Live-donor renal transplantation at the Urology & Nephrology Center of Mansoura: 1976-1998.

Based on more than 1,200 living donor transplants performed at the Urology & Nephrology Center at Mansoura University between 1976-1998, we report: 1. The overall graft survival rate was 75.8% and 51.9% at 5 and 10 years, respectively, with a projected half-life of 10.7 years. 2. Three factors acted as independent variables that significantly influenced graft survival: the number of HLA mismatches, the number of acute rejection episodes and the presence of posttransplant hypertension. a. Grafts with 2 or fewer HLA-A, -B and -DR mismatches had a significantly better survival rate. b. The incidence and the number of early acute rejection episodes had a significant negative impact on graft survival. c. A significant reduction in graft survival was associated with hypertension uncontrolled by or newly developed after transplantation. 3. Bilharziasis had no impact on the outcome. 4. Despite improvements in tissue matching and immunosuppression, an important proportion of grafts is still lost following living-donor kidney transplantation. 5. Efforts must be directed to identify better regimens, which can provide adequate immunosuppression and minimal nephrotoxicity.

A predictive model of survival after radical cystectomy for carcinoma of the bladder.

OBJECTIVE: To evaluate the effect of patient and tumour characteristics on the disease-free survival after radical cystectomy for infiltrating bladder cancer, and to use these to help in constructing a meaningful prognostic index. METHODS: The disease-free survival was initially evaluated in 1026 patients (the reference series, 1969-1990). A multivariate analysis showed that the tumour P stage, grade and nodal involvement were the only factors which had an independent and significant association with survival. The computed regression coefficients were then used to classify patients into one of four risk categories and the results then validated by applying the model to a prospective test series (1991-1995). RESULTS: The 5-year disease-free survival of both groups was similar. When the results for the risk categories of the reference series were compared with those of the test series, there was no significant difference. CONCLUSION: This comprehensive prognostic model for the results of radical cystectomy was validated and verified in a prospective group of patients. Adjuvant therapies are indicated for patients with a high risk score.

Primary adenocarcinoma of the urinary bladder: a report of 185 cases.

OBJECTIVE: To evaluate the outcome after the treatment of primary non-urachal vesical adenocarcinoma and to determine the significant prognostic factors. PATIENTS AND METHODS: The records of 185 patients with vesical adenocarcinoma were reviewed. The pathological evaluation included the determination of pathological stage, tumour grade, presence or absence of mucin and its location, evidence of bilharzial infestation and flow-cytometric DNA analysis. The mean follow-up of the treated patients was 3.1 years. Disease-free survival was estimated and the results correlated with patient and tumour characteristics (univariate analysis). Cox's proportional hazards analysis was used to determine prognostic factors. RESULTS: The overall 5-year disease-free survival was 55%; only three factors had a significant impact on survival, the tumour pathological stage and grade, and lymph node involvement. CONCLUSIONS: Radical cystectomy remains the only satisfactory treatment option for primary vesical adenocarcinoma. Tumour stage, grade and lymph node involvement are the only significant prognostic factors.

Renal diseases and transplantation in children.

The diseases that are most commonly responsible for renal damage and end-stage renal disease are unique in children. The devastating effect of chronic renal failure on the mental and physical development of children offers many challenging management problems. Although less than perfect, successful renal transplantation is considered the best available treatment option for children, with the alternative of dialysis often made difficult by access problems, growth retardation and renal osteodystrophy. Children comprise between 5 and 8% of our transplant programme, and we consider transplantation and dialysis to be complementary rather than competitive.

Radical cystectomy for carcinoma of the bladder: critical evaluation of the results in 1,026 cases.

PURPOSE: We performed a critical analysis of the different prognostic factors affecting survival among patients with carcinoma of the bladder for whom cystectomy was indicated. The different patient and tumor characteristics were correlated to survival data by a univariate as well as multivariate analysis. MATERIALS AND METHODS: Between 1969 and 1990, 764 men and 262 women, average age plus or minus standard deviation 43 +/- 8 years, with invasive carcinoma of the bladder were eligible for 1-stage radical cystectomy and urinary diversion. Patients were followed regularly and examined signs for and location of treatment failure. Followup ranged from 0 to 24.2 years, with a median plus or minus standard deviation of 4.05 +/- 4.16 years. RESULTS: Postoperative mortality was 4%. Most of the patients presented with advanced stage (greater than P3) disease. Squamous tumors accounted for 59% of cases, transitional carcinoma 22% and adenocarcinoma 11%. Bilharzial eggs were seen in 85% of the specimens. Regional lymph nodes were involved in 18.3% of the cases. The 5-year survival rate was 48%. The survival estimate was correlated to patient and tumor characteristics by univariate and multivariate analyses. Only tumor stage and grade, and lymph node status had a significant impact on survival. CONCLUSIONS: Contemporary cystectomy with continent diversion for muscle invasive disease provides minimal morbidity, offers good locoregional disease control and results in acceptable quality of life. The presence of positive regional lymph nodes is not a contraindication to this therapy.

Double folded rectosigmoid bladder with a new ureterocolic antireflux technique.

PURPOSE: We present a new method of urinary diversion to the rectum. MATERIALS AND METHODS: Between 1992 and 1995 a new surgical procedure was used in 32 women, 20 men and 12 children 3 to 60 years old (mean age plus or minus standard deviation 35.4 +/- 2.2). The main indication for diversion was invasive bladder carcinoma. Surgery entailed creation of an S-shaped double folded rectosigmoid reservoir with implantation of the ureters via an extramural serous lined antireflux technique. RESULTS: One patient died of a massive pulmonary embolism postoperatively. Followup ranged from 6 to 36 months (mean 19.2 +/- 7.0). During the observation period 6 patients died of local recurrence and/or distant metastasis within 8 months. Of the patients 57 are currently evaluable. All patients are continent during the day with an emptying frequency of 2 to 4 times. Nocturnal enuresis was observed in 4 children who responded favorably to imipramine hydrochloride therapy. Upper urinary tract function was maintained or improved in 95% of the patients. No clinical evidence of acidosis was observed, since all patients were kept on prophylactic oral alkalization. CONCLUSIONS: The procedure can circumvent some of the inherent disadvantages of ureterosigmoidostomy and is a good alternative to orthotopic bladder substitution when the urethra cannot be used.

Clinical, radiological and histological features of adrenal myelolipoma: review and experience with a further eight cases.

OBJECTIVE: To review published reports of surgically treated adrenal myelolipomas and report experience with a further eight cases. PATIENTS AND METHODS: Eight patients (three men and five women, mean age 50.7 years) with adrenal myelolipoma were treated surgically because of the tumour size, symptomatology and/or associated renal pathology. Associated medical problems included hypertension in three patients and diabetes mellitus in one but none of the tumours was endocrinologically active. RESULTS: Five patients were diagnosed definitively by abdominal ultrasonography, computed tomography and angiography while the other three were incidentally diagnosed during surgical intervention for ipsilateral renal cell carcinoma in one patient, hydronephrotic kidney in another and multiple renal stones in the third. On pathological examination, the masses removed were surrounded by a thin fibrous capsule and compressed cortical tissue. A cut section was bright yellow with foci of red-brown discoloration. Microscopically, the tumour consisted mainly of mature adipose tissue with scattered islands of haemopoietic cells. There was no operative mortality and no gross morbidity. CONCLUSION: The management of adrenal myelolipoma should be appropriate to each individual case. Operative intervention should be reserved for symptomatic patients or those with large 'silent' tumours that may produce life-threatening shock secondary to spontaneous haemorrhage. Small asymptomatic tumours with definite radiological findings can be followed expectantly.

Late malignancy in bowel segments exposed to urine without fecal stream.

OBJECTIVES: This study was constructed so as to screen malignant transformation after uroenteric reconstructions using bowel segments exposed to urine without fecal stream for more than 10 years. METHODS: Follow-up data were available for 186 patients who underwent various uroenteric reconstructions using bowel segments exposed to urine without fecal stream for more than 10 years. There were 68 eligible patients with isolated rectosigmoid bladder, 23 with bladder augmentations (15 ileocystoplasty and 8 colocystoplasty), 57 with ileal ureter, and 38 with ileal loop conduit. Besides routine laboratory and radiologic investigations, urine for cytology was obtained from all patients. Moreover, endoscopy and random biopsy of the part of bowel exposed to urine were carried out in all patients. RESULTS: Uroenteric malignancy was diagnosed in 4 patients (2%): 2 adenocarcinoma in an isolated rectosigmoid bladder, 1 transitional cell carcinoma following augmentation colocystoplasty, and 1 squamous cell carcinoma after ileal ureter. None of the patients developed tumors in ileal loop conduits. CONCLUSIONS: Malignant changes do not only occur after ureterosigmoidostomy but are also observed after different uroenteric reconstructions not exposed to fecal stream. Hematuria, ureteral obstruction, and abnormal urine cytology are warning signs of malignancy. Routine cytology is recommended at least yearly beginning 10 years after surgery.

Postrenal transplant urethral Kock pouch.

We report on a man with schistosomal bladder who developed stage T3N0M0, grade II transitional cell carcinoma of the bladder 9 years following successful renal transplantation. Radical cystoprostatectomy was performed and urethral Kock pouch was implanted in the same setting. The patient was continent and the graft function was maintained without reflux or obstruction at a follow-up period of 2 years. No complications due to poor intestinal healing or intraabdominal sepsis were observed despite immunosuppression and electrolyte disorders were minor.

Bladder substitutes controlled by the anal sphincter: a comparison of the different absorption potentials.

A comparative study of the absorption potentials of the simple rectal bladder (10 patients), modified rectal bladder (20) and ureterosigmoidostomy (10) was done with intrarectal instillation of 22sodium. Results indicate that absorption is significantly greater among patients with ureterosigmoidostomy. The emptying patterns of ureterosigmoidostomy and the modified rectal bladder were also studied by ascending scintigraphy with 99mtechnetium. Evidence was provided that in cases with ureterosigmoidostomy the isotope is distributed throughout the entire colon. These studies proved the role of the colorectal valve in preventing reflux of urine from the rectum to the proximal colon. Consequently, the surface area of colonic mucosa exposed to urine is decreased and the rate of reabsorption is limited.