Pyelovesicostomy as an Alternative Surgical Treatment for Complex Ureteral Lesions After Kidney Transplant.

OBJECTIVES: We evaluated the feasibility, safety, and long-term outcomes of pyelovesicostomy as an alternative surgical treatment for complex ureteral lesions after kidney transplant. MATERIALS AND METHODS: A single-center, retrospective, observational cohort study was conducted on 5 adult kidney transplant recipients who underwent pyelovesicostomy between January 2000 and June 2023. The collected data included patient demographics, surgery indication, time from transplant to pyelovesicostomy, procedure details, and kidney function at various time points after surgery. Primary outcomes were allograft function and complications. RESULTS: The 5 patients (4 female, 1 male) had a mean age of 65.8 years and mean body mass index of 26.8. Indications were complex ureteral lesions. The time between transplant and reoperation ranged from 4 days to 12 years. Renal function improved for all patients, with a progressive decrease in mean serum creatinine concentration. The mean follow-up period extended to 7 years. One patient died with the graft still functional at 20 years after the operation, whereas the remaining 4 patients continue to live with functional grafts. CONCLUSIONS: Our study suggests that pyelovesicostomy may provide a potent alternative for the management of complex ureteral lesions after kidney transplant. We have observed good short-term and long-term outcomes in specific patients, pointing toward a promising avenue oftreatment worth further exploration. This reaffirms the importance of a personalized approach in medicine, to consider each patient's unique conditions and characteristics during therapeutic decisions.

Investigation of ochratoxin A biomarkers in biological materials obtained from patients suffering from renal cell carcinoma.

Ochratoxin A (OTA) exposure can result in chronic renal diseases and cancer. The incidence of kidney, renal pelvis, and ureter malignant neoplasms in the Czech Republic is approximately 29.5 renal tumours per 100,000 inhabitants. The question arises whether mycotoxins are also involved in kidney disease and cancer. A sensitive validated analytical methodology, based on an immunoaffinity clean-up followed by HPLC with fluorescence detection, was developed to explore whether OTA accumulates in clear renal cell carcinoma-adenocarcinoma in Czech patients. Simultaneously, DNA-adducts and OTA metabolites were qualitatively analysed in tissues and urine. OTA was analysed in 33 kidney and tumour samples from 26 men and 7 women collected during nephrectomy from patients of the East Bohemian region from 2015 to 2017. OTA was found in 76% of the analysed samples. Its concentrations ranged from not detectable to 390 ng/kg with a median of 167 ng/kg in kidney samples and from not detectable to 430 ng/kg with a median of 122 ng/kg in tumour samples. Urinary OTA metabolites and DNA adducts were qualitatively analysed for the corresponding 20 patients. The presence of some OTA metabolites such as ochratoxin A hydroquinone and/or decarboxylated ochratoxin A hydroquinone correlate with the presence of OTA-DNA adducts.

Solitary metastasis of clear cell renal cell carcinoma in sternum diagnosed unexpectedly during cardiac surgery - A rare but potentially fatal trap.

We present a very rare case of fatal complication during the cardiac surgery caused by unrecognized solitary metastasis of clear cell renal cell carcinoma in the sternum.

Characteristic CT features of pheochromocytomas - probability model calculation tool based on a multicentric study.

OBJECTIVES: The aim of the study was to evaluate the CT features of adrenal tumors in an effort to identify features specific to pheochromocytomas and second, to define a feasible probability calculation model. METHODS: This multicentric retrospective study included patients from the period 2003 to 2017 with an appropriate CT examination and a histological diagnosis of an adrenal adenoma, pheochromocytoma, adrenocortical carcinoma, or metastasis. In total, 346 patients were suitable for the CT image analysis, which included evaluation of the largest diameter, the shape of the lesion, the presence of central necrosis and its margins, and the presence of an enhancing peripheral rim ("ring sign"). RESULTS: Pheochromocytomas have a significantly more spherical shape (P<0.001), whereas an elliptical shape significantly reduces the probability of a pheochromocytoma (odds ratio = 0.015), as does another shape (odds ratio = 0.006). A "ring sign" is also more frequent in pheochromocytomas compared to other adrenal tumors (P=0.001, odds ratio = 6.49). A sharp necrosis also increases the probability of a pheochromocytoma more than unsharp necrosis (odds ratio 231.6 vs. 20.2). The probability calculation model created on the basis of the results confirms a high sensitivity and specificity (80% and 95%). CONCLUSION: This study confirms the value of anatomical features in the assessment of adrenal masses with the ability to significantly improve the identification of pheochromocytomas. Advanced assessment of the tumor shape was defined and a original comprehensive calculating tool of the pheochromocytoma probability was created on the basis of the results presented here and could be used in clinical routine.

Analyses of biomarkers of exposure to nephrotoxic mycotoxins in a cohort of patients with renal tumours.

The Czech Republic occupies the first place in the world in the frequency of renal and other urinary tract tumours, but their aetiology is unknown. To explore whether carcinogenic and nephrotoxic mycotoxins may contribute to kidney diseases in the Czech population, biomarkers of ochratoxin A (OTA) and citrinin (CIT) exposure were determined in biological specimens from a cohort of 50 patients with malignant renal tumours. Biomarker analyses in blood and urine samples used validated targeted methods for measuring OTA and CIT plus dihydrocitrinone (DH-CIT) after enrichment of analytes by specific immunoaffinity clean-up. OTA and CIT plus its metabolite DH-CIT were frequently detected in patient urine samples (OTA 62%; CIT 91%; DH-CIT 100%). The concentration ranges in urine were 1-27.8 ng/L for OTA, 2-87 ng/L for CIT and 2-160 ng/L for DH-CIT. The analyses of blood samples revealed also a frequent co-occurrence of OTA and CIT, in the ranges of 40-870 ng/L serum for OTA and 21-182 ng/L plasma for CIT. This first analysis of biomarkers in blood and urine samples of Czech patients revealed no major differences in comparison with published data for the general healthy Czech and European populations. Nonetheless, a frequent co-occurrence of CIT and OTA biomarkers in patient samples may be of interest with regard to potential interactions with other risk factors for renal disease.

The susceptibility to fosfomycin of Gram-negative bacteria isolates from urinary tract infection in the Czech Republic: data from a unicentric study.

BACKGROUND: Against a background of rapid increase of ß-lactamase-producing or multi-resistant pathogenic bacteria and the resulting lack of effective antibiotic treatment, some older antibiotics have been tested for new therapeutic uses. One of these is fosfomycin, to which according to studies these resistant bacteria are very sensitive. Our study was designed because there is no data on the fosfomycin susceptibility rate in the Czech Republic. METHOD: In this study from January 2013 to June 2014 3295 unique isolates of Gram-negative bacteria which had caused urinary tract infections were examined. The antibiotic susceptibility was measured by disk diffusion test. Both EUCAST and CLSI guidelines criteria (for fosfomycin only) were used for the antibiotic susceptibility evaluation. RESULTS: The most frequently tested bacterial isolates were Escherichia coli (51.3%, n = 1703), Klebsiella pneumoniae (19.4%, n = 643) and Proteus spp. (11.8%, n = 392). Among all isolates 29.0% (n = 963) were resistant to fluoroquinolones, 11.3% (n = 374) produced extended spectrum ß-lactamase and 4.2% (n = 141) produced AmpC ß-lactamase. The overall in vitro susceptibility was significantly higher for fosfomycin compared to the other tested per-oral antibiotics (nitrofurantoin, ampicillin, co-trimoxazole, ciprofloxacin and cefuroxime) against all tested Gram-negative rod isolates (excluding Morganella morgani and Acinetobacter spp. isolates). Fosfomycin also remained highly active against those isolates with extended spectrum ß-lactamase (ESBL) production (95.8% in Escherichia coli isolates and 85.3% in Klebsiella pneumoniae isolates), unlike other tested per-oral antibiotics, which showed significant (p < 0.0001) susceptibility decrease. CONCLUSION: We have confirmed in the Czech Republic the very high susceptibility to fosfomycin trometamol of urinary tract infection pathogens, particularly Gram-negative rods including those producing ß-lactamase.

Methylation status as a predictor of intravesical Bacillus Calmette-Guérin (BCG) immunotherapy response of high grade non-muscle invasive bladder tumor.

BACKGROUND AND AIMS: Genetic and epigenetic alterations play an important role in urothelial cancer pathogenesis. Deeper understanding of these processes could help us achieve better diagnosis and management of this life-threatening disease. The aim of this research was to evaluate the methylation status of selected tumor suppressor genes for predicting BCG response in patients with high grade non-muscle-invasive bladder tumor (NMIBC). MATERIALS AND METHODS: We retrospectively evaluated 82 patients with high grade non-muscle-invasive bladder tumor (stage Ta, T1, CIS) who had undergone BCG instillation therapy. We compared epigenetic methylation status in BCG-responsive and BCG-failure groups. We used the MS-MLPA (Methylation-Specific Multiplex Ligation-Dependent Probe Amplification probe sets ME001 and ME004. The control group was 13 specimens of normal urotel (bladder tissue)). RESULTS: Newly identified methylations in high grade NMIBC were found in MUS81a, NTRK1 and PCCA. The methylation status of CDKN2B (P=0.00312**) and MUS81a (P=0.0191*) is associated with clinical outcomes of BCG instillation therapy response. CDKN2B and MUS81a unmethylation was found in BCG failure patients. CONCLUSION: The results show that the methylation status of selected tumor suppressor genes (TSGs) has the potential for predicting BCG response in patients with NMIBC high grade tumors. Tumor suppressor genes such as CDKN2b, MUS81a, PFM-1, MSH6 and THBS1 are very promising for future research.

Percutaneous radiofrequency and microwave ablation in the treatment of renal tumors - 10 years of experience.

INTRODUCTION: The standard radical treatment of renal cell carcinoma is surgical resection, but it is not suitable for patients with serious medical comorbidities and solitary kidney tumors. Minimally invasive ablation techniques could be an appropriate therapeutic alternative. AIM: To retrospectively evaluate the technical success, mid-term and long-term efficacy and safety of radiofrequency and microwave ablation in patients with small renal tumors. MATERIAL AND METHODS: Over the course of 10 years, 91 ablation procedures in 64 patients for 68 tumors, of size 12-60 mm, were performed using only conscious sedation. These ablations were done under the guidance of computed tomography. We treated 41 males and 23 females with solitary kidney tumors (14 cases) and tumors in non-surgical candidates (54 cases). RESULTS: In 50 (73.5%) tumors single treatment was successful; in 13 (19.1%) cases a second procedure was used successfully, and in the 5 largest tumors (sizes 45-60 mm, 7.4%) a third treatment was necessary. Within the follow-up 10 (15.6%) patients died, but none due to metastatic renal cell carcinoma. Only 1 serious complication was observed - retroperitoneal and psoatic hematoma. Early recurrence occurred in 18 (26.5%) tumors. Late recurrence was detected in 5 (7.4%) cases. In all cases complete local control of the renal tumors was reached. CONCLUSIONS: Percutaneous ablation is a very effective treatment for patients with small renal tumors of the T1a group with a minimal complication rate.

Laparoscopic radical prostatectomy and resection of rectum performed together: first experience.

INTRODUCTION: Laparoscopy is an increasingly used approach in the surgical treatment of rectal cancer and prostate cancer. The anatomical proximity of the two organs is the main reason to consider performing both procedures simultaneously. AIM: To present our first experience of laparoscopic rectal resection and radical prostatectomy, performed simultaneously, in 3 patients. MATERIAL AND METHODS: The first patient was diagnosed with locally advanced rectal cancer and tumor infiltration of the prostate and seminal vesicles. The other 2 patients were diagnosed with tumor duplicity. The surgery of the first patient started with laparoscopic prostatectomy except division of the prostate from the rectal wall. The next step was resection of the rectum, extralevator amputation of the rectum and vesicourethral anastomosis. In the other patients, resection of the rectum, followed by radical prostatectomy, was performed. RESULTS: The median follow-up was 12 months. The median operation time was 4 h 40 min, with blood loss of 300 ml. The operations and postoperative course were without incident in the case of 2 patients. However, 1 patient had stercoral peritonitis and a vesicorectal fistula in the early postoperative stage. Sigmoidostomy and postponed ureteroileal conduit were carried out. All patients were in oncologic remission. CONCLUSIONS: Combined laparoscopic rectal resection and radical prostatectomy is a viable option for selected patients with locally advanced rectal cancer or tumor duplication. The procedures were completed without complications in 2 out of 3 patients.

Endoscopic treatment of a rectovesical fistula following radical prostatectomy by over-the-scope clip (OTSC).

The successful management of a rectovesical fistula after radical prostatectomy is difficult. Minimally invasive treatment by over-the-scope clip (OTSC) is a novel method. The authors present results with the use of OTSC. This method was used in 2 patients. The first patient had a rectovesical fistula detected on the fifth day after a prostatectomy. The second patient experienced rectal perforation during prostatectomy and a recurrent fistula after fistulorrhaphy. Both patients had a small fistula located in the vesicourethral anastomosis. Both patients underwent endoscopic OTSC placement. The median follow-up was 26 months. The success rate was 50%. The first patient healed successfully and the second patient had a relapse. The York-Mason procedure was eventually successful. According to our initial experience, the OTSC is suitable for small fistulas detected shortly after a prostatectomy. A more complex fistula, though small, carries a higher recurrence risk.

Urological surgery in elderly patients: results and complications.

PURPOSE: Owing to the large aging population, a growing number of elderly patients are undergoing surgical treatment. Surgical procedures in elderly patients are associated with a higher risk of complications. The aim of this study was to evaluate the efficacy and safety of urological surgeries in old patients. METHODS: The authors carried out a retrospective study, evaluating results and early postoperative complications in patients aged 75 years and older. The cohort of patients included 221 patients who underwent surgical procedures in the department of urology between January 2011 and December 2012. The average age of patients was 78. The results and complications were categorized based on the type of surgery performed, and the Dindo-Clavien scale. RESULTS: The median follow-up was 18 months. All surgeries for malignant tumors were performed successfully with no residual disease. Totally, 48 (22%) complications were recorded. The most serious were as follows: one patient (<0.5%) died; and four (<2%) patients underwent reoperation. The most common complications involved infection, mainly sepsis and surgical site infections. Other complications included mild respiratory insufficiency, delirium, bleeding, etc. CONCLUSION: Surgeries in elderly patients were effective and safe. The cornerstone of safety is careful preparation and treatment of comorbidities. Complications occurred mainly as a result of emergency procedures during emergency procedures and in major surgeries such as cystectomy and nephrectomy. The standard use of low molecular-weight heparin caused no incidence of thromboembolic disease.

Long-term survival after radical surgery for renal cell carcinoma with tumour thrombus extension into the right atrium.

UNLABELLED: What's known on the subject? and What does the study add? Surgical treatment of renal cell carcinoma (RCC) with tumour thrombus extending into the right atrium remains, despite its complexity and specific technical aspects, the only radical therapeutic option. This single-centre study, unique in size for this rare condition, reports early and late results over a period of 18 years. All patients were operated on using a standardised protocol with use of cardiopulmonary bypass and deep hypothermic circulatory arrest. Overall and cancer-specific cumulative survival was better than in other reports. OBJECTIVE: To evaluate the long-term results of radical surgical management of renal cell carcinoma (RCC) with tumour thrombus extension (TTE) level IV into the right atrium (RCC/TTE IV) in a large single-institution series. PATIENTS AND METHODS: Radical complex urological and cardio-surgical procedure was performed over a period of 18 years (1993-2010) on 21 patients with RCC/TTE IV. A radical nephrectomy was performed followed by sternotomy, institution of cardiopulmonary bypass and extraction of the intracardiac tumour thrombus under direct visual control during deep hypothermic circulatory arrest (DHCA). Perioperative and postoperative variables, and long-term overall and cancer-specific survival using the Kaplan-Meier method were analysed. RESULTS: In all patients, precise removal of tumour thrombus was accomplished in a bloodless field during DHCA. The mean (sd) duration of circulatory arrest was 16 (6) min at a mean hypothermia of 20 (3) °C. In-hospital mortality was 9.5% (two patients). The median survival (including in-hospital mortality) was 25 months. In Kaplan-Meier analysis, 2- and 5-year overall cumulative survival rate was 57 (95% confidence interval, CI 36-78)% and 37 (95% CI 15-58)%, respectively. Cancer-specific cumulative survival was 68 (95% CI 49-89)% at 2 years and 51 (95% CI 28-74)% at 5 years. CONCLUSIONS: Late outcome after radical surgical treatment in patients with RCC and TTE reaching up to the right atrium justifies this extensive procedure. Cardiopulmonary bypass with DHCA allows safe and precise extirpation of all intracaval and intracardiac tumour mass.

Psychosocial implications and the duality of life outcomes for patients with prostate carcinoma after bilateral orchiectomy.

OBJECTIVES: The study presented focuses on patients' psychosocial status after a prostate cancer diagnosis that underwent a bilateral orchiectomy. METHODS: We evaluated the psychosocial implications of 89 patients with prostate cancer after performing castration and a bilateral orchiectomy. RESULTS: Patients suffered significantly more from sleep disorders during hospitalisation when compared to their time prior to an orchiectomy (p<0.0005). There were some increases in the severity of sleep disorder after discharge (level of evidence p<0.05). However, no additional medications for sleep disorders were required. Additionally, there was a significant reduction in the abuse of medication (p<0.001). Ten per cent of the patients were in the care of a psychologist or a psychiatrist before their diagnosis, and 21% asked for the help of a psychologist or a psychiatrist after having a bilateral orchiectomy. The occurrence of mood disorders is also very different than the occurrence of sleep disorders. Mood disorders occurred much less often after orchiectomy and discharge (p>0.085) compared with the period before surgery. Forty per cent of the patients had mood disorders before their operation, while only 37% still had these after discharge. There was a significant decrease in abuse of medication for anxiety. Twenty-four per cent of the patients took medication during hospitalisation, and only 10% continued after orchiectomy. CONCLUSIONS: The results of the study show that patients who were notified about their cancer diagnosis, particularly their health status, exhibited moderate stress and psychological impact.

Radical prostatectomy in high-grade prostate cancer, salvage and adjuvant radiotherapy.

INTRODUCTION: Prostate cancer with a Gleason score (GS) of 8-10 is linked to a higher risk of recurrence and progression. The aim of this paper is to evaluate treatment results of our high-risk patient cohort. PATIENTS AND METHODS: The cohort of 42 patients with radical prostatectomy (RP) specimen histology GS 8-10 was assessed. The patients were followed up after RP and radiotherapy (RT) was delivered in case of a biochemical relapse. Adjuvant radiotherapy (aRT) was delivered only in case of a positive surgical margin (PSM). The following parameters were evaluated: biochemical progression-free survival (BPFS), overall survival (OS) and cancer-specific survival (CSS). The second objective was to evaluate adverse effects of RP and RT. RESULTS: The median follow-up time was 88 months (18-168). RP led to BPFS in 16 patients (38%). Five patients with PSM underwent aRT and 20 underwent salvage radiotherapy (sRT). One patient died of myocardial infarction and 1 patient died of metastatic disease. Skeletal metastases were recorded in 2 patients. The BPFS in RP combinations with sRT or aRT was reached in 29 patients (69%). The OS and CSS in our cohort reached 95 and 98%, respectively. CONCLUSION: Management with aRT only in PSM was very effective, according to our retrospective study.

Bipolar transurethral resection of anastomotic strictures after radical prostatectomy.

PURPOSE: The efficacy of the bipolar endoscopic resection for anastomotic stricture was assessed and compared with holmium laser treatment. PATIENTS AND METHODS: We studied a cohort of 39 patients with anastomotic strictures in years 1999 to 2007. Twenty-two patients had undergone bipolar resection, and 17 patients had undergone holmium laser treatment. The mean age of the bipolar cohort was 63.8 years; initial prostate-specific antigen (PSA) level was 10.7 ng/mL. The mean age of the laser cohort was 64 years; initial PSA level was 7.8 ng/mL. The results were evaluated by measurement of the maximum urinary flow (Qmax) and the postvoid residual volume of urine (PVR) before surgery, and at 6 weeks and 6 months after surgery. The Wilcoxon rank-sum test was used for statistical analysis, and a P value <0.05 was considered significant. RESULTS: The mean follow-up period was 42 (14-74) months. Improvements in Qmax and PVR were recorded in the two cohorts. In the bipolar cohort, the mean values of Qmax were 3.9 mL/s, 14 mL/s, and 13 ml/s, while PVR values were 46 mL, 10 mL, and 11 mL. The mean values of Qmax in the laser cohort were 3.7 mL/s, 11 mL/s and 6.1 mL/s; PVR were 25 mL, 16 mL, and 19 mL. Statistically significantly better results of Qmax over 6 months were in the bipolar cohort (P < 0.001). No perioperative complications and no deterioration of urinary continence were recorded. CONCLUSION: The bipolar resection of an anastomotic stricture is a highly effective method that produces better long-term results than the holmium laser treatment.

The estimation of post-transplant lymphocele origin using creatine kinase activity.

INTRODUCTION: The aim of this research was to create a laboratory instrument for the estimation of post-transplant lymphocele origin. It is based on the enzymatic activity of creatine kinase (CK) in the lymphocele content. MATERIAL AND METHODS: A total of 120 lymph samples from different retroperitoneal regions were obtained from non-transplanted patients; equal numbers from the iliac region, renal cysts, and the subdiaphragmatic retroperitoneum. Activities of creatine kinase (CK) and gamma-glutamyl transpeptidase (GGT) were determined in all samples and statistically analyzed against their activity in serum from patients without surgery. RESULTS: Activities of CK in the pelvis, retroperitoneum, renal cysts, and serum were 5.06, 0.83, 6.48 (P<0.001), 2.50, 0.73, 3.60 (P<0.001), 0.02, 0.01, 0.05 (P<0.001), and 0.66, 0.41, 0.79 microkat/l, respectively. Activities of GGT in the same lymph samples were 0.26, 0.16, 0.36 (P=0.048), 0.41, 0.25, 0.48 (non-significant), 0.11, 0.07, 1.17 (P=0.003) and 0.34, 0.24, 0.55 microkat/l, respectively. A graph was constructed relating CK activity to lymph origin. CONCLUSION: Significantly different CK enzyme activity was observed in different regions of the retroperitoneum. The presented graph is a simple instrument for the estimation of the lymphocele content origin. The method requires percutaneous aspiration of the lymphocele and evaluation of the CK and GGT activity in the sample. From the graph the estimated proportion of renal lymph in the lymphocele can be read directly. This instrument can provide better understanding of post-transplant lymphocele fluid source.

The Taguchi technique of the transplanted kidney ureter implantation--single centre experience.

Taguchi technique of ureteral implantation was used in 22 kidney transplant patients (group T). Group T was compared with 25 patients who were treated using Lich-Gregoir technique (group LG). Immunosuppression, incidence of biopsy evidenced acute cellular rejection (ACR), haematuria rate and ureteral complications (stricture, reflux) were assessed in both groups. The immunosuppression used was based on cyclosporin A (63.6%), tacrolimus (27.3%) and sirolimus (8.1%) in T group. Cyclosporin A(72%), tacrolimus (20%) and sirolimus (8%) were used in LG group. No induction was used. The incidence of ACR was similar in both groups--T resp. LG was 50% resp. 52%. Haematuria after operation was on average 4.0 days in the T group and on average 3.1 in the LG group. Ureteral complications were observed in 18.2% of cases in T group and in 16% of cases in LG group. No reflux was evidenced in any group. Taguchi technique is fast and very easy to do. A slightly higher incidence of ureteralcomplications and a longer period of postoperative haematuria were observed in T group. Taguchi technique is very easily performed with a shorter operating time. We advocate it as a method of ureteral implantation on the thin-wall urinary bladder. The results were very good in these cases.