A 20-year experience in cadaveric pediatric en bloc kidney transplantation in adult recipients.

BACKGROUND AND OBJECTIVES: En bloc kidney transplantation (EBKT) from pediatric donors into adult recipients increases the donor pool. However, this surgical procedure is not widely performed in many transplant centers. To evaluate the long-term outcomes of EBKT from pediatric donors into adult recipients in a single center. MATERIAL AND METHODS: Retrospective analysis of 42 patients who received pediatric cadaveric EBKT in our center since 1999. Median follow-up period was 73 months (5-233) in which renal function tests were taken and complications registered. RESULTS: We have performed 42 EBKT from pediatric donors into adult recipients in our center. The recipients' age was 44.1 ± 11.8 years. Pediatric donors were 22.4 ± 14.7 months old and weighted 11.3 ± 3.6 kg. Cold ischemia time was 15.7 ± 4.5 h. During a median follow-up of 73 months, 35 patients (83.3%) had graft survival with excellent function (first-year serum creatinine levels of 0.99 ± 0.25 mg/dl). There were seven graft losses (16.7%) in the immediate postoperative period (four cases of vascular thrombosis, one anastomosis dehiscence and two cortical necrosis). CONCLUSIONS: The pediatric en bloc renal graft transplantation into adults is a safe technique with excellent medium- to long-term functional performance. The vast majority of significant complications leading to graft loss were reported in the immediate postoperative period. A good selection of donors and recipients as well as an adequate surgical technique are essential to minimize the occurrence of adverse events.

[Assessment of tobacco impact on penile vascularization with echo-Doppler and intracavernous injection]. / Evaluación de la influencia del tabaco en la vascularización peneana mediante eco-Doppler e inyección intracavernosa.

The negative role of smoking on circulation is widespread knowledge and it has been rated as a vascular risk factor. This paper evaluates the influence of smoking on the arterial supply to the erectile tissue, establishing the flow speed parameters in cavernous arteries with eco-doppler both at rest and after intracavernous PgE1 injection. Four groups were studied: non-smokers, without arterial disease and with arterial disease of non-smoking etiology; smokers with vascular disease, and another group where smoking was the only verified etiological factor. No significant differences were detected in flow speed parameters at rest among smokers and non smokers both in individuals with preserved erectile potency or with erectile dysfunction. Following drug therapy, impotent smokers showed the worse erectile response. With regard to flow speed parameters, although the differences were not significant, it can be seen that smokers, whether potent or not, show less differential speed, flow time, and acceleration, exhibiting a certain degree of arterial rigidity. That flow speed parameters, in cases with erectile dysfunction, can be superposed in individuals with arterial-origin impotence and those where smoking is the sole risk factor, indicates that this is a factor which causes erectile dysfunction due to vascular damage, as severe as any other caused by other factors such as arteriosclerosis, diabetes, or hypertension.

[Vascular penile study with Doppler ultrasonography in subjects without vascular disease]. / Estudio vascular peneano con eco-Doppler en sujetos sin patología vascular.

The Eco-Doppler technique allows a fast, non-invasive and effective study of pental vascularization. Ninety-three subjects, aged 20-66, with no vascular disease were studied: 20 healthy volunteers and 73 with psychogenic dysfunctions. All subjects underwent a baseline study, and 89 a second study after intracavitary injection (ICI) (10 papaverine and 79 PgE1). No differences were seen between both drugs. Flowmetry parameters were analyzed at rest and post-ICI. At baseline, patients with psychogenic dysfunctions showed less diastolic speed (p < 0.05), acceleration (p < 0.001) and resistance index (p < 0.05) than normal subjects. After administration of the drug, no differences were detected between both groups that formed an homogeneous sample. Subjects with no vascular disease presented arterial dilatation after ICI, the vessels appearing with thin and parallel walls, homogeneous lumen and following a straight course. Flow speed parameters experienced significant changes: systolic speed increase by 153 +/- 97% (p < 0.001) and reached 34.7 +/- 9.3 cm/s; increase of diastolic speed was lower; but flow time and acceleration also increases although not significantly due to their high variability. At 20 minutes after ICI the resistance index is 0.83 +/- 0.1, higher (p < 0.001) than that observed at rest, expressing the high intracavitary pressure that exists when full erection is achieved.

[Erectile dysfunction of arterial origin. Vascular study of the penis with Doppler ultrasonography]. / Disfuncíon eréctil de causa arterial. Estudio vascular del pene con eco-Doppler.

The etiological diagnosis of an erectile dysfunction usually requires a study of penis vascularization. The arterial origin involves a high percentage of erectile dysfunctions. The eco-doppler allows to perform the study in a fast, non-invasive and effective way, providing information on the morphological aspects of arteries and flow parameters. This paper reports on a study conducted in 151 subjects, aged 27-80 years, where the cause of impotence was arterial; the existence of clinical signs of vascular deficit in other domains had already suggested the condition in a group (36 subjects), while the another group (115) had no clinical symptoms and was diagnosed through eco-doppler. 75.5% were smokers and 83.1% hypertensive. All subjects underwent a baseline study, repeated in 148 after intracavitary injection (ICI). The arteries were difficult to identify at rest, but easier after ICI, presenting morphological features which were suggestive of disease: twisted course, irregular lumen, thickened walls. Flow parameters at rest presented no differences between groups, both speed (p < 0.001) and flow time (p < 0.05) being lower than in subjects with no vascular disease. Only 25.7% reached full erection with ICI, beats being noticed in 44 (91.9%). After administration of the drug there was a significant increase in systolic speed (p < 0.001), rising to 16 +/- 4.9 cm/s vs 34.7 +/- 9.3 cm/s in subjects with no vascular disease (p < 0.001). Flow time increases after ICI, reaching 345 +/- 215 msec, less than in healthy subjects (p < 0.001). RI, highly variable at rest, does not change significantly after ICI, 0.71 +/- 0.11, lower than subjects with no disease (p < 0.001). The increases seen in flow speed are greater in subjects with no ischaemic symptomatology (p < 0.01), same as RI (p < 0.05), and reveals a better arterial response. Those who obtain full erection reach greater RI (0.77 +/- 0.13) than those without full erection (0.68 +/- 0.08) (p < 0.001).

[Value of Doppler ultrasonography in the diagnosis of erectile dysfunction of venous origin]. / Valor del eco-Doppler en el diagnóstico de disfunción erectil de causa venosa.

Corporeal vein-occlusive dysfunction (CVOD) is a frequent cause of impotence. A study with eco-doppler was conducted in 36 cases where leaking was the single cause of dysfunction and in 12 associated to arterial disease, in order to evaluate whether this technique is able to diagnose the condition. The study with eco-doppler, at rest and 20 minutes after intracavitary injection (ICI) with a vasodilating agent, shows changes in the arterial vascularization that allow to suggest the existence of venous disease: similar arterial dilation and peak systolic speed as in subjects with no disease, diastolic speed higher than the control group (p < 0.01), flow during diastole (p < 0.001) and resistance index lower than the control group (p < 0.001). All the above involve a high sensitivity (97.2%) with 81.4% positive predictive value in the diagnosis of venous conditions. Specificity, however, is low (27.3%) since some subjects with no arterial disease do not display full erection 20 minutes post-ICI. By evaluating the ecodoppler and the overall erectile response, the diagnostic ability is increased when leaking is the only cause of dysfunction, reaching a 100% positive and 91.7% negative predictive value. When etiology of the condition is both arterial and venous, the eco-doppler is unable to indicate the existence of the venous condition.

[Echo-Doppler in diabetic erectile dysfunction]. / El Eco Doppler en la disfunción erectil de los diabéticos.

The erectil dysfunction is a common disorder in diabetic patients resulting from neurological, arterial and endocrine factors. This paper presents an eco-doppler evaluation of the arterial factor in 88 diabetics: 17 controlled with diet, 38 with oral anti-diabetic agents and 33 with insulin. Age, ranging from 23 to 70 years old, was similar in subjects controlled with diet (55.6 +/- 6.4) or anti-diabetic agents (57.6 +/- 7.9), but greater in insulin-treated subjects (46.8 +/- 10.5) (p < 0.01). Fifty-six subjects (63.6%) has nocturnal and 43 (48.9%) diurnal erections, 45 (51.1%) achieving penetration. There was 65 (73.9%) smokers, 28 (31.8%) hypertensives, and 24 (27.3%) reported stress. A baseline evaluation was performed in all cases, in 87 after I.I.C (papaverin 26 and PgL1 61), full erection being achieved in 18 cases, non-rigid erection in 15, tumescence in 50 and with no response in 4. No differences were seen by type of diabetes. The variance analysis showed no differences in the flow speed indicators among the three groups, both at rest and after I.I.C., the sample being therefore homogeneous, superposable to arterial dysfunctions and significantly lower than those of the control group (p < 0.01). We conclude that diabetes induces arterial changes which are superposable to those caused by other vascular risk factors and independent for the type of diabetes.

[Assessment of vascular factor in erectile dysfunction occurred following surgical intervention]. / Evaluación del factor vascular en la disfunción eréctil aparecida tras intervención quirúrgica.

Study of 33 subjects with erectile dysfunction after undergoing pelvic surgery, who were stratified in two groups: 16 where surgery appears to have no relation with the dysfunction and 17 where surgery appears to be the cause of the condition. They were compared with 151 cases with arterial dysfunction. Mean age in the group with surgery-related dysfunction (60 +/- 9.6) is higher than in the group with no relation (51.6 +/- 6.7) (p < 0.05), and in both cases similar to the group with arterial-related impotence. Both groups have vascular risk factors, superposed to those who had arteriogenic dysfunction. All flow-rate parameters in the baseline eco-doppler, degree of erectile response after intracavitary injection and flow-rate parameters after ICI can be superposed to those found in the arterial-related impotence. This suggests the existence of a likely pre-existent arterial disease which becomes unstable after surgery as a result of the vascular and nervous lesions as well as due to psychological changes. We insist on the need to gather information prior to surgery, and in the basically vascular nature of erectile dysfunctions developed in subjects who undergo pelvic surgery.

[Perirenal abscess following lithotripsy]. / Absceso perirrenal post-litotricia.

Presentation of one case of perirenal abscess secondary to lithotrity on a calcified cyst simulating a pyelic lithiasis. A pathogenic hypothesis and the importance of urography in the confirmation diagnosis of the lithiasic disease is raised.

[Treatment of prostatic benign hyperplasia with endoscopically controlled laser fiber]. / Tratamiento de la hiperplasia benigna de próstata con fibra de láser bajo control endoscópico.

Between October 1992 and February 1993, 12 patients with benign prostate hyperplasia (BPH) were treated with Neodymium-YAG laser through an endoscopically-guided right angle fibre, and follow-up is now over 1 year. Follow-up consisted in the symptomatic assessment using I-PSS questionnaires, vesicoprostate ultrasound with flowmetry and residue measurement and urethrocystometry at least every 3 months. Mean time for suprapubic catheter withdrawal was 23.4 days (range 9-34), and one patient did not resumed micturition spontaneously. Symptomatology improved after the first month. remaining stable after 6 months, with a mean score decrease at one year of 11,2 (p < 0,001). All flowmetry parameters improved although only peak and mid-stream flow showed statistical differences, peak flow increasing at one year by an average of 5,9 ml/sec (P < 0,001). In 4 of the 12 patients surgery was performed; 1 underwent early surgery due to absence of spontaneous micturition and was excluded from the results assessment, and 3 due to persistence of symptomatology at 16, 18 and 21 months post-laser. In spite of the advantages presented by the laser when compared to conventional surgical approaches, such as short time application, absence of haemorrhage and likely used in an ambulatory setting, the major initial irritative symptomatology and the need for a suprapubic catheter during at least three weeks, are in general poorly tolerated and limit its use. The apparent improvement in symptomatology after one month is not accompanied by objective changes in flowmetry, since in our series only 1 patient presented Qmax greater than 15 ml/sec with no residues. Therefore, we consider that treatment with endoscopically-guided laser fibre in BPH has, with the technology currently available. a very limited use.

[Balloon dilatation in tuberculous ureteral stenosis]. / Dilatación con balón de estenosis ureteral tuberculosa.

We report on a case of tuberculous ureteral stricture submitted to balloon dilatation, a procedure currently advocated by many authors as an alternative to surgical correction in benign ureteral stricture. Transluminal balloon dilatation of ureteral strictures is not a standardized technique, although it follows some essential maneuvers. The procedure can be performed antero or retrogradely and always with temporary internal or external diversion. It is not a harmless procedure, but the complications are scant. However, many aspects have yet to be elucidated.

[Retroperitoneal ganglioneuroma]. / Ganglioneuroma retroperitoneal.

We report a case of retroperitoneal ganglioneuroma that had been incidentally discovered during ultrasound evaluation in a young female patient. The plain X-ray, IVP and ultrasonography only revealed the presence of a retroperitoneal mass and its approximate size. CT and arteriography provided further information relative to the location, nature of the extrarenal mass, its borders, and size although these did not permit us to determine its origin.

[Duplex echography in acute scrotum. Diagnostic possibilities]. / El eco duplex en el escroto agudo. Posibilidades diagnósticas.

Acute scrotum is a frequent reason for consultation at the urological emergency service. The most common causes, apart from trauma, are acute orchiepididymitis, torsion of the hydatids of Morgagni and torsion of the spermatic cord. Apart from a detailed examination of patient history and a careful physical examination, few diagnostic techniques can be utilized. To date, only the Doppler ultrasound has proved useful in corroborating the suspicion of vascular involvement, although this technique is very limited. With the availability of the duplex ultrasound, the possibility of making the differential diagnosis in the acute scrotum is enhanced. This technique permits morphological and functional assessment and avoids unnecessary exploration surgery within the scrotum.

[Value of bone gammagraphy and pain in the follow-up of carcinoma of the prostate]. / Valor de la gammagrafía ósea y el dolor en el seguimiento del carcinoma prostático.

We reviewed 382 bone scans from 161 patients with prostatic adenocarcinoma submitted to scintigraphic evaluation over the period 1980 to 1988. Each patient had a mean of 2.37 bone scans (1 to 9 scans). Seventy-three patients had positive scans (64 initially and 9 in the course of patient follow-up). Sixty-four presented bone pain (56 initially and 8 in the course of the disease). The remaining 17 patients were asymptomatic throughout follow-up; however, bone metastasis was undemonstrable. In our view, pain is a reliable indicator of the appearance or progression of bone metastasis. Routine follow-up bone scans are unnecessary in patients with positive or negative scintiscans who remain asymptomatic.

[Duplex ultrasound before and after intracavernous papaverine injection in the diagnosis of impotence]. / El eco dúplex pre y post-inyección intracavernosa de papaverina en el diagnóstico de la impotencia.

The study of impotentia coeundi requires separating the organic from the psychogenic cause. Arteriogenic impotence falls within the first group and has been assessed with the papaverine test, simple Doppler and arteriography. Currently, more sophisticated techniques such as the pulsed Doppler permit noninvasive assessment of the blood supply to the penile arteries. Intracavernous injection of vasoactive substances such as papaverine cause vascular changes. Evaluation of these changes permits making the diagnosis of arterial insufficiency without recurring to more invasive diagnostic techniques such as arteriography. Currently, this invasive technique is only justified in revascularization surgery but not for diagnosis. The availability of color Doppler facilitates arterial evaluation even further.