Tumor-associated macrophages impair NK cell IFN-γ production and contribute to tumor progression in clear cell renal cell carcinoma.

Tumor-associated macrophages (TAM) are abundant in several tumor types and usually correlate with poor prognosis. Previously, we demonstrated that anti-inflammatory macrophages (M2) inhibit NK cell effector functions. Here, we explored the impact of TAM on NK cells in the context of clear-cell renal cell carcinoma (ccRCC). Bioinformatics analysis revealed that an exhausted NK cell signature strongly correlated with an M2 signature. Analysis of TAM from human ccRCC samples confirmed that they exhibited an M2-skewed phenotype and inhibited IFN-γ production by NK cells. Moreover, human M0 macrophages cultured with conditioned media from ccRCC cell lines generated macrophages with an M2-skewed phenotype (TAM-like), which alike TAM, displayed suppressive activity on NK cells. Moreover, TAM depletion in the mouse Renca ccRCC model resulted in delayed tumor growth and reduced volume, accompanied by an increased frequency of IFN-γ-producing tumor-infiltrating NK cells that displayed heightened expression of T-bet and NKG2D and reduced expression of the exhaustion-associated co-inhibitory molecules PD-1 and TIM-3. Therefore, in ccRCC, the tumor microenvironment polarizes TAM toward an immunosuppressive profile that promotes tumor-infiltrating NK cell dysfunction, contributing to tumor progression. In addition, immunotherapy strategies targeting TAM may result in NK cell reinvigoration, thereby counteracting tumor progression.

The MICA-NKG2D axis in clear cell renal cell carcinoma bolsters MICA as target in immuno-oncology.

NKG2D is a major natural killer (NK) cell-activating receptor that recognizes eight ligands (NKG2DLs), including MICA, and whose engagement triggers NK cell effector functions. As NKG2DLs are upregulated on tumor cells but tumors can subvert the NKG2D-NKG2DL axis, NKG2DLs constitute attractive targets for antibody (Ab)-based immuno-oncology therapies. However, such approaches require a deep characterization of NKG2DLs and NKG2D cell surface expression on primary tumor and immune cells. Here, using a bioinformatic analysis, we observed that MICA is overexpressed in renal cell carcinoma (RCC), and we also detected an association between the NKG2D-MICA axis and a diminished overall survival of RCC patients. Also, by flow cytometry (FC), we observed that MICA was the only NKG2DL over-expressed on clear cell renal cell carcinoma (ccRCC) tumor cells, including cancer stem cells (CSC) that also coexpressed NKG2D. Moreover, tumor-infiltrating leukocytes (TIL), but not peripheral blood lymphoid cells (PBL) from ccRCC patients, over-expressed MICA, ULBP3 and ULBP4. In addition, NKG2D was downregulated on peripheral blood NK cells (PBNK) from ccRCC patients but upregulated on tumor-infiltrating NK cells (TINK). These TINK exhibited impaired degranulation that negatively correlated with NKG2D expression, diminished IFN-γ production, upregulation of TIM-3, and an impaired glucose intake upon stimulation with cytokines, indicating that they are dysfunctional, display features of exhaustion and an altered metabolic fitness. We conclude that ccRCC patients exhibit a distorted MICA-NKG2D axis, and MICA emerges as the forefront NKG2DL for the development of targeted therapies in ccRCC.

Tumor-Experienced Human NK Cells Express High Levels of PD-L1 and Inhibit CD8+ T Cell Proliferation.

Natural Killer (NK) cells play a key role in cancer immunosurveillance. However, NK cells from cancer patients display an altered phenotype and impaired effector functions. In addition, evidence of a regulatory role for NK cells is emerging in diverse models of viral infection, transplantation, and autoimmunity. Here, we analyzed clear cell renal cell carcinoma (ccRCC) datasets from The Cancer Genome Atlas (TCGA) and observed that a higher expression of NK cell signature genes is associated with reduced survival. Analysis of fresh tumor samples from ccRCC patients unraveled the presence of a high frequency of tumor-infiltrating PD-L1+ NK cells, suggesting that these NK cells might exhibit immunoregulatory functions. In vitro, PD-L1 expression was induced on NK cells from healthy donors (HD) upon direct tumor cell recognition through NKG2D and was further up-regulated by monocyte-derived IL-18. Moreover, in vitro generated PD-L1hi NK cells displayed an activated phenotype and enhanced effector functions compared to PD-L1- NK cells, but simultaneously, they directly inhibited CD8+ T cell proliferation in a PD-L1-dependent manner. Our results suggest that tumors might drive the development of PD-L1-expressing NK cells that acquire immunoregulatory functions in humans. Hence, rational manipulation of these regulatory cells emerges as a possibility that may lead to improved anti-tumor immunity in cancer patients.

Circulating and Tumor-Infiltrating NK Cells From Clear Cell Renal Cell Carcinoma Patients Exhibit a Predominantly Inhibitory Phenotype Characterized by Overexpression of CD85j, CD45, CD48 and PD-1.

Although natural killer (NK) cells infiltrate clear cell renal cell carcinomas (ccRCC), the most frequent malignancy of the kidney, tumor progression suggests that they become dysfunctional. As ccRCC-driven subversion of NK cell effector functions is usually accompanied by phenotypic changes, analysis of such alterations might lead to the identification of novel biomarkers and/or targets in immuno-oncology. Consequently, we performed a phenotypic analysis of peripheral blood NK cells (PBNK) and tumor-infiltrating NK cells (TINK) from ccRCC patients. Compared to HD, PBNK from ccRCC patients exhibited features of activated cells as shown by CD25, CD69 and CD62L expression. They also displayed increased expression of DNAM-1, CD48, CD45, MHC-I, reduced expression of NKG2D, and higher frequencies of CD85j+ and PD-1+ cells. In addition, compared to PBNK from ccRCC patients, TINK exhibited higher expression of activation markers, tissue residency features and decreased expression of the activating receptors DNAM-1, NKp30, NKp46, NKp80 and CD16, suggesting a more inhibitory phenotype. Analysis of The Cancer Genome Atlas (TCGA) revealed that CD48, CD45, CD85j and PD-1 are significantly overexpressed in ccRCC and that their expression is associated with an NK cell infiltration signature. Calculation of z-scores revealed that their expression on PBNK, alone or combined, distinguished ccRCC patients from HD. Therefore, these molecules emerge as novel potential biomarkers and our results suggest that they might constitute possible targets for immunotherapy in ccRCC patients.

Prognostic Factors in De Novo Metastatic Renal Cell Carcinoma: A Report From the Latin American Renal Cancer Group.

PURPOSE: To assess the effect of clinical and pathological variables on cancer-specific and overall survival (OS) in de novo metastatic patients from a collaborative of primarily Latin American countries. PATIENTS AND METHODS: Of 4,060 patients with renal cell carcinoma diagnosed between 1990 and 2015, a total of 530 (14.5%) had metastasis at clinical presentation. Relationships between clinical and pathological parameters and treatment-related outcomes were analyzed by Cox regression and the log-rank method. RESULTS: Of 530 patients, 184 (90.6%) had died of renal cell carcinoma. The median OS of the entire cohort was 24 months. American Society of Anesthesiology classification 3-4 (hazard ratio [HR]: 1.64), perirenal fat invasion (HR: 2.02), and ≥ 2 metastatic organ sites (HR: 2.19) were independent prognostic factors for 5-year OS in multivariable analyses. We created a risk group stratification with these variables: no adverse risk factors (favorable group), median OS not reached; one adverse factor (intermediate group), median OS 33 months (HR: 2.04); and two or three adverse factors (poor risk group), median OS 14 months (HR: 3.58). CONCLUSION: Our study defines novel prognostic factors that are relevant to a Latin American cohort. With external validation, these easily discerned clinical variables can be used to offer prognostic information across low- and middle-income countries.

Small renal masses in Latin-American population: characteristics and prognostic factors for survival, recurrence and metastasis - a multi-institutional study from LARCG database.

BACKGROUND: To evaluate demographic, clinical and pathological characteristics of small renal masses (SRM) (≤ 4 cm) in a Latin-American population provided by LARCG (Latin-American Renal Cancer Group) and analyze predictors of survival, recurrence and metastasis. METHODS: A multi-institutional retrospective cohort study of 1523 patients submitted to surgical treatment for non-metastatic SRM from 1979 to 2016. Comparisons between radical (RN) or partial nephrectomy (PN) and young or elderly patients were performed. Kaplan-Meier curves and log-rank tests estimated 10-year overall survival. Predictors of local recurrence or metastasis were analyzed by a multivariable logistic regression model. RESULTS: PN and RN were performed in 897 (66%) and 461 (34%) patients. A proportional increase of PN cases from 48.5% (1979-2009) to 75% (after 2009) was evidenced. Stratifying by age, elderly patients (≥ 65 years) had better 10-year OS rates when submitted to PN (83.5%), than RN (54.5%), p = 0.044. This disparity was not evidenced in younger patients. On multivariable model, bilaterality, extracapsular extension and ASA (American Society of Anesthesiologists) classification ≥3 were predictors of local recurrence. We did not identify significant predictors for distant metastasis in our series. CONCLUSIONS: PN is performed in Latin-America in a similar proportion to developed areas and it has been increasing in the last years. Even in elderly individuals, if good functional status, sufficiently fit to surgery, and favorable tumor characteristics, they should be encouraged to perform PN. Intending to an earlier diagnosis of recurrence or distant metastasis, SRM cases with unfavorable characteristics should have a more rigorous follow-up routine.

Solitary Fibrous Tumor of the pelvis involving the bladder. Case report and literature review.

A case of a patient with diagnosis of Solitary Fibrous Tumor of de urinary bladder is presented. A 69 year old man presented with abdominal pain localized at the hypogastrium. In the computed tomography appears a mass of 100 × 80 mm at the minor pelvis. Mass resection, radical cystoprostatectomy and ileal conduit diversion were done. A Solitary Fibrous Tumor of the urinary bladder was diagnosed. CD 34 (+). Surgical resection with negative margins has curative intention. Is necessary long-term follow up to assure there is not local or distant recurrence.

American Confederation of Urology (CAU) experience in minimally invasive partial nephrectomy.

PURPOSE: To describe the perioperative and oncology outcomes in a series of laparoscopic or robotic partial nephrectomies (PN) for renal tumors treated in diverse institutions of Hispanic America from the beginning of their minimally invasive (MI) PN experience through December 2014. METHODS: Seventeen institutions participated in the CAU generated a MI PN database. We estimated proportions, medians, 95 % confidence intervals, Kaplan-Meier curves, multivariate logistic and Cox regression analyses. Clavien-Dindo classification was used. RESULTS: We evaluated 1501 laparoscopic (98 %) or robotic (2 %) PNs. Median age: 58 years. Median surgical time, warm ischemia and intraoperative bleeding were 150, 20 min and 200 cc. 81 % of the lesions were malignant, with clear cell histology being 65 % of the total. Median maximum tumor diameter is 2.7 cm, positive margin is 8.2 %, and median hospitalization is 3 days. One or more postoperative complication was recorded in 19.8 % of the patients: Clavien 1: 5.6 %; Clavien 2: 8.4 %; Clavien 3A: 1.5 %; Clavien 3B: 3.2 %; Clavien 4A: 1 %; Clavien 4B: 0.1 %; Clavien 5: 0 %. Bleeding was the main cause of a reoperation (5.5 %), conversion to radical nephrectomy (3 %) or open partial nephrectomy (6 %). Transfusion rate is 10 %. In multivariate analysis, RENAL nephrometry score was the only variable associated with complications (OR 1.1; 95 % CI 1.02-1.2; p = 0.02). Nineteen patients presented disease progression or died of disease in a median follow-up of 1.37 years. The 5-year progression or kidney cancer mortality-free rate was 94 % (95 % CI 90, 97). Positive margins (HR 4.98; 95 % CI 1.3-19; p = 0.02) and females (HR 5.6; 95 % CI 1.7-19; p = 0.005) were associated with disease progression or kidney cancer mortality after adjusting for maximum tumor diameter. CONCLUSION: Laparoscopic PN in these centers of Hispanic America seem to have acceptable perioperative complications and short-term oncologic outcomes.

Anastomosis ampliada con injerto de mucosa yugal en el tratamiento de la estrechez de uretra bulbar / Buccal mucosa graft augmented anastomotic urethroplasty for the treatment of bulbar urethral strictures

OBJETIVO: Reportar nuestros resultados con la utilización de la anastomosis ampliada con injerto de mucosa yugal para el manejo de la estrechez compleja de la uretra bulbar. MÉTODOS: Análisis retrospectivo de 65 pacientes operados en 2 Centros Hospitalarios independientes de cirugía reconstructiva, entre octubre de 2007 y enero de 2011. Se analizaron datos demográficos, resultados y complicaciones. RESULTADOS: La edad promedio de los pacientes fue de 50,09 años (rango: 25 a 75), siendo la longitud media de la estrechez de 3,95 cm (rango: 3 a 7) y un seguimiento promedio de 33,13 meses (rango: 12,7 a 52,77). El 80% de los pacientes había sido tratado previamente con múltiples uretrotomías internas y dilataciones. Las etiologías más frecuentes fueron instrumental (46,15%) e idiopática (35,38%). La tasa de éxito fue del 96,92%, recidivando en 2 pacientes, que fueron exitosamente tratados con uretrotomía interna. Las complicaciones fueron menores, Clavien Dindo I-II, ocurriendo en el 39,92% de los pacientes, y ninguna de ellas dejó secuelas incapacitantes a largo plazo. CONCLUSIÓN: La anastomosis ampliada permite corregir en un tiempo extensos procesos cicatrizales de la uretra y con gran compromiso de la luz uretral. Los resultados obtenidos en nuestra serie se comparan con aquellos de las series internacionales ya reportados

OBJECTIVE: To report our outcomes with the use of buccal mucosal graft anastomotic urethroplasty to reconstruct complex anterior urethral strictures. METHODS: Between October 2007 and January 2011 we conducted a retrospective review of a series of 65 patients from 2 different centers. We analyzed demographic data, surgical outcomes and complications. RESULTS: Patient mean age was 50.09 years (range: 25 to 75), mean stricture length was 3.95 cm (range: 3 to 7 cm) and mean follow-up 33.13 months (range: 12.7 to 52.77). Eighty percent of patients had prior treatments, mainly direct visual internal urethrotomy (DVIU) and urethral dilatation. Most frequent etiologies were iatrogenic in 46.15% of patients and idiopathic in 35.38% of patients. Success rate was achieved in 96.92% of patients; only 2 patients presented recurrence and were treated successfully with one DVIU. Clavien Dindo I-II complications were found in 59% of patients. No patient had chronic sequels. CONCLUSION: Augmented anastomotic urethroplasty using dorsal onlay buccal mucosa graft enables correction, in one time, of long segment urethral strictures with severe spongiofibrosis and/or obliterated lumen. Our outcomes are comparable with those of previously reported in international series

International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results.

OBJECTIVE: To present mid-term outcomes from an international, multi-institutional cohort of patients undergoing vessel-sparing excision and primary anastomosis urethroplasty for the reconstruction of the anterior urethra. MATERIALS AND METHODS: From June 2003 to December 2011, 68 patients underwent vessel-sparing anterior urethral reconstruction at five different international institutions using the vessel-sparing technique described by Jordan et al. (J Urol 177(5):1799-1802, 2007). RESULTS: Patients' age range was from 3 to 82 years (mean 51.2). Stricture length ranged from 1 to 3 cm (mean 1.78). After a mean follow-up of 17.6 months, 95.6 % of patients had a widely patent urethral lumen. Three patients failed the procedure, requiring either direct vision internal urethrotomy or urethral dilation, after which all were free of symptoms and did not require further instrumentation. Complications were minimal and as expected following open urethroplasty. CONCLUSION: Preservation of blood supply is a noble pursuit in surgery; however, it can be technically difficult and often requires more time and effort. This vessel-sparing technique for anterior urethral reconstruction is reproducible and appears to be reliable in this international cohort. Larger studies and longer follow-up are needed to support these encouraging results.

Cumulative incidence, indications, morbidity and mortality of transplant nephrectomy and the most appropriate time for graft removal: only nonfunctioning transplants that cause intractable complications should be excised.

PURPOSE: We assessed the cumulative incidence of transplant nephrectomy in our population of patients who underwent transplantation and those in whom the transplant failed due to immunological causes. Transplant nephrectomy indications, morbidity and mortality were analyzed to establish the most appropriate time for graft removal. MATERIALS AND METHODS: We included all patients who underwent transplantation and graft removal at our institution from January 1, 1970 through January 1, 2000. We estimated the noncumulative incidence of transplant nephrectomy, morbidity and mortality. The cumulative incidence of transplant nephrectomy was estimated by Kaplan-Meier curves. RESULTS: Of the 631 renal transplants performed in 598 patients we studied a total of 91 transplant nephrectomies in 85 patients. The cumulative incidence of transplant nephrectomy 15 years after the date of transplantation was 25% (95% CI 14 to 40). The cumulative incidence of transplant nephrectomy at 10 years after the date of return to dialysis was 74% (95% CI 49 to 90). The main indication for transplant nephrectomy was graft related complications associated with chronic rejection in 58.2% of cases. The morbidity rate was 48.3% (95% CI 37.7 to 59). Hemorrhagic events were the chief complication. In 7 patients there was a total of 10 reoperations (10.9%, 95% CI 5.3 to 19.2). The mortality rate was 7% (95% CI 2.6 to 14.7). These patients died of sepsis. Urgent transplant nephrectomies had statistically higher morbidity and mortality (p <0.01 and 0.002, respectively). CONCLUSIONS: Most transplant nephrectomies were performed within 2 years of the transplant date and almost half were done within year 1 after the return to dialysis. The advent of cyclosporine significantly decreased the transplant nephrectomy rate at the expense of fewer graft failures but not at the expense of a lower amount of graft related symptoms after patients returned to dialysis. Bleeding was the leading cause of morbidity and infection was the main cause of mortality. Considering the high morbidity and mortality of transplant nephrectomy, and the potential benefits of leaving nonfunctioning grafts in situ our current policy is to remove the graft only in cases of failed transplants that cause intractable complications.

Comparing Taguchi and Lich-Gregoir ureterovesical reimplantation techniques for kidney transplants.

PURPOSE: We compared the incidence of urological and anastomotic complications, and the duration of ureteral reimplantation for the Taguchi and Lich-Gregoir techniques. MATERIALS AND METHODS: We recorded all urological and anastomotic complications that developed from the date of transplantation through December 31, 2001. The cutoff date for transplantation was August 30, 2000. The urological complications evaluated included complicated hematuria, urinary fistula, ureteral stenosis, symptomatic vesicoureteral reflux and operative time. The chi-square test was done to compare the proportion of complications in the groups and the Mann Whitney test was used to compare the duration of ureteral reimplantation. RESULTS: Of the 575 transplants evaluated 416 and 159 were performed via the Lich-Gregoir and Taguchi techniques, respectively. The incidence of anastomotic complications was 10.7%. Complications in the Lich-Gregoir group included fistula in 4.7% of cases, stenosis in 4.1%, symptomatic vesicoureteral reflux in 1.9% and complicated hematuria in 0.5%. Complications in the Taguchi group included urinary fistula in 6.3% of cases, stenosis in 2.5% and complicated hematuria in 2.5%. Symptomatic reflux was not observed in this group. There was a higher proportion of hematuria at the limit of statistical significance in the Taguchi group (p = 0.05). There were a higher number of urological complications in transplants from live donors in the Lich-Gregoir group (p = 0.01), mostly involving fistula (p = 0.05). There were no significant differences in the groups in overall complications. Average operative time for the Taguchi and Lich-Gregoir techniques was 14.2 and 29 minutes, respectively. This difference was significant (p = 0.02). CONCLUSIONS: In the sample studied Taguchi ureterocystoneostomy proved to be a more rapid method without increasing the incidence of urological or anastomotic complications. There were no cases of symptomatic reflux in the Taguchi group and select fistula cases could be managed conservatively. The Lich-Gregoir cohort was at greater risk for the urological complications of live donor transplantation. The Taguchi method has become the ureterovesical reimplantation technique of choice in our setting.

[Value of gray scale ultrasonography in the early diagnosis of urologic complications of renal transplantation]. / Valor de la ultrasonografía en escala de grises en el diagnóstico precoz de las complicaciones urológicas del trasplante renal.

OBJECTIVE: To determine the significance of gray scale ultrasound as a tool for diagnosis, follow-up and treatment of urological complications of renal transplantation based on the experience of our institution. METHODS: A retrospective, longitudinal and observational study was carried out. We reviewed the patients' perioperative ultrasound scans and their respective urological complications from January 1, 1982 to January 1, 2000. The patients were consecutively taken from the kidney transplant registry of the Urology and Nephrology and Transplant Departments. We describe the ultrasound findings of normal functioning grafts as well as those with urological complications, such as fluid collections (lymphocele, hematoma, urinoma and abscess), uronephrosis and its possible causes, and symptomatic vesicourethral reflux. RESULTS/CONCLUSIONS: Diagnostic and therapeutic algorithms in kidney transplant patients have been changed since the advent of ultrasound in our country in 1981. Rapid diagnosis and better therapeutic options have been the hallmarks of ultrasound. Added advantages are: it is low-cost, non-invasive, not time consuming. It can be performed regardless of kidney function, can be repeated as many times as required, subsequent scans can be compared. It can be carried out in special care units. The superficial location of the graft makes it highly sensitive. Its disadvantages are low specificity to identify either the nature of the fluid collections or the precise site of urinary tract obstruction, apart from depending on the skill of the operator. Specialists should be familiar with the surgical anatomy of the kidney graft and its variations in order to utilize completely its diagnostic and therapeutic potentials.

Valor de la ultrasonografía en escala de grises en el diagnóstico precoz de las complicaciones urológicas del trasplante renal / Value of gray scale ultrasonography in the early diagnosis of the urological complications of renal transplantation

Objetivo: Establecer el valor de la ecografía en escala de grises para el diagnóstico, seguimiento y eventual tratamiento de las complicaciones urológicas del trasplante renal basado en la experiencia de nuestro centro. Métodos: Se revisaron los informes ecográficos y las complicaciones urológicas de los pacientes trasplantados desde el 1 de enero de 1982 hasta el 1 de enero del 2000. El muestreo fue consecutivo, no probabilístico en base a los registros documentados en la sección Urología y en el Servicio de Nefrología y Trasplante de la Institución. El diseño fue retrospectivo, longitudinal y observacional. Resultados: Se describen los hallazgos ecográficos de injertos con buen funcionamiento y aquellos con complicaciones urológicas, a saber: colecciones (linfoceles, hematomas, urinomas y abscesos), uronefrosis con sus posibles causas y reflujo sintomático. Conclusiones: Desde el advenimiento de la ecografía en nuestro país en 1981 se han modificado tanto los algorritmos diagnósticos como los tiempos terapéuticos en esta población de pacientes. Se ha ganado en precocidad diagnóstica y mayor serenidad al momento de decidir por un tratamiento, dado por un sin fin de ventajas: bajo costo, no invasividad, rápida realización, no altera ni perjudica la función del injerto, puede repetirse cuantas veces sea necesario lo que hace que los sucesivos estudios sean comparables entre sí, al ser portátil puede llevarse a cabo dentro de las áreas especiales para pacientes inmunosuprimidos y la localización superficial del injerto contribuye a hacer de este un procedimiento altamente sensible. Sus desventajas son su baja especificidad para distinguir el contenido de las colecciones o el nivel exacto de las obstrucciones, y el hecho de ser un procedimiento operador dependiente. El buen especialista debe estar profundamente familiarizado con la anatomía quirúrgica del trasplante y sus variantes a los efectos de obtener de la ecografía el 100 por ciento de su potencial diagnóstico y terapéutico (AU)

Anatomía quirúrgica del transplante renal / Surgical anatomy of the renal transplant

Este trabajo se basa en la experiencia adquirida en transplantes de riñón, por un mismo equipo quirúrgico, a través de 19 años de actuación, en una misma institución CEMIC. Desde el inicio, en 1970, se estudió exahustivamente la antomía del dador, del receptor y del aparato urinario, en relación con el injerto renal, lo que se expresa en los correspondientes capítulos de este trabajo. El objeto es disminuir la agresión al máximo aprovechando las vías de abordaje anatomicamente más simples de evolución más satisfactoria y con mejor recuperación del paciente. También describimos en detalle y así lo referimos, la celda renal y sus relaciones, la estructura del riñon y la arquitectura intrarrenal, tanto canicular como vascular. La primera por la posibilidad de derivaciones urinarias tradicionales y desde 1985 de la cirugía endourológica pos-trasplante. La segunda por la relación de los elementos vasculares del pedículo renal entre sí, con los órganos vecinos y con los grandes vasos. Importan y se describen también las malformaciones que se pueden diagnosticar previamente y que hacen a la selección del dador vivo relacionado, o que durante el acto operatorio, obliguen a cirugías complementarias inmediatas. Expuestas en otro capítulo, la estructura anatómica y funcional de la vía excretora así como su irrigación y las oportunidades que esta brinda en la reconstrucción canicular urinaria. Se estudian también las técnicas posibles en la anastomosis vasculares y en la vía excretora así como sus variaciones. Se describen los recaudos quirúrgicos, basados en la antomía del aparato urinario, que permite prevenir ciertas complicaciones, como por ejemplo, el reflujo y las intervenciones complementarias, si a pesar de todo aquellas ocurren. Finalmente se hace mención a la posibilidad del uso de segmentos entéricos, en reemplazo de sectores urinarios.

Anatomía quirúrgica del transplante renal / Surgical anatomy of the renal transplant

Este trabajo se basa en la experiencia adquirida en transplantes de riñón, por un mismo equipo quirúrgico, a través de 19 años de actuación, en una misma institución CEMIC. Desde el inicio, en 1970, se estudió exahustivamente la antomía del dador, del receptor y del aparato urinario, en relación con el injerto renal, lo que se expresa en los correspondientes capítulos de este trabajo. El objeto es disminuir la agresión al máximo aprovechando las vías de abordaje anatomicamente más simples de evolución más satisfactoria y con mejor recuperación del paciente. También describimos en detalle y así lo referimos, la celda renal y sus relaciones, la estructura del riñon y la arquitectura intrarrenal, tanto canicular como vascular. La primera por la posibilidad de derivaciones urinarias tradicionales y desde 1985 de la cirugía endourológica pos-trasplante. La segunda por la relación de los elementos vasculares del pedículo renal entre sí, con los órganos vecinos y con los grandes vasos. Importan y se describen también las malformaciones que se pueden diagnosticar previamente y que hacen a la selección del dador vivo relacionado, o que durante el acto operatorio, obliguen a cirugías complementarias inmediatas. Expuestas en otro capítulo, la estructura anatómica y funcional de la vía excretora así como su irrigación y las oportunidades que esta brinda en la reconstrucción canicular urinaria. Se estudian también las técnicas posibles en la anastomosis vasculares y en la vía excretora así como sus variaciones. Se describen los recaudos quirúrgicos, basados en la antomía del aparato urinario, que permite prevenir ciertas complicaciones, como por ejemplo, el reflujo y las intervenciones complementarias, si a pesar de todo aquellas ocurren. Finalmente se hace mención a la posibilidad del uso de segmentos entéricos, en reemplazo de sectores urinarios. (AU)