Enhanced Recovery After Surgery Pathway in Kidney Transplantation: The Road Less Traveled.

Enhanced recovery after surgery (ERAS) pathway is a multimodal perioperative care pathway designed to achieve early recovery after surgery. ERAS protocols have not yet been well recognized in kidney transplantation. The aim of this study was to investigate the impact of ERAS pathway on early recovery and short-term clinical outcomes of kidney transplant. Methods: This is a single-center retrospective analysis comparing the outcomes of 20 adult kidney transplant recipients subjected to ERAS pathway with 20 adult recipients operated before ERAS with traditional standard of care. Results: There were no significant differences between both groups regarding age, gender, race, dialysis status, living donor percentage, cold ischemia time, and warm ischemia time. Median hospital stay for ERAS patients was 2 d. Overall median pain scores were significantly lower in the ERAS group versus non-ERAS group (morning after surgery pain score 2 versus 5; peak pain score 4.5 versus 10; lowest pain score 0 versus 2; P = 0.0001). ERAS patients had earlier ambulation (walking) and oral nutrition (regular diet) (first versus second day postoperatively in traditional group). Earlier bowel movement was observed in ERAS patients. There were no significant differences in graft function or 30-d readmission rates between both groups. Conclusions: Implementation of ERAS pathway in kidney transplantation is feasible. Using ERAS is associated with less pain, earlier ambulation and advancement of oral nutrition, and short hospital stay.

Presacral and retroperitoneal lymph node involvement in urothelial bladder cancer: results of a prospective mapping study.

PURPOSE: We evaluated the incidence of positive lymph nodes in the presacral and retroperitoneal regions in patients who underwent radical cystectomy and extended pelvic lymph node dissection for urothelial bladder cancer. MATERIALS AND METHODS: As part of a prospective mapping study, 143 patients underwent radical cystectomy and extended pelvic lymph node dissection for urothelial bladder cancer between 2006 and 2010. Lymph nodes from 6 separate regions were labeled, including bilateral pelvic and common iliac, presacral and retroperitoneal. We evaluated pathological features, treatment outcomes and cancer specific survival in patients with or without lymph node positive disease in the presacral and retroperitoneal regions. RESULTS: A median of 37 lymph nodes (IQR 27-49) were removed. Overall 52 (36%) patients had positive lymph nodes, of whom 24 (46%) had metastatic disease in the presacral or retroperitoneal region. Four patients (3%) had an isolated solitary positive lymph node in these 2 templates. Two-year overall survival in patients without vs with presacral/retroperitoneal lymph node positive disease was 44% (95% CI 24-64) vs 25% (95% CI 5-45) (p = 0.11). In contrast, 2-year cancer specific survival in the 2 groups was 55% (95% CI 33-77) and 29% (95% CI 7-51), respectively (p = 0.02). CONCLUSIONS: A substantial proportion of patients have lymph node positive disease in the presacral and retroperitoneal regions, including some with isolated and/or solitary lymph node involvement. While the limited positive lymph node burden in these templates suggests a potential therapeutic role for extending the anatomical boundaries of lymph node dissection, patient survival was poor. Extended lymph node dissection provides important staging information but to our knowledge the therapeutic benefit has yet to be definitively proved.

The use of bovine pericardium for complex urologic venous reconstruction.

OBJECTIVE: To describe the use of bovine pericardium (BP) in several scenarios for venous patching and as a tubularized graft in urologic surgery. METHODS: BP was used as patch or tubularized graft in 7 patients between 2010 and 2013. Clinical scenarios and operative indications were reviewed. We used BP as a patch graft for the inferior vena cava (IVC) (N = 3) and for the iliac venous system (N = 1) to restore venous outflow. Tubularized grafts were used (N = 2) to replace the left renal vein in oncology procedures and during renal autotransplantation (N = 1). Surgical technique is reviewed in detail. RESULTS: We used BP as a venous patching in 4 cases and as a tubularized graft in 3 cases. There was no evidence of venous thrombosis of the replaced system with a mean of 14.8 months (range, 9-26) follow-up. CONCLUSION: The use of BP as a patch or tubularized graft is an option for complicated urologic venous reconstruction. Although the follow-up interval is relatively short and this initial series small, our initial results are promising.

Neoadjuvant systemic therapy or early cystectomy? Single-center analysis of outcomes after therapy for patients with clinically localized micropapillary urothelial carcinoma of the bladder.

OBJECTIVES: To analyze the treatment outcomes of patients with micropapillary bladder cancer (MPBC). MPBC is a rare variant of urothelial carcinoma with aggressive clinical behavior. Radical cystectomy is considered the standard approach for treatment of patients with localized disease; however, the role of perioperative systemic therapy has been poorly defined. MATERIAL AND METHODS: A retrospective review identified 38 consecutive patients who had been treated at our institution for MPBC from 2000 to 2010. The patient data were analyzed for the pre- and postoperative clinicopathologic features, treatment course, and cancer-specific survival. RESULTS: The median follow-up of surviving patients after cystectomy was 17 months (range 2-75). At the initial transurethral biopsy, 28 patients (74%) had clinical Stage T2N0 or less. In this group, 26 (93%) of 28 were upstaged to nonorgan-confined and/or lymph node-positive disease. Overall, 32 patients (86%) had evidence of lymph node metastasis on the final pathologic examination. All patients with cTis-T1 who had undergone initial bladder-sparing therapy with bacille Calmette-Guérin had pathologically advanced disease at cystectomy. All 15 patients who had received perioperative cisplatin-based chemotherapy died of metastatic disease. The 5-year overall survival rate was 40% (95% confidence interval 16-64). CONCLUSIONS: MPBC is an aggressive disease with a high likelihood of regional lymph node metastasis at the initial presentation. Although radical cystectomy plays a critical role in treatment, systemic neoadjuvant chemotherapy might be a more appropriate strategy than immediate cystectomy. Because of the poor response to current chemotherapy agents, the development of new and effective drugs for this subset of patients could be needed.

Bilateral pelvicalyceal duplication with contralateral drainage.

We report on a peculiar congenital duplication anomaly of the kidney and collecting system. A bifid left renal pelvis receives the ureter draining the lower moiety of a fully duplicated right system. To our knowledge, such an anomaly has not been previously described.

Extracorporeal shock wave lithotripsy in impacted upper ureteral stones: a prospective randomized comparison between stented and non-stented techniques.

OBJECTIVES: To assess the need for pre-extracorporeal shock wave lithotripsy (pre-ESWL) stenting in management of impacted upper ureteral stones of size < or = 2 cm and to verify whether stenting would influence the success of therapy. METHODS: Between 2007 and 2008, a total of 60 patients with solitary, radio-opaque impacted upper ureteral stones measuring < or = 2 cm were divided into 2 equal groups: a stented group with a Double-J stent fixed pre-ESWL and a non-stented group treated by in situ ESWL. All patients were treated by ESWL using Dornier Doli S lithotripter. Results were compared in terms of clearance rates, number of shock waves and sessions, morbidity, and incidence of complications. Pretreatment KUB (kidneys, ureters, and bladder) and intravenous pyelogram and post-treatment KUB were used to evaluate fragmentation and clearance. RESULTS: Overall stone-free rate was 88.3%. No significant statistical difference was observed in stone-free rate between the stented and non-stented groups being 90% and 86.7%, respectively (P = .346). One session was required in 28.3% of patients, whereas multiple sessions were required in 71.7% of patients. No significant statistical difference was noted in re-treatment rate in the 2 groups. Patients in the stented group significantly complained of side effects attributable to the stent predominantly dysuria, urgency, frequency, and suprapubic pain. CONCLUSIONS: ESWL is an effective and reasonable initial therapy in the management of impacted upper ureteral stones measuring < or = 2 cm. Pre-ESWL ureteral stenting provides no additional benefit over in situ ESWL. Moreover, ureteral stents are associated with significant patient discomfort and morbidity.

Minimally invasive surgery for renal cell carcinoma.

The oncologic principles of the surgical management of renal cell carcinoma (RCC) have remained essentially the same since first proposed by Robson in 1963. RCC remains a chemo- and radiation-resistant tumor; hence, surgical treatment is still the mainstay of curative therapy. Extirpative management of RCC via open radical nephrectomy (and later open partial nephrectomy) has been the standard of care for decades. With the advent of laparoscopic surgery and its intense application in urology in the early 1990s, a paradigm shift to minimally invasive renal surgery was initiated and has spurred an array of technologies, methods and procedures. Guidelines on the proper selection of patients and treatment modalities have been developed and established, allowing patients to benefit from better oncologic efficacy and reduced morbidity, and requiring urologic surgeons to master minimally invasive procedures alongside the techniques of open surgery. This review focuses on the minimally invasive management of RCC, discussing the advantages and disadvantages of laparoscopy, partial nephrectomy, probe ablation and newer treatment modalities. In order to provide material for this review, a search of the MEDLINE database was performed through January 2009 using the National Center for Biotechnology Information PubMed internet site to review the world literature regarding the minimally invasive treatment of RCC.

Safety of ungated shockwave lithotripsy in pediatric patients.

OBJECTIVE: Ungated extracorporeal shockwave lithotripsy (ESWL) in adults is associated with cardiac arrhythmias. We report on the safety and efficacy of this method for treatment of renal calculi in children. PATIENTS AND METHODS: Children under 14 years with radio-opaque renal stones were treated by ungated ESWL. Pre-treatment plain radiographs and intravenous urography and post-treatment ultrasonography and plain films were used to follow up clearance of fragments. All children were monitored for arrhythmias. RESULTS: Thirty-seven children (28 males, nine females) with a median age of 5 years (range 2-14 years) underwent 69 ungated ESWL sessions for renal calculi. Nineteen children had stones located in the left kidney, 17 had stones located in the right kidney and one child had bilateral renal stones. The stone size ranged from 6 to 25 mm (mean 9.9 mm). Shockwave number ranged from 800 to 3650 (mean of 2500 shockwaves per session). All children underwent lithotripsy with a gradual incremental energy increase from 14 to 20 kV. No patient had cardiac arrhythmias or other intra-procedural complications. No patient required conversion to gated ESWL. The overall stone-free rate was 86%. CONCLUSION: The results suggest that ungated ESWL is safe in children under 14 years. The efficacy was comparable to that of gated ESWL from previously published series.

Extracorporeal shock wave lithotripsy monotherapy for renal stones >25 mm in children.

OBJECTIVES: To determine the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) as monotherapy for renal stones >25 mm in children. METHODS: Our prospective study included 24 children <14 years old with radiopaque renal stones >25 mm treated by ESWL as first-line treatment using the electromagnetic Dornier DoLi S device. Pretreatment kidney, ureter, and bladder plain films and intravenous urography and post-treatment ultrasonography and kidney, ureter, and bladder plain films were used to monitor the clearance of fragments. Stone clearance was assessed at 1 and 3 months. A stone-free state was defined as no radiologic evidence of stone. Asymptomatic noninfectious and nonobstructive fragments <3 mm were considered insignificant. RESULTS: The 24 children, aged 2-14 years (mean 7) underwent 53 ESWL sessions. Of the 24 children, 10 had stones located in the left kidney and 14 had stones located in the right kidney. The stone size was 25-35 mm (average 31). The average number of shock waves was 3489 per session. All children underwent lithotripsy with a gradual incremental energy increase from 14 to 20 kV. The overall stone-free rate was 83.3%. Four patients had clinically insignificant fragments and were followed up for the possibility of stone regrowth, microscopic hematuria, and urinary tract infection. Complications affected 25% of patients. CONCLUSIONS: ESWL is highly effective for treatment of large renal stones in children as a first-line treatment with minimal morbidity. The placement of a stent is not a prerequisite for success of treatment.

Predictive factors of lower calyceal stone clearance after Extracorporeal Shockwave Lithotripsy (ESWL): a focus on the infundibulopelvic anatomy.

INTRODUCTION: Controversy exists as to whether ESWL is suitable for lower pole renal stones, given the dependent position of the lower calyces. This study aims to test the effect of lower pole anatomy, namely lower polar infundibulo-pelvic angle, infundibular length and width, on clearance of fragments after ESWL. PATIENTS AND METHODS: We conducted a retrospective study of 205 renal units with single lower pole stones of not more than 25 mm in their greatest diameter that were treated by ESWL alone. Exclusion criteria included multiple stones, patients requiring stenting or percutaneous drainage for various reasons. Pretreatment IVU was used to measure lower polar dimensions. Post treatment ultrasonography and KUB were used to assess clearance of fragments. RESULTS: The right kidney was involved in 68% and the left in 42% of cases. Average number of sessions was 1.6 with an average 3277 shockwaves per session. 134 patients (65.3%) required one session, 41 requiring 2 sessions (20%), 18 requiring 3 sessions (8.7%), 6 requiring 4 sessions (2.9%) and 8 requiring 5 sessions (3.9%). Complete clearance was attained in 141 cases, while 64 cases had residual fragments, 20 were asymptomatic and required no further management. The lower pole infundibulo-pelvic angle (LIP-A) was the most significant factor in clearance (p value 0.00001). Infundibular length (IL) was also statistically significant (p value 0.039). CONCLUSION: Lower pole anatomy has a significant impact on ESWL results. LIP-A not less than 70 degrees and an infundibular length of < 50 mm is preferable to achieve favorable outcome.