Intraductal carcinoma of the prostate in an Irish prostate cancer patient cohort-an aggressive pathology and a strong familial link

Background

The prevalence of intraductal carcinoma of the prostate (IDC-P) is poorly studied in the Irish population. This study investigated the incidence and clinicopathologic characteristics of IDC-P in an Irish prostate cancer (PCa) patient cohort. The study also discusses the rationale for genetic counseling and screening in Irish patients with familial risk factors for IDC-P.

Materials and methods

This study investigated patients diagnosed with IDC-P on prostate biopsy from 2012 to 2016. Primary outcome measurements were incidence, management, and clinical outcomes after follow-up in patients with IDC-P. The secondary outcome measurement was to identify a familial link for IDC-P.

Results

A total of 1,143 patients were diagnosed with PCa on needle biopsy, of which 30 (2.3%) had concomitant IDC-P. Mean age and prostate-specific antigen at diagnosis were 68.6 ± 10.5 years (range 53–85 years) and 9.15 ± 8.65 ng/mL (range 2.1–166 ng/mL), respectively. In total, 17 of 30 patients (57%) were diagnosed with concomitant high-grade (i.e., ≥Gleason score 8) PCa. Eight patients (27%) were treated with radical prostatectomy; of which five had biochemical recurrence (BCR) after 10.55 ± 25.9 months. Eleven patients (37%) received radical radiotherapy; of which one had BCR after 36 months. Eleven patients (37%) presented with advanced PCa and were managed with androgen deprivation therapy ± chemotherapy. A family history for PCa in first-degree relatives was found in eight patients (27%).

Conclusions

IDC-P is associated with more aggressive clinicopathologic features and an increased risk of BCR after treatment. In Ireland, clinical guidelines and a genetic screening pathway are required to provide early detection and appropriate multimodal management of patients with IDC-P.

Laparoscopic and hand-assisted laparoscopic donor nephrectomy: A systematic review and meta-analysis

Objective

To compare the perioperative outcomes of hand-assisted laparoscopic donor nephrectomy (HALDN) and pure LDN, as HALDN and LDN are the two most widely used techniques of DN to treat end-stage renal disease.

Methods

In this systematic review and meta-analysis, we performed a literature search of PubMed, Embase, Web of Science, and Cochrane from 01/01/1995 to 31/12/2014. The primary outcome was conversion to an open procedure. Secondary outcomes were warm ischaemia time (WIT), operation time (OT), estimated blood loss (EBL), complications, and length of stay (LOS). Data analysed were presented as odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs), I², and P values. Subgroup analysis was performed.

Results

There were 24 studies included in the meta-analysis; three randomised controlled trials (RCTs), one randomised pilot study, two prospective, and 18 retrospective cohort studies. There were no differences in conversion to an open procedure between the two techniques for both RCTs (OR 0.42, 95% CI 0.06, 2.90; I² = 0%, P < 0.001) and cohort studies (OR 1.06, 95% CI 0.63, 1.78; I² = 0%, P = 0.84). WIT was shorter for the HALDN (-41.79 s, 95% CI -71.85, -11.74; I² = 96%, P = 0.006), as was the OT (-26.32 min, 95% CI -40.67, -11.97; I² = 95%, P < 0.001). There was no statistically significant difference in EBL, complications or LOS.

Conclusion

There is little statistical evidence to recommend one technique. HALDN is associated with a shorter WIT and OT. LDN has equal safety to HALDN. Further studies are required.

Efficacy of vacuum erectile devices (VEDs) after radical prostatectomy: the initial Irish experience of a dedicated VED clinic

Controversy exists regarding optimal penile rehabilitation program following radical prostatectomy (RP). Vacuum erectile devices (VEDs) have become an important component of penile rehabilitation protocols. The aim of this study was to assess the efficacy and patient satisfaction of a dedicated VED clinic. A voluntary telephone questionnaire was performed of all patients who attended a VED clinic to date in two university teaching hospitals. Patient demographics, histopathological characteristics and functional status (International Index of Erectile Function (IIEF) scores) were obtained from a retrospective review of a prospectively maintained database. Sixty-five men attended the dedicated VED clinic in the two university teaching hospitals. Forty-men (76.3%) men purchased a VED following the dedicated clinic. There was significant differences noted between the mean preoperative and the 3-month postoperative IIEF scores (22.08±3.16 vs 11.3±3.08, P=0.0001) and between the 3-month postoperative IIEF score and the post-VED use IIEF score (11.3±3.08 vs 16.74±2.62, P=0.0001). Despite VED use, there was a significant reduction in erectile function from presurgery status (22.08±3.16 vs 16.74±2.62, P=0.0001). All patients reported that the dedicated VED was helpful and would recommend it to other patients. Our study demonstrates that, despite a reduction in erectile function after RP, successful erections are attainable with a VED. There is potential and need for the development of a standard penile rehabilitation program and treatment of ED after RP internationally.

Single centre experience of hypothermic machine perfusion of kidneys from extended criteria deceased heart-beating donors: a comparative study

INTRODUCTION

Kidneys from extended criteria donors are associated with higher rates of delayed graft function (DGF). Hypothermic machine perfusion (MP) for storage is associated with more favourable outcomes.

METHODS

A retrospective analysis was performed in 93 patients where the kidney was stored using hypothermic MP (LifePort(®)) and compared to an age-matched control group where the kidney was stored in cold static storage (CSS) using University of Wisconsin solution.

RESULTS

Median age was similar in both groups (59.2 years in MP vs 59.9 years in CSS, p = 0.5598). Mean cold storage time was 15.6 h in MP vs 17.9 h in CSS. Post transplant mean serum creatinine was as follows; MP group-144.7 μmol/L at 1 month; 138.3 μmol/L at 3 months and 129.5 μmol/L at 12 months. In the CSS group-163 μmol/L at 1 month; 154.9 μmol/L at 3 months and 140.2 μmol/L at 12 months. There was a statistically significant difference at 1 month (p = 0.0096) and 3 months (p = 0.0236). DGF was defined as the need for haemodialysis within 7 days post transplant. In the MP group, DGF occurred in 17.2 % patients with mean of 6 days (range 1-18). In the CSS group, 25.8 % patients with mean of 8.1 days (range 3-25). One-year graft survival rate was better in the MP group (97.85 vs 96.77 %).

CONCLUSION

Our experience to date recommends the use of hypothermic MP for storage of kidneys from extended criteria deceased heart-beating donors.

Active surveillance for low-risk prostate cancer: diversity of practice across Europe

BACKGROUND

Active surveillance (AS) is a recognised treatment option for low-risk prostate cancer (PCa).

AIMS

To review AS criteria in terms of patient selection, follow-up and indications for intervention.

METHODS

A total of 2,959 potential participants were identified and invited via email to complete an online survey. Only urologists practising in an EU country were eligible to participate. Statistical analyses were carried out using SPSS version 18.0. The χ (2) test was used to compare responses between those who do and do not follow an AS protocol.

RESULTS

Response rate was 8% (n = 226). Ninety-seven per cent urologists offer AS; 25% (n = 53/215) within a clinical trial and a further 28% (n = 60/215) using an official AS protocol. Gleason score ≤ 3 + 3 = 6 (87 %, n = 173/200) and prostate-specific antigen (PSA) ≤ 10 ng/ml (86%, n = 170/198) are the commonest selection criteria. There was a statistically significant association between having an AS protocol and using PSA as an eligibility criterion (p = 0.03). For urologists not following a protocol, 11% do not consider PSA as an eligibility criterion and 81% consider PSA ≤ 10 ng/ml to decide on AS, compared to 2 and 90%, respectively, who adhere to a protocol. Twenty-four per cent of urologists without a protocol do not re-biopsy in comparison to 11% with a protocol (p = 0.026). Gleason score progression trigger the most intervention (n = 168/192, 87%).

CONCLUSIONS

Urologists not adhering to an AS protocol or participating in a clinical trial appear to apply less rigorous criteria for both eligibility and monitoring in AS.

Ureteral diverticulum: a review of the current literature

INTRODUCTION

Ureteral diverticulum is a rare urological condition with only 45 cases described in the literature. These previously reported cases vary in their presentation, diagnosis and management and there is no consensus in the literature on the best diagnostic tool available. We describe our experience on diagnosing and managing this condition in two patients and provide a descriptive review of the current literature on ureteral diverticulum.

MATERIALS AND METHODS

A Medline search was performed to identify all reported cases of ureteral diverticulum. Key words used were: ureteral diverticulum; abortive bifid ureter; congenital diverticulum; acquired diverticulum. We also reviewed the records of two patients who presented consecutively to our institution with a ureteral diverticulum. The clinical and radiological characteristics of this entity were then evaluated.

RESULTS

Forty-one manuscripts were identified, encompassing single case reports and case series, the largest of which contained seven patients. Two additional cases were diagnosed in our institution; a true congenital diverticulum and an abortive bifid ureter which is synonymous with a true ureteral diverticulum. Both were uncomplicated cases and were managed conservatively. Retrograde pyelography was used for definitive diagnosis of this lesion.

CONCLUSION

Ureteral diverticulum may present as an incidental finding or with a secondary complication. Conservative management is advocated in the literature for non-complicated cases. Retrograde pyelography is our diagnostic tool of choice.

Initial experience with transperitoneal laparoscopic nephrectomy in an Irish hospital setting

INTRODUCTION

Laparoscopic nephrectomy has gained widespread acceptance as a treatment for both benign and malignant conditions and is becoming increasingly popular in Irish hospitals. We report a single surgeon, single centre experience with 20 consecutive laparoscopic nephrectomies comparing them to 20 open cases performed prior to the establishment of a laparoscopic service.

METHODOLOGY

A retrospective comparative analysis was carried out over an 18 month period. Transperitoneal approach was used in the laparoscopic group with renal vessels divided using an Endo GIA stapling device. Parameters examined included age, weight, indication, operative time, blood loss, tumour size, length of stay and analgesic requirements. Comparison was made with 20 open nephrectomies.

RESULTS

Mean age (p=0.26) and weight (p=0.08) were similar in both groups. Average tumour size was similar (4.98 cm [range 2.8-9] in laparoscopic group versus 6.4 cm [range 3-10], p=0.61). Mean operative blood loss was reduced in the laparoscopic group (65 ml (range 50-200) versus 351 ml (50-1740) (p=or<0.05 L.N. versus O.N.). Laparoscopic patients were discharged earlier; 3.9 days (range 3-6) versus 6.5 (range 5-11) postoperatively (p=or<0.05 L.N. versus O.N.). Analgesia requirements were reduced in terms of both total hours using PCA (25.05 hours [range 1-45] versus 41.6 hours (range 7-226)) (p=or<0.05 L.N. versus O.N.) and total morphine requirements (35.5 mg [range 2-94] versus 72.4 mg [range 18-113] [p=or<0.05 L.N. versus O.N.]). There were no complications in the laparoscopic group, while one patient developed an incisional hernia in the open group.

CONCLUSION

Laparoscopic nephrectomy is less invasive and demonstrates improved results in terms of analgesia, blood loss and reduced overall stay.

Ureterocolic fistula in the presence of a solitary kidney

Among the entero-urinary fistulae, those between the ureter and colon are rare. Most spontaneous ureterocolic fistulae are caused by urinary calculi. We report a case of a spontaneous ureterocolic fistula which occurred as a consequence of diverticular disease. This rare presentation was further complicated as it occurred in the presence of a solitary kidney. The patient underwent a laparoscopic defunctioning loop ileostomy and after 6 weeks underwent definitive surgical treatment of the ureterocolic fistula. We describe the presentation and management of this fistula and review the current literature.

Genital self-mutilation

A 53-year-old man was brought to the emergency department having removed both testicles and amputated his penis using a bread knife. Examination of the amputated penis showed it to be unsuitable for an attempted replant procedure. The patient was taken to theatre where the perineal wound was debrided and the remaining urethra brought down as a perineal urethrostomy, with a local cutaneous flap rotated to provide coverage for the urethra. Discussed herein are the incidence, predisposing factors, management and complications of genital self-mutilation in the adult male, and the existing literature is reviewed on the subject.

Vascular complications of allograft nephrectomy

OBJECTIVES

To identify risk factors that predisposes patients to vascular complications from allograft nephrectomy and to determine the safe management of this group of patients.

DESIGN

This is a retrospective review of 1543 renal transplants performed in our institution between January 1990 and January 2002.

PATIENTS AND METHODS

During this period, 161 (10.4%) transplant nephrectomies were performed, of which we identified nine patients (5.6%) who sustained significant vascular complications.

RESULTS

Seven patients required ligation of external iliac artery for control of haemorrhage. Immediate vascular reconstructions (femoral-femoral cross-over bypass in two cases and one vein patch to an external iliac artery defect) were performed in three patients. Two patients had endovascular stenting of their external iliac artery pseudoaneurysm. No patient suffered limb loss. However, three patients died-two died from overwhelming sepsis and one patient died of an intra-cerebral haemorrhage.

CONCLUSIONS

While vascular complications associated with transplant nephrectomy are relatively rare, they are associated with a significantly poor outcome. Immediate attempts to reconstruct the vascular supply to the lower limb are associated with a high complication rate. We advocate that where possible, vascular reconstruction should be deferred and that external iliac artery ligation can be performed safely with surprisingly low limb ischaemia rate.

Laparoscopic vs open living donor nephrectomy: a contemporary series from one centre

OBJECTIVE

To report our experience of laparoscopic living donor nephrectomy (LDN) vs open donor nephrectomy (ODN), as LDN offers potential advantages to the donor and has become a routine procedure for live kidney procurement worldwide.

PATIENTS AND METHODS

Between February 2000 and August 2005 we performed 183 donor-recipient operations at our institution (ODN, 83; LDN, 100). We prospectively collected information on all donors and recipients for the same period to audit our experience with the first 100 LDNs. Patients made their operative choice after discussions that included unit experience and published information. We present our findings with the emphasis on donor operative details and early recipient graft outcome.

RESULTS

Donor and recipient age, gender, body mass index, human leukocyte antigen mismatches, and vascular anastomotic times did not differ significantly between the groups. There were two conversions to an open operation in the LND group; neither affected recipient-graft outcome. The mean (sd) operative duration was 178 (38) min for the LDN and 159 (34) min for the ODN (P < 0.05). The mean (sd) hospital stay was 4.7 (1.2) days in the LND group and 6.8 (1.5) days in the ODN group (P < 0.05). There was one case of delayed graft function in both groups. Serum creatinine levels at 1, 6 and 12 months after transplantation did not differ significantly between the groups.

CONCLUSIONS

Our contemporaneous series shows the safe introduction of a laparoscopic living-donor programme without compromising donor patient safety or allograft outcome.

Chest drain insertion may result in the acute scrotum

Pneumoscrotum is an extremely rare occurrence following a variety of procedural and pathological causes. We describe a case following multiple chest drain insertions which was managed conservatively. It is important to differentiate pneumoscrotum from other causes of acute scrotum as it may precede a serious pathology and may require medical or surgical intervention.

Pelvic recurrence in stage I seminoma: A new phenomenon that questions modern protocols for radiotherapy and follow-up

OBJECTIVE

To highlight the increased risk for pelvic relapse in patients with stage 1 seminoma treated with adjuvant radiotherapy limited to para-aortic template alone.

PATIENTS AND METHODS

Over a four-year period, three patients presented with early pelvic recurrence after radical orchidectomy and adjuvant irradiation for stage 1 seminoma. In each case, radiotherapy had been limited to the para-aortic region with omission of the ipsilateral hemi pelvis.

RESULTS

Pelvic recurrences occurred on the ipsilateral tumor side. Durable complete remission was achieved in each case; however, treatment was complex and there was associated morbidity.

CONCLUSION

This significant incidence of pelvic recurrence questions the validity of modern radiotherapy protocol which excludes the ipsilateral pelvis from the radiation field.

An audit of 2273 ureteroscopies--a focus on intra-operative complications to justify proactive management of ureteric calculi

BACKGROUND

At the national Stone Centre we have adopted a proactive management approach involving early ureteroscopy for ureteric calculi. As the efficacy of ureteroscopy is known this study focuses on the low intra-operative complication rate as justification for a proactive management protocol.

PATIENTS AND METHODS

A retrospective study (1987-1997) identified 1936 patients undergoing 2273 ureteroscopies. A database was created from inpatient hospital records. The male to female ratio was 3 to 1, age range was 25 to 84 years.

RESULTS

Twenty-three patients (1%) had an intra-operative complication during ureteroscopy. Immediate ureteric JJ stenting was performed in 16 cases with ureteric injury. Two cases underwent percutaneous drainage and delayed antegrade ureteric stenting, ureteroscopy was terminated because of poor visibility. Five patients (0.22%) underwent open surgery for: ureteric perforation (n = 2); Dormia basket ureteric avulsion (n = 1); impacted Dormia basket and stone (n = 1); and impacted balloon dilator and stone (n = l). Ureteroscopic complications were not related to the level of ureteric calculus.

CONCLUSION

A protocol of proactive management of ureteric calculi facilitates rapid turnover of large patient numbers. This approach is supported by the low intra-operative complication rate, most of which can be managed by further endoscopic procedures. In the event of corrective open surgery a favourable outcome has resulted.

Urological evaluation prior to renal transplantation

Renal transplantation is the best available therapy for patients with end-stage renal failure. Urologists are often consulted regarding pretransplant evaluation and treatment of potential renal transplant recipients. Frequently the urologist is the primary surgeon in the transplant unit. This review highlights the importance of performing a comprehensive urological assessment before renal transplantation. A retrospective review of the urological and transplant literature using Medline was performed from 1976 to 2002, searching for renal transplantation and its association with urological cancers and urinary tract malformations. The pretransplant urological assessment aims to diagnose, treat, and optimize any preexisting urological disease. On occasion, certain urological diseases may not be obvious or may not have contributed to the progression to end-stage renal failure such as occult urinary tract neoplasms, urinary calculus disease, or benign prostatic hyperplasia. A thorough evaluation of the urinary tract prior to renal transplantation is mandatory to avoid unforeseen problems occurring posttransplant. If this assessment is consistently adhered to, only in very rare circumstances does a potential recipient have to be denied the opportunity of receiving an allograft based on a preexisting urological disease.

Toxoplasmosis after a simultaneous pancreas and kidney transplantation

We report the case of a simultaneous kidney and pancreas transplant recipient who presented with vague neurologic symptoms 21 months following the surgery. Computed tomography, magnetic resonance imaging, and fundoscopy findings were normal. Serology titers for antitoxoplasmic antibodies were increased. This was an atypical presentation of toxoplasmosis in a simultaneous kidney and pancreas transplant patient.

Long-term protective effects of hypothermia on reperfusion injury post-testicular torsion

OBJECTIVE

As many as two-thirds of salvaged testes post-torsion will atrophy within 2 years. Subsequent testicular damage is due at least in part to an ischaemia/reperfusion injury. Thus we analysed the long-term protective effects of subjecting the ischaemic testis to hypothermia in an attempt to prevent or attenuate subsequent testicular damage.

MATERIAL AND METHODS

Forty male Sprague-Dawley rats (mean age 97 days; mean weight 408 g) were randomized to one of two groups. The left testis was removed as a control and the right testis was subjected to torsion through 720 degrees in a clockwise direction and maintained in this position for 3 h. Half of the models were subjected to hypothermia by submerging the testis in a cooling bath, which was kept at a constant temperature of 2-4 degrees C for the final hour prior to detorsion. Testes were retrieved at 1 and 12 weeks and examined by a single blinded pathologist using the following histological criteria: mean seminiferous tubular diameter, mean tubular wall thickness (MTWT) and Johnsen's score.

RESULTS

Histological examination revealed significant injury after 1 week of reperfusion in both groups. However, after 12 weeks of reperfusion there was a marked benefit seen in the testes subjected to hypothermia. MTWT (p=0.007) and Johnsen's score (p=0.05) were significantly better in the cooled testes after 12 weeks of reperfusion.

CONCLUSION

Hypothermia reduces the degree of long-term testicular damage post-torsion and, if applied in clinical practice, may improve long-term salvage rates.

Mechanical deformation induced apoptosis in human proximal renal tubular epithelial cells is caspase dependent

PURPOSE

Ureteral obstruction (UO) results in apoptosis of renal tubular epithelial cells. We postulated that mechanical deformation and inflammation contribute to the cellular loss that occurs as a result of UO and it is mediated through altered heat shock protein 70 (HSP-70) expression and the caspase cascade.

MATERIALS AND METHODS

Human HK-2 renal tubular cells were subjected to mechanical stretch. Cell viability and apoptosis were assessed by flow cytometry; HSP-70 and caspase 3 protein expression by Western blotting, and caspase 3 activity by fluorescence substrates.

RESULTS

Mechanical stretch caused direct apoptosis induction and it also primed for tumor necrosis factor-alpha induced apoptosis, which was caspase 3 dependent. Although HSP-70 protein expression was increased during mechanical stretch, the protective effects of HSP-70 were only seen after further induction by heat shocking.

CONCLUSIONS

Altering HSP-70 expression and manipulating the caspase cell death proteases represent a novel pathway to protect against renal tubular cell apoptosis and the potential for progression to renal failure in UO.

Exogenous and endogenous angiogenic stimuli do not augment splenic autotransplantation

OBJECTIVE

To find out if angiogenic stimulation improves the ability of the spleen to regenerate.

DESIGN

Experimental study.

SETTING

Teaching hospital, Republic of Ireland.

ANIMALS

27 male Sprague-Dawley rats.

INTERVENTIONS

Each spleen was removed and half was reimplanted in the greater omentum. The rats were randomised into three groups of 9 each: the first (control) group was given no stimulation; the second had the implanted spleen sutured into the omentum with 6/0 polypropylene; and in the third group the implanted spleen was injected with human recombinant vascular endothelial growth factor (VEGF) 500 microg.

MAIN OUTCOME MEASURES

Clearance of Howell-Jolly bodies, and the weight and histological appearance of the splenic remnant at 3 months.

RESULTS

The splenic remnant was significantly larger at 3 months in the control group (p = 0.0006). Histological examination of the tissue from the control group showed that it was architecturally similar to that of normal functioning spleen, whereas the tissue from the two treated groups contained less lymphoid tissue and showed widespread acute and chronic inflammatory changes. There was a significantly greater clearance of Howell-Jolly bodies (an index of splenic function) from the peripheral blood of the control group (p = 0.0009).

CONCLUSION

The excellent recovery of the splenic remnant in the control group suggests that the procedure of splenic autotransplantation might warrant further consideration and study.

Outcome of cadaveric renal transplantation in patients with psychiatric disorders

Psychiatric illness has hitherto been considered a contraindication to solid organ transplantation in many centres. Reasons cited include a perceived lack of compliance with therapeutic drug regimes and the potential psychopharmacological interactions between psychotropic and immunosuppressant medication. We retrospectively examined the outcomes in 24 patients with psychiatric illnesses definable within the confines of the ICD 10 classification who underwent cadaveric renal transplantation between January 1990 and October 1999. The mean age was 31.5 +/- 17.1 years (range 9-68) at the time of transplantation. There were 13 male and 11 female patients. All received cyclosporine, azathioprine and steroid triple immunosuppressive therapy. The 1,3 and 5 year patient and graft survival was 87%, 82% and 65% respectively. The mean follow-up time was 43.67 +/- 38.11 months (range: 1 month-10 years 4 months). Compliance was excellent in all 24 cases. Seven patients died. The causes of graft loss were death with a functioning graft (n=3), vascular thrombosis (n=2), chronic rejection (n=2). The mean serum creatinine of the remaining 17 patients is 129 +/- 45.2mmol/l. Psychiatric illness, in itself, does not preclude the possibility of successful cadaveric renal transplantation.

Long-term followup of cadaveric renal transplantation in patients with spina bifida

PURPOSE

Access related problems in hemodialysis and peritoneal dialysis are increased in cases of spina bifida due to vascular and body habitus limitations. Reports of renal transplantation in this patient group are exceedingly rare. We report long-term followup data on cadaveric renal transplantation for end stage renal failure in cases of spina bifida.

MATERIALS AND METHODS

Between February 1986 and April 2000, 17 cadaveric renal transplants were performed in 11 females and 5 males with spina bifida. Mean age at transplantation was 20.2 years (range 10 to 35). Of the patients 11 were wheelchair bound and 5 were independently mobile. Before transplantation surgical management of the urological tract included clean intermittent self-catheterization in 3 cases, enterocystoplasty and clean intermittent self-catheterization in 8, and ileal conduit urinary diversion in 5. A total of 14 patients were on renal replacement therapy before receiving the graft. Cyclosporine based triple therapy was administered to maintain immunosuppression in all cases and antithymocytic globulin was given for induction in 7.

RESULTS

Six grafts have failed, including 1 in a patient who underwent successful re-transplantation. Median graft survival was 7.23 years. Two patients died after graft nephrectomy. At a mean followup of 52.8 months (range 1 month to 14 years) 11 of 17 grafts are functioning with a mean serum creatinine of 112.7 +/- 29.4 mmol./l.

CONCLUSIONS

These data demonstrate the feasibility of cadaveric renal transplantation in patients with spina bifida and end stage renal failure. We currently recommend that these patients should not be deprived of the benefits of renal transplantation.

Long-term followup of cadaveric renal transplantation in patients with spina bifida

PURPOSE

Access related problems in hemodialysis and peritoneal dialysis are increased in cases of spina bifida due to vascular and body habitus limitations. Reports of renal transplantation in this patient group are exceedingly rare. We report long-term followup data on cadaveric renal transplantation for end stage renal failure in cases of spina bifida.

MATERIALS AND METHODS

Between February 1986 and April 2000, 17 cadaveric renal transplants were performed in 11 females and 5 males with spina bifida. Mean age at transplantation was 20.2 years (range 10 to 35). Of the patients 11 were wheelchair bound and 5 were independently mobile. Before transplantation surgical management of the urological tract included clean intermittent self-catheterization in 3 cases, enterocystoplasty and clean intermittent self-catheterization in 8, and ileal conduit urinary diversion in 5. A total of 14 patients were on renal replacement therapy before receiving the graft. Cyclosporine based triple therapy was administered to maintain immunosuppression in all cases and antithymocytic globulin was given for induction in 7.

RESULTS

Six grafts have failed, including 1 in a patient who underwent successful re-transplantation. Median graft survival was 7.23 years. Two patients died after graft nephrectomy. At a mean followup of 52.8 months (range 1 month to 14 years) 11 of 17 grafts are functioning with a mean serum creatinine of 112.7 +/- 29.4 mmol./l.

CONCLUSIONS

These data demonstrate the feasibility of cadaveric renal transplantation in patients with spina bifida and end stage renal failure. We currently recommend that these patients should not be deprived of the benefits of renal transplantation.

Pre-transplant bilateral native nephrectomy for medically refractory hypertension

Hypertension arising from retained native kidneys can compromise both the patient and graft survival. Bilateral nephrectomy should be considered in a select group of patients, whom have refractory hypertension, prior to renal transplantation. Between January 1991 and July 1998 we performed 10 bilateral nephrectomies where hypertension was the indication. The mean age was 23 yrs (range 11-45) at the time of surgery. Nine patients were on dialysis pre-operatively (6-H/D, 3-CAPD). All 10 patients witnessed a reduction in the number of antihypertensive medications they were obliged to take daily. We also found less surgical morbidity associated with performing surgery through bilateral dorsal lumbotomy incisions as opposed to through a midline incision. Also the post-operative hospital stay was less in the patient group who under went bilateral dorsal lumbotomy. Seven patients at a mean follow up period of 46.43+/-26.06 months have functioning grafts with a mean serum creatinine of 164.14+/-42.83 micromol/dl. We have shown in our patient group how bilateral nephrectomy can be successfully used for refractory hypertension in patients prior to renal transplantation. We also believe that where possible these kidneys should be removed through a bilateral dorsal lumbotomy incision rather than a midline one.

Primary lymphoma of the bladder: a report of three cases

BACKGROUND

Primary lymphoma of the bladder is rare and its management is an evolving field.

AIMS

To highlight primary lymphoma of the bladder as a possible diagnosis in cases of bladder neoplasm and to illustrate the currently favoured management options.

METHODS

Three cases of primary bladder lymphoma are reported and management is reviewed.

RESULTS

Each of the three cases was managed differently with each management approach yielding a favourable outcome.

CONCLUSION

Chemotherapy combined, if necessary, with surgery or radiation therapy, should be the standard of care, depending on the full histological diagnosis.

Successful transplantation of kidneys from a donor with HELLP syndrome-related death

We report on the successful use of kidneys procured from a donor with HELLP syndrome. The use of organs from a donor with HELLP syndrome has not been reported previously, perhaps because of the renal complications associated with it. Both recipients have been doing well since renal transplantation, with immediate graft function and acceptable graft function at 2 years of follow-up. In view of the continuing shortage of cadaveric kidneys for transplantation, this report highlights how organs from "marginal" donors should not be discarded without worthy consideration.

Renal transplantation in patients with an augmentation cystoplasty

OBJECTIVE

To retrospectively review our experience over a 10-year period of renal transplantation in patients with augmented bladders and thus assess the safety of this procedure.

PATIENTS AND METHODS

Ten transplant recipients who had previously undergone augmentation cystoplasty were reviewed; a cadaveric kidney was transplant in each case. The donor ureter was anastomosed to the augment bladder in six patients, in three to the native ureter and in one the donor renal pelvis was anastomosed to the native ureter.

RESULTS

No patients died and nine of the 10 grafts were functioning at a mean follow-up of 27 months. The mean (SD) serum creatinine level at the follow-up was 100.8 (27.25) mmol/L. Four patients had 10 episodes of urosepsis requiring hospital admission, with only one graft lost.

CONCLUSION

Renal transplantation can be performed safely in patients with an augmentation cystoplasty.