The approach by midline incision for extraperitoneal kidney transplantation.

UNLABELLED: No data are available on incisional hernia in renal transplant recipients using a midline incision. This study evaluated the incidence of abdominal wall incisional hernia, comparing two surgical approaches: midline and J-shaped incisions. METHODS: Between 1991 and 2005, 415 consecutive patients underwent renal transplantation: between 1991 and 1997, 139 patients through a lateral incision; between 1997 and 2005, 137 of 276 renal transplant patients via a midline incision, and 139 via a J-shaped incision. We evaluated the incidence of incisional herniae in these patients. Analyzed factor risks included: age, sex, body mass index, diabetes, reoperation, lymphocele, dialysis time, underlying renal disease, and immunosuppressive therapy. RESULTS: During follow-up, 15 patients of 415 transplantations were dead or lost to follow-up. Incisional herniae were identified in 12 cases of 132 (9%) between 1991 and 1997. Between 1997 and 2005 we identified 3 of 133 (2.2%) patients who underwent a midline incision and 15 of 135 (11.1%) who received a J-shaped incision (P=.005). Comparing midline and J-shaped incisions before and after 1997, the incidence reduction was significant (P=.01). Comparing the incidence among patients treated with J-shaped incision before versus after 1997, the increased incidence was insignificant (P=.6). Multivariate analysis found the most important risk factor was obesity followed by polycystic kidney disease, reoperation, wound infection, and mycophenolate mofetil therapy. CONCLUSIONS: Our data showed an advantage of a midline incision. Strategies to prevent surgical complications, such as abdominal wall relaxation and poor cosmetic results, are needed; the midline incision may be a possible alternative to address this complication.

The treatment of fistulae and ureteral stenosis after kidney transplantation.

INTRODUCTION: The incidence of urological complications after kidney transplantation varies from 3% to 14%, with a probable loss of the graft in 10% to 15% of cases and a mortality rate of up to 15%, despite improvements in prevention, diagnosis, and treatment as well as the use of new immunosuppressive therapies. Urinous fistulae, which are considered early complications of transplantation, are due to ischemic damage or necrosis generally occurring in the distal third of the ureter. Preservation of accessory arteries to the lower portion of the kidney is important, as they may constitute the blood supply of this segment of the collecting system or ureter. Their ligation may lead to necrosis and urinary fistulae. Ureteral stenosis, as late complication, is related to a pathology of the ureter itself, to infections, to abscesses, to fibrosis, and to ischemia. An early endoscopic approach permits resolution in 70% of cases. The aim of this retrospective study was to determine incidence and treatment of these complications. MATERIALS AND METHODS: From 1991 to 2004 we performed 453 kidney transplantations both from cadaveric and living donors. In 199 patients we performed a transvesical ureteroneocystostomy (UNCS), and in 260, an extravesical UNCS. RESULTS: The nine patients who showed fistulae (1.9%) underwent surgical treatment. In eight we used a direct ureteral reimplantation, and in one, a Boari flap technique. Nephrectomy was necessary in four patients, including two who died of septic complications. In all 26 cases of ureteral stenosis (5.6%), we used an endourological approach (anterograde or retrograde), with surgical treatment afterward in 11 patients (42%) nine direct reimplants, one anastomosis to the native ureter (transplantation from a living donor), and in one case a Boari flap technique four patients who underwent surgical treatment showed progressive damage to graft function. CONCLUSIONS: In all patients who showed fistulae we suggest surgical review: for patients with ureteral stenosis, we suggest first an endourological approach and only when it is not successful do we consider surgical treatment.

Endoluminal stent placement after percutaneous transluminal angioplasty in the treatment of post-transplant renal artery stenosis.

PURPOSE: We report our experience with endoluminal stent placement after percutaneous transluminal angioplasty for the treatment of post-transplant renal artery stenosis. MATERIALS AND METHODS: From October 1992 to September 1996, 8 stents were successfully implanted in 7 patients affected by resistant transplant renal artery stenosis. All transplanted kidneys were procured from cadaver donors. The patients were routinely evaluated with duplex sonography and the median interval between transplantation and stenosis detection was 7.4 months (range 0.5 to 17). When serious renal stenosis was diagnosed (greater than 50%), selected angiography and percutaneous transluminal angioplasty were performed. In 8 cases (7 patients) an endoluminal metallic Palmaz stent was placed in the site of the restenosis. One patient received 2 stents repeatedly positioned in different stenosis sites. RESULTS: No major complications occurred. Clinical outcome was positive in 5 patients (71.4%) and Stenosis recurred in 2 (28.5%) (less than 50% and less than 35%, respectively). Median followup after stent placement was 14.8 months (range 1 to 37). CONCLUSIONS: Percutaneous endoluminal stent procedures after resistant transplant renal artery stenosis or for ex novo treatment for severe anastomotic stenoses appears to be promising. Longer followup periods are necessary for true evaluation of this procedure.

[Comparison of flow-cytometry and immunohistochemistry with proliferating monoclonal antibody. Cell nuclear antigen (PCNA) in the study of proliferative kinetics of renal carcinoma]. / Confronto tra citometria a flusso e immunoistochimica con AcP monoclonale anti-proliferating. Cell nuclear antigen (PCNA) nello studio della cinetica proliferativa del carcinoma renale.

Tumor Proliferative Fraction (TPF) has been shown to correlate with prognosis in some malignancies. A reliable, accurate method for application in a clinical practice is still being sought. The aim of this study is to compare TPF as determined by Proliferating Cell Nuclear Antigen (PCNA) and Flow Cytometry (FC) in 36 consecutive patients affected by Renal Cell Carcinoma (RCC). Proliferating cells were identified in paraffined sections using a anti-PCNA monoclonal antibody (PC 10 Dako). Cell suspension for FC were prepared from fresh/frozen samples DNA index and S phase were evaluated using a computerized program (Multicycle, Phoenix). 16 samples (47.1%) were found to be aneuploid by FC (DI range 0.72-2.40). Aneuploid vs diploid tumors had significantly higher mean FC-S phase (p = 0.049) and PCNA LI (p = 0.034). Weak correlation (r-Spearman 0.416 p = 0.01) was found between PCNA LI and grading and near to significativity between PCNA LI and tumor size (r = 0.335 p = 0.0061). When patients are classified according to nuclear grading, is evident that all PCNA G4 are aneuploid and that 62.5% of PCNA G1 are diploid. A week correlation near to significativity is found between PCNA LI and S phase only in the aneuploid tumors. A more reliable measurement of TPF in RCC could be provided by combining the two methods. Further research on larger series is needed.

Sacrococcygeal chordoma: clinicoradiological study.

A case of sacrococcygeal chordoma is presented. We review the literature and we discuss the problems related to the etiology, the symptoms, the diagnosis and the treatment of this rare neoplasm. We present and discuss here the importance and the different possibilities of new diagnostic techniques, such as the CT and the MRI in the diagnosis and management of sacrococcygeal chordoma.