Vascular complications in adults and pediatrics live-donor renal transplantation: 3 decades of single centre experience

We analyzed the incidence of vascular complications in adults and pediatrics live donor renal transplantations over 3 decades and compared its impact upon patient and graft survival in both groups.Material and methods: Between March 1976 and December 2005, 1785 live-donor renal transplantswere performed in a single institute, of the 1546 adults and 239 pediatric (age ≤18 years). The incidence of different types of vascular complications were determined in both groups. Long term patient and graft survival in patients with or without vascular complications and in various types of vascular complications were calculated & compared in both groups.Results: The overall incidence of vascular complications was 2.9%, it was equally 2.9% in both groups. In adults, 46 complications in 45 patients included 16 arterial, 10 renal artery thrombosis (0.6%), 2 cases of spasm in renal artery(0.1%), renal artery stenosis in 5 (0.3%), renal vein thrombosis in one (0.06%) and hemorrhagic complications in 28 patients whereas there were no thrombotic complications in the pediatric group, 6 case of hemorrhage (2.5%) and one case of renal artery stenosis (0.4%). There is steady decrease of vascular complications over the last 3 decades. The vascular complications significantly adverse patient and graft survival in both groups (p<0.001). The 5-years patient and graft survival in adults and pediatrics with or without vascular complications were 59.5 ± 9.2%, 89.14 ± 0.89%, 57.5 ± 18.7% and 90.18 ± 2.2% for the patient and 40.14 ± 7.75%, 97.79 ± 1.14%, 28.57 ± 17.07% and 77.18 ± 3.02% for the graft. There is no statistical significant difference in either patient or graft survival in thrombotic, stenotic or hemorrhagic complications in adult or hemorrhagic complications in the pediatric group (p=0.22 and p=0.142 respectively).Conclusions: There is no increase in incidence of vascular complications in pediatrics than adult transplants. The survival either graft or patient is comparable between adult and pediatric with or without vascular complications and the subgroups of vascular complications

Does the afferent tubular segment in an orthotopic bladder substitution compromise ureteric antireflux properties? an experimental study in dogs

Objective: To study the effects of a short ureter on renal function and histology in an orthotopic bladder substitution model using a long afferent limb, in a canine model. Materials and methods: The study included nine adult mongrel dogs. A 40-cm segment of ileum was isolated, the distal half detubularized, configured into a U-shape and sutured to form a flat plate; this was then used to augment the bladder. The proximal half of the isolated ileum remained in continuity with the enterocystoplasty to form an isoperistaltic ileal ‘chimney’. The left ureter was divided at its lumbar part and anastomosed to the chimney using a refluxing end-to-side Nesbit technique. The contralateral ureter was divided at its lower end and then anastomosed directly to the augmented segment of the bladder in a similarly refluxing manner to act as a control. The assessment after surgery included biochemical studies, ascending cystography, intravenous urography (IVU) and radioisotope renography at 6 weeks. The last two methods were repeated at intervals of 3 and 6 months after surgery. Urine culture was obtained and both kidneys were examined histopathologically at 6 months. Results: The biochemical values assessed in all dogs were comparable to those before surgery. The urine culture obtained from the augmented bladders showed significant bacterial growth in all dogs. IVU at all follow-up sample times showed a normal configuration of both kidneys. Ascending cystography showed reflux in four of nine dogs on the right and six on the left side. There was a progressive decrease in the mean selective renographic clearance values of each of the right and left kidneys at intervals of 6 weeks, 3 and 6 months. The mean percentage reduction of renographic clearance was significantly higher in the left kidneys at 6 weeks and 3 months. Histopathological examination showed evidence of interstitial nephritis in all nine dogs and pyelonephritis in four of the left kidneys, while none of the right kidneys showed evidence of inflammation. Conclusion: Adequate peristalsis in a healthy long ureter is superior to the ileal segment substitution for protecting the kidney tissue against inflammation in the absence of an anatomical antireflux mechanism

Can frozen-section analysis of ureteric margins at the time of radical cystectomy predict upper tract recurrence?

Objective: To summarise the currently available literature and analyse available results of the outcome of intraoperative frozen-section analysis (FSA) on upper urinary tract recurrence (UUTR) after radical cystectomy (RC). Materials and methods: A systematic review of the literature was performed according to the Cochrane Reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Articles discussing ureteric FSA with RC were identified. Results: The literature search yielded 21 studies, on which the present analysis was done. The studies were published between 1997 and 2019. There were 10 010 patients with an age range between 51 and 95 years. Involvement of the ureteric margins was noted in 2–9% at RC. The sensitivity and specificity of FSA were ~75% and 99%, respectively. Adverse pathology on FSA and on permanent section, prostatic urothelial carcinoma involving the stroma but not prostatic duct, and ureteric involvement on permanent section were all more likely to develop UUTR. Neither evidence of ureteric involvement nor ureteric margin status on permanent section were significant predictors of overall survival. Conclusion: Routine FSA is mandatory for a tumour-free uretero–enteric anastomosis and is predictive of UUTR. To lower the UUTR, FSA is not necessary if the ureters are resected at the level where they cross the common iliac vessels. FSA is indicated whenever the surgeon encounters findings suspicious of malignancy, e.g. ureteric obstruction, periureteric fibrosis, diffuse carcinoma in situ, induration or frank tumour infiltration of the distal ureter is discovered unexpectedly during surgery, and prostatic urethral involvement. Abbreviations CIS: carcinoma in situ; FSA: frozen-section analysis; HR: hazard ratio; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RC: radical cystectomy; (UT)UC: (upper tract) urothelial carcinoma; UUT(R): upper urinary tract (recurrence)

Static T2w MRU in Noncalcular Urinary Obstruction: Comparison of Its Two Techniques

The purpose of this study was to compare the diagnostic accuracy of T2-weighted (T2w) MR urography (MRU) techniques — the standard MRU using fast spin echo (FSE) and postprocessing maximum intensity projection (MIP) and the single-shot MRU — in the diagnosis of ureteric obstruction in patients with noncalcular urinary obstruction. The study included 150 patients admitted to our center between January 2005 and December 2006. There were 203 renal units with noncalcular obstruction; 53 patients had bilateral obstruction. Patients with calcular obstruction were excluded. There were 85 males and 65 females with a mean age of 50 (range: 5–83) years. All patients were examined with static MRU using both single-shot (thick slab) and multisection MRU. Using single-shot MRU, we obtained images at the direct coronal and oblique coronal, as well as sagittal, planes for each renal unit. Postprocessing MIP for the standard coronal heavy T2 source images to obtain coronal and oblique images was done. Among the obstructed 203 units, the intrinsic causes were present in 157 units (151 were stricture and six were ureteric tumors), while the extrinsic causes were present in 46 units (35 bladder tumor, four ureterocele, five retroperitoneal fibrosis, one prostatic tumor, and one local pelvic recurrence after radical cystectomy for bladder cancer). The overall accuracy of single-shot MRU was 89% and was 93% for the multisection MRU in cases of intrinsic ureteric obstruction, while in cases of extrinsic obstruction, it was 20% for single-shot MRU and 96% for multisection MRU. T2w static MRU is a very useful technique in diagnosing noncalcular ureteric obstruction. Multisection MRU has a high diagnostic accuracy and reliability over that of the single-shot technique. The single-section technique is very rapid and useful in diagnosing ureteric stricture so it could be used as a localizer, while multisection images with postprocessing MIP is mandatory, especially in cases of suspected ureteric tumors or extraureteric causes

Role of urinary biomarkers in the diagnosis of congenital upper urinary tract obstruction

Background: Congenital obstructive uropathy constitutes a significant cause of morbidity in children. Currently, there is no reference standard for the diagnosis of renal obstruction in children. The noninvasive measurement of biomarkers in voided urine has considerable appeal as a potential application in children with congenital obstructive nephropathy. The aim of the present review is to explore the current role of biomarkers in the diagnosis and follow-up of obstructive uropathy in children. Materials and Methods: The literature database (PubMed) was searched from inception to May 2007 regarding the role of urinary biomarkers in the diagnosis and follow-up of children with congenital obstructive uropathy. Results: The review included 23 experimental and 33 prospective controlled clinical studies. Several cytokines, peptides, enzymes and microproteins were identified as major contributors to or ensuing from obstruction-induced renal fibrosis and apoptosis. The most important biomarkers were transforming growth factor-β1 (TGFβ1 ), epidermal growth factor (EGF), endothelin-1 (ET-1), urinary tubular enzymes [N-acetyl-β-D-glucosaminidase (NAG), γ-glutamyl transferase (GGT) and alkaline phosphatase (ALP)], and microproteins [β2 -microglobulin (β2 M), microalbumin (M.Alb) and micrototal protein (M.TP)]. All biomarkers showed different degrees of success but the most promising markers were TGFβ1 , ET-1 and a panel of tubular enzymes. These biomarkers showed sensitivity of 74.3% to 100%, specificity of 80% to 90% and overall accuracy of 81.5% to 94% in the diagnosis of congenital obstructive uropathy in children. Moreover, some of the markers were valuable in differentiation between dilated non-obstructed kidneys in need of conservative management and obstructed kidneys in need of surgical correction. Some studies demonstrated that urinary biomarkers are helpful in the evaluation of success of treatment of children with congenital renal obstruction. Some limitations of the previous studies include lack of different types of controls and small sample size. Larger studies with variable controls are invited to confirm the clinical usefulness of biomarkers in the diagnosis and follow-up of children with congenital obstructive uropathy. Conclusion: Urinary biomarkers are a promising tool that could be used as a noninvasive assessment of congenital renal obstruction in children

[44] Long-term outcome of shockwave lithotripsy in the management of patients presenting with calcular acute urinary retention

Objective: To evaluate the efficacy of shockwave lithotripsy in the long-term in the treatment of calcular acute urinary retention (AUR). Methods: From March 2015 to February 2017, a prospective study was conducted, and included a total of 50 male patients who were diagnosed with AUR as a result of urethral or vesical radio-opaque stone(s) at the Mansoura Urology and Nephrology Center. All patients underwent extracorporeal shockwave therapy. Results: A total of 47 of 50 patients (94%) were included, as only they underwent an initial successful treatment by shockwave lithotripsy. The mean (SD) age was 44.5 (11.8) years, the mean (SD) stone greatest dimension was 12.2 (3) mm, 33 stones (70.2%) were migratory and 14 stones (27.6%) were secondary in nature. At long-term follow-up of this patient cohort, there was recurrence of vesical stones in none, two (4%), and seven (15%) at 6-, 12- and 18-month intervals, respectively. The mean (SD) age of the nine recurrent cases (19%) was 52.3 (5.7) years and eight were secondary with one migratory in nature. Conclusion: Shockwave lithotripsy is a successful modality of treatment in vesical stones; however, it should be used with caution in patients aged >50 years and with a history suggestive of infravesical obstruction

Oral desmopressin in nocturia with benign prostatic hyperplasia: A systematic review of the literature

Objective: To evaluate the effect of oral desmopressin in patients with nocturia associated with benign prostatic hyperplasia (BPH). Patients and methods: With a rise of the use of oral desmopressin in the treatment of nocturia in patients with BPH, a systematic review was performed according to the Cochrane systematic reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Results: The literature search yielded 18 studies. The studies were published between 1980 and 2017, and included 3072 patients. Eligible patients were men aged ≥50 years with lower urinary tract symptoms (LUTS) and persistent nocturia. There was a significant 43% reduction in nocturia after using desmopressin alone. Combined α-blockers and desmopressin lead to a decrease in the frequency of night voids by 64.3% compared to 44.6% when using α-blockers only. The first sleep period, significantly increased from 82.1 to 160.0 min and from 83.2 to 123.8 min when using desmopressin + α-blocker and α-blocker only, respectively. The desmopressin dose ranged from the lowest dose (0.05 mg) to the optimum dose (0.4 mg) at bed time. The incidence of hyponatraemia associated with desmopressin use was 4.4–5.7%. Conclusion: Low-dose oral desmopressin therapy alone is an effective treatment for nocturia associated with LUTS in patients with BPH. Oral desmopressin combined with α-blockers is well tolerated and beneficial for improving the International Prostate Symptom Score and nocturnal symptoms. All patients should be educated about the mechanism of desmopressin action to avoid treatment discontinuation due to adverse events. Keywords: Nocturia, Nocturnal polyuria, Oral desmopressin, LUT

Selective embolisation for intractable bladder haemorrhages: A systematic review of the literature

Objective: To establish the current evidence and assess the effectiveness and safety of selective transarterial embolisation (STE) to control intractable bladder haemorrhage (IBH). Materials and methods: With a rise in the use of STE for the treatment of IBH, a systematic review was performed according to the Cochrane reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Results: The literature search yielded 38 studies, of which 11 were excluded because of irrelevance of data. All included studies were observational cohort studies, with no randomisation or control groups apart from in relation to the materials used for embolisation. The studies were published between 1978 and 2016. There were 295 patients with an age range between 51 and 95 years. The success rate ranged from 43% up to 100%. The most reported complication was post-embolisation syndrome, although other complications were described such as mild transient gluteal claudication, nausea, and vomiting. Conclusion: STE of the internal iliac artery is a safe and effective alternative technique to control severe IBH, and has been successfully applied over many years to treat bladder haemorrhage associated with terminal pelvic malignancy