Technical modifications of laparoscopic donor nephrectomy: improved results with refinements in technique that mimic open nephrectomy.

INTRODUCTION: We have performed laparoscopic donor nephrectomy (lap Nx) since 2000. In June 2002, we modified the technique to minimize the known disadvantages of ATN and delayed graft function. We review our series of lap Nx before and after introduction of these modifications, respectively. METHODS: Four technical modifications of lap Nx were introduced following the initial previously described 28 cases (Group I) and applied to the consecutive 42 cases described herein (Group II): (1) decreasing the intra-abdominal pressure from 15 mm Hg to 8 mm Hg; (2) early dissection of the ureter and gonadal vein followed by vascular dissection (sharp and blunt using hydrodissection); (3) leaving the left gonadal vein in continuity with the left renal vein; and (4) early introduction of the Endocatch bag. RESULTS: Operative time was 276.6 +/- 67.1 min vs 210.0 +/- 38.0 min for groups I and II, respectively (P = .04). Warm ischemia was 4.9 +/- 1.9 min vs 1.5 +/- 0.9, min for groups I and II, respectively (P < .01). ATN occurred in 3/28 (10.7%) in group I vs 2/42 (4.8%) in-group II. There was one-vascular insult in the initial 5 Rt lap Nx, namely, transection of a segmental artery, that was reconstructed by bench repair without an impact on the outcome. Conversion was needed in 3/28 (10.7%) group I, but none of group II donors. CONCLUSION: The outcome of lap Nx can be significantly improved by applying technical modifications that simulate open Nx.

A controlled sequential evaluation of laparoscopic donor nephrectomy versus open donor nephrectomy: an update.

INTRODUCTION: In this study, we compared laparoscopic (lap Nx) to open donor nephrectomy (open Nx) with specific emphasis on outcomes in the donor and recipient. METHODS: This single-center sequential analysis recruited 100 consecutive donor-recipient pairs operated on from 1997 until 2003. The open Nx (n = 30), were performed between 1997 and 2000; the lap Nx (n = 70) were performed between 2000 and 2003. Prospective records included operative data, anatomic details of the graft, hospital stay, and donor recovery. RESULTS: Donor characteristics and renal function were similar for open Nx and lap Nx. Operative parameters were similar except for the longer warm ischemia time in lap Nx versus open Nx (3.14 +/- 2.10 vs 1.5 +/- 0.5 minute, P < .001). Donor complications were equivalent in number, but differed in spectrum with a trend toward more intraoperative complications with lap Nx versus more postoperative complications for open Nx. Donor recovery, hospital stay, and return to work were improved in lap Nx versus open Nx (P < .001). Renal function of grafts after lap Nx were similar to open Nx: 2-year serum creatinine values of 1.26 +/- 0.21 versus 1.31 +/- 0.40, respectively. Graft survivals were similar. CONCLUSION: Compared to open Nx lap Nx offers major advantages to the donor, and yields similarly favorable results in graft outcomes. However, it is more surgically demanding. Consequently, lap Nx should be adopted as the procedure of choice for living kidney retrieval.

A controlled sequential evaluation of open donor nephrectomy versus classical and modified laparoscopic donor nephrectomy: an update.

This study sought to determine the procedure of choice for kidney retrieval for transplantation by comparing open donor nephrectomy to laparoscopic donor nephrectomy and modified laparoscopic donor nephrectomy and by analyzing intraoperative donor and recipient graft function parameters. In this single-center, controlled, sequential analysis, 100 consecutive donor-recipient pairs were recruited, grouped according to surgical procedure, and operated upon between 1997 to 2004, as follows: group 1, open donor nephrectomy (n = 30), performed from 1997 to 2000; group 2, laparoscopic donor nephrectomy (n = 28), performed from 2000 to 2002; and group 3, modified laparoscopic donor nephrectomy (n = 42), performed from 2002 to 2004. Data were analyzed by type of operative procedure, graft function, length of hospital stay, and donor recovery time. Operative time was similar for all three surgical approaches. Warm ischemia times for open donor nephrectomy and modified laparoscopic donor nephrectomy were similar. Acute tubular necrosis occurred in 7% of patients in all groups. Donor recovery and lengths of hospital stay were significantly shorter for laparoscopic approaches. Donor complications were similar in numbers, differing only in complication type. Graft function and survival were similar for all three surgical approaches. We conclude that modified laparoscopic donor nephrectomy is the procedure of choice for living kidney retrieval.

Observations on quadruple immunosuppression maintenance therapy using rapamycin, low-dose cyclosporine, mycophenolate mofetil, and prednisone following ATG induction.

INTRODUCTION: We prospectively evaluated an immunosuppressive regimen consisting of rapamycin (Rapa), low-dose cyclosporine (CsA), low-dose mycophenolate mofetil (MMF), and prednisone (group 1) versus a regimen of CsA, MMF, and prednisone (group 2) in mismatched living related donor (LRD) and living unrelated donor (LUD) kidney transplantation. METHODS: Group 1 included 24 transplant recipients of eight mismatched LRD and 16 LUD, treated with Rapa, low-dose MMF, CsA, and prednisone. Group 2 included 53 transplant recipients (25 LRD, 27 LUD, and one cadaveric donor), treated with MMF, CsA, and prednisone. All patients in group 1 received a single bolus of rabbit-anti-human T-lymphocyte immune serum (ATG-Fresenius 4 to 6 mg/kg). In group 2, patients received either a single ATG or an extended ATG course (3 to 5 days postoperatively). RESULTS: Acute rejection occurred in one patient in group 1 (4.2%) and in five patients (9.4%) in group 2, all of which resulted in graft loss. Serum creatinine was not significantly different between the two groups. CONCLUSION: The immunosuppressive protocol of Rapa, CsA, MMF, and prednisone with single-bolus induction ATG achieves excellent immunosuppression and graft survival with no apparent risks in the short and intermediate term.

Evaluation of the effect of experimental cyclosporine toxicity on male reproduction and renal function. Reversal by concomitant human chorionic gonadotropin administration.

Administration of cyclosporine to rats has been shown to impair testicular function, resulting in a decrease in sperm counts and fertility. In order to determine whether or not the deleterious effects of CsA could be reversed by hormonal therapy, mature male Sprague Dawley rats were treated with CsA (40 mg/kg/day, s.c.) alone or in combination with human chorionic gonadotropin (hCG) (5 micrograms/day/r; s.c.) for 14 days. Cyclosporine administration decreased the body weight (290 +/- 5.30 vs. 339 +/- 8.7 g; P less than 0.05) and reproductive organ weights (testis 1.49 +/- 0.42 vs. 1.60 +/- 0.03 g; epididymis 0.41 +/- 0.02 vs. 0.49 +/- 0.002 g; seminal vesicle 0.61 +/- 0.09 vs. 1.60 +/- 0.05 g; prostate 0.28 +/- 0.04 vs. 0.60 +/- 0.06 g; P less than 0.05) testicular sperm counts (5.80 +/- 0.42 vs. 8.49 +/- 0.48 x 10(7)/100 mg tissue; P less than 0.05) and epididymal sperm counts, (28.2 +/- 0.95 vs. 51 51.62 +/- 2.17 x 10(7)/100 mg tissue; P less than 0.05) and fertility (25% vs. 100%). Serum levels of LH were elevated (101.98 +/- 21.48 vs. 25.6 +/- 5.18 ng/ml; P less than 0.05) and testosterone was decreased (0.48 +/- 0.07 vs. 2.06 +/- 0.56 ng/ml; P less than 0.05). The administration of hCG to the CsA-treated rats restored the reproductive organ weights (testis 1.56 +/- 0.043 g; seminal vesicle 1.04 +/- 0.05 g; prostate 0.70 +/- 0.06 g) and sperm counts (testicular 7.88 +/- 1.0 x 10(7)/100 mg tissue; epididymal 59.86 +/- 4.16 x 10(7)/100 mg tissue; P less than 0.05) Serum levels of testosterone (18.63 +/- 4.45 ng/ml) and LH (431.65 +/- 31.41 ng/ml) were significantly elevated, as compared with control and CsA-treated groups (P less than 0.05). All the rats in the gonadotropin-treated group were fertile, as compared with 25% in the CsA-treated group. CsA reduced the kidney weight (1.17 +/- 0.02 vs. 1.27 +/- 0.03 g; P less than 0.05) and increased the levels of serum creatinine (0.97 +/- 0.07 vs. 0.59 +/- 0.03 mg/dl; P less than 0.05): these changes were ameliorated by the administration of hCG (kidney weight 1.35 +/- 0.03 g; creatinine 0.76 +/- 0.09 mg/dl).

The mechanism of cyclosporine's action in the inhibition of testosterone biosynthesis by rat Leydig cells in vitro.

We have previously demonstrated that cyclosporine inhibits testosterone (T) biosynthesis in vivo. To better understand the mechanism by which CsA inhibits T synthesis, interstitial cells were isolated from rat testes and incubated in the standard medium 199 with or without CsA (0-10 micrograms/ml) in the presence or absence of human chorionic gonadotropin (hCG, 10(-7) M) and 8-bromo cyclic AMP (cAMP, 0.5 mM) for 3 hr at 32 degrees C. The levels of cAMP and T were determined by RIA. CsA did not inhibit the basal secretion of T, but inhibited hCG-stimulated T production in a dose-dependent manner (4 ng/10(6) cells vs. 10 ng/10(6) cells at a CsA dose of 5 micrograms/ml, P less than 0.05). Radioligand binding of 125I-hLH to testicular membranes was not affected by CsA, as CsA did not compete with hCG/LH for binding sites (25-28% binding with or without CsA). Similarly, the MIX-stimulated cAMP production was not affected by CsA (24.03 +/- 1.09 vs. 20.60 +/- 0.38 pmol/10(6) cells), suggesting that CsA does not inhibit the accumulation of the second messenger. However, when interstitial cells were incubated with CsA in the presence of cAMP, a significant dose-dependent decline in T secretion was observed (7 ng/10(6) cells vs. 20 ng/10(6) cells at a CsA dose of 5 micrograms/ml). To determine whether CsA inhibits the steps beyond cAMP stimulation of T secretion, the kinetic parameters (Km and Vmax) of steroidogenic enzymes, delta 4-3 keto-17 alpha hydroxylase (17 alpha-hydroxylase), and delta 4-3 keto-17 beta hydroxy steroid dehydrogenase (17B-HSD) were determined by using Michaelis Menten analysis. Results are shown in the presence of CsA vs. no CsA: Km and Vmax values for 17 alpha-hydroxylase were (2.32 vs. 7.98 microM) and (27.96 vs. 100.97 pmol/mg protein/min), respectively. For 17B-HSD the Km and Vmax were (2.14 vs. 1.52 microM) and (15 vs. 15 pmol/mg protein/min), respectively. These results indicate that CsA inhibits the activity of 17 alpha-hydroxylase uncompetitively and 17B-HSD activity competitively. In conclusion the primary site for CsA inhibition is the cAMP stimulation and, CsA inhibits T synthesis at multiple sites.

A critical look at survival of diabetics with end-stage renal disease. Transplantation versus dialysis therapy.

The survival of 100 consecutive patients with diabetic nephropathy after treatment with hemodialysis, peritoneal dialysis, or renal transplantation was reviewed at our institution from 1976 to 1982. Standard actuarial survival analysis revealed an overall survival of 83% and 61% at one and two years, respectively. Coronary angiography was used as a screening procedure for renal transplantation. In the dialysis group, 27 patients were considered acceptable transplant candidates on the basis of the coronary angiography but were not transplanted for other reasons. When the survival analysis was limited to those "transplant candidates" the survival rates were 78%, 51%, and 8% at 1, 2, and 5 years, respectively. In comparison, survival after transplantation was 81%, 67%, and 45%, at 1, 2, and 5 years, respectively. In order to eliminate bias, survival comparisons were subsequently made using the Cox Proportional Hazard Model to take into account the time the transplant patients spent on dialysis prior to renal transplantation. When this analysis was performed, there was no significant difference in survival between transplantation and dialysis for the first two years, but overall survival after five years was significantly better after renal transplantation even when the comparison was limited to acceptable transplant candidates who remained on dialysis (P = .04). Survival for patients with significant coronary disease (greater than 70% stenosis of a coronary vessel or moderate to severe left ventricular dysfunction) was analyzed according to therapeutic modality. Although overall prognosis was poor in this group as a whole (1, 2, and 5 year survivals were 76%, 45%, and 19%, respectively), the cardiac patients had a trend to better survival after renal transplantation than when maintained on dialysis (P = .22). In addition to other factors such as quality of life, rehabilitation, and progression of other diabetic complications, the benefit of renal transplantation on patient survival must be considered when deciding between renal transplantation and maintenance dialysis therapy for diabetic patients with renal failure.

Missile injury of upper ureter treated by delayed renal autotransplantation and ureteropyelostomy.

We report a case of extensive upper ureteral loss due to a missile injury managed by delayed renal autotransplantation and ureteropyelostomy using the residual lower ureteral segment. The successful outcome attests to the value of this therapeutic strategy in severe traumatic injuries to the ureter secondary to bullet or shrapnel fragments.

Successful transplantation of a kidney with early membranous nephropathy.

This report describes a patient with end-stage renal disease secondary to long-standing type II diabetes mellitus who received a cadaveric renal transplant from a 37-year-old woman who died of massive cerebral infarction. An autopsy performed on the donor following organ procurement revealed no obvious contraindications to transplantation. A renal biopsy of the donor kidney performed at the time of transplantation, however, subsequently showed early membranous nephropathy by electron microscopy. There was immediate graft function and the recipient continues to have good renal function 3 years post-transplantation.

Comparison of renal transplantation and dialysis in rehabilitation of diabetic end-stage renal disease patients.

We have reviewed the outcome of replacement therapy for end-stage renal disease (ESRD) in 100 diabetic patients with emphasis on late complications, extrarenal diabetic manifestations, and overall patient rehabilitation. Long-term complications, other than myocardial infarction, were not different after renal transplantation compared with chronic dialysis. Overall rehabilitation was better after renal transplantation compared with chronic dialysis (p less than 0.05). Retinopathy and neuropathy were more stable with renal transplantation and peritoneal dialysis compared with hemodialysis (p less than 0.05). These factors should be considered along with expected patient survival when deciding between different treatment modalities for diabetic ESRD.

Surgical aspects of renal transplantation: new approaches.

Refinements in surgical techniques and newer approaches to renal transplantation have yielded a safe and consistent operation that can be applied to most patients with end-stage renal disease. It is important that the transplant surgeon is familiar with the variety of approaches, especially when dealing with high-risk recipients due to prior transplantation of aortoiliac atherosclerotic disease. This article reviews the different technical approaches for renal transplantation and the recent advances in the management of postoperative complications.

Use of small and large bowel in renal transplantation.

The continued success of renal transplantation has provided a higher quality of life for properly selected patients with ESRD. It is also a much more cost-effective and efficient treatment of ESRD compared with chronic dialysis. Innovative urologic reconstructive surgery using enteric segments for both continent and incontinent urinary diversions has permitted this therapeutic modality to be offered to the recipient with lower urinary tract disease not previously amenable to renal transplantation. These same reconstructive techniques using ileal segments have also permitted preservation of renal allografts with previously nonreconstructable renal pelvic or ureteral disease.

Diminished operative risk and improved results following revascularization for atherosclerotic renovascular disease.

Refinements in patient selection, preoperative preparation, and the technical performance of vascular reconstruction have improved the results of revascularization in atherosclerotic renovascular disease. These advances have expanded the eligibility criteria for surgical therapy in this group and now also appear to be favorably influencing late patient survival. This article documents this improved outlook and focuses on the policies in management that have been primarily responsible for its development.

Revascularization to preserve renal function in patients with atherosclerotic renovascular disease.

There are a significant number of patients with advanced atherosclerotic renovascular disease whose blood pressure is well controlled with medical therapy but in whom such vascular disease poses a grave risk to overall renal function. This article reviews current concepts regarding screening, evaluation, and selection of patients with this disease for revascularization to preserve renal function. The underlying rationale for this approach is an increasing awareness that, in selected patients, atherosclerotic renovascular disease represents a surgically correctable cause of progressive renal failure.

Leiomyoma of the urethra: report of 3 cases of a rare entity.

Leiomyomas are benign tumors of smooth muscle origin that can occur at any location in the urinary tract. Although rare, they are the most common mesenchymal neoplasms of the urethra. They are more frequent in females than in males. Only 3 cases of leiomyomas of the male urethra and multiple cases in the female have been reported in the English-language literature. We report 2 additional cases of leiomyoma of the male urethra and 1 more case of the female urethra and describe their differential diagnoses and management.

A guideline to clinical utility of prostate specific antigen.

Prostate cancer has emerged as the most common tumor effecting adult men. In the USA, 300,000 cases each year, and some 40,000 deaths per year are expected from this disease. Once prostate cancer gets to an advanced stage, one cannot prevent its progression and cure is no longer possible. Thus, to effect the course of prostate cancer and to diminish the death rate from this disease, it should be detected at its early stages. The prostate specific antigen serum test is the best tumor marker present but it is certainly not perfect. The proper utility of prostate specific antigen testing, and analysis of prostate specific antigen parameters, will allow us to detect prostate cancer at earlier stages, and prevent progression and death rates from this disease. In this manuscript, we review the current status of prostate specific antigen testing for early detection and staging of prostate cancer, as well as its role for monitoring response to various forms of therapy.

The value of free and total prostate specific antigen in identifying patients for prostatic biopsy and its relationship to Gleason score and number of positive cores.

INTRODUCTION AND OBJECTIVES: The percentage of free over total prostate specific antigen (%F/T PSA) seems to enhance the predictive value of PSA in diagnosing prostate cancer. We evaluated the value of F/T PSA in 50 consecutive patients who underwent prostate needle biopsy, its relationship to the Gleason score and number of positive cores. MATERIAL AND METHODS: 50 patients underwent prostate needle biopsy for abnormal PSA and/or abnormal digital rectal examination (DRE). There were 8 patients with PSA equal or less than 4 ng/ml, 6 with F/T PSA < 20%, group I (GI). 27 patients with PSA between 4.1 ng/ml and 10.0 ng/ml, 20 with F/T PSA < 20%, group II (GII) and 15 patients with PSA > 10.1 ng/ml (13 with F/T PSA < 20%), group III (GIII). At least six needle biopsies were obtained guided by transrectal ultrasound selectively or randomly. Pathological evaluation included Gleason grade and number of cores involved. RESULTS: 21/50 patients (42%) had positive biopsies, 3/8 in GI, 8/27 in GII (6 had negative DRE) and 10/15 in GIII (9 had positive DRE). 19/21 patients with positive biopsies had F/T PSA < 20%. The sensitivity, specificity and positive predictive value of PSA between 4-10 ng/ml and F/T PSA < 20% was 87.5%, 31% and 35% respectively. Stratifying patients with positive biopsies to F/T PSA < 10%, F/T PSA > 10% and the three PSA groups, there was no relationship to either Gleason score or number of positive cores. CONCLUSION: With a cutoff of 20%, F/T PSA seems to be an important parameter in selecting patients with abnormal PSA for biopsy. It will be helpful mostly with PSA 4-10 ng/ml. No relationship was observed between the level of F/T PSA, grade or number of positive cores.