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We sought to determine whether loss of renal function increases risk of recurrence and metastases in renal cell carcinoma (RCC), and whether this impact was age-related.We performed a retrospective analysis of the International Marker Consortium for Renal Cancer (INMARC) registry. Patients were separated into younger (65 years old) and elder (≥65 years old) age groups, and rates of de novo estimated glomerular filtration rate (eGFR45 mL/min/1.73m2 [eGFR45]) were calculated. Multivariable analysis (MVA) was conducted for predictors of progression-free survival (PFS) and all-cause mortality (ACM). Kaplan-Meier Analysis (KMA) was conducted for PFS and overall survival (OS) in younger and elder age groups stratified by functional status.We analyzed 1805 patients (1113 age65, 692 age≥65). On MVA in patients65, de novo eGFR45 was independently associated with greater risk for worsened progression (HR=1.61, P=.038) and ACM (HR=1.82, P=.018). For patients ≥65, de novo eGFR45 was not independently associated with progression (P=.736), or ACM (P=.286). Comparing patients with de novo eGFR45 vs. eGFR ≥45, KMA demonstrated worsened 5-year PFS and OS in patients65 (PFS: 68% vs. 86%, P.001; OS: 73% vs. 90%, P.001), while in patients ≥65, only 5-year OS was worsened (77% vs. 81%, P.021).Development of de novo eGFR45 was associated with more profound impact on patients65 compared to patients ≥65, being an independent risk factor for PFS and ACM. The mechanisms of this phenomenon are unclear but underscore desirability for nephron preservation when safe and feasible in younger patients.

Sundas Maqsood,1,2 Kareem Elsawah,3 Navpreet Dhillon,1 Shady Soliman,3 Masara Laginaf,2 Vaishali Lodhia,2 Damian Lake,1 Samer Hamada,1 Mohamed Elalfy1– 3 1Corneo-Plastic Unit, Queen Victoria Hospital NHS, East Grinstead, UK; 2Eye Department, Maidstone and Turnbridge Wells Hospitals, Maidstone, UK; 3Cornea Department, Research Institute of Ophthalmology, Giza, EgyptCorrespondence: Mohamed Elalfy Tel +44 1342 414560Email m.elalfy@nhs.netObjective: To report the outcomes of using human amniotic membrane-derived dry matrix (AMDDM) in the management of persistent corneal epithelial defects (PEDs) of various etiologies.Methods: A cohort study of 84 patients age range 7 to 92 years with 93 PEDs were treated with AMDDM (Omnigen® using OmniLenz® at two centers (Queen Victoria Hospital and Maidstone Hospital) in the UK. The main outcome measures were healing response of PED and time to heal after application of AMDDM.Results: A total of 106 applications of AMDDM were recorded for 81 patients (52 males, 29 females) with a spectrum of different etiologies. Fifty-eight percent of the eyes showed complete healing, and 28% showed partial decrease of the size of PEDs with average treatment length recorded as 22.4± 12.3 days. In patients with limbal stem cell deficiency (n=44; aniridia=12, chemical injury=9, Stevens–Johnson syndrome=10), 50% of PEDs showed complete healing and 27% showed partial healing. In patients with microbial keratitis (n=21) (bacterial: 13, fungal: 4, herpetic: 3, acanthamoeba: 1) 57% of PEDs showed complete healing and 33% were partially healed. In patients with keratoplasty (n=16), 56% of PEDs showed complete healing and 31% were partially healed. Vision remained stable in 59% and improved in 27% of the study the population.Conclusion: AMDDM can be easily applied in the clinical setting and has demonstrated its efficiency as a new tool to treat persistent epithelial defects.Keywords: persistent epithelial defects, amniotic membrane derived dry matrix, suture less amniotic membrane

Background: Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for large renal calculi. The primary goal of treatment is absolute clearance of stone. The incidence of residual stones after PCNL ranges from 10% to 60% and may be higher in radiolucent stones. Aim of work: Our objective was to assess the effectiveness of the use of ultrasound during PCNL in patients with radiolucent stones in reducing the incidence of residual fragments postoperatively. Patients and Methods: This was a single center prospective study over a 6 year period. We identified 86 patients undergoing PCNL with radiolucent stones. Ultrasound was used in conjunction with traditional fluoroscopy to identify residual fragments. Each patient had a first day post-operative computed tomography to assess for residual fragments. The sensitivity of ultrasound with fluoroscopy was compared to clinically or radiologically [CT] detected residual fragments. Results: Our overall stone clearance rate was 82.6% [as evidenced by postoperative CT]. The sensitivity of intra-operative ultrasound when compared to postoperative CT was 95.8%, specificity 40.0%, the positive predictive value 88.3% and negative predictive value 66.7%Conclusions: The use of intra-operative ultrasound during PCNL for radiolucent stones may help in reduction of postoperative imaging. However, future studies are recommend.

We sought to evaluate outcomes of lymph node dissection (LND) in patients with upper tract urothelial carcinoma.We performed a multicenter retrospective analysis utilizing the ROBUUST (for RObotic surgery for Upper Tract Urothelial Cancer Study) registry for patients who did not undergo LND (pNx), LND with negative lymph nodes (pN0) and LND with positive nodes (pN+). Primary and secondary outcomes were overall survival (OS) and recurrence-free survival (RFS). Multivariable analyses evaluated predictors of outcomes and pathological node positivity. Kaplan-Meier analyses (KMAs) compared survival outcomes.A total of 877 patients were analyzed (LND performed in 358 [40.8%]/pN+ in 73 [8.3%]). Median nodes obtained were 10.2 for pN+ and 9.8 for pN0. Multivariable analyses noted increasing age (OR 1.1, p0.001), pN+ (OR 3.1, p0.001) and pathological stage pTis/3/4 (OR 3.4, p0.001) as predictors for all-cause mortality. Clinical high-grade tumors (OR 11.74, p=0.015) and increasing tumor size (OR 1.14, p=0.001) were predictive for lymph node positivity. KMAs for pNx, pN0 and pN+ demonstrated 2-year OS of 80%, 86% and 42% (p0.001) and 2-year RFS of 53%, 61% and 35% (p0.001), respectively. KMAs comparing pNx, pN0 ≥10 nodes and pN010 nodes showed no significant difference in 2-year OS (82% vs 85% vs 84%, p=0.6) but elicited significantly higher 2-year RFS in the pN0 ≥10 group (60% vs 74% vs 54%, p=0.043).LND during nephroureterectomy in patients with positive lymph nodes provides prognostic data, but is not associated with improved OS. LND yields ≥10 in patients with clinical node negative disease were associated with improved RFS. In high-grade and large tumors, lymphadenectomy should be considered.

INTRODUCTION AND OBJECTIVE:Impact of lymph node dissection (LND) at the time of radical nephrectomy (RN) for renal cell carcinoma (RCC) remains contentious, though the prognostic benefit in advance...

INTRODUCTION AND OBJECTIVE:Utility of lymph node dissection (LND) in localized upper tract urothelial carcinoma (UTUC) is controversial. We evaluated outcomes of LND in patients with UTUC using a m...

Bladder outlet obstruction in younger men is usually secondary to urethral stricture disease. In the elderly, it is often a due to benign prostatic hyperplasia (BPH). Bladder obstruction secondary to Brunn's Cyst should be considered as a differential diagnosis in young men with acute onset of obstructive symptoms and a cystic lesion at the bladder neck. We report a case of bladder outlet obstruction secondary to Brunn's cyst in a 21-year-old male. Radiological investigations, cystoscopy, and histological examination revealed the rare pathology, which was managed by endoscopic de-roofing of the cyst. The symptoms resolved dramatically, with no recurrence.

INTRODUCTION AND OBJECTIVE:Management of small renal masses (SRM) represents a therapeutic quandary given the low oncologic risk of most tumors and increasing incidental detection. We investigated ...

International audience; Cerebral cavernous malformations (CCMs) are common neurovascular lesions caused by loss-of-function mutations in 1 of 3 genes, including KRIT1 (CCM1), CCM2, and PDCD10 (CCM3), and generally regarded as an endothelial cell-autonomous disease. Here we reported that proliferative astrocytes played a critical role in CCM pathogenesis by serving as a major source of VEGF during CCM lesion formation. An increase in astrocyte VEGF synthesis is driven by endothelial nitric oxide (NO) generated as a consequence of KLF2- and KLF4-dependent elevation of eNOS in CCM endothelium. The increased brain endothelial production of NO stabilized HIF-1α in astrocytes, resulting in increased VEGF production and expression of a "hypoxic" program under normoxic conditions. We showed that the upregulation of cyclooxygenase-2 (COX-2), a direct HIF-1α target gene and a known component of the hypoxic program, contributed to the development of CCM lesions because the administration of a COX-2 inhibitor significantly prevented the progression of CCM lesions. Thus, non-cell-autonomous crosstalk between CCM endothelium and astrocytes propels vascular lesion development, and components of the hypoxic program represent potential therapeutic targets for CCMs.

Key Points Question Was the Patient Protection and Affordable Care Act (ACA) associated with changes in insurance coverage and stage of diagnosis for patients with renal cell carcinoma (RCC), and were differences based on income? Findings In this cohort study of 78 099 patients with RCC, the ACA was associated with increased insurance coverage through Medicaid for low-income patients and detection at an earlier stage of disease. Insurance coverage increased to a greater degree in states that expanded their Medicaid eligibility. Meaning These findings suggest that the ACA was associated with significant increases in insurance coverage for lower-income patients and early diagnosis of RCC., Importance The association of the Patient Protection and Affordable Care Act (ACA) with insurance status and cancer stage at diagnosis among patients with renal cell carcinoma (RCC) is unknown. Objective To test the hypothesis that the ACA may be associated with increased access to care through expansion of insurance, which may vary based on income. Design, Setting, and Participants This retrospective cohort analysis included patients diagnosed with RCC from January 1, 2010, to December 31, 2016, in the National Cancer Database. Data were analyzed from July 1 to December 31, 2020. The periods from 2010 to 2013 and from 2014 to 2016 were defined as pre- and post-ACA implementation, respectively. Patients were categorized as living in a Medicaid expansion state or not. Exposures Implementation of the ACA. Main Outcomes and Measures The absolute percentage change (APC) of insurance coverage was calculated before and after ACA implementation in expansion and nonexpansion states. Secondary outcomes included change in stage at diagnosis, difference in the rate of insurance change, and change in localized disease between expansion and nonexpansion states. Adjusted difference-in-difference modeling was performed. Results The cohort included 78 099 patients (64.7% male and 35.3% female; mean [SD] age, 54.66 [6.46] years), of whom 21.2% had low, 46.2% had middle, and 32.6% had high incomes. After ACA implementation, expansion states had a lower proportion of uninsured patients (adjusted difference-in-difference, −1.14% [95% CI, −1.98% to −1.41%]; P = .005). This occurred to the greatest degree among low-income patients through the acquisition of Medicaid (APC, 11.0% [95% CI, 8.6%-13.3%]; P, This cohort study tests the hypothesis that implementation of the Patient Protection and Affordable Care Act may be associated with increased access to care through expansion of insurance, which may vary based on income, among patients with renal cell carcinoma.

Objective: To determine the odds of accessing telemedicine either by phone or by video during the COVID-19 pandemic. Methods: We performed a retrospective study of patients who were seen at a single academic institution for a urologic condition between March 15, 2020 and September 30, 2020. The primary outcome was to determine characteristics associated with participating in a telemedicine appointment (video or telephone) using logistic regression multivariable analysis. We used a backward model selection and variables that were least significant were removed. We adjusted for reason for visit, patient characteristics such as age, sex, ethnicity, race, reason for visit, preferred language, and insurance. Variables that were not significant that were removed from our final model included median income estimated by zip code, clinic location, provider age, provider sex, and provider training. Results: We reviewed 4,234 visits: 1,567 (37%) were telemedicine in the form of video 1402 (33.1%) or telephone 164 (3.8%). The cohort consisted of 2,516 patients, Non-Hispanic White (n=1,789, 71.1%) and Hispanic (n=417, 16.6%). We performed multivariable logistic regression analysis and demonstrated that patients who were Hispanic, older, or had Medicaid insurance were significantly less likely to access telemedicine during the pandemic. We did not identify differences in telemedicine utilization when stratifying providers by their age, sex, or training type (physician or advanced practice provider). Conclusions: We conclude that there are differences in the use of telemedicine and that this difference may compound existing disparities in care. Additionally, we identified that these differences were not associated with provider attributes. Further study is needed to overcome barriers in access to telemedicine.

Mohamed Elalfy, 1– 3,* Sundas Maqsood, 1,* Shady Soliman, 3 Sherif Momtaz Hegazy, 3Ahmed Abdou Hannon, 3 Zisis Gatzioufas, 1, 4 Damian Lake, 1 Samer Hamada 1 1Corneo Plastic Unit, Queen Victoria Hospital, East Grinstead, UK; 2Eye Department, Maidstone and Turnbridge Wells Hospital, Maidstone, UK; 3Research Institute of Ophthalmology, Giza, Egypt; 4Eye Department, University Hospital Basel, Basel, Switzerland*These authors contributed equally to this workCorrespondence: Mohamed ElalfyQueen Victoria Hospital, Holtye Road, East Grinstead, West Sussex, RH19 3DZ, UKTel +44 01342414560Email m.elalfy@nhs.netPurpose: To evaluate the incidence, demographics, associated risk factors, management and clinical outcomes of ocular hypertension/glaucoma after Descemet stripping automated endothelial keratoplasty (DSAEK).Methods: A cohort review of 81 DSAEK cases was performed at Queen Victoria Hospital, United Kingdom. Patients with pre-existing glaucoma, transient increased IOP within the first 48 hours post-graft, additional post-transplant surgery, or failed to complete one year follow-up were excluded from the study. Ocular hypertension was defined as intraocular pressure (IOP) elevation > 21mmHg or ≥ 6mmHg from baseline at any postoperative visit. The study looked at the incidence, risk factors, response to anti-glaucoma treatment, graft failure and best corrected visual acuity.Results: The incidence of post-DSAEK ocular hypertension and glaucoma was 51.9% and 13.6%, respectively. Steroid-induced IOP elevation was the most frequent cause, with an incidence of 38.3%. Risk factors such as pseudophakia (p=0.024) and preoperative IOP> 16 (p=0.003) were found to be associated with post-DSAEK ocular hypertension. Preoperative IOP> 16 had 5.27 times risk of IOP elevation. Eyes with graft dislocation and/or detachment were significantly associated with post-DSAEK glaucoma (p=0.038). There was no negative effect of OHT on visual acuity and graft status.Conclusion: Glaucoma and OHT are common postoperative complications of DSAEK. Although steroid-induced IOP elevation was the most frequent cause, there are other reasons associated with development of post-DSAEK glaucoma, including graft dislocation and detachment. Eyes with preoperative IOP> 16 mm Hg may require a close monitoring of IOP. In addition, management by medical treatment results in good visual acuity and graft clarity.Keywords: Descemet’s stripping endothelial keratoplasty, DSAEK, glaucoma, ocular hypertension

To evaluate trends and factors predicting use of renal mass biopsy (RMB) for localized Renal Cell Carcinoma in the United States (US) in the context of current guidelines recommendations.We queried the National Cancer Database for cT1-cT3N0M0 Renal Cell Carcinoma diagnosed between 2004 and 2015. Temporal trends of RMB were characterized based on tumor size, treatment (partial nephrectomy [PN], radical nephrectomy [RN], ablation, and no treatment), age and Charlson Comorbidity Index with slopes compared using analysis of variance. Multivariable analysis was used to determine factors associated with use of RMB.Of 338,252 patients analyzed, 11.9% (40,276) underwent RMB. Use of RMB increased throughout the study period from 1,586 (7.6%) in 2004 to 5,629 (16.2%) in 2015 (P0.001). Use of RMB increased greatest for ablation (27 to 63%, P0.001) and tumors 2-4 cm (9 to 20%, P0.001). Multivariable analysis showed year of diagnosis (OR = 1.06; P0.001), higher education (OR = 1.09; P0.001) and insured status (OR = 1.23; P0.001) were associated with increased RMB. Compared to tumors ≤2 cm, tumors 2.1-4 cm (OR = 1.36; P=0.001), 4.1-7 cm (OR = 1.18; P0.001) and7 cm (OR = 1.05; P = 0.03) were associated with higher rates of RMB. Compared to RN, PN was not associated with increased RMB (OR = 1.00; P = 0.92), while ablation (OR = 10.90; P0.001) and no surgical treatment (OR = 4.83; P0.001) were.RMB utilization increased overall, with largest increase associated with ablation. Nonetheless, only two-thirds of patients underwent RMB with ablation, suggesting persistent underutilization. Rates of RMB for tumors ≤2 cm and in those undergoing no treatment increased less, suggesting less utilization for surveillance. However, rates for tumors2-4 cm increased more, suggesting selective utilization of RMB to guide decision-making and risk stratification in small renal masses.

Objective To determine the impact of health care system access on outcomes for Hispanic and Non-Hispanic White patients with renal cell carcinoma (RCC). Methods We retrospectively analyzed Hispanic and non-Hispanic White patients diagnosed with localized RCC between 2007 and 2020. We used Health Resources and Services Administration criteria to identify patients living in Medically Underserved Areas (MUA). Primary outcome all-cause mortality and cancer-specific survival using Log Rank test on Kaplan Meier Analysis. Secondary outcome was all-cause mortality and cancer specific survival on Cox Regression when adjusting for risk factors. Results We analyzed 774 patients, 246 (31.8%) Hispanic patients and 528 (68.2%) Non-Hispanic White patients. Hispanic ethnicity was associated with lower risk of ACM (HR 0.53, P = 0.019) and there was no difference for cancer specific survival (HR 0.57, P = 0.059). Living in a MUA was associated with worse all-cause mortality (P = 0.010) but not cancer specific survival (CSS) (P = 0.169). Comparing Hispanic and Non-Hispanic Whites, KMA revealed no difference in 5-year all-cause mortality (83.1% vs. 78.8%, P = 0.254) and 5-year CSS (85.7% vs. 85.4%, P = 0.403). Conclusions Hispanics had lower all-cause mortality risk and no significant differences in 5-year overall survival and CSS compared to non-Hispanic Whites. Our findings indicate that tertiary referral centers may help mitigate inequalities in access to care.

We describe a method to purify primary brain microvascular endothelial cells (BMEC) from mice bearing floxed alleles of Krit1 (Krit1fl/fl) or Pdcd10 (Pdcd10fl/fl) and an endothelial-specific tamoxifen-regulated Cre recombinase (Pdgfb-iCreERT2), and used these to delete Krit1 or Pdcd10 genes in a time-controlled manner. These BMEC culture models contain a high degree of purity and have been used to identify the major molecular processes involved in loss of Krit1/Pdcd10-induced altered brain endothelial phenotype and function. In addition, these in vitro models of cerebral cavernous malformations (CCMs) enable molecular, biochemical, and pharmacological studies that have contributed significantly to understand the pathogenesis of CCMs. The findings using this in vitro CCMs model have been validated in mouse CCM models and observed in human CCMs. In this chapter, we summarize procedures for isolation and purification of BMEC from transgenic mice, as well as our experience to genetically inactivate CCM genes in the brain endothelium.

281 Background: We aimed to determine whether insurance expansions implemented through the Patient Protection and Affordable Care Act (ACA) were associated with changes in insurance coverage status, stage at diagnosis, and overall survival for patients with renal cell carcinoma (RCC). Methods: We identified patients 40 to 64 years old diagnosed with RCC between 2010 and 2016 in the National Cancer Database. States were categorized as participating on time in Medicaid expansion or not participating. We stratified patients into advanced cancer (stage III + IV) and localized cancer (stage I + II) groups. We stratified patients into low, middle, and high income groups. Stage trend and insurance trend analysis were performed to based on income status amongst patients living in expansion and non-expansion states. Absolute percentage change (APC) was calculated for insurance status and stage migration. Cox Regression Multivariable Analysis was conducted to assess risk of all-cause mortality (ACM) for patients before and after the implementation of the ACA, adjusting for insurance status, income, education, age, race, ethnicity, comorbidity, and living in an expansion state. Results: We identified 78,099 patients who met inclusion criteria. Following implementation of ACA, APC of patients with insurance increased in both Medicaid and non-expansion states by 4.0% and 2.10% (p

Objectives To report a high-volume institution experience with salvage techniques for vascular accidents during live donor renal allotransplantation. Methods Between March 1976 and January 2011, 2208 recipients underwent live donor renal allotransplantation. A retrospective review of recipients with vascular accidents – renal artery thrombosis and renal vein thrombosis – was carried out. Salvage procedures were recorded and their outcomes were assessed. Results A total of 23 (1%) vascular accidents occurred, including renal artery thrombosis and renal vein thrombosis in 19 (0.8%) and four (0.18%) recipients, respectively. All renal artery thrombosis patients were treated by open revascularization and the graft was salvaged in 12 patients (63%). Two renal vein thrombosis events were resolved by percutaneous catheter-directed thrombolytic therapy. Of the other two allografts, one was salvaged by thrombectomy and revascularization, and the other was lost. On univariable analysis, older recipients (P = 0.003), pretransplant hypertension (P = 0.001), more human leukocyte antigen mismatches (≥3; P = 0.036), shorter ischemia time (≤45 min; P = 0.004) and longer time to diagnosis (>3.5 days; P = 0.013) were significantly associated with non-salvage of the graft after vascular accidents. Nevertheless, none of these variables were significant on the multivariable analysis. Over a median follow up of 35 months, the median (range) serum creatinine was 2 mg/dL (range 0.8–8.8 mg/dL), and 11 (79%) recipients were living with functioning grafts. Conclusions Despite the devastating complications, vascular accidents are salvageable and revascularization is crucial for graft salvage. Angiographic percutaneous techniques are viable alternatives for renal vein thrombosis.

To determine risk factors for and the effects of impaired perfusion (IP)-"reduced or non-perfusion"-of graft areas supplied by an accessory artery on allograft function.One hundred five consecutive grafts with multiple renal arteries were prospectively evaluated using Doppler ultrasound (US) to detect the perfusion of allograft segments supplied by the accessory artery. We studied factors predicting and the effects of IP on graft function.Doppler US diagnosed IP of allograft accessory arteries in 11 (10.5%) allografts. Mean values ± standard deviations and median (range) of renographic clearance of grafts with IP were 50.5 ± 26 and 40 (range, 21-92) mL/min, while those of grafts with patent accessory arteries were 68.6 ± 18.9 and 67.2 (range 21-117; P.01). The percentage change in renographic clearance before versus after transplantation increased among grafts with patent arteries and decreased for those with IP (P = .03). On multivariate analysis, factors predicting IP of the accessory artery were delayed graft function (odds ratio [OR] = 9.9; 95% confidence interval [CI] = 1.6-58.6; P = .01) and upper polar arteries (OR = 8.9; 95% CI = 1.8-43.4; P.01).When considering transplants with accessory arteries, greatest attention and efforts should be exerted on upper polar arteries to avoid delayed graft function.

Objectives To compare the haemorrhagic and vascular complications between paediatric and adult renal transplant recipients with a long-term follow-up. Patients and methods Between March 1976 and December 2006, in all, 1865 live-donor renal transplants were carried out. Patients were stratified according to their ages into two groups; paediatric (⩽18 years; 259) and adult (>18 years; 1606). Variables assessed included incidence, risk factors, management and sequelae of vascular and haemorrhagic complications. The effect of these complications on patient and graft survival was compared. Results Haemorrhage requiring active intervention (percutaneous drainage or surgical exploration) was reported in seven children (2.7%) and 29 adults (1.8%), while thrombotic or stenotic complications were recorded in two children (0.77%) and 19 adults (1.18%; P

Objective To determine factors affecting the stone-free rate and complications of percutaneous nephrolithotomy (PNL) for treatment of staghorn stones. Methods The computerized database of patients who underwent PNL for treatment of staghorn stones between January 2003 and January 2011 was reviewed. All perioperative complications were recorded and classified according to modified Clavien classification system. The stone-free rate was evaluated with low-dose noncontrast computed tomography (CT). Univariate and multivariate statistical analyses were performed to determine factors affecting stone-free and complication rates. Results The study included 241 patients (125 male and 116 female) with a mean age of 48.7 ±14.3 years. All patients underwent 251 PNL (10 patients had bilateral stones). The stone-free rate of PNL monotherapy was 56% (142 procedures). At 3 months, the stone-free rate increased to 73% (183 kidneys) after shock wave lithotripsy. Independent risk factors for residual stones were complete staghorn stone and presence of secondary calyceal stones (relative risks were 2.2 and 3.1, respectively). The complication rate was 27% (68 PNL). Independent risk factors for development of complications were performance of the procedure by urologists other than experienced endourologist and positive preoperative urine culture (relative risks were 2.2 and 2.1, respectively). Conclusion Factors affecting the incidence of residual stones after PNL are complete staghorn stones and the presence of secondary calyceal stones. Complications are significantly high if PNL is not performed by an experienced endourologist or if preoperative urine culture is positive.

There is a lack of a standardized reporting methodology for surgical complications of pediatric renal transplantation. We applied Martin criteria and the modified Clavien-Dindo classification in pediatric renal transplantation.We retrospectively reviewed the charts of 447 patients 20 years or younger who underwent renal transplantation between March 1976 and January 2011. Martin criteria were fulfilled and complications were graded according to the modified Clavien-Dindo classification. For early complications grades I and II were considered low grade and III to V high grade. A similar grading system was adopted for late complications.A total of 84 early complications (18.5%) occurred in 77 transplant recipients (17%). Of grade I complications 37 (8.1%) were asymptomatic lymphoceles. Grade II complications were observed in 2 patients (0.4%). Grade IIIa complications included aspiration of hematoma (1 case), percutaneous nephrostomy fixed for ureteral obstruction (3), percutaneous tube drain for symptomatic lymphoceles (7) and antegrade ureteral stenting for ureteral leakage (6). Grade IIIb complications included exploration for wound dehiscence (1 case), revision of ureterovesical anastomosis (8), marsupialization of lymphoceles (4), hemorrhage (3) and vascular thrombotic accidents (6). Graft nephrectomy (grade IVa) complications occurred in 2 transplant recipients. Among 4 mortalities (grade V) only 1 patient died due to surgical complications. On multivariate analysis delayed graft function was the only predicator of high grade surgical complications (p = 0.005). High grade surgical complications affected recipient but not graft survival.Using a standardized, high quality reporting methodology is feasible in pediatric renal transplantation. However, consensus should be sought regarding medical complications and a grading system should be developed for reporting of late complications.

What's known on the subject? and What does the study add? It is known that the kidney damage continues even after release of ureteric obstruction. This study found that giving ferulic acid, antioxidant, after release of ureteric obstruction enhanced the recovery of kidney functions in solitary kidney. OBJECTIVE • To evaluate the effect of ferulic acid (FA) on the recovery of renal function and renal damage after relief of partial ureteric obstruction (PUO) of a solitary kidney. METHODS • Male mongrel dogs (n= 32) were classified into three groups: sham (eight), control (12) and study (12). • A right nephrectomy was carried out and dogs in the study and control groups were subjected to 4 weeks of PUO. • Serum creatinine, creatinine clearance (CrCl) and renographic clearance (RC) were measured at baseline, after 4 weeks of obstruction and 8 weeks after relief of obstruction. • Markers of lipid peroxidation (malondialdehyde [MDA]), superoxide dismutase (SOD), and reduced glutathione (GSH), and immunostaining of markers of apoptosis (caspase 3 and Bcl2), cell proliferation (Ki67) and interstitial fibrosis in the kidney were evaluated at the end of experiment. RESULTS • Ferulic acid enhanced the recovery of serum creatinine, CrCl and RC by an extra 22%, 26% and 33.7%, respectively, of the basal values at 8 weeks, after relief of 4 weeks' obstruction. • In addition, FA caused a significant decrease in MDA and a significant increase in GSH and SOD. • Ferulic acid also significantly reduced the interstitial fibrosis, and caspase 3 expression, and significantly increased the expression of Bcl2 and Ki67 in kidney tissues at 8 weeks after relief of the obstruction. CONCLUSION • Ferulic acid enhances the recoverability of renal function and minimizes the renal damage through reduction of oxidative stress, tubular apoptosis and the interstitial fibrosis in the solitary kidney after relief of PUO.

Purpose To analyse the long-term outcome in relation to multiple graft arteries (MGA) in live-donor renal transplantation, and assess its effect on graft and patient survival. Patients and methods Between March 1976 and November 2009, a total of 2100 live-donor renal transplants were carried out at our centre. Patients were stratified according to the number of graft arteries into two groups, i.e. MGA (two or more arteries; 237 patients) and single-graft artery (SGA; 1863 patients). Variables assessed included patient demographics, site of vascular anastomosis, ischaemia time, onset of diuresis, delayed graft function, acute tubular necrosis (ATN), acute rejection, vascular and urological complications. Moreover, long-term patient and graft survival were compared among both groups. Patients were followed up for a mean (SD) of 112 (63) months. Results Grafts with MGA were associated with a prolonged ischaemia time (P = 0.001) and ATN (P = 0.005). Vascular thrombosis (arterial and venous) had a higher incidence in MGA (2.5%) than SGA (0.6%) (P = 0.01). Both groups were not significantly different for the onset of diuresis, acute rejection and urological complications (P = 0.16, 0.23 and 0.85, respectively). Graft and patient survival were comparable in both groups. The mean (SD) 1-, 5-, 10- and 20-year graft survival rates (%) for MGA were 96.1 (1.26), 86.6 (2.39), 61.3 (4.42) and 33.8 (7.23), and 97.5 (0.36), 86.8 (0.84), 66.0 (1.35) and 37.3 (2.76) for SGA (P = 0.54). Conclusions Although there was a higher incidence of prolonged ischaemia time, ATN and vascular thrombosis in live-donor renal transplants with MGA, it did not adversely affect patient or graft survival. The early, intermediate- and long-term follow-up showed an outcome comparable to that in patients with SGA.

Kamal MM, El-Hefnawy AS, Soliman S, Shokeir AA, Ghoneim MA. Impact of posterior urethral valves on pediatric renal transplantation: A single-center comparative study of 297 cases. Pediatr Transplantation 2011: 15: 482–487. © 2011 John Wiley & Sons A/S. Abstract: Objective: This is a retrospective long-term evaluation of the renal allografts and bladder functions in pediatric recipients who had posterior urethral valves (PUV). Patients and methods: Between March 1976 and February 2009, 2033 live-donor renal transplantations were carried out in our center. Of these, 297 (14.2%) were in the pediatric age (≤18 yr). The pediatric recipients included 20 (6.7%) boys who developed end-stage renal disease as a late complication of PUV and recognized as group I while the remaining 277 pediatric recipients were defined as group II. Demographic characteristics, post-transplant complications and graft function were compared among both groups. Patient and graft survivals of both groups were also estimated. Moreover, the bladder function of the study group was evaluated by urodynamic studies. Results: Patients with PUV (group I) were significantly younger than group II. Although the overall rate of urological complications in both groups was essentially similar, the incidence of urinary fistulae and urinary tract infection were higher in group I. The mean (SD) follow up periods for group I and II were 4.7 (4.1) and 6.4 (4.8) yr, respectively. At last follow up the serum creatinine values were similar among patients of both groups. Moreover, there were no differences in graft or patient survival at five and 10 yr. Detrusor over-activity could be elicited in only one of group I patients. Schafer nomogram showed non-obstructed pattern in all cases. Conclusion: Good functional outcome could be achieved for patients with PUV if renal transplantation is necessary. Pre-transplant surgical procedures may be required such as nephroureterectomy, cytoplasty or injection of refluxing ureters. A robust anti-refluxing uretero-vesical anastomosis is important, and can be achieved by a Lich-Gregoir procedure.

Objectives We evaluated the effect of an angiotensin-converting enzyme inhibitor (enalapril) on renal function during and after the relief of partial unilateral ureteric obstruction (UUO). Materials and methods Thirty-two male mongrel dogs were classified into three groups: sham (eight), control (12; left partial UUO + no medication) and study (12; left partial UUO + enalapril). Dogs in the study and control groups were subjected to 4 weeks of partial UUO. After that, the dogs were re-opened and subjected to Lich-Gregoir vesico-ureteric re-implantation, and were killed humanely by the end of the eighth week after relief of obstruction. The study and control groups were evaluated at baseline, after 4 weeks of obstruction and at 4 and 8 weeks after relief of obstruction, by measuring selective creatinine clearance (CCr), selective renographic clearance (RCr) and renal resistive index (RI). The sham group had sham surgery at 4 and 8 weeks and was evaluated as the other two groups. Results Sham surgery showed no significant effect on any of the evaluated variables. Compared with the control, enalapril offset the reductions of CCr and RCr by an extra 11% and 12% of the basal values by the end of the fourth week of obstruction, respectively. Moreover, compared with the control, enalapril enhanced the recovery of CCr by an extra 10% and of RCr by an extra 23% of the basal values at 8 weeks after relief of the 4-week obstruction. In addition, the increase in RI was significantly less in the enalapril group. Conclusion Enalapril decreases the deterioration of renal function in partial UUO and enhances the recoverability of renal function after relief of obstruction.

OBJECTIVES To evaluate the effect of angiotensin receptor blocker (losartan) on renal function during and after relief of partial unilateral ureteral obstruction (PUO). METHODS A total of 32 male mongrel dogs were classified into 3 groups: sham (8), control (12; left PUO + no medications), and study (12; left PUO + losartan). Dogs of the study and control groups were subjected to 4 weeks of PUO. After that, they were reopened and subjected to Lich-Grigoir ureterovesical reimplantation and then were killed by the end of 32 weeks after relief of obstruction after being evaluated at basal condition; fourth week of obstruction; and at 4, 8, and 32 weeks after relief of obstruction by measurement of selective creatinine clearance (CCr), selective renographic clearance (RC), and renal resistive index. Sham group underwent sham surgery at 4 and 32 weeks and evaluated as the other 2 groups. RESULTS Sham surgery showed no significant effect on any of the evaluated parameters. Compared with the control, losartan saved reduction in CCr by 11% and RC by 20% of the basal value by the end of the fourth week of obstruction, respectively. Moreover, compared with the control, losartan enhanced regain of CCr by 26% and RC by 26% also of the basal value at 32 weeks after relief of fourth week obstruction, respectively. In addition, the increase in renal resistive index was significantly less in the losartan group. CONCLUSION Losartan decreases the deterioration of renal function in PUO and enhances recoverability of renal function after relief of obstruction.

We determined the factors predicting unfavorable results of semirigid ureteroscopy for ureteral calculi.We reviewed the computerized files of 841 patients who underwent a total of 908 ureteroscopic procedures for ureteral stones from January 2003 through December 2006. A semirigid 6/7.5Fr ureteroscope was used in pediatric patients and an 8/10Fr or 8.5/11.5Fr ureteroscope was used in adults. Patients with favorable results were those who became stone-free after a single ureteroscopic procedure without any complications. They were compared with patients who had unfavorable results using univariate (chi-square and t tests) and multivariate (logistic regression) statistical tests to identify risk factors for unfavorable results.The study included 567 males and 274 females with a mean age of 48.5 years (range 2 to 81). The complication rate was 6.7% (61 procedures). The stone-free rate after a single ureteroscopic intervention was 87% (791 procedures). Favorable results were documented in 751 procedures (82.7%). Significant factors for unfavorable results were proximal ureteral stones, ureteroscopy done by surgeons other than experienced endourologists, stone impaction and stone width (relative risk 4, 2.5, 1.8 and 1.2, respectively).Semirigid ureteroscopy is a safe and highly effective treatment modality for ureteral stones.

Objectives To determine the exact value of postoperative heparinization in preventing thrombotic sequelae in non-risky renal transplants and to assess the possible hazards of this therapy through a prospective randomized trial. Methods Of 120 consecutive live-donor renal transplants, 45 patients were excluded because of young age, multiple or atheromatous graft arteries, a history of thromboembolic disease, or intraoperative technical difficulties. The remaining patients were prospectively randomized into three groups, with 25 patients each. Group 1 did not undergo heparinization. Groups 2 and 3 received a prophylactic dose of low-molecular-weight heparin and conventional heparin, respectively, for 1 week. Results None of our patients in any group developed graft vascular thrombosis, deep venous thrombosis, or pulmonary embolism, and the rate of spontaneous closure of arteriovenous fistulas was comparable among the three groups (P = 0.79). No statistically significant difference was found among the three groups in terms of the development of significant perirenal hematomas, rate of blood transfusions, or mean number of transfused units (P = 0.37, P = 0.56, and P = 0.69, respectively). In contrast, a significant decrease in the hemoglobin level occurred in group 3 compared with group 1 among nontransfused patients (1.6 ± 0.8 g% and 0.7 ± 0.9 g%, respectively; P = 0.01). Moreover, a significant shortening of lymph drainage time and a reduction of the total amount of lymphorrhea were found in group 1 compared with groups 2 and 3 (P = 0.01, P = 0.03, respectively). Conclusions Postoperative heparinization should not be routinely indicated in non-risky live-donor renal transplantation.

Purpose: We compared in a prospective fashion the short-term outcome of rotoresection to transurethral resection of the prostate.Materials and Methods: A total of 50 patients with bladder outlet obstruction secondary to benign prostatic hyperplasia were randomized into 2 groups, rotoresection and transurethral resection of the prostate. Mean ± SD patient age was 60.76 ± 5.85 years in the rotoresection and 64.24 ± 6.84 in the transurethral resection groups. All patients had an International Prostate Symptom Score of 8 or more, maximum free flow rate less than 15 ml per second, prostate volume 20 to 100 ml and prostate specific antigen 1 to 4 ng/ml. Pressure flow study revealed bladder outlet obstruction (Schafer’s grade 3 or more). Patients were assessed at 1, 3 and 6 months by International Prostate Symptom Score, maximum free flow rate, transrectal ultrasound, pressure flow study, hemoglobin and urinalysis.Results: At 6 months International Prostate Symptom Score decreased from 26.2 ± 4.06 to 5.32 ± 1.52...

The aims of this study were to report the diagnosis, treatment and functional consequences of postcaesarean section vesicouterine fistula (VUF), and to investigate the need for hysterectomy.The study included 22 cases with VUF after caesarean section (mean age 30.5 years) between 1999 and September 2012. Total urinary incontinence was found in seven women, occasional incontinence in 15 and cyclic haematuria in 17. VUF was diagnosed by ascending cystography in 14 patients and by computed tomography/magnetic resonance imaging in six. Cystoscopy revealed VUF in all women. VUF repair was conducted by a transabdominal approach. The bladder was opened, the fistula was defined, a circumferential bladder incision was made around the fistula and the fistulous tract was excised. The uterine rent and bladder were closed with omentum interposition.Mean follow-up was 2.8 years (range 0.5-7 years). The repair was successful in all women. Hysterectomy was needed in only one case with dysfunctional uterine bleeding and an enlarged uterus. The incontinence disappeared in all cases. The menstrual cycle became regular after a mean of 5 months in all women who retained their uterus. Five women became pregnant and had a successful delivery after 2-3 years. All women were able to have sexual intercourse after 2 weeks.Cystoscopy was the mainstay of diagnosis of VUF in the current study. Imaging was not able to show very small fistulae. Unless otherwise indicated, there is no need to remove the uterus even if the fistula is large. Although the repair is challenging, it was successful in all cases and pregnancy is possible after repair.

To evaluate the long-term functional outcome of percutaneous nephrolithotomy (PNL) for calculi in solitary kidneys and to determine factors leading to renal function deterioration.The computerized files of patients with solitary kidneys who underwent PNL between January 2002 and December 2009 were retrospectively reviewed. Patients with follow-up2 years were excluded. Complications, secondary procedures, and stone-free rates were recorded. Changes in the renal function were judged by comparing preoperative and postoperative estimated glomerular filtration rates. Preoperative, intraoperative, and postoperative factors that may affect renal function were tested using univariate and multivariate analyses to define risk factors for deterioration of renal function on long-term follow-up.The study included 200 patients (133 men [66.5%] and 67 women [33.5%] with mean age 52.3 ± 11.7 years). Complications were reported in 34 patients (17%). Severe bleeding was noticed in 10 patients (5%). The overall stone-free rate was 89.5%. After a mean follow-up of 3 ± 1.4 years (range, 2-8), there was significant improvement of the estimated glomerular filtration rate from 57 to 64 mL/min (P.001). Thirty-one patients (15.5%) showed deterioration of the renal function. Multiple punctures and postoperative bleeding were independent risk factors for renal function deterioration (odds ratio was 3.7 and 4.5, respectively).PNL for calculi in solitary kidneys provided significant improvement in renal function at long-term follow-up. Multiple punctures and severe bleeding are independent risk factors for deterioration of the kidney function.

Objectives: To discuss various endourological techniques used for treatment of urological complications after renal transplantation. Comparison between different endourological options, optimization of patient selection, and criteria of success of these minimally invasive procedures are also provided.

This is a retrospective long-term evaluation of the renal allografts and bladder functions in pediatric recipients who had posterior urethral valves (PUV).Between March 1976 and February 2009, 2033 live-donor renal transplantations were carried out in our center. Of these, 297 (14.2%) were in the pediatric age (≤18 yr). The pediatric recipients included 20 (6.7%) boys who developed end-stage renal disease as a late complication of PUV and recognized as group I while the remaining 277 pediatric recipients were defined as group II. Demographic characteristics, post-transplant complications and graft function were compared among both groups. Patient and graft survivals of both groups were also estimated. Moreover, the bladder function of the study group was evaluated by urodynamic studies.Patients with PUV (group I) were significantly younger than group II. Although the overall rate of urological complications in both groups was essentially similar, the incidence of urinary fistulae and urinary tract infection were higher in group I. The mean (SD) follow up periods for group I and II were 4.7 (4.1) and 6.4 (4.8) yr, respectively. At last follow up the serum creatinine values were similar among patients of both groups. Moreover, there were no differences in graft or patient survival at five and 10 yr. Detrusor over-activity could be elicited in only one of group I patients. Schafer nomogram showed non-obstructed pattern in all cases.Good functional outcome could be achieved for patients with PUV if renal transplantation is necessary. Pre-transplant surgical procedures may be required such as nephroureterectomy, cytoplasty or injection of refluxing ureters. A robust anti-refluxing uretero-vesical anastomosis is important, and can be achieved by a Lich-Gregoir procedure.

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