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The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.

Introduction: The Royal College of Physicians and Surgeons of Canada’s Competence by Design (CBD) initiative presents curricula challenges to ensure residents gain proficiency while progressing through training. To prepare first-year urology residents (R1s), we developed, implemented, and evaluated a didactic and simulation-focused boot camp to implement the CBD curriculum. We report our experiences and findings of the first three years. Methods: Urology residents from two Canadian universities participated in the two-day boot camp at the beginning of residency. Eleven didactic and six simulation sessions allowed for instruction and deliberate practice with feedback. Pre-and post-course multiple-choice questionnaires (MCQs) and an objective structured clinical exam (OSCE) evaluated knowledge and skills uptake. For initial program evaluation, three R2s served as historical controls in year 1. Results: Nineteen residents completed boot camp. The mean age was 26.4 (±2.8) and 13 were male. Participants markedly improved on the pre- and post-MCQs (year 1: 62% and 91%; year 2: 55% and 89%; year 3: 58% and 86%, respectively). Participants scored marginally higher than the controls on four of the six OSCE stations. OSCE scores remained >88% over the three cohorts. All participants reported higher confidence levels post-boot camp and felt it was excellent preparation for residency. Conclusions: During its first three years, our urology boot camp has demonstrated high feasibility and utility. Knowledge and technical skills uptake were established via MCQ and OSCE results, with participants’ scores near or above those of R2 controls. This boot camp will remain in our CBD curriculum and can provide a framework for other urology residency programs.

Introduction: Placement of a ureteral stent at the time of renal transplantation can reduce complications when compared to non-stented anastomoses. Removal by flexible cystoscopy can be associated with discomfort, risk for infection, and high costs. New magnetic stents offer a means of bypassing cystoscopy by use of a magnetic retrieval device. Our objective was to compare clinical and cost-related outcomes of conventional and magnetic stents in patients undergoing deceased donor renal transplantation. Methods: Patients were randomized to receive either a conventional or a Black-Star® magnetic stent. Clinical, procedural, and cost outcomes were assessed, and the Ureteral Stent Symptom Questionnaire (USSQ) was administered with the stent in situ and after stent removal. All variables were compared between groups. Results: Forty-one patients were randomized to conventional (n=19) or Black-Star (n=22) stent. The total time for stent removal under cystoscopy was significantly longer compared to Black-Star removal (6.67±2.47 and 4.80±2.21 minutes, respectively; p=0.019). No differences were found in the USSQ domains between groups. Rates of urinary tract infections and surgical complications between groups were similar. Stent removal was well-tolerated in both groups. Black-Star stent use resulted in a cost savings of $304.02 Canadian dollars (CAD) per case. Conclusions: USSQ scores suggest that stent removal with the Black-Star magnetic stent is as equally well-tolerated as flexible cystoscopy by renal transplant patients. Black-Star stent removal was significantly faster than conventional stents. No differences in discomfort, infection rate, or complication rate were found. Use of the Black-Star stent resulted in an estimated annual savings of $27 360 CAD at our centre.

Renal cell carcinoma (RCC) in transplanted kidneys has been reported sporadically with incidence of about 0.5%. There are currently no standard guidelines on the management of allograft RCC in renal transplant recipients. Our objective was to study effectiveness of nephron-sparing surgery (NSS) for allograft RCC. We performed a retrospective analysis of patients with RCC in renal allografts managed with NSS in our institution from January 2000 to December 2015. Patient demographics, interval between transplant and RCC diagnosis, operative parameters, perioperative complications, final pathology, and renal function were evaluated. Three females underwent successful NSS for allograft RCC. Cause of end-stage renal disease was IgA nephropathy in all; mean time between renal transplant and diagnosis of RCC was 23 years. We were able to stay extraperitoneal in all the cases. In the final pathology, two had papillary and one had clear cell RCC. One patient developed pyelocutaneous fistula which was managed by stenting. Long-term functional outcomes of NSS are excellent; none of our patients is dialysis dependent.

Introduction: Patient compliance to best practice guidelines is a significant factor in preventing renal stone recurrence. While patient compliance has been historically poor, there remains a paucity of data in the renal stone setting. We evaluated compliance of the recurrent renal stone former with current Canadian Urological Association (CUA) best practice guidelines.Methods: A prospective, cross-sectional study design was used to evaluate patient compliance. Recurrent renal stone former patients were consecutively recruited from McMaster’s Institute of Urology and completed a one-time questionnaire developed in accordance with CUA best practice guidelines. Questionnaire sections included: 1) demographics; 2) interaction(s) and satisfaction with their healthcare provider; and 3) knowledge, attitudes, and compliance with best practices.Results: A total of 300 patients were enrolled in the study; 55.3% were men, 69.5% had a history of stone surgery, while 23.7% had a positive family history. Participants perceived satisfactory education from their urologist and primary care physician 82.7% and 59.7% of the time, respectively (p

Introduction: The objective of this study was to evaluate the safety and feasibility of using a polyethylene glycol (PEG)-coated collagen patch (Hemopatch®) in patients undergoing deceased donor renal transplant. The primary outcome was the amount of intraoperative estimated blood loss in those patients receiving the patch compared to without. Secondary outcomes were the subjective achievement of hemostasis, perigraft collection, and drop in hemoglobin 48 hours postoperatively. Methods: We performed a single-center, prospective, randomized trial. Patients scheduled to undergo deceased donor renal transplant surgery were randomized to receive the PEG-coated patch or standard hemostasis (i.e., electrocautery and clips). Results: A total of 30 patients were enrolled over 15 months and randomized to receive the PEG-coated patch (n=15) or standard hemostasis (n=15). The mean age was 62.5 years. As determined by the operating surgeon, hemostasis was successfully achieved in all 15 cases using the PEG-coated patch. In the PEG-coated patch group, there was a trend towards less estimated blood loss (237 cc vs. 327 cc; p=0.11) and a lower drop in hemoglobin 48 hours postoperatively (22.27 g/L vs. 29.53 g/L; p=0.09) compared to the standard hemostasis group. Perigraft collection was similar between groups (27% vs. 40%; p=0.43). Subgroup analysis on patients who received anticoagulation therapy revealed no significant difference in blood loss between groups. Conclusions: Based on our single-center experience, the PEG-coated patch (Hemopatch®) is a safe and feasible option to aid hemostasis during deceased donor renal transplant surgery. Hemostasis was successfully achieved in all cases using the PEG-coated patch.

The present study was conducted to find out any alteration in the expression and activity of alkaline phosphatase in the brush border membrane (BBM) from renal cell carcinoma (RCC) in comparison to normal renal BBM. The specific activity of alkaline phosphatase was drastically reduced in homogenate as well as BBM from RCC kidney when compared to ALP activity in BBM of normal kidney. Kinetic studies revealed that diminished activity of alkaline phosphatase in BBM isolated from RCC was fraternized with decrease in maximal velocity (Vmax) and increase in affinity constant (Km) of the enzyme. SDS-PAGE studies showed that the BBM proteins having molecular weights ranging from 95 to 170 kDa were poorly expressed in RCC BBM in relative to normal kidney BBM. Incubation of SDS-PAGE gel with BCIP/NBT dye clearly showed that the expression of ALP in tumor renal BBM was markedly reduced as compared to normal kidney. Further, Western blot analysis using anti-alkaline phosphatase antibody also confirmed the reduced expression of ALP in tumor renal BBM. Lipid composition in reference to phospholipids, glycolipids and cholesterol in tumor renal BBM was altered to that of normal renal BBM, indicating alteration in membrane fluidity of tumor renal BBM.

Emphysematous pyelonephritis (EPN) in renal allograft is rare but potentially lethal complication and requires aggressive medical and/or surgical therapy to achieve cure. We report a case of 60-year-old diabetic male with poor cardiac function on maintenance hemodialysis, who underwent delayed allograft nephrectomy for EPN in failed renal allograft. Blood culture grew Bacteroides. He was stable in the postoperative period but passed away on day 4 due to myocardial infarction likely secondary to poor baseline cardiac function. Delay in diagnosis and treatment could have contributed to this unfavorable outcome. There is a paucity of published literature regarding EPN in the transplant population, such that management decisions (percutaneous conservative versus urgent surgical) are challenging. Further studies are required to establish treatment guidelines.

The mechanism of proteinuria in many common kidney diseases involves glomerular hemodynamic effects and local expression of angiogenic, fibrogenic, and vasoactive factors. Transforming growth factor (TGF)-β has been associated with many diseases involving proteinuria and renal fibrosis. TGF-β has been shown to induce podocyte dedifferentiation in vitro , but its in vivo effects on the glomerular filtration barrier are not well described. In this study, we used an adenovirus vector to transfer active TGF-β1 to the glomeruli of rat kidneys. Transient TGF-β1 overexpression induced significant proteinuria, podocyte foot process effacement, nephrin down-regulation, and nephrinuria. The expression of synaptopodin was also significantly down-regulated by TGF-β1. Increased glomerular expression of Snail, suggestive of an in vivo dedifferentiation process, was associated with a loss of podocyte epithelial markers. The expression of angiopoietin-1 and angiopoietin-2 was significantly increased in TGF-β1–transfected glomeruli, and TGF-β1 increased the expression of the angiopoietin receptor, Tie2, in podocyte cell culture. TGF-β1 down-regulated nephrin and synaptopodin expression in podocytes in cell culture; this effect was reversed by the blockade of both angiopoietin and Tie2 activities. These findings suggest that locally produced TGF-β1 can cause podocyte dedifferentiation marked by a loss of synaptopodin, nephrin, and foot process effacement, partly regulated by angiopoietins. This process represents a novel pathway that may explain proteinuria in a variety of common renal diseases.

A unilateral impacted lower ureteric calculus presenting as bilateral urinoma is rare, and spontaneous rupture of the ureter being the cause is even rarer. It is important to distinguish this uncommon condition from the much commoner condition of urinary extravasation from forniceal rupture. We are reporting a case of left lower ureteric calculus causing spontaneous rupture at the upper ureter presenting as bilateral retroperitoneal urinoma.

Purpose : Data of laparoscopic donor nephrectomy (LDN) with multiple renal arteries for donor and recipient outcomes were reviewed, with the aim of clarifying whether the laparoscopic approach is safe in the presence of multiple renal arteries. Materials and Methods : All donor nephrectomies performed at our institution from 2004 to 2008 were reviewed retrospectively. Results were compared between LDN kidneys with multiple arteries and those with a single renal artery. Results : Out of 171 donor nephrectomies, 21 (12%) were performed for kidneys with multiple renal arteries. All of the 150 (88%) donor nephrectomies in the single vessel group were performed laparoscopically. In the multiple artery group, 9 (43%) underwent an open procedure while 12 (57%) underwent a laparoscopic procedure. The warm ischemia time was longer in the multiple artery group than the single artery group, but the difference was not statistically significant (4.25±0.87 min vs. 4.12±0.95 min, respectively). Regarding transplant recipients, the vascular anastomosis time was similar in both groups (30±4.6 min vs. 29.5±3.7 min). The operative blood loss in the transplant recipients was significantly more in the multiple artery group compared to the single artery group (339±292 ml and 130.7±44.8 ml, respectively; P =0.03). The recipient renal function was similar for both the groups at postoperative day 7, 1 month, and at 1 year. Conclusion : The data support the fact that the laparoscopic approach to donor nephrectomy in the presence of multiple renal arteries can be performed safely with adequate laparoscopic experience.