Prone and supine percutaneous nephrolithotomy

Since the first successful stone extraction through a nephrostomy in 1976, percutaneous nephrolithotomy (PCNL) has became the preferred procedure especially for treatment of large, complex and staghorn calculi. For decades this method has been performed with the patient in the prone position. More recently, particular interest has been taken on supine PCNL due to less anestesiological risks and the possibility of simultaneous anterograde and retrograde access to the whole urinary tract. Although many retrospective studies have been published, only two prospective trials comparing the two positions are reported in the literature. The best access to PCNL represents still a controversial issue. The overall experience reported in literature indicates that each modality is equally feasible and safe. Therefore, to date the surgeon's preference is the prime indication to one access over the other.

Allograft nephrectomy: what is the best surgical technique?

BACKGROUND

The objective of this study was to evaluate differences in outcomes of allograft nephrectomies performed by extracapsular versus intracapsular techniques.

METHODS

From 1993 to 2010, we performed 89 allograft nephrectomies, including 57 by extracapsular techniques and 32 by intracapsular, chosen according to feasibility at the beginning of the surgery. Fisher exact test and logistic regression were used for statistical analysis. Survival estimates after allograft nephrectomy were calculated according to the Kaplan-Meier method.

RESULTS

After a mean graft survival of 49.7 months, the indications for transplant nephrectomy were chronic rejection (39.3%), acute rejection (22.5%), infection/sepsis (19.1%), gross hematuria (6.7%), renal vein thrombosis (6.7%), renal artery thrombosis (3.4%), and graft rupture (2.3%). Mean operative time, blood loss, transfusions, and complications were similar between the extracapsular and intracapsular groups. The only difference in surgical aspects between the 2 groups was the mean hospital stay, which was longer for the extracapsular group (13.8 vs 7.6 days; P = .01), a result that was confirmed by multivariate analysis (odds ratio, 1.05; 95% confidence interval, 1.0-1.1; P = .03).

CONCLUSIONS

Our experience showed no significant advantages in favor of the intracapsular technique except for a shorter length of hospital stay than after the extracapsular procedure.

Genotypes and haplotypes in the 3' untranslated region of the HLA-G gene and their association with clinical outcome of hematopoietic stem cell transplantation for beta-thalassemia

Polymorphisms in the 3' untranslated region (3'UTR) of HLA-G, an important player in immunological tolerance, could be involved in post-transcriptional expression control, and their association with different clinical immune-related conditions including autoimmunity and transplantation is of mounting interest. Most studies have focused on a 14 base pair (bp) insertion/deletion (ins/del), while additional single-nucleotide polymorphisms (SNPs) in the HLA-G 3'UTR have been described but not extensively investigated for their clinical relevance. Here we have comparatively studied the association between 3'UTR haplotypes of HLA-G, or the 14 bp ins/del, with clinical outcome of HLA-identical sibling hematopoietic stem cell transplantation (HSCT) in 147 Middle Eastern beta-thalassemia patients. Sequence based typing of 3'UTR HLA-G polymorphisms in the patients and in 102 healthy Italian blood donors showed strong linkage disequilibrium between the 14 bp ins/del and five 3'UTR SNPs, which together could be arranged into eight distinct haplotypes based on expectation-maximization studies, with four predominant haplotypes (UTRs1-4). After HSCT, we found a moderate though not significant association between the presence of UTR-2 in double dose and protection from acute graft versus host disease (hazard ratio (HR) 0.45, 95% confidence intervals (CI): 0.14-1.45; P = 0.18), an effect that was also seen when the corresponding 14 bp ins/ins genotype was considered alone (HR 0.42, 95% CI: 0.16-1.06; P = 0.07). No association was found with rejection or survival. Taken together, our data show that there is no apparent added value of considering entire 3'UTR HLA-G haplotypes for risk prediction after allogeneic HSCT for beta-thalassemia.

Obesity in kidney transplantation affects renal function but not graft and patient survival

INTRODUCTION

The number of overweight and obese patients undergoing renal transplantation has increased dramatically over the past two decades. Studies on graft survival and posttransplantation complications have often yielded conflicting results. Some authors have reported similar results for graft and patient survivals between obese and normal weight patients, but with a marginally increased rate of postoperative complications. In contrast, other reports note higher percentage of graft losses as well as increased mortality. In our study, we analyzed early- and long-term outcomes among obese versus nonobese kidney transplant recipients.

PATIENTS AND METHODS

Between January 2000 and December 2008, we performed 563 cadaveric kidney transplantations. Recipients were classified in 1 of 5 groups based on their body mass index (BMI) at the time of transplantation: group A (n = 68; BMI < 18.5); group B (n = 310; 18.6 < BMI < 24.9); group C (n = 143; 25 < BMI < 29.9); group D (n = 32; 30 < BMI < 34.9); and group E (n = 10; BMI ≥ 35). The comparative analysis included patient and graft survivals, postoperative complications, onset of delayed graft function (DGF), acute rejection episodes, hospital stay, and serum creatinine values in the first 3 years posttransplantation.

RESULTS

At a mean follow-up of 53 months (range, 3-112 months), DGF was observed in 20 patients in group A (29.4%), 82 in group B (26.4%), 43 in group C (30%), 16 in group D (50%), and 4 in group E (40%). Nevertheless, obese patients (groups D and E) showed higher mean serum creatinine values and worse renal function at 6 months (P = .001), 1 year (P < .001), and 3 years (P = .001). Moreover, they were at increased risk of an acute rejection episode (P = .01) and more susceptible to cardiovascular and metabolic complications (P = .01). Morbidly obese patients displayed a higher incidence of postsurgical complications (P = .002). There were no differences in the incidences of chronic allograft nephropathy (CAN) or infectious complications. Despite the differences in morbidity among the 5 groups, we failed to observe significant differences in patient or graft survivals at 6, 12, 36, or 60 months.

CONCLUSION

Our findings suggested that obese patients should not be discriminated against simply based on the BMI. At our center, obese (BMI >35) transplantation candidates undergo a thorough cardiac evaluation, as well as pulmonary, endocrine, and nutritional counseling seeking to minimize medical and surgical complications and improve survival and quality of life.

Hematopoietic stem cell transplantation in thalassemia

SCT still remains the only cure currently available for patients with thalassemia. Results of transplants in this disease have steadily improved over the last two decades due to improvements in preventive strategies, effective control of transplant-related complications and development of new preparative regimens. Currently, high-resolution HLA typing has enabled physicians to perform transplants from unrelated volunteer donors for thalassemia with results comparable with those obtained employing an HLA-identical sibling. The probabilities for obtaining thalassemia-free survival after transplant in thalassemia from an HLA-identical donor, family member or MUD are between 85 and 87%. Therefore, when an HLA-identical donor is present, the transplant of allogeneic stem cell should be performed as allogeneic gene therapy. In the light of advances in transplantation for thalassemia, patients with an HLA-identical donor should be offered SCT.

"Deviceless" hand-assisted laparoscopic donor nephrectomy

Hand-assisted laparoscopic nephrectomy (HLN) in living donors is a minimally invasive surgical modality that uses classic laparoscopic techniques combined with the surgeon's hand as a support tool during renal dissection. We describe our experience with 14 donors undergoing HLN with a novel "deviceless" technique (DL-HLN). We used a midline or a paramedian incision. The first 10-mm trocar (camera) was inserted near the umbilicus and another 10-mm trocar placed under laparoscopic vision at the level of the anterior axillary line above the iliac crest. DL-HLN was performed in 14 patients (11 women and 3 men) of overall mean age of 40 years (range=33-60). Left nephrectomy was performed in all cases. Mean surgical time was 105 minutes (range=60-150). Estimated blood loss was 50 to 800 mL (mean=200 mL). Mean warm ischemia time was 3.5 minutes (range=2-11). Mean hospital stay was 4 days (range=3-6). In one case, uncontrollable hemorrhage developed due to a renal vein lesion at the level of the adrenal vein outlet, requiring conversion to open surgery. As to graft function, recipient serum creatinine on day 7 ranged from 0.9 to 2.6 mg/dL (mean=1.6). We used no device in our technique. The pneumoperitoneum was maintained by the sealing effect of the muscular fascia around the surgeon's wrist. Moreover, the kidney was removed through the hand port without an Endobag. Our modified HLN technique avoids the use of costly disposables and offers the advantages of a smaller incision.

Adult Type Testicular Granulosa Cell Tumor: Case Report and Review of the Literature

Granulosa cell tumors represent a special group of the so-called sex cord-stromal tumors of the gonads, and are divided into 2 histological types: adult and juvenile. Adult type testicular granulosa cell tumor is a rare neoplasia: 22 cases of this testicular tumor only have been described in literature so far. They are often discovered accidentally and exhibit no endocrine-related symptoms.

We report a case of adult type granulosa cell tumor in a 45-year-old man likely affected by a 15-year-old painless tumor with increased right testicular size; he underwent radical orchiectomy.

This case and a review of the literature indicate that this kind of tumor is a rare, slow-growing neoplasm. Since distant metastases may occur late in the clinical course, long term follow-up of these patients is recommended.

Relationship between number of allergic sensitizations and immunity impairment: anything new in immunotherapy for allergies and vaccines planning?

To 106 14-56 year-old allergic people (30 monosensitized, 24 sensitized to 2 pollens, 52 polysensitized) we have evaluated the Global Immune Competence Status (GICS). That's a compound score, made of ten parameters, six regarding cell-mediated immunity (WBC/mmc, Gr/mmc, Ly/mmc, Ly CD3+/mmc, Ly CD4+/mmc, CD4/CD8 Ratio), four regarding nutritional status and humoral immunity (Tot. Protein mg/dl, Albumin mg/dl, Gammaglobulins mg/dl, IgG mg/dl). Each parameter is brought on a grid including 4 worth scores worsening from 4 to 1, related to different ranges of values; this way quickly leads to characterize type and grade of immune deficiency. So doing we found that in 30 monosensitized people 27 (90%) show a complete immune competence, while just 3 people (10%) have impaired GICS: in these 1 (3%) regards cell-mediated immunity, while 2 (7%) regard humoral immunity. In 24 patients sensitized to 2 allergenes, 18 (75%) showed complete immune competence, while 6 (25%) a GICS impairment regarding cell-mediated immunity. In leaving 52 polysensitized patients, 30 people showed complete immune competence (58%), while 20 (38%) showed a GICS impairment regarding cell-mediated immunity and 2 (4%) impaired humoral immunity. This work shows that the higher the number of sensitizations is, the stronger the cell-mediated immunity impairment in allergic people become.

Recipient mHag-HA1 disparity and aGVHD in thalassemic-transplanted patients

In order to determine the influence of HA-1 minor histocompatibility antigen mismatch on BMT outcome, we analyzed a pool of 94 thalassemic transplanted patients all selected for the presence of HLA-A(*)0201 allele. The HA-1 typing was performed using SSP analysis. All the patients received bone marrow from HLA-identical MLC nonresponsive siblings. As graft-versus-host-disease (GVHD) prophylaxis, all patients received cyclosporin and short methotrexate. Grades II-IV GVHD occurred in five (33.3%) of the 15 patients with recipient HA-1 disparity compared with 14 (17.7%) of the 79 patients without HA-1 disparity. Despite the higher incidence of acute graft-versus-host-disease (aGVHD) in the group of patients with HA-1 incompatibility, these data were not statistically significant. However, it was interesting to observe that no GVHD developed in any of the 15 cases in which the recipient was HA-1 negative and the donor HA-1 positive.

Correlation of bone marrow angiogenesis and mast cells with tryptase activity in myelodysplastic syndromes

Bone marrow samples from 30 patients with myelodysplastic syndromes (MDS) grouped according to the International Prognostic Scoring System for MDS were investigated for counts of microvessels, total metachromatic mast cells (MC) and MC expressing tryptase, an angiogenesis-inducing molecule. Counts were higher in patients with a poor prognosis. The observation of a high correlation between microvessel counts and both total metachromatic and tryptase-reactive MC in all samples suggests that angiogenesis in MDS increases with their progression and that MC may intervene in the angiogenic response in MDS through tryptase contained in their secretory granules.

Role of seminal osmolarity in the reduction of human sperm motility

Mammalian sperm at ejaculation are suspended in the seminal plasma, a heterogeneous mixture deriving from the testicular/epididymal fluid and from secretions of seminal vesicles, prostate and bulbourethral glands. Biochemical characteristics of seminal fluid change along the male reproductive tract when considering its inorganic and organic composition and pH but it is known that in each region of the male genital tract seminal osmolarity is higher than that of serum. It has been previously demonstrated that in invertebrate and vertebrate sperm, seminal plasma osmolarity influences sperm motility and activity, and human sperm have been shown to possess osmosensitive calcium entry pathway that controls important functions such as acrosome reaction and oocyte penetration. In the present study, we have determined seminal plasma osmolarity in a large number of normozoospermic fertile and asthenozoospermic infertile subjects correlating it with sperm motility percentages and kinematic characteristics determined utilizing a computerized motion analysis system. Our results confirm that seminal plasma osmolarity is higher than that of serum (336.1 +/- 20.2 vs. 291.1 +/- 6.9 mOsm/L, respectively). Normozoospermic subjects show seminal osmolarity values that are significantly lower with respect to asthenozoospermic patients (317.8 +/- 12.2 vs. 345.2 +/- 22.6 mOsm/L, p<0.001), irrespective of the cause of asthenozoospermia. Seminal plasma osmolarity negatively correlates with sperm progressive motility percentages and kinetic characteristics (curvilinear velocity, linear velocity, linear coefficient and lateral displacements of sperm head). Furthermore, when sperm from fertile subjects were suspended in medium with an osmolarity increasing from 300 to 600 mOsm, sperm motility percentages and kinetics characteristics were progressively reduced and nearly abolished when medium osmolarity was 600 mOsm. On the contrary, when sperm from asthenozoospermic subjects with high semen osmolarity were resuspended in medium with lower osmolarity, sperm motility parameters improved significantly. Sperm motility parameters did not correlate with seminal plasma concentrations of sodium, potassium, chloride with a weak correlation only with seminal calcium concentration. No correlations are present between seminal plasma osmolarity and ionic composition. In conclusion, the present study confirms and extends the knowledge that, in human, seminal plasma osmolarity is higher than that of serum and demonstrates that seminal osmolarity influences sperm motility characteristics and then it may contribute to the pathogenesis of some forms of asthenozoospermia and male infertility.

Fate of chronic myeloid leukemia patients treated with allogeneic bone marrow transplantation or chemotherapy and/or interferon at a single center: long-term results

From April 1981 to February 2000, 105 patients with chronic myeloid leukemia (CML) underwent BMT from HLA-identical related donors at a single center. Eighty-eight patients were in chronic phase (CP), 11 patients in accelerated phase and six patients in blast crisis. Ten of these patients received a second BMT (BMT2). Comparison of BMT in CP with chemotherapy and/or alpha-IFN (n=70) was also made. Patients were given cyclophosphamide (CY) and single-dose TBI (CYTBI, n=38) or busulfan (BU) and CY (BUCY, n=67). Overall 54 patients are alive and 52 of them are disease-free with a median follow-up of 11.3 (range 1.1-19.4) years. Ten-year disease-free survival (DFS) in CP patients was better after BUCY, 61% (95% CI, 47-68%) than after CYTBI, 41% (95% CI, 23-61%) (P=0.07). For 88 patients who received a transplant in CP, results were significantly improved when BMT was performed within 1 year after diagnosis (P=0.02) or at an age < or = 25 years old (P=0.01). Ten-year survival in patients who received BMT in CP was better than in patients treated with chemotherapy (56% vs 10%; P=0.0001) or alpha-IFN-based treatment (33%; P=0.09) with survival curves crossing at 4.2 years and at 4 years, respectively. The probability of DFS after BMT2 was 60% (95% CI, 26-87%). CP patients who received BMT after CYTBI had a higher probability of relapse and transplant-related mortality than patients receiving BUCY (53% and 58% vs 9% and 34%; P=0.002 and P=0.08, respectively). All but six patients are currently on no medication and have resumed all activities without any limitation. These long-term results confirm that allogeneic BMT is the only curative approach for CML patients and should be offered to all patients with a suitable donor as soon after diagnosis as possible.

Novel approaches to the treatment of chronic graft-versus-host disease

Chronic graft-versus-host disease (cGvHD) continues to be the major problem in long-term survivors of allogeneic haematopoietic stem cell transplants and is the principal cause of morbidity and non-relapse mortality. Over the past twenty years, diagnosis, prophylaxis and treatment of cGvHD have slowly evolved. An effective therapy for cGvHD is designed to prevent complications through targeting the disease mechanisms. None of the present therapies for cGvHD are successful in the majority of patients. Conventional drugs in different combinations can control the disease in approximately 50% of patients. Attempts to improve survival have led to evaluation of several alternative approaches in the treatment of refractory cGvHD with varying degrees of success. Clinical trials are needed to establish the role of these new approaches in the treatment of cGvHD as first line or salvage therapy without causing significant side effects. This review summarises the currently available knowledge on conventional and new treatment approaches for cGvHD.

A novel HLA-A*02 allele, A*02202, identified by nucleotide sequencing

In this paper we report the identification of a new HLA-A*02 allele in two members of an Afghan family. This novel allele, designed as A*02202, differs from A*02201 by a silent substitution at codon 66 (AAC-->AAT) in the alpha1 domain. A*02202 appears to be the result of a novel mutation (Note).

A three or more drug combination as effective therapy for moderate or severe chronic graft-versus-host disease

We analyzed the results of a three or more drug combination as treatment for moderate or severe cGVHD developing after transplantation for thalassemia, in 45 patients with median age of 11 (range 2-26) years. Eighteen patients received a three drug regimen with cyclosporine (CsA), methylprednisolone (MP) and azathioprine (AZ) as first line therapy, 16 patients received this regimen as salvage therapy and 11 patients were given a four or five drug regimen with CsA, MP, AZ, cyclophosphamide (CY) and/or methotrexate (MTX) mainly as salvage therapy. The overall complete response (CR) rate was 77.3%, with 94% of CR in patients receiving the three drug regimen as first line, 88% in patients receiving it as salvage therapy and 36.6% in patients given the four or five drug regimen. The probability of CR in patients given the three drug regimen as first or salvage therapy or the four/five drug regimen was 89%, 53% and 30%, while the probability of survival was 89%, 65% and 58%, respectively. The incidence of treatment failure was low in our patients. Patients treated with the three drug regimen as first line therapy had less treatment-related complications than patients receiving this regimen as salvage therapy or patients given the four or five drug regimen. The main causes of treatment-related mortality (20%) were infectious complications. This retrospective study showed that a three or more drug combination is safe and effective for treatment of moderate or severe cGVHD at least in younger patients.