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We systematically evaluated the impact of positive surgical margins (PSM) on oncological outcomes after partial nephrectomy for renal cell carcinoma. Forty-two studies comprising 101,153 subjects were included and five distinct meta-analyses were performed. PSM was associated with increased risk of local recurrence (hazard ratio (HR) 6.11—high certainty), metastasis (HR 3.29—moderate certainty), overall relapse (HR 2.25—high certainty), overall mortality (HR 1.30—moderate certainty), and may be associated with increased cancer-specific mortality (HR 1.91—low certainty). Patients with PSM should be counseled for the possibility of additional surgery, novel adjuvant therapies, and more rigorous surveillance.

Introduction: Renal cell carcinoma (RCC) has various histopathological tumor subtypes which have a significant implication on the oncological outcome of these patients. We aimed to evaluate the distribution of RCC subtypes presenting at a tertiary care center in the Middle East, in comparison to the distribution reported in different geographic areas worldwide. Methods: A retrospective chart review was conducted on all patients who underwent partial or radical nephrectomy for RCC at the American University of Beirut Medical Center between January 2012 and January 2018. Data on histologic subtypes were compiled and compared to representative series from different continents. Results: One hundred and seventy-nine patients with RCC were identified, of whom 122 (68.2%) were classified as clear cell, 30 (16.8%) as papillary, 17 (9.5%) as chromophobe, and 10 (5.6%) as unclassified. When compared to other regions of the world, this Middle Eastern series demonstrated a higher prevalence of the chromophobe subtype compared to Western populations (9.5% in the Middle East vs. 5.3% in the US and 3.1% in Europe) and a lower prevalence of clear cell subtype (68.2% in the Middle East vs. 78.7% in the US and 85.8% in Europe). Conversely, there was a higher prevalence of papillary RCC in the Middle East (16.8%) compared to North America (13.1%, 95% confidence interval [CI]: 12.7–13.6), Europe (11.1%, 95% CI: 10.0–12.1), and Australia (10.2%). The prevalence of chromophobe and clear cell RCC in the Middle East was similar to that reported in South America. Conclusions: The distribution of RCC subtypes in this Middle Eastern cohort was significantly different from that reported in the Western hemisphere (Europe and the US) but similar to that reported in South America and Australia. These findings may point to a possible genetic predisposition underlying the global variation in distribution.

Autosomal dominant polycystic kidney disease is the fourth most common single cause of end-stage renal disease worldwide with both renal and extrarenal manifestations, resulting in significant morbidity. Approaches to the management of this disease vary widely, with no broadly accepted practice guidelines. Herein, we reviewed the various surgical and interventional management options that are targeted toward treating the symptoms or addressing the resulting kidney failure. Novel treatment modalities such as celiac plexus blockade and renal denervation appear to be promising in pain relief; however, further studies are lacking. Renal cyst decortication seems to have a higher success rate in targeting cyst-related pain compared with aspiration only. In terms of requiring major surgical intervention, such as need and timing of native nephrectomy, there are several considerations when deciding on transplantation with or without a pretransplant native nephrectomy. Patients who are not candidates for native nephrectomy may consider transcatheter arterial embolization. Based on our review of the contemporary indications for genitourinary interventions in the management of autosomal dominant polycystic kidney disease, we propose an algorithm that depicts the decision-making process on assessing the indications and timing of native nephrectomy in patients with end-stage renal disease awaiting transplant.

Objectives We aim to compare the outcomes of a 3-arm versus a 4-arm robotic assisted partial nephrectomy (RAPN) using the da Vinci Si model; as well as, illustrate the deployment of long ports to decrease arm collision during the 4-arm approach. Patients and Methods Results of RAPN in a Middle Eastern tertiary referral center from August 2013 to December 2017 are reported. Comparison between 3 versus 4-arm robotic approaches was done in regards to patient and tumor characteristics, operative parameters, and postoperative outcomes. Statistical analysis was performed with the Student's t-test and chi-squared test. Results Forty consecutive 3-arm RAPNs and 40 consecutive 4-arm RAPNs were retrospectively evaluated. Differences in tumor complexity between the two groups were statistically insignificant. Similarly, surgical margin positivity, mean ischemia time, estimated blood loss, length of hospital stay, and mean change in serum creatinine were statistically insignificant between the two groups. Mean operative time was significantly shorter by 42 minutes in the 4-arm vs 3-arm group (p=0.01). Conclusions The addition of a 4th arm in RAPN can be of benefit in centers that still rely on the da Vinci Si model. The ease of hilar dissection, retraction, and surgeon independence instigated a statistically significant decrease in operative time with 4-arm use.

Objective To report on the surgical, oncological and early functional outcomes of robot-assisted radical prostatectomy (RARP) at our tertiary care centre, as there is a scarcity of reports on outcomes of robotic surgery from the Middle East. Patients and methods We reviewed the electronic health records for patients undergoing RARP between 2013 and 2019 at the American University of Beirut Medical Center. We collected patients’ demographics and preoperative oncological factors including prostate-specific antigen (PSA), clinical oncological stage, and World Health Organization (WHO) grade. PSA persistence, biochemical recurrence (BCR) and positive surgical margin (PSM) were reported. Complications were categorised by Clavien–Dindo grade. Moreover, the postoperative oncological outcomes including the rates of adjuvant and salvage androgen-deprivation therapy (ADT) and external-beam radiation therapy (EBRT), chemotherapy, and metastasis were reported. Additionally continence and potency results were retrieved. Results For the designated period, 250 patients underwent RARP of which 182 (72.8%) underwent lymph node dissection. The median (interquartile range) anaesthesia time was 330 (285–371) min and the estimated blood loss was 200 (200–300) mL. The overall complication rate was 8%, with 2% Clavien–Dindo Grade III–IV complications. The PSM and BCR rates were 21.6% and 6.4%, respectively. Adjuvant ADT and EBRT was administered to 7.2% of the patients. Functional data was available for 112 patients. Continence was 68%, 82% and 97% of the patients at 3, 6 and 12 months, respectively. For 65 patients who had bilateral nerve sparing potency was 37%, 60% and 83% at 3, 6 and 12 months, respectively. Conclusion This is the largest RARP series from the Middle East. The surgical, oncological and functional outcomes are consistent with those published in the literature. This confirms the safety and efficacy of applying robotic technology in our region during the implementation phase. Abbreviations: ADT: androgen-deprivation therapy; AJCC: American Joint Committee on Cancer; AUBMC: American University of Beirut Medical Center; BCR: biochemical recurrence; CPT: Current Procedural Terminology; EBRT external beam radiation therapy; IQR, interquartile ranges; LOS: length of stay; PLND: pelvic lymph node dissection; PSM: positive surgical margin; (O)(RA)RP, (open) (robot-assisted) radical prostatectomy

Background: Data from the Middle East regarding second primary malignancy (SPM) after radical prostatectomy are limited. Our objective was to estimate the overall risk of developing second primary malignancy (SPM) among Middle Eastern men with prostate cancer who underwent surgical extirpation of their prostate. Materials and methods: We conducted a retrospective study of 406 patients who underwent radical prostatectomy in a tertiary centre and who had no evidence of previous malignancy from 1998 to 2012. Standardized incidence ratios (SIRs) and 95% confidence interval (CI) were calculated to analyze the risk of SPM in our population compared with the general population. Cox-regression models were also conducted to correlate the clinicopathological factors with the development of SPM. Results: After 14 years of follow-up, the incidence rate of SPM was 100.9 per 1,000 person-years. The most frequent SPMs were bladder cancer (n = 11, 27%) followed by hematological malignancies (n = 9, 22%) and lung cancer (n = 7, 17%). The overall risk for men with prostate cancer to develop SPM is lower than the men in the general population (standardized incidence ratios = 0.19; 95% CI: 0.14–0.25). A multivariate analysis failed to correlate any of the clinicopathological factors with the development of SPM. Conclusion: Patients with prostate cancer who underwent surgical expiration of their prostate are at lower risk of developing SPM compared with the general population. Keywords: Prostate Cancer, Radical Prostatectomy, Second Primary Malignancies, Standardized Incidence Ratios

Background: The aim of the study was to evaluate the utility of multiparametric magnetic resonance imaging (mp-MRI)-transrectal ultrasound (TRUS) cognitively targeted biopsy in identifying the most significant cancerous lesion in the prostate to decrease the incidence of pathologic upgrading after radical prostatectomy. Methods: We conducted a retrospective review of all radical prostatectomies at the American University of Beirut Medical Center between January 2016 and 2017. Pathology reports for both, TRUS biopsy and surgically resected specimens were analyzed and compared using SPSS. Results: Among 66 patients who underwent radical prostatectomy, 44 patients underwent a standard random 12-core biopsy of the prostate, while 22 patients underwent 4 - 5 cognitively targeted biopsies. Biopsy Gleason scores were compared to surgically resected specimens. Of mp-MRI targeted biopsies, 86% were identical to the surgical specimen, while 14% were upgraded. Of the random biopsy, 55% patients upgraded after surgery, while 38% were concordant with the random biopsy result. Moreover, 13/24 patients who upgraded after random biopsy, did so from Gleason 6 (3+3) to Gleason 7 (3+4). The difference in pathological upgrading among both groups is statistically significant, and confirms the importance of MRI-TRUS cognitively targeted biopsy in identifying the highest risk lesion. This may have significant implications on the choice of treatment prior to embarking on surgical resection of prostate cancer. Conclusion: MRI-TRUS targeted biopsy is more accurate than random biopsy in identifying the most significant cancerous lesion, resulting in a decreased incidence of pathologic upgrading after prostatectomy. This may have significant implications on the choice of treatment especially in low risk prostate cancer. Larger scale multicenter studies are required. World J Nephrol Urol. 2018;7(1):12-16 doi: https://doi.org/10.14740/wjnu285w

Background: Prostate cancer (PCa) is the second most frequent cause of cancer-related death in men worldwide. It is a heterogeneous disease at molecular and clinical levels which makes its prognosis and treatment outcome hard to predict. The epithelial-to-mesenchymal transition (EMT) marks a key step in the invasion and malignant progression of PCa. We sought to assess the co-expression of epithelial cytokeratin 8 (CK8) and mesenchymal vimentin (Vim) in locally-advanced PCa as indicators of EMT and consequently predictors of the progression status of the disease. Methods: Co-expression of CK8 and Vim was evaluated by immunofluorescence (IF) on paraffin-embedded tissue sections of 122 patients with PCa who underwent radical prostatectomies between 1998 and 2016 at the American University of Beirut Medical Center (AUBMC). EMT score was calculated accordingly and then correlated with the patients' clinicopathological parameters and PSA failure. Results: The co-expression of CK8/Vim (EMT score), was associated with increasing Gleason group. A highly significant linear association was detected wherein higher Gleason group was associated with higher mean EMT score. In addition, the median estimated biochemical recurrence-free survival for patients with < 25% EMT score was almost double that of patients with more than 25%. The validity of this score for prediction of prognosis was further demonstrated using cox regression model. Our data also confirmed that the EMT score can predict PSA failure irrespective of Gleason group, pathological stage, or surgical margins. Conclusion: This study suggests that assessment of molecular markers of EMT, particularly CK8 and Vim, in radical prostatectomy specimens, in addition to conventional clinicopathological prognostic parameters, can aid in the development of a novel system for predicting the prognosis of locally-advanced PCa.

Background: Several studies have alluded to a detrimental impact of the surgeon’s “learning curve” on outcomes of minimally invasive surgery. In this study, we evaluated the outcomes of robotic-assisted partial nephrectomy (RAPN) versus open partial nephrectomy (OPN) for kidney tumors, during the introduction of Robotic Urologic Oncology at our institution. Methods: A retrospective review of all consecutive partial nephrectomies (PN), RAPN and OPN, performed at the American University of Beirut Medical Center since the inception of the robotic program in July 2013 until July 2015. Thirty-four consecutive patients underwent PNs, 19 OPN and 15 RAPN. Preoperative variables (patient characteristics, tumor size, and RENAL score) and perioperative renal functional/patient outcomes (% change in glomerular filtration rate (GFR), ischemia time, blood loss, need for blood transfusions, total operating time, and length of hospital stay) were compared using SPSS. Results: Preoperative variables, including the size and RENAL score of the tumor were analyzed. The difference in the median size of the tumor between OPN and RAPN was not statistically significant (4.5 ± 2.7 cm vs. 3.6 ± 1.7 cm, respectively, P = 0.25). RENAL score was significantly higher for OPN compared to RAPN (7.3 ± 2.3 vs. 4.9 ± 1.5, respectively, P < 0.05). Mean operative time was significantly shorter for OPN vs. RAPN (178 ± 52 min vs. 296 ± 86 min, respectively, P < 0.05). Cold ischemia time was 24 ± 3 min in OPN, and warm ischemia time was 17.5 ± 2 min for RAPN; 10 out of the total 15 robotic cases were performed with a warm ischemia time of < 20 min. Intraoperative blood loss was comparable for both approaches (225 ± 132 mL in OPN vs. 243 ± 192 mL in RAPN), and there was no need for blood transfusions in either group. Hospital stay was significantly longer for OPN vs. RAPN (6 ± 1.6 days vs. 4 ± 0.9 days, respectively, P = 0.01). The change in GFR was comparable among both procedures (OPN = -9% vs. RAPN = -7%); pathological margin status was also comparable among both procedures, with 1/19 (5%) positive focal margins in OPN vs. 0/14 in RAPN. None of the robotic procedures required conversion to the laparoscopic or open approach. Conclusions: RAPN is currently an established approach for the treatment of kidney tumors with the advantages of decreased crude ischemia time and a shorter hospital stay, with comparable intraoperative blood loss and risk of GFR reduction. Our data show that tumor characteristics were not equivalent, with higher RENAL scores noted in patients allocated to OPN vs. RAPN, thus limiting a fair comparison of outcomes. However, the data confirm that with proper selection of patients for RAPN, outcomes were equivalent to OPN and were not jeopardized during the initial robotic learning curve. Larger prospective studies are needed to validate our results. World J Nephrol Urol. 2016;5(4):79-82 doi: https://doi.org/10.14740/wjnu286w

Background Radical cystectomy (RC) remains the standard of care for muscle-invasive bladder cancer (MIBC). Because of the higher overall risks associated with RC, particularly in the elderly patients with multiple comorbidities, other less invasive bladder preservation strategies have been considered. Methods This is a retrospective chart review of patients diagnosed with MIBC, pT2–4N0–2M0, at the American University of Beirut Medical Center between 2007 and 2017. Results 98 patients, 85 (86.7%) males and 13 (13.3%) females, were included. Of the 98 patients, 19 (19.3%) patients were treated with upfront CRT, 35 (35.7%) were treated with upfront RC and 44 (45%) were treated with NAC. 26 (26.5%) patients underwent RC after NAC and 18 (18.4%) received CRT after NAC. The mean overall survival (OS) for the different treatment modalities was 69.4, 60.4, 56.1 and 44.2 months for RC, CRT, RC post-NAC and CRT post-NAC, respectively (p = 0.83). The median disease-free survival (DFS) was 29, 22, 21 and 16 months for RC, CRT, RC post-NAC and CRT post-NAC, respectively (p = 0.49). Patients with pT3/T4 had a higher risk of death by 3.335 folds compared to pT2 (95% CI [1.321–8.422], p Conclusions No difference was noted in the OS and DFS between the groups who underwent RC post-NAC and CRT post-NAC. These findings further support the possibility of bladder preservation after the treatment with NAC for MIBC. The pathologic T stage at diagnosis is an important prognostic factor regardless of treatment modality.

Background Positive surgical margin (PSM) is a predictor of biochemical recurrence (BCR) following radical prostatectomy (RP). Attempts to stratify PSM based on linear length, Gleason score, location and number have failed to add to predictive models using margin status alone. We evaluated the prognostic significance of Ki-67 expression in this setting. Methods Immunohistochemical staining for Ki-67 was done on prostatectomy specimens from 117 patients who had a PSM. Ki67 expression was measured at the margin and in the index lesion. Patients were dichotomized based on Ki-67 expression into three groups. Group 1 with no Ki-67 expression, Group 2 with Ki-67 ≤ 2%, and Group 3 with Ki-67 ≥ 3%. To eliminate the impact of the adjuvant treatment (AT) on the outcome, data were analyzed by the Cox proportional hazards in which AT was Considered as a time-dependent covariate. Results The discordance rate of Ki-67 expression between matched index lesion and margin specimens was 44/117 (37.6%). There was a trend for higher risk of BCR (HR:2.06, (0.97–4.43), P = 0.06) in patients expressing high Ki67 at the surgical margin although this was not statistically significant. However High Ki-67 expression in the index lesion was an independent predictive factor for BCR in this subset of patients. (HR:4, (1.64–9.80), P = 0.002). Conclusion High Ki67 expression in the index prostate cancer lesion is an independent predictor of BCR in patients with positive surgical margin following radical prostatectomy. Our findings need to be validated in a larger cohort.

Background The aim of this study is to investigate the effect of tumor characteristics and parameters of treatment response in predicting biochemical disease-free survival (BFS) for patients with intermediate or high risk prostate cancer treated by combined definitive external beam radiation therapy (EBRT) and androgen deprivation therapy (ADT). Methods Between June 1995 and January 2015, 375 patients with localized prostate cancer and a National Comprehensive Cancer Network (NCCN) intermediate or high risk categories were treated by definitive EBRT and ADT. Median duration of androgen blockade was 10 months (range: 3–36 months); Median radiation dose was 72 Gy (Range: 70–78 Gy). Median follow-up time was 5.8 years (range: 0.8–16.39 years). The main study endpoint was biochemical disease free survival (BFS). Results Forty seven patients (12.5%) developed biochemical recurrence (BCR) during the observation period. Monovariate analysis identified baseline PSA (bPSA) (p = 0.024), T-stage (p = 0.001), Gleason’s score (GS) (p = 0.042), radiation dose (p = 0.045), PSA pre-radiation therapy (p = 0.048), and nadir PSA (nPSA), (p

Gallium-68 prostate-specific membrane antigen positron emission tomography-computed tomography (Ga-68 PSMA PET/CT) is an imaging modality that promises improved sensitivity and specificity of detection of prostate cancer lesions based on their increased uptake of PSMA-based radiotracers. It remains an emerging modality that has not yet been endorsed in the guidelines for the management of prostate cancer pending more established evidence to prove its efficacy. The objective of the study is to assess the value of Ga-68 PSMA PET/CT in the detection and localization of patients diagnosed with intermediate or high risk prostate cancer. Twenty three patients with intermediate or high risk prostate cancer had undergone Ga-68 PSMA PET/CT imaging prior to robotic assisted radical prostatectomy. Surgical specimens were then submitted for histological examinations. Lesions visualized on PET/CT and histology were independently mapped unto a 36-segment (Prostate Imaging Reporting and Data System version 2 [PI-RADS v.2]) map of the prostate. Concordance of visualization on PET/CT as compared to the histology as gold standard reference was then assessed. Lesions visualized on PET/CT and histology were independently mapped unto a 36-segment (PI-RADS v.2) map of the prostate. Concordance of visualization on PET/CT as compared to the histology as gold standard reference was then assessed. Sensitivity for all lesions identified on Ga-68 PSMA PET/CT was 42.37%; specificity was 88.61%. Both parameters were higher when considering only index lesions for which sensitivity was 68.42% and specificity was 98.23%. Sensitivity for the index lesions in intermediate risk group was 53.2% and was higher in the high risk group reaching 83.33%. Ga-68 PSMA PET/CT provides accurate localization of tumor lesions in patients with intermediate and high risk prostate cancer.

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.

Introduction: Docetaxel has become the standard chemotherapy for patients with castration-resistant prostate cancer (CRPC). We wanted to assess the efficacy and safety of a weekly high-dose calcitriol, docetaxel and zoledronic acid combination in CRPC. Patients and Methods: Thirty patients were enrolled to receive calcitriol 0.5 µg/kg orally in 4 divided doses over 4 h on day 1 of each treatment week, docetaxel 36 mg/m2 i.v. infusion on day 2 of each treatment week and zoledronic acid 4 mg i.v. on day 2 of the first and fifth week of each cycle. Treatment was administered weekly for 6 consecutive weeks on an 8-week cycle. Results: Out of 23 evaluable patients, there was a response of prostate-specific antigen (PSA) in 11 patients (47.8%); 6 (26.1%) had a stable PSA level for a median of 4.2 months. The median survival time was 15 months (95% confidence interval 13.9–16.1 months). The regimen was generally tolerated; anemia was the only grade 3/4 hematological toxicity in 2 patients. Conclusions: This regimen was tolerated, and half of the patients had a PSA response. Although our response rates are inferior to some studies using docetaxel, we believe our response rates are acceptable knowing that we are treating CRPC, which still has variable outcomes.

High risk renal transplant recipients experience excess graft loss despite overall improvements in the results of cadaveric renal transplantation. We evaluated a novel immunosuppression regimen consisting of simultaneous administration of OKT3, cyclosporine, azathioprine and prednisone. Of the 12 high risk patients studied 5 received 2 transplants, 1 received 3 transplants and 8 had peak panel reactive antibodies of greater than 60%. The protocol consisted of cyclosporine (7 mg./kg. orally or 3 mg./kg. intravenously per day) starting from the day of transplant regardless of graft function; 5 mg. OKT3 per day for 10 to 14 days starting intraoperatively; 5 mg./kg. azathioprine per day for 2 days, then 1.5 mg./kg. per day and adjusted according to white blood cell counts, and prednisone taper at 2 to 0.4 mg./kg. per day on day 10. The dose of cyclosporine was increased to 14 mg./kg. per day orally when serum creatinine was less than 3 mg./dl. The cyclosporine whole blood levels (measured by high performance liquid chromatography) were maintained between 250 and 400 ng./ml. in the first 3 months. Followup evaluations ranged from 3 to 28 months (median 8.5). Seven patients (58.3%) had acute tubular necrosis and required dialysis support for 2 to 5 weeks. Six patients (including 5 with acute tubular necrosis) experienced 1 episode of acute rejection in the first 3 months (2 of these were due to accelerated vascular rejection). Two rejections responded to pulse steroid treatment, while 4 (including 2 with vascular rejection) were treated with antilymphoblast globulin rescue therapy for 10 to 14 days. Symptomatic cytomegalovirus pneumonia occurred in 3 patients (25%). There were no deaths or graft losses. No case of malignancy was observed to date. The serum creatinine is less than 2 mg./dl. in 9 patients, and 2.5 to 2.9 mg./dl. in the remaining 3. We conclude that simultaneous quadruple immunosuppressive regimen that includes induction cyclosporine and OKT3 is a highly effective therapy for high risk patients, yielding excellent short-term and intermediate success rates. Long-term results of this regimen, including neoplastic potentiation, cannot be addressed because of the limited followup of these patients.

Objectives To summarize the experience of the Middle East in laparoscopic donor nephrectomy (LDN), to discuss the associated advantages and salient problems, to examine the learning curve encountered compared with that of the pioneering centres in the West, and the contribution of the regional centres to the worldwide experience. Methods We searched Medline and PubMed for all centres performing LDN in the Middle East. Questionnaires were e-mailed to the regional transplantation centres, and programme directors, and leading urological and transplant surgeons were contacted by telephone. Results LDN in the Middle East was first introduced in 2000; this approach has been pioneered and practised at seven transplant centres within five countries in the region, and was restricted to only three Arab countries, i.e. Lebanon, Egypt and Kuwait. Data collection yielded a total of 888 procedures over one decade, representing only 2% of the total of ≈50,000 transplants during the same period. Despite variability of accurate reporting the overall outcomes were similar to those of open DN. The spectrum of complications was comparable to that from major centres in the USA during their learning curve. Conclusions The introduction of LDN in the Middle East has been gratifying. The relative hesitancy in introducing LDN in the rest of the Arab Middle East is multifaceted. The advantages conferred to the donor underscore the need for further expansion of this approach for kidney retrieval.

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.

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.

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

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

Transplant recipient sensitization to major histocompatibility complex (MHC) antigens is a major problem in clinical organ transplantation in terms of both magnitude and implication. Highly sensitized patients (HSPs) waiting for renal transplantation constitute a high-risk group with difficult management problems. In this review the factors involved in sensitization, detection of sensitization in the pretransplant period, various strategies tried in its prevention, and the current therapeutic approach to management of HSPs are discussed. Although prevention of sensitization is ideal, in practice a certain percentage of transplant recipients continue to exhibit hypersensitization despite all measures. Methods to remove preformed antibodies are effective but are expensive and not freely available. Aggressive immunosuppression based on cyclosporine (CsA) induction protocols constitute the mainstay in the management of HSPs. The availability of newer, potent, and more specific immunosuppressive agents, particularly those suppressing antibody synthesis, has opened a new avenue for more specific immunosuppression and better graft and patient survival following transplantation. Their clinical utility in improving patient and graft survival in HSPs needs to be evaluated.

Group I included 105 consecutive primary renal transplants prospectively followed using a triple protocol of MMF (1 gm P.O. BID), ME-CsA (8-12mg/kg per day) and prednisone taper (60mg to 30mg over eight days). These included 34 Cadaver donors (CAD)(32.4%), 20 living unrelated donors (LUD)(19%), and 51 living related donors (LRD)(48.6%) that included five HLA identical and 46 haplo-identical and non-identical grafts. Group II included 137 consecutive transplant recipients with similar pretransplant demographics; CAD: 60/137 (43.8%), LUD 5 10/137 (7.3%), LRD 5 67/137 (48.9%), that included 11 HLA identical, and 56 HLA haplo-identical or nonidentical grafts. The number of retransplants in Group I (MMF) was five (4.76%) and in Group II 5 seven (5.11%). CsA dosing was diligently applied according to CsA target trough levels as previously reported. All patients received anti-CMV prophylaxis using high dose Acyclovir 3200 mg/day for D1/R2 and D2/R1 and Ganciclovir if ATG or OKT3 were used for rejection treatment.

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.

From 1962 to 1984 splenorenal bypass was performed in 69 patients with renal artery disease caused by either atherosclerosis (n = 54) or fibrous dysplasia (n = 15). Renal revascularization was performed to control hypertension in 27 patients, to preserve renal function in nine patients, and for both of these reasons in 33 patients. The mean follow-up interval is 5.4 years. Postoperatively hypertension was cured or improved in 52 of 60 patients (87%); the serum creatinine level was improved or stable in 37 of 42 patients (88%) who underwent revascularization to preserve renal function. Postoperative graft thrombosis (n = 2) or stenosis (n = 3) occurred in five patients (7%). Splenorenal bypass is an excellent method of revascularization of the left renal artery, particularly for patients with a troublesome aorta that precludes performance of an aortorenal bypass. (J VASC SURG 1985;2:547-51.)

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.

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.

Introduction: Children with complex urinary tract stones present a treatment challenge. There is still no clear consensus regarding their management. Therefore, our goal was to review the endourological therapies in children presenting with complex nephrolithiasis, updated to 2013. Methods: This was a review of published articles, from 1981 to 2013, related to pediatric nephrolithiasis, staghorn calculi, lower pole kidney stones, and uninephric children. The sites from which information was retrieved covered PubMed, the American Urological Association, and Medline. Results: We reviewed 147 articles that demonstrated that small lower pole stones of

From 1980 to 1982, 100 consecutive cadaver renal transplants were performed. All but 2 recipients received preoperative transfusion and all received an initial 2-week course of antilymphoblast globulin. A prospective controlled evaluation of high versus low maintenance prednisone, and antilymphoblast globulin versus intravenous methylprednisolone for first rejection therapy was done. Over-all 1-year graft and patient survivals were 77 and 96 per cent, respectively. Graft survival was equal in the high and low steroid groups. Antilymphoblast globulin was as effective as intravenous methylprednisolone in reversing first rejections. Graft survival was improved with better donor-recipient matched grafts. We conclude that excellent results can be obtained in transfused cadaver renal allograft recipients managed with azathioprine, prednisone and antilymphoblast globulin. The regimen of prophylactic antilymphoblast globulin, low maintenance prednisone and antilymphoblast globulin alone for first rejections is immunologically effective and steroid sparing.

The results of 54 renal transplants performed on 48 patients with end stage renal disease and insulin-dependent diabetes mellitus are reported. Pre-transplant screening with coronary angiography was done to determine the presence and severity of coronary artery disease and left ventricular dysfunction. There were 12 living related donor (group 1) and 42 cadaver renal transplants. The cadaver transplant recipients were grouped further into those who received additional prophylactic immunosuppression with antilymphoblast globulin (group 2, 18 patients) and those who received standard immunosuppression with azathioprine and prednisone (group 3, 18 patients). The 2-year patient and graft survival rates in groups 1 to 3 were 81 and 67, 88 and 69, and 61 and 32 per cent, respectively. The use of prophylactic antilymphoblast globulin for adjunctive immunosuppression resulted in significantly improved graft survival among cadaver recipients (p less than 0.003). Selection of patients for transplantation on the basis of preliminary screening with coronary angiography was found to have a major impact on patient survival.

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.