The lack of space, as an indication for a native unilateral nephrectomy for positioning a future kidney graft in the absence of other autosomal dominant polycystic kidney disease-related symptoms, remains controversial.

To evaluate the surgical comorbidity and the impact on graft survival of an associated ipsilateral native nephrectomy during isolated kidney transplantation in patients with autosomal dominant polycystic kidney disease.

One hundred and fifty-four kidney transplantations performed between January 2007 and January 2019 of which 77 without (kidney transplant alone (KTA) group) and 77 with associated ipsilateral nephrectomy (KTIN group), were retrospectively reviewed. Demographics and surgical variables were analyzed and their respective impact on surgical comorbidity and graft survival.

Creation of space for future graft positioning was the main reason (n = 74, 96.1%) for associated ipsilateral nephrectomy. No significant difference in surgical comorbidity (lymphocele, wound infection, incisional hernia, wound hematoma, urinary infection, need for blood transfusion, hospitalization stay, Dindo Clavien classification and readmission rate) was observed between the two study groups. The incidence of primary nonfunction and delayed graft function was comparable in both groups [0% and 2.6% (P = 0.497) and 9.1% and 16.9% (P = 0.230), respectively, in the KTA and KTIN group]. The 1- and 5-year graft survival were 94.8% and 90.3%, and 100% and 93.8%, respectively, in the KTA and KTIN group (P = 0.774). The 1- and 5-year patient survival were 96.1% and 92.9%, and 100% and 100%, respectively, in the KTA and KTIN group (P = 0.168).

Simultaneous ipsilateral native nephrectomy to create space for graft positioning during kidney transplantation in patients with autosomal dominant polycystic kidney disease does not negatively impact surgical comorbidity and short- and long-term graft survival.

Ex vivo surgery may provide a chance at R0 resection for conventionally unresectable tumors. However, long-term outcomes have not been well documented. In this study, we analyze our 11-year outcomes to define its role.

We retrospectively analyzed 46 consecutive patients who underwent ex vivo surgery at our institution 2008-2019.

The types of tumors were: carcinoma (n = 20), sarcoma (n = 20) and benign to low grade tumor (n = 6). The type of ex vivo surgery was chosen based on tumor location and vascular involvement. The most commonly performed procedure was ex vivo hepatectomy (n = 18), followed by ex vivo resection and intestinal autotransplantation (n = 12), ex vivo Whipple procedure and liver autotransplantation (n = 8) and multivisceral ex vivo procedure (n = 7). Twenty-three patients (50%) are currently alive with median follow-up of 4.0-years (11 months-11.8 years). The overall survival was 70%/59%/52%, at 1-/3-/5-years, respectively. Patient survival for benign to low grade tumors, sarcoma, and carcinoma was 100%/100%/100%, 65%/60%/50%, and 65%/45%/40%, at 1-/3-/5-years, respectively. Ninety-one percent patients had R0 resection, and 57% had no recurrence to date with median follow-up of 3.1-years. Two patients (4.3%) died within 30 days due to sepsis and gastroduodenal artety (GDA) stump blowout. Two additional patients died between 30 and 90 days due to sepsis. Perioperative mortality in the last 23 consecutive cases was limited to 1 patient who died of sepsis between 30 and 90 days.

For a selected group of patients with conventionally unresectable tumors, ex vivo surgery can offer effective surgical removal with a reasonably low perioperative mortality at experienced centers.

If endourological approaches are not applicable to treat vesicoureteral anastomotic complications after kidney transplantation, the surgical gold standard in many transplant centers is pyeloureterostomy or ureteroureterostomy using the native ureter. We report an original preperitoneal technique that can be used for vesicoureteral reanastomosis in kidney transplant recipients not eligible for endourological treatment.

Between January 2011 and December 2015, 18 kidney transplant recipients underwent this new surgical procedure. Of this number, 15 subjects with at least 1 year of follow-up were included in the analysis. The indications were vesicoureteral reflux, anastomotic stenosis, and leakage in 8, 5, and 2 patients, respectively. Briefly, a double J stent was preoperatively inserted into the grafted ureter. Surgery was performed through a Pfannenstiel incision. The preperitoneal space surrounding the bladder was dissected and the distal part of the grafted ureter was identified and mobilized. The anastomotic area was resected and another vesicoureteral anastomosis was performed (Lich-Gregoir technique), keeping the JJ stent in place for three weeks.

This procedure was performed 213 days (range 17-2608) after kidney transplantation. Median surgical duration was 179 minutes (range 112-314) and median hospital stay 8 days (range 4-14). The success rate was 86.7% (13/15), with a median follow-up of 1148 days (range 517-1808). In two patients, symptomatic recurrence of vesicoureteral reflux required a pyeloureterostomy using the native ureter.

The authors describe a simple technique that avoids transperitoneal dissection, potentially yielding more esthetic results thanks to easy access, as well as excellent outcomes.

The incidence of urologic complications after kidney transplantation remains high despite improvements in diagnosis and operative techniques. Urinary tract reconstruction is usually done by ureteroneocystostomy (UCNS), and several techniques are available. In this study, we evaluated the outcomes of 2 different UCNS techniques performed in our department, the transvesical Leadbetter-Politano (L-P) and the extravesical Lich-Gregoire (L-G) technique.

We evaluated the outcomes of 2 different UCNS techniques, L-P versus L-G, performed in our department between July 1, 2006, and December 31, 2011. During this period, we performed 524 consecutive renal transplantations-264 cases using the L-P technique (50.3%) and 260 cases with L-G technique (49.7%). Renal grafts were obtained from cadaveric donors in 146 cases (27.86%) and from living-related donors in 378 cases (72.14%). Recipient mean age was 35.64 years and the male to female ratio was 1.63:1.

Urologic complications after kidney transplantation occurred in 22 cases in the L-P UCNS group (8.33%). The most common complications were ureteral stenosis (3.41%) and leakage (2.65%). Other complications recorded were lymphoceles (1.89%) and hematoma with secondary ureteral obstruction (0.38%). Compared with the L-P UCNS technique, the L-G technique was associated with fewer overall complications (6.15% vs 8.33%; P = .06), a lesser rate of ureteral stenosis (2.31% vs 3.41%; P = .08), and a similar rate of leakage. However, statistical analysis revealed no differences between the 2 techniques (P = .06). In addition, we did not note any differences in graft and patient survival between the 2 groups.

In our study, the extravesical L-G technique has a lower complication rate compared with transvesical L-P procedure, but without statistical differences. Furthermore, the L-G technique is easier and faster to perform, it avoids a separate cystotomy, and requires a shorter ureteral length. In conclusion, we recommend L-G technique as technique of choice in kidney transplantation.

Different arterial wall properties can significantly increase the risk of blood turbulent fluxes leading to complications such as atherosclerosis. Since the mechanical properties of arterial vessels are influenced by age, we investigated, in a retrospective study, the effects on renal artery stenosis of an age difference >15 years between donor and recipient in a cohort of 164 patients undergoing renal transplantation between 1981 and 1991. The age difference between donor and recipient was ≤15 years in 87 patients (53.0%) (Group A) and >15 years in 77 patients (47.0%) (Group B, p = ns). None of the Group A patients developed an anastomotic arterial stenosis, whereas 8/77 Group B patients (10.4%) had an anastomotic arterial stenosis (p < 0.001). This study shows that an age difference >15 years is significantly linked to the risk of developing arterial stenosis after renal transplantation. Indeed, different wall properties can significantly increase the risk of generation of blood turbulent fluxes and involve, in the arterial vessels, the development of complications such as atherosclerosis.

Stenting of the extravesical ureteroneocystostomy in renal transplantation is controversial. This study is a metaanalysis of 49 published studies over 30 years time in which the extravesical technique was used. Stented and nonstented anastomoses were compared. One-hundred six articles published between 1973 and 2002 were reviewed and 49 met criteria for inclusion. Articles were required to list original, numeric, previously unpublished data and to report or to describe the use of an extravesical ureteroneocystostomy, with or without stent. Data were analyzed within separate groups, (1) randomized, controlled trials and (2) case series. Data were included from five randomized, controlled trials and 44 case series. In the controlled trials group, there were urologic complications in 6 of 407 stented (1.5%), and 35 of 389 nonstented subjects (9.0%) (p < 0.0001, OR 0.24, 95% CI 0.10-0.57). In the case-series group, there were urologic complications in 137 of 4245 stented (3.2%) and 433 of 9077 nonstented subjects (4.8%) (p = 0.007, OR 0.58, 95% CI 0.39-0.86). Renal transplants with stented extravesical ureteroneocystostomy have a significantly lower urologic complication rate than those with nonstented anastomoses. All five randomized, controlled trials individually found stented anastomoses to have a lower complication rate and this was confirmed by metaanalysis of these trials and of case-series data.

Vascular complications are reported in a significant proportion of patients following renal transplantation and are a contributory cause of graft dysfunction. Of these, pseudoaneurysm formation is one of the least common. We present three patients in whom extra-renal transplant artery pseduoaneurysms arising from the surgical anastomosis between the external iliac and renal transplant artery were initially diagnosed with colour Doppler ultrasound, and outline their subsequent management.

Of 1130 patients who had undergone a total of 1298 kidney transplantations, 40 developed a stenosis of the ureter (3.1%). In all of the transplants, the anastomosis between the ureter and the urinary bladder was established as extravesical ureteroneocystostomy. Up until 1984, in cases where an obstruction in the urinary tract was suspected, the diagnosis was made by an i.v. pyelogram or by nuclear scans of the transplant. Thereafter, in 28 patients, in cases of sonographically suspected stenosis of the ureter, the diagnosis was established by means of a simplified Whitaker test. Nearly one-half of the stenoses of the ureter developed within the first 3 months after transplantation. In five patients (12.5%) the stenosis developed significantly later, 3-10 years after kidney transplantation. Seventy percent of the stenoses were localized in the distal third of the ureter. About 75% of the surgically explored stenoses could be corrected by resection and reimplantation of the ureter. During the post-operative follow-up, restenosis occurred in three patients. At present, 62% of all patients whose ureteric stenoses were corrected have well-functioning kidney transplants.

We report 3 cases of urinary leakage occurring in male kidney transplant recipients within 6 weeks of renal transplantation. Voiding cystometrography showed that high voiding detrusor pressure was the contributing factor. Endoscopic bladder outlet surgery restored normal detrusor voiding pressure and led to spontaneous resolution of urinary leakage without recurrence in all cases.

A chronology of the biological preliminaries of human transplantation science is proposed together with a chronological listing of the applications which transplants have had in clinical medicine in general and in pediatrics in particular. The most significantly immunological elements which surface from this assortment of experiences (in which those of pediatric interest have a considerable role) contribute easily to a more deeply perceived culture of man's biological individuality.

The results of 600 consecutive renal transplant operations (540 cadaver and 60 living related donor) in 491 patients were assessed with respect to urological complications. In nearly all cases the ureter was inserted into the bladder using a Leadbetter-Politano ureteroneocystostomy technique. The bladder was drained by Foley catheter for 5 days and the operation site by vacuum drain for a variable period. After 26 operations in 26 patients, 27 episodes of ureteric obstruction were identified (one reobstruction). These occurred between 1 day and 45 months after transplantation and involved the lowest third of the ureter 19 times, the middle third 3 times and the proximal third 4 times. They were due to stricture (11), pelvic collection (7), redundant or twisted ureter (3) or other cause (5). An anatomical predisposing factor in either patient or graft was identified in 31 per cent of these caes. After 18 operations in 18 patients, 21 episodes of urine leakage were identified (three re-leakages). These occurred between 1 day and 6 months after transplantation and an anatomical predisposing factor in either patient or graft was present in 59 per cent. Thus, overall, 7 per cent of patients developed a urological complication in this series. This rate has declined in recent years in parallel with a general reduction in steroid dose for immunosuppression. This last feature, combined with the surgical technique described, has resulted in a low incidence of urological complication after transplantation, being now between 1 and 2 per cent.

A retrospective comparison of pyeloureterostomy and external ureteroneocystostomy as methods of reconstructing the urinary tract in 128 renal transplants is presented. There was one urological complication in 52 pyeloureterostomies (1.9%) compared with 4 in the 76 ureteroneocystostomies (5.3%). 6/0 Polydioxanone (PDS) is preferred to Prolene for the anastomosis because of possible calculus formation on the latter. Wound sepsis is commoner in pyeloureterostomies undergoing concomitant nephrectomy, despite prophylactic antibiotics, though this is not statistically significant and the overall sepsis rate is higher for ureteroneocystostomy. Nephrectomy was avoided in 17 selected cases by simply ligating the recipient ureter where the pre-transplant urine output was low. Two of these patients developed hydronephrosis in the isolated kidney and required later nephrectomy.

Infectious complications in the renal transplant patient are common, and infecting agents include opportunistic organisms as well as common pathogens. However, we were only able to document 6 patients who had septic arthritis from more than 800 who received a renal transplant at our institution over an 18-year period. Furthermore, only 16 other cases of infectious arthritis have been reported in the literature. All of our patients had an apparent predisposing factor and 3 patients had prior infection with the same organism. The knee was the most commonly infected joint. The initial synovial fluid white blood cell count was usually greater than 30,000 cells/mm3, but 1 patient with viral arthritis initially had noninflammatory fluid. The peripheral blood white blood cell count may not be elevated. All of our cases of initial joint infection occurred by 18 months posttransplant. Blood cultures were positive in 3 of 4 patients with bacterial infection. Followup of these 6 patients averaged 4.3 years. Numerous other rheumatologic syndromes and disorders peculiar to the posttransplant period may mimic a septic joint. Consequently, despite the low frequency of occurrence of septic arthritis, persistent attention to the locomotor system in the transplant patient is warranted.

The urologic complications were reviewed in 159 consecutive renal transplantations. There were 23 major complications (14%) in 22 patients. One patient died as a consequence of urologic complications and two other grafts were lost. In the remaining cases the grafts could be saved by surgical revision or conservative treatment. The principles of diagnosis and treatment of these complications are discussed.

Pseudomonas exotoxin A has been implicated as a possible virulence factor in Pseudomonas infections. This toxin has a direct cytotoxic effect on a number of cell types, including macrophages and their precursors, and therefore may affect other cells of the immune system. NFR/N(H-2q) (+/nu or nu/nu) mice were immunized with either T-dependent or T-independent antigens along with various doses of exotoxin A. The immune response was then assayed by a modification of the Jerne plaque assay. Exotoxin A induced a dose-dependent suppression of the in vitro and in vivo immune responses to T-dependent and T-independent antigens in immunocompetent +/nu mice. However, in NFR/N nu/nu mice, suppression of the immune response to the T-independent antigen trinitrophenylated-Ficoll was not observed. Instead, a marked enhancement of the response was observed at doses of 100 and 10 ng of exotoxin A. Removal of T-cells with anti-Thy 1.2 antiserum plus complement before antigen and exotoxin A stimulation in +/nu mice results in abrogation of the suppression. These data suggest that Pseudomonas exotoxin A exerts an effect on both B- and T-lymphocyte populations to modulate the immune response and that this activity may be one facet of the pathogenic effects of this toxin.

Between 1967 and 1981 27 children 6-15 years of age with end stage renal failure were treated in Queensland. The major cause of renal failure was reflux nephropathy (10). Actuarial graft survival was 55%, 50% and 35% at one, two and five years. Patient survival was 88%, 83% and 63% at one, two and five years. Seven deaths occurred, the major cause being hypertension in five children. Since 1978, patient survival has improved with a 93% survival at 3 years. Rehabilitation has been satisfactory with eleven of twelve school-aged children now attending school full time.

During a 33-month interval 106 consecutive renal transplants were performed. Prophylactic parenteral antibiotics, local wound irrigation with antibiotic solutions and drains were used. The over-all incidence of wound infection was 11.3 per cent. The true incidence in primary wounds was 8.4 per cent and in reopened wounds it was 21.7 per cent. Graft loss owing to infection was 33.3 per cent. Sepsis occurred in 25 per cent and death in 16.6 per cent of the patients with wound infection. The incidence of infections in hematomas was 27.5 per cent. The use of prophylactic measures contributed to a lower incidence of wound infection, while the use of drains and the occurrence of hematomas increased the incidence of infections.

Two hundred and one urological complications have been diagnosed and treated in 123 transplant recipients in a series of 1000 consecutive renal transplant operations (overall incidence 12.5%). Obstructive uropathies and urinary fistulae accounted for 95% of these complications and all of the mortality (22%). Details of management and patient and graft survival are given. A relationship between mortality from a urological complication and steroid dosage was found. A 30% incidence of recurrent or secondary urological complications was also noted with correspondingly worsened prognosis. Early diagnosis followed by early aggressive surgical treatment is advocated.

Sixty-one patients with bilateral synchronous renal cell carcinoma have undergone total excision of their neoplastic disease. True follow-up of the patients has been obtained from the surgeons or the patients themselves. Fifty-one patients underwent renal parenchymal-sparing procedures in one- or two-stage operations. Successful extracorporeal tumor resection was performed on 17 kidneys. The local tumor recurrence rate is 10%. Ten patients underwent bilateral nephrectomy with maintenance hemodialysis, and 4 of these underwent renal transplantation. The 69% survival rate of the group at five years is better than that of unilateral renal cell carcinoma.

Review of the results of the use of an external ureterovesical anastomosis in 266 renal transplantations showed that urinary fistulae occurred in 34 patients (12.8%), and ureteric obstruction in six (2.3%). The fistulae were due to technical failure of the anastomosis in 13 patients, to distal ureteric necrosis in 13, to total ureteric necrosis in six, and to other causes in two. Fistula management was successful in 26 cases (76.5%), but multiple operations were often necessary and wound complications frequent (41.2%). The continuing high incidence of urological complications following ureterovesical anastomosis has resulted in increasing use of ureteroneocystostomy as the primary form of urinary reconstruction after transplantation in this unit.

The depression of contact sensitivity to oxazolone in mice infected with Pseudomonas aeruginosa was studied. In oxazolone-sensitized mice, P. aeruginosa infection affects cell proliferation in the lymph nodes draining the site of sensitization. This impaired cell proliferation does not seem to be due to an altered lymphocyte reactivity, since lymph node and spleen cells from infected animals show a normal mitotic responsiveness to both T and B cell mitogens. In addition, the draining lymph nodes and spleens of mice exhibiting a depressed response to oxazolone contain a cell population able actively to suppress the response to the same antigen of syngeneic recipients sensitized immediately before the cell transfer. These suppressor cells require antigenic stimulation and appear to act on the induction phase of contact sensitivity.

One hundred and nine patients undergoing 119 transplants have been followed up from 8 months to 9 years. Urological complications occurred in 16 transplants, an incidence of 13.4%. Ureteroneocystostomy was performed primarily in all cases; in 98 by the conventional Politano-Leadbetter technique with 9 (9.2%) urological complications and in 32 by an extravesical technique with 7 (21.8%) urological complications. One patient died as a result of ureteric obstruction, without operation. In 3 patients with lower ureteric obstruction, transurethral ureteric meatotomy was successful in 2 cases and resulted in no change in renal function in the third. Two patients with urinary fistulae were managed successfully by continuous drainage with indwelling urethral catheters. The remaining 10 patients required 12 open surgical procedures for relief of ureteric obstruction, with improvement in function in 7 patients.

Sixty-four rejection crises in 55 kidney transplant patients were treated with high doses of corticosteroids, either 1) prednisone, administered orally in doses ranging between 150 and 600mh/day;2)methylprednisolone, administered i.v. in doses of 0.5 to 1 g/day (total dose: 2 to 8 g); or 3) methylprednisone administered i.v. in the same dosage in combination with heparin 5000 U/day. Acute rejection was reversed successfully in 60% of the crises without any apparent difference between the three treatment groups. Nineteen patients died from steroid-related complications. A total methylprednisolone dosage exceeding 3 to 5 h apparently was not accompanied by a sufficiently improved therapeutic response to warrant the high risk of such treatment.

The indications for transplantation, complications, management and results in 127 consecutive patients who had received renal transplants between October 1960 and December 1974 are presented. In 2 cases the donor was an identical twin, in 22 a living relative other than a twin, in 2 an unrelated individual in whom nephrectomy was performed for therapeutic reasons and in 101 a cadaver. At the end of the period under review there were 37 patients alive with grafts which had functioned for 6 months or more; of these, 28 had survived for more than 2 years, 13 for more than 5 years, 6 for more than 8 years and 2 for more than 12 years. Thirty-four patients were employed or doing routine housework or receiving full-time education. One patient fathered a child 4 years after transplantation; another gave birth to a healthy infant 3 years after transplantation.

A retrospective analysis of 193 renal transplant recipients yielded 15 patients who developed pulmonary mycosis posttransplantation and one case in which mycotic lung infection existed at the time of transplant surgery. Agent responsible for infection included Nocardia asteroides in 8 cases, Asperigillus flavus in 5 cases, Cryptococcus neoformans in 4 patients and Candida albicans in 2 cases. Two cases had mixed mycotic infections. Ten patients died, of which 7 had diagnosis established antemortem. Two cases had diagnosis established by thoracotomy and 1 case by transtracheal aspiration. Problems in establishing accurate diagnosis are discussed with emphasis placed on the need for more frequent use of transtracheal aspiration and thoracotomy for precise diagnosis.

Total ureteropelvic necrosis of the transplanted kidney occurred more than one month after transplantation in 5 of 575 consecutive renal transplants performed at the University of Minnesota Hospital since 1963. Necrosis became evident long after normal renal function had been established. Histologic signs of rejection were minimal, but perinephric or periureteral hematomas were found in 3 of 5 patients: post-transplant acute tubular necorsis requiring hemodialysis occurred in all. The pathogenesis of this complication probably involves (1) a primary deficit of blood supply from the renal vessels to the pelvis and ureter, (2) a failure to develop a new ureteral blood supply because of surrounding hematoma, (3) early swelling of the ischemic ureter resulting in oliguria interpreted as acute tubular necrosis, (4) resolution of edema resulting in diuresis, and (5) late patchy ureteral necrosis and fistula formation due to ureteral ischemia.

The effect of TCE on the intraocular pressure was investigated in eight patients under thiopentone nitrous oxide/oxygen anaesthesia, using a muscle relaxant (pancuronium bromide). Pulmonary ventilation was controlled and the end-tidal carbon dioxide was maintained at 5 per cent. In every patient the intraocular pressure was observed to rise as TCE was administered and then to return to the initial level when the administration of TCE ceased.

Four patients in terminal renal failure who had various malignant tumours were treated by haemodialysis and cadaveric renal transplantation. One patient with a testicular seminoma and one with leiomyosarcomatous changes in polycystic kidneys were successfully grafted after removal of the tumours and both were healthy at three and two-and-a-half years afterwards without evidence of recurrence of tumour.One patient with an invasive carcinoma of the renal pelvis was successfully transplanted and remained well for eight months but rapidly deteriorated and died of extensive metastases. Another patient with a malignant melanoma died more than one year after unsuccessful grafting.The presence of concomitant malignant disease in patients with chronic renal failure need not necessarily exclude them from the chance of long-term treatment, including renal transplantation. Each patient should be considered individually from the point of view of the nature of the malignancy, its duration, and treatment.

Thirty-three patients with end-stage renal failure have had transplants over a three-year period, four patients receiving kidneys from siblings and the remainder cadaver organs. Twenty-seven kidneys survived with stable function for periods of six months to three years. Graft survival at one year was 85% and at two years 82%. One patient died and five were returned to dialysis. Complications included rejection episodes, technical problems, respiratory and wound infections, gastrointestinal disorders, and side effects of steroids.