[Results of surgical treatment of varicocele in male infertility]

To evaluate the results of surgical treatment of varicocele on infertile men, especially regarding sperm count, 245 patients, surgically treated from 1993 to 2003, were evaluated. Patients underwent to ligature and section of the pampiniform plexus, through the subinguinal approach and local anaesthesia. At the follow-up (3-6-12 months) an improvement of sperm count was relieved in 79.5% of patients and the incidence of complications and relapses was of 3.7% and 1.2%, respectively. The Authors stress the efficacy of surgical treatment of varicocele in male infertility and hold the subinguinal approach as an effective treatment, minimally invasive and low cost.

[Clinical-therapeutic features of gynecomastia]

This study reports 36 cases of gynaecomastia surgically treated. The median age was 25-years old (range 14-65 years). In 27 patients (75%) gynaecomastia was bilateral, in the others only one breast was interested. According to Simon's classification; 12 patients with stage 1, 18 stage 2a, 3 stage 2b and 3 stage 3 were observed. A specific cause was discovered in 12 cases: 2 Klinefelter syndrome and 10 adipomastia. Other 24 cases had an idiopathic origin. Subcutaneous mastectomy, through inferior periareolar approach was performed to all patients while submammary approach was reserved in selected patients (stage 3).

Long-term results of pancreas transplantation under tacrolius immunosuppression

BACKGROUND

The long-term safety and efficacy of tacrolimus in pancreas transplantation has not yet been demonstrated. The observation of prolonged pancreatic graft function under tacrolimus would indicate that any potential islet toxicity is short-lived and clinically insignificant. We report herein the results of pancreas transplantation in patients receiving primary tacrolimus immunosuppression for a minimum of 2 years.

METHODS

From July 4, 1994 until April 18, 1996, 60 patients received either simultaneous pancreas-kidney transplant (n=55), pancreas transplant only (n=4), or pancreas after kidney transplantation (n=1). Baseline immunosuppression consisted of tacrolimus and steroids without antilymphocyte induction. Azathioprine was used as a third agent in 51 patients and mycophenolate mofetil in 9. Rejection episodes within the first 6 months occurred in 48 (80%) patients and were treated with high-dose corticosteroids. Antilymphocyte antibody was required in eight (13%) patients with steroid-resistant rejection.

RESULTS

With a mean follow-up of 35.1+/-5.9 months (range: 24.3-45.7 months), 6-month and 1-, 2-, and 33-year graft survival is 88%, 82%, 80%, and 80% (pancreas) and 98%, 96%, 93%, and 91% (kidney), respectively. Six-month and 1-, 2-, and 3-year patient survival is 100%, 98%, 98%, and 96.5%. Mean fasting glucose is 91.6+/-13.8 mg/dl, and mean glycosylated hemoglobin is 5.1+/-0.7% (normal range: 4.3-6.1%). Mean tacrolimus dose is 6.5+/-2.6 mg/day and mean prednisone dose 2.0+/-2.9 mg/day at follow-up. Complete steroid withdrawal was possible in 31 (65%) of the 48 patients with functioning pancreases.

CONCLUSIONS

These data show for the first time that tacrolimus is a safe and effective long-term primary agent in pancreas transplantation and provides excellent long-term islet function without evidence of toxicity while permitting steroid withdrawal in the majority of patients.

En bloc pancreas and kidney transplantation in a patient with limited vascular access

We report a successful en bloc pancreas and kidney transplantation on a type I diabetic patient with advanced peripheral arterial calcific disease, who had frequent life-threatening episodes of hypoglycemia. The en bloc double organ, created by joining the graft renal artery to the arterial Y graft of the pancreas, was implanted to the proximal left common iliac artery, which was the only site available for an arterial anastomosis. Under appropriate circumstances, this procedure would be an option for potential combined pancreas-kidney transplant recipients with severe calcific arterial disease.

Spontaneous arterioenteric fistula after pancreas transplantation

Chronic pancreas transplant rejection with enteric exocrine drainage can lead to significant long-term complications. We report a case of a 47-year-old male insulin-dependent diabetic who survived the complications of peripancreatic abscess, enterocutaneous fistula, and arterioenteric fistula related to pancreas transplantation. To avoid these long-term complications, we now recommend elective removal of nonfunctioning, enterically drained pancreas allografts.

Combined simultaneous kidney/bone marrow transplantation

On the basis of observations in patients with long-term (28-30 years) renal allograft survival, all of whom had evidence of systemic microchimerism, we began a program of combined simultaneous kidney/bone marrow transplantation. Between 12/14/92, and 10/31/94, 36 kidney transplant recipients received 3-5 x 10(8) unmodified bone marrow cells/kg; 6 patients also received pancreatic islets, and 7 patients also received a pancreas. The mean recipient age was 39.0 +/- 10.8 years, and the mean donor age was 31.8 +/- 16.1 years; the mean cold ischemia time was 23.0 +/- 9.1 hr. Twenty control patients received kidneys alone, mainly because of refusal by the donor family to consent to vertebral body recovery; 3 of these patients also received a pancreas. The mean recipient age was 47.9 +/- 11.7 years, and the mean donor age was 41.5 +/- 17.9 years; the mean cold ischemia time was 28.6 +/- 6.2 hr. All patients received tacrolimus-based therapy, without radiation, cytoreduction, or induction antilymphocyte preparations. Blood was drawn prior to and at regular intervals after transplantation for detection of chimerism and for immunologic studies. With a mean follow-up of 11.1 +/- 5.8 months, all 36 study patients are alive, and 33 (92%) have functioning allografts with a mean serum creatinine of 1.9 +/- 1.2 mg/dl and a BUN of 26 +/- 9 mg/dl. Graft vs. host disease was not seen in any patient. The incidence of rejection was 72%; 11% of the patients required OKT3 or ATG for steroid-resistant rejection. The incidence of CMV was 14%, and that of delayed graft function was 17%. A total of 18 (90%) control patients are alive, and 17 (85%) have functioning allografts, with a mean serum creatinine of 2.1 +/- 1.3 mg/dl, and a BUN of 30 +/- 13 mg/dl. The incidence of rejection was 60%, and 10% required OKT3 or ATG. CMV was seen in 15%, and delayed graft function in 20% (P = NS). In the study patients, chimerism was detected in the peripheral blood of 30 of 31 (97%) evaluable patients by either PCR or flow cytometry. In the control patients, chimerism was seen in 9 of 14 (64%) evaluable patients (P < .02). Decreasing donor-specific responsiveness was seen in 6/29 (21%) evaluable study, and 4/14 (29%) evaluable control patients (P = NS). We conclude that combined kidney/bone marrow transplantation is associated with acceptable patient and graft survival, augmentation of chimerism, and no change in the early events after transplantation.

The superiority of tacrolimus in renal transplant recipients -- the Pittsburgh experience

Tacrolimus is a superior immunosuppressive agent in patients undergoing renal transplantation. In adults, the 1- and 3-year actuarial patient survivals were 95% and 92%, and the 1- and 3-year actuarial graft survivals were 89% and 80%. For first cadaver kidneys, the 1- and 3-year actuarial graft survivals were 91% and 82%, with a projected half-life of 11.9 years. Sixty-nine percent of successfully transplanted patients were weaned off steroids. In pediatric patients, the 1- and 4-year actuarial patient survivals were 100% and 96%, and the 1- and 4-year actuarial graft survivals were 99% and 85%. Seventy-three percent of successfully transplanted children were weaned off steroids. Tacrolimus was also useful as a rescue agent, with an initial success rate of 74%. Tacrolimus has been used successfully in kidney/ pancreas transplantation, with 100% patient, 95% kidney, and 79% pancreas graft survival. Tacrolimus should be considered the immunosuppressive agent of choice in renal transplantation.

["Telescopic" terminoterminal pancreatico-jejunal anastomosis after duodenocephalopancreatectomy]

Pancreaticojejunostomy represents the most important step of the reconstructive process following pancreaticoduodenectomy. Anastomotic dehiscence at this level accounts for two thirds of total postoperative mortality. In order to reduce the incidence of anastomotic complications, we have recently adopted a new technique of "telescopic" end-to-end-pancreaticojejunostomy where, differently from our previous technique, we are not any longer invaginating the small bowel over the pancreatic stump. Our preliminary results obtained in 5 consecutive patients appear to be promising.

Prolactin, thymulin and zinc in chronic hemodialysis: effect of renal transplant

The interrelationships between PRL, thymulin and Zn, were studied in 25 patients with chronic renal failure (CRF) undergoing kidney transplantation and immunosuppressed with cyclosporine A (CsA). The possible role of serum PRL levels in predicting allograft rejection was also investigated. Before the kidney transplant serum PRL levels were significantly higher than in normals (mean +/- SE, 28.3 +/- 7.1 vs 7.5 +/- 0.6 micrograms/l, p less than 0.001) and their response to TRH (200 micrograms iv) was impaired (mean delta % at peak, 45.4 +/- 9.5 vs + 641 +/- 47.5, p less than 0.001). After kidney transplantation a dramatic decrease in serum PRL concentrations was observed in all patients, followed by a slight upward trend in the following two weeks, while TRH test administered on 3rd, 7th and 14th day, induced a progressive increase in serum PRL responses (delta % at peak, 201 +/- 43.3, 220 +/- 37.1 and 305 +/- 15.5, respectively). No difference in serum PRL patterns was observed between patients with (8 cases) and without (17 cases) clinical features and kidney fine needle biopsies suggestive of rejection. Basal serum Zn levels of patients with CRF (18.1 +/- 0.6 mumol/l) were similar to those observed in normals (17.7 +/- 0.2 mumol/l) and without any correlation with serum PRL levels. A decrement in serum Zn was recorded during CsA infusion and on the first day after the surgery, followed by a slight and slow upward trend. Basal serum thymulin titers were low [2.92 +/- 0.18 (1/log2)], were further reduced after CsA infusion [1.68 +/- 0.15 (1/log2)] and returned to the pretransplant levels in the two weeks after grafting.(ABSTRACT TRUNCATED AT 250 WORDS)

Controlled trial of two different methylprednisolone doses in cadaveric renal transplantation

In a controlled trial the effects of two different methylprednisolone (MP) schedules were studied in 100 cadaver kidney adult recipients followed for 18-46 months. Group A patients were given 160 mg/day i.v. for 3 days, then oral MP (0.8 mg/kg/day), which was tapered by 4 mg/week to a maintenance dose of 16 mg/day up to the 6th month. Group B patients were given 80 mg/day i.v. for 3 days followed by 0.4 mg/kg/day oral MP; the dose was reduced by 2 mg/week to 16 mg/day. In both groups, the dose was further reduced bimonthly to a final dose of 8 mg/day. No significant differences were evidenced between the two groups in patients and kidney survival or in the incidence of complications. The number of patients with at least one rejection episode was significantly higher in the lower dose group.

Autoimmune hemolytic anemia in a cadaveric renal transplant recipient treated with cyclosporine

A case of autoimmune anti-c hemolytic anemia was observed in a cadaveric renal transplant recipient treated by cyclosporine. Severe anemia had been preceded by an episode of cholangitis followed within a few days by a viral infection. Anemia improved after three plasmaphereses and after cyclosporine therapy was substituted by azathioprine and steroid doses were increased. It is hypothesized that cyclosporine withdrawal may have favored the improvement of hemolysis by favoring the suppression of antibody-producing cells.