An updated analysis of the surgical and urological complications of 789 living-related donor kidney transplantations: Experience of a single center.

BACKGROUND: This study aims to review retrospectively the surgical and urological complications encountered in 789 cases of living-related donor kidney transplantations (LRDKTs). METHODS: In this study, the clinical records of 789 LRDKTs, which were performed between 1983 and 2017, were reviewed retrospectively concerning surgical and urological complications. RESULTS: Overall, urological and surgical complications were encountered in 87 (11.02%) of the cases. Of the 789 patients, urological complications were detected in 44 of them (5.6%), including 8 urinary fistula (with 1 distal ureteral necrosis), 10 ureteric stenosis, 1 renal calculus, 9 symptomatic vesicoureteral reflux and 16 lymphoceles requiring intervention. As surgical complications (n=43), vascular complications were encountered in 8 cases; there were 5 cases with renal artery stenosis and 3 with renal vein thrombus. Wound infection was detected in 14 patients. Eighteen patients underwent surgical explorations due to perinephric hematoma during the early postoperative period. Renal allograft rupture due to accelerated rejection was developed in 2 cases. A lower segmental arterial injury occurred in 1 patient during the operation. CONCLUSION: In our series, urological and surgical complications were detected in 11.02% of the recipients. Although complications still encountered, early identification of these complications with proper management strategies significantly decreases the risk of graft loss.

Impact of ureteral access sheath force of insertion on ureteral trauma: In vivo preliminary study with 7 patients.

BACKGROUND: Ureteral access sheaths (UASs) are commonly used in retrograde intra-renal surgery (RIRS). Despite their advantages, there is a risk of ureteral trauma during their placement and subsequent stricture following surgery. The aim of this study was to evaluate the UAS force of insertion (FOI) during placement and its impact on ureteral trauma. METHODS: Seven female patients who underwent RIRS for kidney stones were included in the study. A digital force gauge (Chatillon DFX II; Ametek Test and Calibration Instruments, Largo, Florida, USA) was connected to the distal end of the UAS and the UAS FOI was continuously measured during insertion. UASs of different sizes were used and ureteral injury was evaluated under direct vision with the Post-Ureteroscopic Lesion Scale (PULS) score. RESULTS: Five pre-stented patients and 2 non-stented patients were included in the study. The size of the UASs used in non-stented patients was 9.5/11.5-F and 10/12-F, whereas one 11/13-F and four 12/14-F sheaths were used in the pre-stented patients. The highest maximal UAS FOI observed was 5.9 Newton (N) in a pre-stented patient with a 12/14-F UAS, where a second attempt was performed after initial failure. The lowest maximal UAS FOI was 0.91 N in a non-stented patient using a 9.5/11.5-F UAS. A semirigid ureteroscopy with a 7.8-F sheath was performed in this patient prior UAS placement. The PULS score was 1 in the 2 non-stented patients and 0 in all of the pre-stented patients. CONCLUSION: In this small cohort, a preoperative JJ stent seemed to protect the ureter, even with larger diameter UASs of 12/14- F. Non-stented RIRS with a UAS is possible, but may cause low-grade ureteral trauma.

Urinary nerve growth factor in children with overactive bladder: a promising, noninvasive and objective biomarker.

OBJECTIVE: This prospective study was designed to determine urinary nerve growth factor (NGF) levels in children with overactive bladder (OAB), and to evaluate whether this factor can be used as a biomarker for diagnosis and monitoring treatment outcome. PATIENTS AND METHODS: Urinary NGF levels were determined in 40 children with OAB and in a control group of 20 children with no urinary symptoms. Urine samples were collected from the patients prior to and at 3 and 6 months after the beginning of treatment. The total NGF levels (pg/mL) were further normalized to the concentration of urinary creatinine (NGF/Cr level). RESULTS: Overall, both NGF and NGF/Cr levels were significantly higher at the beginning of the study. Mean NGF levels were 30.75 ± 8.35 and 9.75 ± 2.11 pg/ml (p = 0.023) and mean NGF/Cr levels were 0.53 ± 0.14 and 0.16 ± 0.04 (p = 0.022) in patients and controls, respectively. After 6 months of therapy, the NGF/Cr level was significantly reduced to almost control levels (0.16 ± 0.02, p = 0.047). CONCLUSION: NGF and NGF/Cr levels were significantly higher in children with OAB than controls at initial evaluation. Furthermore, the NGF/Cr level was significantly reduced following 6 months of therapy. NGF and NGF/Cr levels show promise as reliable biomarkers for OAB diagnosis and to monitor therapy in the pediatric age group.

Appetite-regulating hormones in chronic kidney disease patients.

OBJECTIVE: Inflammation and loss of appetite is the most common problem in patients with chronic kidney disease (CKD). This comparative cross-sectional study aimed to characterize the changes in circulating levels of ghrelin, obestatin, leptin, all of which have an effect on food intake, and proinflammatory cytokines interleukin (IL)-6 and tumor necrosis factor-alpha (TNF-α) in patients with CKD who were undergoing different treatments. DESIGN AND SETTING: Study participants included 36 patients who had undergone hemodialysis (body mass index [BMI]: 22.3 ± 4.17 kg/m(2)); 41 who had undergone peritoneal dialysis (BMI: 23.5 ± 3.10 kg/m(2)), 30 with early stage CKD (BMI: 24.4 ± 3.32 kg/m(2)), and 31 healthy subjects (24.3 ± 2.14 kg/m(2)). The patients with CKD were kept under a standard diet with restricted salt, potassium, and protein intake. INTERVENTION: Levels of leptin, acylated ghrelin, obestatin, TNF-α, and IL-6 were measured by commercially available enzyme-linked immunosorbent assay kits. Total nitrite/nitrate was analyzed using colorimetric assay kit. RESULTS: Significantly high leptin levels, accompanied by low acylated ghrelin levels, were observed in patients with CKD. Maintenance dialysis did not affect these levels. TNF-α and IL-6 levels were significantly higher in CKD patients than in healthy subjects, the highest being in dialysis patients. Obestatin levels were relatively low in patients who had undergone hemodialysis. CONCLUSION: Low acyl-ghrelin levels, accompanied with high levels of TNF-α and IL-6 may be involved in the loss of appetite and poor nutritional status in CKD patients.

[The relationship between level of injury and bladder behavior in patients with post-traumatic spinal cord injury]. / Posttravmatik spinal kord lezyonlu hastalarda travma seviyesi ile mesane davranisi arasindaki iliski.

BACKGROUND: After the spinal shock period, suprasacral injuries classically result in detrusor hyperreflexia/overactive bladder and detrusor sphincter dyssynergia. Sacral cord injuries produce detrusor areflexia consistent with lower motor neuron injury and often increased bladder compliance. However, previous investigators have noted an inexact correlation between spinal cord injury level and urodynamic findings. The aim of this study was to evaluate the relationship between level of injury and urodynamic findings. METHODS: Fifty-one patients with post-traumatic spinal cord injury were classified by the radiographically determined level of injury, clinical neurologic level and completeness of injury. Urodynamic studies were performed in all patients. RESULTS: Twenty-six of 36 patients with suprasacral injuries had hyperreflexia/overactive bladder (72.2%). Twenty-nine (80.5%) had detrusor sphincter dyssynergia, 9 (25%) had normal compliance and 1 (2.8%) had areflexia. Six of the 14 patients with sacral injuries had areflexia (42.8%), 2 (14.3%) had hyperreflexia/overactive bladder, 2 (14.3%) had detrusor sphincter dyssynergia, and 6 (42.8%) had normal compliance. CONCLUSION: The correlation between somatic neurologic findings or spinal imaging studies and urodynamic findings in patients with spinal cord injury is not exact. These data suggest that the neurologic examination alone is not an adequate parameter to predict urological dysfunction and that urodynamic evaluation provides a more precise diagnosis for each patient.

Dimethylarginines and inflammation markers in patients with chronic kidney disease undergoing dialysis.

The aim of this study was to investigate the pro-oxidant and proinflammatory biomarkers and their relationship with dimethylarginines (DMAs) in patients at various stages of chronic kidney disease (CKD). We studied 114 CKD patients, 36 were hemodialyzed, 41 peritoneal dialyzed and 37 nondialyzed (early stage) CKD patients. The control group consisted of 31 healthy subjects. Plasma levels of asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), L-arginine, nitric oxide (NO) and proinflammatory cytokines (TNF-alpha and IL-6) were determined, and their relationships with the degree of disease were evaluated. Both DMAs were at high levels in all CKD patients, whereas arginine concentrations were low in patients undergoing dialysis. Elevated TNF-alpha and IL-6 in CKD patients were indicative of ongoing chronic inflammatory state. A significant positive correlation between SDMA and creatinine suggests that plasma SDMA level may be an index for renal function.

Hidden female urinary incontinence in urology and obstetrics and gynecology outpatient clinics in Turkey: what are the determinants of bothersome urinary incontinence and help-seeking behavior?

The purpose of this study was to assess the prevalence of female urinary incontinence (UI) and risk factors of bothersomeness and help-seeking behavior of hidden female UI in urology and obstetrics and gynecology outpatient clinics. This multicentric and cross-sectional study was conducted as a part of the Turkish Overactive Bladder Study. Female patients (n = 5,565) who were referred with complaints other than UI and overactive bladder symptoms were surveyed using the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) with supplementation of five more questions. The crude prevalence of UI was found to be 35.7%. The prevalence of frequent and severe incontinence was 8.2 and 6.8%, respectively. The mean age of incontinent patients was significantly higher (p < 0.001). The prevalence of stress, urge, and mixed UI was 39.8, 24.8, and 28.9%, respectively. More than half (53%) of incontinent patients were not bothered by UI, and only 12% of incontinent patients had previously sought medical help for their problem. Frequency, severity, and type of UI were independent factors for predicting bothersome UI, while only bothersomeness increased help-seeking behavior. The ICIQ-SF score of 8 has been found to be the best cutoff value to delineate the bothersome UI. Although the crude prevalence of female UI was found to be high, bothersome UI was not so common. The majority of incontinent female patients did not seek medical help. Frequency, severity, and mixed type of UI were found to be the determinants of bothersome UI for which the ICIQ-SF cutoff score of 8 was obtained.

The impact of late presentation of posterior urethral valves on bladder and renal function.

PURPOSE: We retrospectively reviewed the records of patients with late presentation of PUVs, and compared bladder and renal function to that in patients with an early diagnosis of PUVs. MATERIALS AND METHODS: We retrospectively reviewed the charts of 36 males (mean age at diagnosis 8.8 years, range 5 to 14) with late presentation of PUVs who were treated at our institution between 1986 and 2004. Of these patients 20 had undergone urodynamic evaluation during followup (mean age 10.65 years, range 5 to 23). We chose as controls 19 age matched children with PUVs who were diagnosed and treated before age 5 years and underwent urodynamic evaluation during followup (mean age at urodynamic evaluation 8.52 years, range 6 to 15). Urodynamic parameters were compared between the 2 patient groups. Renal function in the late presenting cases was also compared to controls. RESULTS: The most common symptoms at presentation were diurnal enuresis (17 patients, 47.2%) poor stream (7, 19.4%) and urinary retention (5, 13.9%). Overall, urodynamic bladder abnormalities were detected in 17 of 20 patients (85%), detrusor overactivity in 3 (15%), significant post-void residual in 9 (45%) and bladder capacity greater than expected for age in 9 (45%). No significant difference in bladder capacity, compliance or post-void residual was demonstrated between the late presenting and control groups. Only detrusor overactivity was significantly lower in the late presenting group (p = 0.013). After a mean followup of 67.03 months age specific creatinine levels were increased in 13 of 27 patients (48.1%), including 7 (25.9%) with ESRD. Renal function was significantly impaired in the late presenting group compared to controls (48.1% vs 13.7%, p = 0.001). CONCLUSIONS: We found a significantly lower rate of detrusor overactivity (15%) in patients with late presenting PUVs. Comparison of urodynamic parameters between the early and late presenting groups did not reveal any significant difference. This similar pattern of bladder dysfunction, independent of age at relief of obstruction, may indicate a common pathophysiological etiology for bladder dysfunction in all patients with PUVs. Also, renal function was significantly impaired in the late presenting group in this series.

The relation between serum MDA and cystatin C levels in chronic spinal cord injury patients.

OBJECTIVES: The assessment of renal function is particularly important in patients with spinal cord injury (SCI). Creatinine (Cr) is known to be unsuitable as a marker of renal function in SCI because of muscle wasting. Although cystatin C (cys-C) is more reliable than Cr, its expression may be affected by oxidative stress accompanying SCI. The aim of the study was to estimate the cys-C levels in SCI patients with normal functioning kidneys. The prooxidant/antioxidant state in plasma of the patients and controls was measured, and any correlations between these parameters and cys-C were determined. DESIGN AND METHODS: Blood samples from 41 chronic SCI patients and 13 controls were obtained. Serum Cr was assayed by the Cobas Integra 400 autoanalyzer and cys-C by particle-enhanced immunoturbidimetry. Heparinized plasma was used for biochemical determinations of vitamin E, total antioxidant status (TAS) and malondialdehyde (MDA). RESULTS: Cr, TAS and MDA levels were significantly lower in SCI patients compared to the controls (P = 0.007, P = 0.019, P = 0.000, respectively), whereas no difference was seen in cys-C and vit E concentrations. Body mass indices (BMI) of SCI patients were less than those of the controls (P = 0.03). No correlation existed between cys-C and MDA in SCI patients and controls. Cys-C levels were independent from the body mass indices of subjects. CONCLUSION: In our study, although BMI and MDA were both affected in SCI patients, cys-C levels were unchanged. Therefore, the measurement of cys-C appeared to be of value for the follow-up of renal function in SCI. The low MDA levels observed in these patients suggest that various adaptation mechanisms may be relevant for subjects undergoing prolonged stress situations.

Determination of diagnostic and prognostic values of urinary interleukin-8, tumor necrosis factor-alpha, and leukocyte arylsulfatase-A activity in patients with bladder cancer.

OBJECTIVES: This study was planned to evaluate the feasibility of the assay of leukocyte arylsulfatase-A (AS-A) activity, and some urinary cytokine levels (tumor necrosis factor-alpha [TNF-alpha] and interleukin-8 [IL-8]), as noninvasive diagnostic tools in different stages of bladder cancer patients. DESIGN AND METHODS: Blood and urine samples of 79 subjects were analyzed, including 28 healthy volunteers, 27 patients with superficial bladder cancer (SBC), and 24 patients with muscle invasive bladder cancer (MIBC). RESULTS: In SBC patients, the mean leukocyte AS-A activity was slightly higher (11.4%) than healthy subjects without reaching statistical significance. On the other hand, the enzyme activity in MIBC patients was significantly higher than those of controls (38.9%) and SBC patients (18.3%). Urinary TNF-alpha levels in both cancer groups were not significantly different from the control group. Urinary IL-8 levels of MIBC patients were significantly increased when compared with the levels of SBC patients and healthy subjects (P < 0.001). CONCLUSIONS: Based on our results, it may be concluded that measurement of leukocyte AS-A activity is not a sufficiently reliable noninvasive diagnostic test in distinguishing early stage bladder cancer from healthy subjects as well as detecting disease progression. Whereas measurement of urinary IL-8 may be valuable as a noninvasive diagnostic and prognostic test especially in patients with advanced bladder cancer. It also appears that complementary biochemical information may be obtained about the prognosis of the disease by monitoring urinary IL-8 profile. However, further confirmatory clinical trials about the prognostic value of the measurement of urinary IL-8 are needed.

Urological and surgical complications in 362 consecutive living related donor kidney transplantations.

OBJECTIVE: The aim of this study is to review retrospectively the surgical and urological complications encountered in 362 cases of living related donor kidney transplantations (LRDTs). MATERIAL AND METHODS: Between 1983 and 2002, 362 consecutive LRDTs were performed at our institution. The urological and surgical complications were determined in these cases. RESULTS: Overall, urological and surgical complications were encountered in 57 (15.7%) of the renal transplants. Of the 362 patients, urological complications were detected in 29 of them (8.01%), including 5 urinary fistula (with 1 distal ureteral necrosis), 2 ureteric stenosis, 1 renal calculi, 8 symptomatic vesicoureteral reflux and 13 lymphocele requiring intervention. Vascular complications were developed in 5 patients such as renal vein thrombus in 1 and renal arterial stenosis in 4 cases. Wound infection was detected in 6 patients. Fourteen patients underwent surgical explorations due to perinephric hematoma during the early postoperative period. Renal allograft rupture due to accelerated rejection was developed in 2 cases. A lower segmental arterial injury occurred in 1 patient during the operation. CONCLUSION: LRDT is an important treatment alternative for patients with end-stage renal disease. Many complications may occur after renal transplantations. Our rate of complications is within the range of the current literature. After a modification of our surgical technique, as not dissecting the external iliac artery, the number of lymphoceles has decreased dramatically and with using ureteric stents, we detected a significant decrease in urinary complication rates.

Urine 8-isoprostane F2alpha concentrations in patients with neurogenic bladder due to spinal cord injury.

BACKGROUND: Isoprostanes are prostaglandin-like end products of arachidonic acid peroxidation that are produced by a free radical-catalyzed mechanism. Considering its free radical-dependent formation and potent contractor effect, it is postulated that isoprostane 8-iso PGF2alpha may play an important role in oxidative stress-related smooth muscle dysfunction. These substances may also influence bladder activity directly by effects on the smooth muscle. The present study was designed to measure traditional biochemical parameters (MDA, TAS, vitamin E) in plasma and 8-iso PGF2alpha concentrations in urine of patients with spinal cord injury and to evaluate the relation of urinary isoprostane concentrations to the bladder function. METHODS: All spinal cord patients underwent urodynamic evaluations. The biochemical tests were performed in both hyperreflexic bladder group (n = 23) and areflexic bladder group (n = 10), and the findings were compared to those of the patients with normally functioning bladder (controls, n = 19). RESULTS: Urine 8-iso PGF2alpha concentrations were significantly increased in hyperreflexic group (median value 0.89 pg/mg creatinine) compared to both control (0.52 pg/mg creatinine) and areflexic groups (p < 0.001). The lowest concentrations of urinary 8-iso PGF2alpha were observed in the areflexic group (0.22 pg/mg creatinine), and these were positively correlated to the plasma MDA concentrations in areflexic patients (p = 0.05; r = 0.684). CONCLUSION: Isoprostanes may be involved in the pathogenesis of neurogenic bladder dysfunction. It may be of value to determine the urinary concentrations of 8-iso PGF2alpha in order to distinguish areflexic bladders from the hyperreflectics.