High-grade blunt traumatic rupture of kidney transplant: is conservative management an option?

Road traffic accidents are the most common cause of blunt native kidney injuries. Transplanted kidneys are more exposed to such injuries due to the common positioning in the iliac fossa compared with the relatively protected position of the native kidneys. The small number of cases identified in the literature describe grade II and III transplant kidney injuries that were treated surgically. In our case a grade IV injury was managed conservatively giving the necessary time to appropriately plan the future renal replacement therapy options for the patient.

30-Day postoperative COVID-19 outcomes in 398 patients from regional hospitals utilising a designated COVID-19 minimal surgical site pathway.

INTRODUCTION: Postoperative pulmonary complications and mortality rates during the COVID-19 pandemic have been higher than expected, leading to mass cancellation of elective operating in the UK. To minimise this, the Guy's and St Thomas' Hospital NHS Foundation Trust elective surgery hub and the executive team at London Bridge Hospital (LBH) created an elective operating framework at LBH, a COVID-19 minimal site, in which patients self-isolated for two weeks and proceeded with surgery only following a negative preoperative SARS-CoV-2 polymerase chain reaction swab. The aim was to determine the rates of rates of postoperative COVID-19 infection. METHODS: The collaboration involved three large hospital trusts, covering the geographic area of south-east London. All patients were referred to LBH for elective surgery. Patients were followed up by telephone interview at four weeks postoperatively. RESULTS: Three hundred and ninety-eight patients from 13 surgical specialties were included in the analysis. The median age was 60 (IQR 29-71) years. Sixty-three per cent (252/398) were female. In total, 78.4% of patients had an American Society of Anesthesiologists grade of 1-2 and the average BMI was 27.2 (IQR 23.7-31.8) kg/m2. Some 83.6% (336/402) were 'major' operations. The rate of COVID-19-related death in our cohort was 0.25% (1/398). Overall, there was a 1.26% (5/398) 30-day postoperative all-cause mortality rate. Seven patients (1.76%) reported COVID-19 symptoms, but none attended the emergency department or were readmitted to hospital as a result. CONCLUSION: The risk of contracting COVID-19 in our elective operating framework was very low. We demonstrate that high-volume major surgery is safe, even at the peak of the pandemic, if patients are screened appropriately preoperatively.

COVID-19 in Kidney Transplant Patients From a Large UK Transplant Center: Exploring Risk Factors for Disease Severity.

BACKGROUND: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has raised concern for the health of immunocompromised individuals, who are potentially at higher risk of more severe infection and poorer outcomes. As a large London transplant center serving a diverse patient population, we report the outcomes of SARS-CoV-2 infection in our cohort of 2848 kidney and/or pancreas transplant patients. METHODS: Data were obtained retrospectively for all transplant patients who attended hospital during the peak of the pandemic and had a positive nasopharyngeal SARS-CoV-2 test. RESULTS: Sixty-six patients were found to be positive for SARS-CoV-2. Twenty percent were treated as outpatients, 59% were admitted to the general ward, and 21% required intensive care. Treatment consisted of reduced immunosuppression, antibiotics for pneumonia or sepsis, and other supportive treatments. Within our cohort, 12 patients died (18%), with an overall mortality of 0.4%. Predictive risk factors for COVID-19 severity were explored. CONCLUSIONS: Severe disease was associated with lower hemoglobin prior to COVID-19 diagnosis and lower lymphocyte count at the time of diagnosis but not age, sex, ethnicity, or preexisting comorbidities. Lower glomerular filtration rate and higher C-reactive protein were associated with more severe disease. Despite no use of hydroxychloroquine, azithromycin, antiviral, or immunomodulatory medications, our mortality rate (kidney and pancreas transplant patients) is similar to current international rates.

Reconstruction of a Damaged Lower Polar Artery for Kidney Transplantation Using Tubularised Donor Aorta.

INTRODUCTION: Live donors, extended donor criteria, and the maximum usage of organs with anatomical variants are some of the mechanisms used to increase the number of organs available. CASE: We present the case of a kidney transplant, in which the organ had an iatrogenic injury to a lower pole arterial branch during retrieval. The donor was a 35-year-old male (DCD, Maastricht III). The right kidney was accepted; it had three veins in a single cava patch and three renal arteries, the main artery with aorta patch that is 8 cm long. A small lower pole artery was sectioned during retrieval surgery at approximately 1 cm from its origin as well as a third small mid-lower pole artery. The lower pole damaged artery was reconstructed using tubularised aorta patch to a total length of 5 cm. No additional donor vessels had been sent. After construction of the tubulised aorta, E-E anastomosis to the damaged polar artery was done with interrupted 7-0 Prolene sutures. CONCLUSION: While the waiting list for a kidney continues to rise and we continue to have organ shortness, vascular retrieval injury should not be an absolute contraindication for transplant.

Prophylactic Ureteric Stents in Renal Transplant Recipients: A Multicenter Randomized Controlled Trial of Early Versus Late Removal.

Prophylactic ureteric stenting in renal transplantation reduces major urological complications; however, morbidity is related to the indwelling duration of a stent. We aimed to determine the optimal duration for stents in this clinical setting. Patients (aged 2-75 years) from six UK hospitals who were undergoing renal transplantation were recruited and randomly assigned to either early stent removal at 5 days (without cystoscopy) or late removal at 6 weeks after transplantation (with cystoscopy). The primary outcome was a composite of stent-related complications defined as pain, visible hematuria, migration, fragmentation, and urinary tract infections (UTIs) within 3 mo of transplantation. Between May 2010 and Nov 2013, we randomly assigned 227 participants, with 205 included in the final analysis of the primary outcome. Stent-related complications were significantly higher in the late versus early stent removal groups (36 of 126 [28.6%] vs. 6 of 79 [7.6%]; p < 0.001). The majority of stent complications consisted of UTIs, with an incidence of 31 of 126 (24.6%) in the late group compared with 6 of 79 (7.6%) in the early group (p = 0.004). We found early stent removal on day 5 significantly reduced stent-related complications and improved quality of life in the first 3 mo after transplantation (ISRCTN09184595).

TCC in Transplant Ureter--When and When Not to Preserve the Transplant Kidney.

We present four cases of transitional cell carcinoma of the transplant ureter (TCCtu). In three cases, localized tumor resection and a variety of reconstructive techniques were possible. Transplant nephrectomy with cystectomy was performed as a secondary treatment in one locally excised case. Transplant nephroureterectomy was performed as primary treatment in one case. The role of oncogenic viruses and genetic fingerprinting to determine the origin of TCCtu are described. Our cases and a systematic literature review illustrate the surgical, nephrological, and oncological challenges of this uncommon but important condition.

Renal replacement and male sexuality.

End-stage renal disease (ESRD) and dialysis have negative impact on lifestyle. Renal transplantation improves many facets of daily life. Male sexuality is a significant predictor of quality of life. This brief review summarizes the impacts of ESRD and renal replacement on a range of sexual domains as presented at the European Association of Urology meeting in Vienna.

Native nephrectomy in transplant patients with autosomal dominant polycystic kidney disease.

INTRODUCTION: This study examined the clinical indications and timing for native nephrectomy (NN), together with the associated pathological findings in transplant patients with autosomal dominant polycystic kidney disease (ADPKD) at our institute over a period of 20 years. METHODS: A retrospective review was performed of ADPKD patients who had undergone both kidney transplantation and NN. Patients were identified from the kidney transplant database between 1988 and 2008 at Guy's and St Thomas' Hospital and the notes reviewed. All NN specimens were re-reviewed and reported according to current guidelines. RESULTS: There were 157 kidney transplants performed for ADPKD (114 cadaveric and 43 living donor). Of these, 31 required NN (28 bilateral). The timing of NN was pre-transplant in 10 cases, at the time of the transplant in 1 case and post-transplant in 20 cases. The indications for NN were urinary tract infection (n=14, 45%), pain (n=12, 39%), tumour suspicion (n=3, 10%), haematuria (n=1, 3%) and space (n=1, 3%). Mortality in this NN series was 3%, with a 65% surgical morbidity rate. The length of hospital stay post-NN was significantly longer with open compared with laparoscopic techniques (p=0.003). There were two renal cell carcinomas (RCCs) in this series. Both patients presented with macroscopic haematuria (bilateral pT1a papillary RCCs in one case and a pT3b clear cell RCC in the other case). The incidence of RCC in this series of ADPKD transplant patients was 1.3%. CONCLUSIONS: We have demonstrated that the majority of ADPKD patients do not require NN, with only 20% of our series undergoing this procedure. The timing of NN is variable and dictated by indication. NN was only required to make space for transplantation in one case (combined kidney and pancreas transplant). The main indications for NN were recurrent infection and pain, where NN can provide a successful outcome. Laparoscopic NN can be performed safely in patients with ADPKD. Haematuria in such patients should not be assumed to be of benign origin and requires exclusion of urinary tract malignancy as the incidence of RCC in this population is at least as common as in the general population.

Differentiation between infection in kidney and liver cysts in autosomal dominant polycystic kidney disease: use of PET-CT in diagnosis and to guide management.

Positron emission tomography-computed tomography (PET-CT) is a useful imaging method for localizing infective lesions. We report a case of autosomal dominant polycystic kidney disease in which PET-CT was used to differentiate between infection in the kidney and liver cysts. Localization of infection to the liver rather than to kidney cysts altered patient management. We briefly review the role of PET-CT in localization of an occult focus of infection.

Acute urinary retention secondary to a urethral calculus in a bladder-drained kidney pancreas transplant patient - a metallic clip nidus.

Urological expertise is usually required for the management of any urological complications of bladder-drained pancreatic allografts whether they are the result of simultaneous pancreas-kidney transplants, pancreas after kidney transplants, or pancreas transplants alone. This study presents a case of urinary retention secondary to prostatic urethra calculus impaction, the nidus of which was found to be metallic staples from the donor duodenal segment of a pancreatic allograft. Knowledge of the pre-transplant benchwork gave a high index of suspicion to the urological sequelae of this case and, in particular, the presence of calculi should suggest a metal clip nidus. We examine the methods of exocrine pancreatic drainage, donor duodenum preparation and case management.

Ablative and reconstructive robotic-assisted laparoscopic renal surgery.

INTRODUCTION: The increasing role of robotic technology to facilitate surgical procedures has attracted much attention from surgeons and patients alike. In particular, the dramatic increase in the number of laparoscopic radical prostatectomies performed using the da Vinci surgical system has led to interest in using this technology for other procedures. We have evaluated our own experience performing ablative and reconstructive laparoscopic renal surgery using the da Vinci system to determine its potential role. AIMS: To review our experience of robotic-assisted laparoscopic procedures of the upper urinary tract. MATERIALS AND METHODS: Our da Vinci system was installed in June 2004. A prospective database has been maintained concerning all patients and procedures performed from that time. Procedures involving the upper urinary tract were identified and the data was examined. This included patient demographics, operative time, blood loss, hospital stay and patient outcomes. RESULTS: Twenty-six robotic procedures involved the upper urinary tract. Of these, two had to be converted to conventional laparoscopic surgery because of da Vinci mechanical failure. Robotic-assisted procedures included pyeloplasty (n = 15), simple nephrectomy (n = 2), radical nephrectomy (n = 1), nephroureterectomy (n = 2), and live donor nephrectomy (n = 4). The mean operative time was 215 min. The anastomotic time for the pyeloplasties averaged 47 min. The mean blood loss was 75 ml. There were no conversions to open surgery. The complication rate was 8.7%. Postoperative stay averaged 2.9 days. CONCLUSION: The da Vinci surgical system may be safely used to assist in the performance of laparoscopic renal surgery.

Extraanatomic stents for transplant ureteric stenosis.

Surgical and standard endourology options are limited in transplant patients with severe ureteric stenosis, particularly when access to the transplant renal pelvis is limited. The use of a silicone-polytetrafluoroethelene (PTFE)-bonded extraanatomic urinary tract stent for urinary tract drainage is described in two patients. This technique of ureteric reconstruction in renal transplantation may be considered when standard approaches have failed. It appears to be safe when performed by radiologists and urologists with expertise in percutaneous renal access.

Transplantation of kidneys from deceased adult polycystic donors.

Renal transplantation is the best treatment for end-stage renal disease. The discrepancy between donor organ supply and demand continues to widen. Maximum efforts should be made to make use of donor kidneys and we suggest that polycystic kidneys can be suitable marginal donor organs. Five polycystic cadaveric donor kidneys were transplanted in four recipients at our institution between year 2000 and 2004. The donor kidneys were either of normal size or moderately enlarged (less than 15 x 10 cm). Donor ages were 24, 46 and 55 years. All donors had normal serum creatinine at the time of organ retrieval. Recipients gave informed consent to be transplanted with the polycystic kidneys. Three of four recipients had primary graft function. The patient with primary nonfunction required graft nephrectomy 8 weeks post-transplantation. One patient died due to cardiovascular causes with a functioning graft 18 months after transplantation. Two patients remain well, 26 and 58 months after transplantation, with normal graft function. Our experience and the limited evidence from the literature suggest that, with careful selection of both donor and recipient, transplantation of cadaveric polycystic donor kidneys should be considered given the current organ shortage.

Robotic assisted retroperitoneoscopic nephroureterectomy -- first experience and the hybrid port technique.

Robot-assisted renal surgery is usually performed transperitoneally due to more available space for excursion of the robotic arms. To our knowledge, we report the first experience with robotic retroperitoneoscopic nephroureterectomy using the Da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) and a hybrid port technique. Robotic retroperitoneal nephroureterectomy was performed on two male patients. One 37-year-old patient had a painful non-functioning hydronephrotic left kidney and megaureter; the other aged 76 had a muscle invasive lower left ureteric tumour. Both the procedures were successfully completed with the robot without conversion. Mean operative time was 182.5 min and estimated blood loss 75 ml. Histological examination confirmed the preoperative diagnoses; margins were clear in the patient with tumour. Postoperative recovery was uneventful. We report the technical feasibility of robotic retroperitoneoscopic nephroureterectomy. However, as with all new technology, the benefits need to be further evaluated and proven before this technique can be widely accepted.

Transcriptional control of the human urothelial-specific gene, uroplakin Ia.

The transcriptional control elements of tissue-specific genes may be exploited in the design of therapeutic constructs for use in human gene therapy. The uroplakins are a family of four proteins which form the asymmetric unit membrane of the urothelium. We have cloned the human uroplakin Ia gene and defined its genomic structure and transcriptional start site. Using quantitative RT-PCR in an extended panel of normal tissues, we have demonstrated highly urothelial-specific expression of this gene. A Dual-Luciferase assay was used to assess the transcriptional activity of a variety of promoter fragments of the human uroplakin Ia gene. A highly specific promoter fragment (consisting of 2147 bp of 5'-flanking sequence, intron 1 and the 5' UTR) was identified which regulated urothelial-specific expression in vitro. The human uroplakin Ia promoter identified has potential use in future gene therapy strategies to restrict transgene expression to the urothelium.