS: Significant controversy still exists regarding indications and timing of surgical management of uHPT. Although the benefits of PTX in the uHPT patient population have been established, there is a significant need for well-designed randomized clinical trials to further clarify existing guidelines and optimize treatment approaches.

Simultaneous liver, pancreas-duodenum and kidney transplantation in a patient with hepatitis B cirrhosis, uremia and insulin dependent diabetes mellitus.

Simultaneous liver, pancreas-duodenum, and kidney transplantation has been rarely reported in the literature. Here we present a new and more efficient en bloc technique that combines classic orthotopic liver and pancreas-duodenum transplantation and heterotopic kidney transplantation for a male patient aged 44 years who had hepatitis B related cirrhosis, renal failure, and insulin dependent diabetes mellitus (IDDM). A quadruple immunosuppressive regimen including induction with basiliximab and maintenance therapy with tacrolimus, mycophenolate mofetil, and steroids was used in the early stage post-transplant. Postoperative recovery was uneventful and the patient was discharged on the 15th postoperative day with normal liver and kidney function. The insulin treatment was completely withdrawn 3 wk after operation, and the blood glucose level remained normal. The case findings support that abdominal organ cluster and kidney transplantation is an effective method for the treatment of end-stage liver disease combined with uremia and IDDM.

Recovery of CYP3A Phenotype after Kidney Transplantation.

End-stage renal disease impairs drug metabolism via cytochrome P450 CYP3A; however, it is unclear whether CYP3A activity recovers after kidney transplantation. Therefore, the aim of this study was to evaluate the change in CYP3A activity measured as 4ß-hydroxycholesterol (4ßOHC) concentration after kidney transplantation. In total, data from 58 renal transplant recipients with 550 prospective 4ßOHC measurements were included in the study. One sample per patient was collected before transplantation, and 2-12 samples per patient were collected 1-82 days after transplantation. The measured pretransplant 4ßOHC concentrations ranged by >7-fold, with a median value of 22.8 ng/ml. Linear mixed-model analysis identified a 0.16-ng/ml increase in 4ßOHC concentration per day after transplantation (P < 0.001), indicating a regain in CYP3A activity. Increasing estimated glomerular filtration rate after transplantation was associated with increasing 4ßOHC concentration (P < 0.001), supporting that CYP3A activity increases with recovering uremia. In conclusion, this study indicates that CYP3A activity is regained subsequent to kidney transplantation.

Uremic pleuritis: A case report and review of recurrent exudative pleural effusions in children.

Despite similar mechanisms driving pleural fluid accumulation, the causes of pleural effusions in children differ significantly from that of adults. When a pleural effusion re-occurs in an adult, literature recommends early thoracentesis, and consideration for pleuroscopy with biopsy to guide the diagnostic evaluation. In children, there is a paucity of literature for guiding management of recurrent exudative pleural effusion. We present an unusual pediatric case of uremic pleuritis with recurrent pericardial and exudative pleural effusions.

Embryonic kidney function in a chronic renal failure model in rodents.

BACKGROUND: Rapid advancements have been made in alternative treatments for renal diseases. Our goal for renal regeneration is to establish a kidney graft derived from human embryonic tissues. In this study, we investigated the effects of host renal failure on the structure and activity of transplanted embryonic kidney and bladder, and found that diuretics effectively induced urine production in the transplanted kidney. METHODS: Uremic conditions were reproduced using a 5/6 renal infarction rat model. An embryonic kidney plus bladder (embryonic day 15) was isolated from a pregnant Lewis rat and transplanted into the para-aortic area of a 5/6 renal-infarcted Lewis rat. Following growth, the embryonic bladder was successfully anastomosed to the host ureter. RESULTS: We assessed graft function in terms of survival rates and found no differences between normal (n = 5) and renal failure (n = 8) groups (median survival: 70.5 vs 74.5 h; p = 0.331) in terms of survival, indicating that the grafts prolonged rat survival, even under renal failure conditions. Furosemide (n = 9) significantly increased urine volume compared with saline-treated controls (n = 7; p < 0.05), confirming that the grafts were functional. We also demonstrated the possibilities of an in vivo imaging system for determining the viability of transplanted embryonic kidney with bladder. CONCLUSION: The results of this study demonstrate that transplanted embryonic kidney and bladder can grow and function effectively, even under uremic conditions.

Simultaneous transplantation of the living donor kidney and deceased donor pancreas and other transplant options for diabetic and uremic patients.

PURPOSE OF REVIEW: Solitary deceased donor kidney and simultaneous pancreas and kidney (SPK) transplantation are the two most common transplant procedures performed for patients with diabetes and uremia, vastly outnumbering all other organ replacement options. Given the improvement in outcomes for solitary pancreas transplantation, the higher mortality for diabetic patients on the waiting list, and the growing shortage of organs (particularly kidneys) for transplantation, the use of living donors for this complex patient population should be more common. RECENT FINDINGS: Yet, despite some clear advantages, sequential pancreas after live donor kidney transplant and especially the combined procedure, simultaneous pancreas (from a deceased donor) and living donor kidney transplantation are relatively uncommon. SUMMARY: Possible reasons for the infrequent use of these options and methods for increasing the use of living donor kidneys for the diabetic and uremic patient are presented.

Sex difference for urologic malignancy risk in uremic patients after kidney transplantation: a population-based study.

BACKGROUND: High urologic malignancy incidence has been reported in end-stage renal disease (ESRD) patients, especially of female sex. This study was undertaken to evaluate whether female recipients still carry an aggravated risk of this malignancy after kidney transplantation (KT). METHODS: The claims data from the Bureau of National Health Insurance of Taiwan were used for analysis. All KT recipients who developed urologic malignancy from January 1, 1999, to December 31, 2007 (n = 2,245) were enrolled in this study. By means of propensity score, a database of 1:4 ratio random incident ESRD patients with matched age, sex, comorbidity rates, and dialysis to index date was used as control (non-KT group, n = 8,980). The last observation period ended on December 31, 2008. RESULTS: The cumulative urologic malignancy incidence rate was significantly higher in female recipients after KT than their female ESRD counterparts without KT (P < 0.001). This gap became more prominent approximately 2 years after transplantation. No similar trend was detected in male KT patients (P = 0.13). Incidence rate ratio of urologic malignancy was significantly higher in female recipients (incidence rate ratio, 2.13; 95% confidence interval [95% CI], 1.53-2.97) than in their male counterparts (incidence rate ratio, 1.43; 95% CI, 0.90-2.25). From multivariate Cox proportional hazard regression tests, female (hazards ratio, 2.10; 95% CI, 1.52-2.95) but not male sex (hazards ratio, 1.47; 95% CI, 0.93-2.32) was determined to be an independent factor for the development of urologic malignancy after KT. After acquiring this malignancy, KT recipients did not have any advantage in cumulative survival compared to ESRD patients without KT (P = 0.07). CONCLUSION: Compared to males, female recipients tended to have a significantly higher urologic malignancy risk after KT.

Simultaneous pancreas and kidney transplantation for liver transplant recipients with diabetes and uremia.

BACKGROUND AND OBJECTIVES: Chronic kidney disease (CKD) has become a critical problem due to immunosuppressant related nephrotoxicity in liver transplant (LTx) recipients, especially in patients with pre-transplant risk factors. LTx recipients with uraemia and diabetes have poor prognosis even when treated with dialysis and insulin. Simultaneous pancreas and kidney transplantation (SPK) has been proven to be an effective treatment for patients with diabetic uraemia, but rarely performed in patients after LTx. Two cases of SPK after LTx were performed in our centre and we present our experience here. PATIENTS AND METHODS: Two patients received LTx because of HBV related liver cirrhosis; both of them had pre-transplant diabetes mellitus (DM), which worsened after the administration of immunosuppressive drugs. These two patients suffered from CKD and developed uraemia due to diabetic nephropathy and immunosuppressive drugs induced renal toxicity years after LTx. They relied on dialysis and insulin injection. SPK were performed years after LTx and the clinical data was retrospectively analyzed. RESULTS: SPK was successfully performed in these two patients. Pancreatic fluid drainage was achieved via a side-to-side duodenojejunostomy into the proximal jejunum. No serious surgical complications, including pancreatitis or pancreatic fistula were observed postoperatively. In both cases, kidney and pancreatic grafts were functioning well as evidenced by euglycemia without the need for insulin injections and normal serum-creatinine level 7days after the operation. One of the patients presented with renal graft impairment 1week after the operation. FK506 was tapered and rapamycin was used when the renal graft biopsy indicated drug toxicity. The patient's kidney graft function recovered gradually after the adjustment. Both patients have good function of liver, kidney and pancreas grafts during a 60-month and 30-month period of follow up. CONCLUSIONS: SPK could serve as an effective option for patients with diabetes and uremia after LTx. Perioperative management, especially the immunosuppressive strategy is crucial to improve the outcome of this procedure.

Uremia-associated immunological aging is stably imprinted in the T-cell system and not reversed by kidney transplantation.

The uremia-induced inflammatory environment in end-stage renal disease (ESRD) patients is associated with premature T-cell aging resulting in a defective T-cell immunity. As kidney transplantation (KTx) reduces the pro-inflammatory environment, we hypothesized that KTx would rejuvenate the aged T-cell system. As aging parameters, we determined in 70 KTx recipients the differentiation status by immunophenotyping, thymic output by the T-cell receptor excision circle (TREC) content together with CD31(+) naïve T-cell numbers and the relative telomere length (RTL) as a measure for proliferative history at pre-KTx, 3, 6 and 12 months post-KTx. In addition, T-cell function was determined by measuring the proliferative capacity and percentages of cytokine-producing cells. Directly post-KTx, memory T-cell numbers were diminished but restored to pre-KTx values at 12 months, except for CD4(+) EM T cells. The RTL of (memory) CD4(+) and CD8(+) T cells did not change. In contrast, TREC content and CD31(+) naïve T-cell numbers were stable post-KTx although the RTL of naïve CD4(+) and CD8(+) T cells decreased implying homeostatic proliferation of naïve cells, in response to a temporary decrease in memory cells. The T-cell function was not improved post-KTx. Our findings demonstrate that the uremia-associated aged phenotype is stably imprinted in the T-cell system and not reversed by KTx.

The first case of atrial fibrillation-related graft kidney infarction following acute pyelonephritis.

Native renal infarction is uncommon in patients with atrial fibrillation (AF)-related thromboembolism. Graft infarction is also rare, with such cases mostly occurring in the main graft artery postoperatively. To date, there have been no studies of AF-related graft kidney infarction. We herein describe the first case of AF-related graft kidney infarction. The clinical manifestations of this condition mimic and follow those of acute pyelonephritis; therefore, these diseases should be differentially diagnosed as early as possible using lactic dehydrogenase testing and computed tomography. Aggressive treatment with intravascular thrombolysis should be administered, even when the diagnosis is delayed, in order to restore a viable renal function.

Use of the ImmuKnow assay to evaluate the effect of alemtuzumab-depleting induction therapy on cell-mediated immune function after renal transplantation.

BACKGROUND: Good outcomes after renal transplantation are dependent on effective immunosuppression while minimizing infection. Alemtuzumab (Campath or Campath-1H) is an anti-CD52 humanized monoclonal IgG1 antibody which induces rapid and sustained depletion of circulating lymphocytes and has been effectively used as an immunosuppressant in post-transplant induction therapy. METHODS: We used the ImmuKnow assay to compare cell-mediated immune function in renal transplant patients treated with alemtuzumab or with conventional immunosuppressive tri-therapy. The ImmuKnow method determines the levels of adenosine triphosphate (ATP) released from CD4 cells following stimulation with a mitogen. RESULTS: We showed a statistically significant difference in the distribution of outcome after transplantation between the conventional and the Campath groups (P = 0.010). A significantly higher number of patients treated with alemtuzumab induction therapy were stable after transplantation compared to those treated with conventional immunosuppressive tri-therapy (96.6 vs. 75.7 %). ATP values were significantly higher in the conventional group compared to the Campath group at 180 days after transplantation (P < 0.001). ATP levels did not change significantly over time in clinically stable kidney recipients treated with alemtuzumab induction therapy (P = 0.554). CONCLUSIONS: The ImmuKnow assay is a useful tool for evaluating the global immune response in alemtuzumab-treated renal transplant patients. Alemtuzumab-depleting induction therapy remains effective for at least 180 days.

[Penile erectile function in renal transplant recipients and uremic men undergoing hemodialysis: a clinical control study].

OBJECTIVE: To observe the changes in penile erectile function and levels of serum sex hormones in renal transplant recipients and uremic men undergoing hemodialysis. METHODS: We analyzed the follow-up data of 35 male renal transplant recipients and 30 uremic men undergoing hemodialysis. We assessed the penile erectile function of the patients using IIEF-5 questionnaire and nocturnal electrobioimpedance volumetric assessment (NEVA), and determined the levels of serum sex hormones. RESULTS: The incidence rate of erectile dysfunction (ED) was 51.4% in the renal transplant recipients, and 73.3% in the uremic men undergoing hemodialysis (P < 0.05). The cases of moderate to severe ED accounted for 25.7% in the renal transplantation group, and 46.6% in the hemodialysis group. The renal transplant recipients showed a higher nocturnal erectile frequency, better erectile hardness and longer erectile duration than those undergoing hemodialysis (P < 0.05). The level of serum testosterone (T) was markedly higher while the levels of estradiol (E2) and prolactin (PRL) significantly lower in the former than in the latter (T: [4.32 +/- 1.37] vs [2.53 +/- 1.12] ng/ml, P < 0.05; E2: [19.57 +/- 2.29] vs [43.38 +/- 5.58] pg/m, P < 0.05; PRL: [8.59 +/- 1.19] vs [17.22 +/- 3.31] mIu/ ml, P < 0.05). CONCLUSION: Renal transplant recipients with renal function have a better overall penile erectile function than uremic men undergoing hemodialysis.

Successful treatment of calcific uraemic arteriolopathy with bisphosphonates.

BACKGROUND AND OBJECTIVES: Calcific uraemic arteriolopathy (CUA), also known as calciphylaxis, is a rare but life-threatening condition that almost exclusively affects patients with chronic kidney disease. Several therapies have been employed to treat this disease but with irregular results. We report a prospective case series of eight patients diagnosed with CUA in our unit between 2002 and 2010. MATERIAL AND METHOD: The series consisted of eight patients with CUA (including 4 men, 5 dialysis patients and 3 with functioning allografts) who were treated with bisphosphonates. The diagnosis was by clinical suspicion and a confirmatory biopsy. Five patients had a previous history of high calcium-phosphorus product, 6 had a history of high parathyroid hormone levels (>800pg/ml), 4 had undergone parathyroidectomy, 5 had a history of high cumulative doses of steroids, and 6 patients were under dicoumarin treatment. None of the patients were obese or had diabetes mellitus. RESULTS: In all patients, progression of skin lesions stopped between 2 to 4 weeks after starting bisphosphonate therapy, with no changes in blood levels of calcium and phosphate. Improvement in pain and lesions was faster in patients receiving intravenous ibandronate. All of these patients remained on bisphosphonate treatment for at least 6 months until the wounds healed completely. No recurrences have been observed after follow-up periods between 1 and 9 years. Renal function remained stable in transplant recipients. The treatment was well tolerated and no adverse effects were observed. CONCLUSIONS: Bisphosphonates could be a new and attractive alternative to treat CUA.

Successful treatment of calcific uremic arteriolopathy with sodium thiosulfate in a renal transplant recipient.

Abstract Calcific uremic arteriolopathy (CUA) is a rare but life-threatening disorder of arteriolar calcification. It frequently leads to severe ischemia, intense pain, and tissue necrosis with non-healing skin ulcerations. CUA usually occurs in patients with chronic kidney disease (CKD), especially those on dialysis, and its occurrence is rare in kidney transplant recipients. The treatment of this disorder is not clearly defined, and no randomized prospective trials are available. Treatment has focused on optimizing dialysis treatment, control of bone mineral parameters, wound care, experimental anticalcification therapies-using bisphosphonates, cinacalcet, parathyroidectomy, and hyperbaric oxygen. Such treatments are based on the pathophysiological considerations and evidences from case reports or series. Recently, several cases have reported about the emerging benefits of intravenous sodium thiosulfate (STS) in the treatment of CUA. STS has resulted in rapid pain relief, wound healing, and prevention of death. We report a case of CUA in a 63-year-old Caucasian man with a functioning renal allograft. In this patient, intravenous STS was administered for 8 months, which was the principal therapy, which resulted in complete resolution of the CUA and skin healing.

Plasma neutrophil gelatinase associated lipocalin (NGAL) is associated with kidney function in uraemic patients before and after kidney transplantation.

BACKGROUND: Neutrophil gelatinase associated lipocalin (NGAL) is a biomarker of kidney injury. We examined plasma levels of NGAL in a cohort of 57 kidney allograft recipients (Tx group, 39 ± 13 years), a uraemic group of 40 patients remaining on the waiting list (47 ± 11 years) and a control group of 14 healthy subjects matched for age, sex and body mass index (BMI). The kidney graft recipients were studied at baseline before transplantation and 3 and 12 months after transplantation and the uraemic group at baseline and after 12 months. METHODS: NGAL was measured using a validated in-house Time-Resolved Immuno-flourometric assay (TRIFMA). Repeated measurements differed by < 10% and mean values were used for statistical analyses. Spearman rank order correlation analysis and the Kruskal-Wallis non-parametric test were used to evaluate the association of NGAL concentrations with clinical parameters. RESULTS: Plasma NGAL levels before transplantation in the Tx and uraemic groups were significantly higher than in the healthy controls (1,251 µg/L, 1,478 µg/L vs. 163 µg/L, p < 0.0001). In the Tx group NGAL concentrations were associated with serum creatinine (R = 0.51, p < 0.0001), duration of end-stage renal failure (R = 0.41, p = 0.002) and leukocyte count (R = 0.29, p < 0.026). At 3 and 12 months plasma NGAL concentrations declined to 223 µg/L and 243 µg/L, respectively and were associated with homocysteine (R = 0.39, p = 0.0051 and R = 0.47, p = 0.0007). CONCLUSIONS: Plasma NGAL is a novel marker of kidney function, which correlates to duration of end-stage renal failure (ESRD) and serum creatinine in uraemic patients awaiting kidney transplantation. Plasma NGAL is associated with homocysteine in transplanted patients. The prognostic value of these findings requires further studies.

Isolation, expansion and functional assessment of CD4+CD25+FoxP3+ regulatory T cells and Tr1 cells from uremic patients awaiting kidney transplantation.

BACKGROUND: The immunosuppressive properties of regulatory T cells have emerged as an attractive tool for the development of immunotherapies in various disease contexts, e.g. to treat transplantation induced immune reactions. This paper focuses on the process of obtaining and functionally characterizing CD4+CD25+FoxP3+ regulatory T cells and Tr1 cells from uremic patients awaiting kidney transplantation. METHODS: From October 2010 to March 2011 uremic patients awaiting living donor kidney transplantation, and their corresponding kidney donors, were enrolled in the study. A total of seven pairs were included. Isolation of CD4+CD25+FoxP3+ regulatory T cells was performed by magnetic activated cell sorting of peripheral blood mononuclear cells obtained from the uremic patients. Donor specific Tr1 cells were differentiated by repetitive stimulation of immature CD4+ T cells with immature dendritic cells, with the T cells coming from the future kidney recipients and the dendritic cells from the corresponding kidney donors. Cells were then expanded and functionally characterized by the one-way mixed leukocyte reaction and assessment of IL-10 production. Phenotypic analysis was performed by flow cytometry. RESULTS: The fraction of CD4+CD25+FoxP3+ regulatory T cells after expansion varied from 39.1 to 50.4% and the cells retained their ability to substantially suppress the mixed leukocyte reaction in all but one patient (3.8-19.2% of the baseline stimulated leukocyte activity, p<0.05). Tr1 cells were successfully differentiated from all but one patient and produced high levels of IL-10 when stimulated with immature dendritic cells (1,275-11,038% of the baseline IL-10 secretion, p<0.05). CONCLUSION: It is practically feasible to obtain and subsequently expand CD4+CD25+FoxP3+ regulatory T cells and Tr1 cells from uremic patients without loss of function as assessed by in vitro analyses. This forms a base for adoptive regulatory T cell therapy in the setting of living donor kidney transplantation.

Simultaneous robot-assisted nephroureterectomy and cystectomy in patients with uremia and multifocal urothelial carcinoma.

BACKGROUND AND PURPOSE: In Taiwan, patients with uremia have a high risk of the development of multifocal urothelial carcinoma. We report on eight patients with uremia and urothelial carcinoma who underwent simultaneous robot-assisted laparoscopic nephroureterectomy and radical cystectomy (RANUC). PATIENTS AND METHODS: Between April 2006 and August 2010, eight patients with uremia (five women, three men; mean age 66.9 y) who were receiving dialysis underwent RANUC. Patients were classified into two groups: Group I, cases 1 to 4 occurring between April 2006 and June 2009; and group II, cases 5 to 8 occurring between July 2009 and August 2010. RESULTS: The mean operative time was significantly shorter in group II (252.5±35.0 min vs 360±25.8 min; P=0.029). The estimated blood loss was also significantly less in group II (332.5±53.8 mL vs 660±137.4 mL; P=0.029). The blood transfusion rate was 75% in group I and 0% in group II. The postoperative stay was reduced from 8.5 days for group I to 7 days for group II. No perioperative morbidity and mortality were noted in either group. None of the patients had died at the short- and intermediate-term mean follow-up of 28.1 months (range 2-54 mos). CONCLUSIONS: Simultaneous RANUC are feasible and can be performed safely. Long-term oncologic data are awaited; however, at intermediate-term oncologic follow-up, results are satisfactory. RANUC for uremic patients with multifocal urothelial carcinoma necessitating complete urinary tract exenteration is a viable option and patients experience a rapid convalescence.