Combined antegrade-retrograde cystourethroscopic rendezvous procedure for the management of a severe urethral stricture during kidney transplantation: A case report

INTRODUCTION

External bladder drainage with an indwelling transurethral catheter is standard during kidney transplant. Difficult Foley catheter placement is a frequent problem and one of the most common reasons for intraoperative urology consults. Suprapubic catheters are usually placed if retrograde urologic instrumentation options fail to cross the urethral obstruction. We report an alternative option with an antegrade-retrograde endoscopic approach.

PRESENTATION OF CASE

This case illustrates a urethral rendezvous procedure applied successfully to traverse an occult mid-urethral stricture for Foley catheter placement during kidney transplantation in a 69-year-old diabetic man with end-stage renal disease and anuria.

DISCUSSION

The combined antegrade-retrograde rendezvous techniques have largely been described in the treatment of complex ureteric strictures more so than urethral strictures. This technique has not been described in the setting of a complex urethral stricture encountered during kidney transplantation. After utilization of the urinary tract rendezvous technique during kidney transplantation, our patient experienced an uneventful post-operative course with excellent renal allograft function.

CONCLUSION

The combined antegrade-retrograde urinary tract rendezvous technique is a feasible and safe technique that can help manage occult severe urethral strictures found at the time of kidney transplantation instead of suprapubic catheter placement when retrograde urologic instrumentation options fail to cross the obstruction.

A Modified Single Mercedes Incision Surgical Technique for Simultaneous Liver Kidney Transplant: A Case Series Report

BACKGROUND

The traditional approach in simultaneous liver-kidney transplantation (SLKT) involves two separate and sequential incisions. We describe modification of the classic Mercedes incision which limits the operation to a single incision yet provides and maintains adequate exposure enabling safe dual-allograft transplantation.

METHODS

Modification of the standard Mercedes incision includes bilateral, subcostal, muscle splitting incision 4-finger-breadths below the rib-edge with a midline, cephalad incision, and inferior±medial, ipsilateral extension on the side of intended iliac fossa laterality for renovascular and ureteroneocystostomy anastomosis.

RESULTS

Five consecutive patients (3 women/2 men; mean age, 49 years; median BMI, 29.8 kg/m2) underwent SLKT for end-stage liver disease and progressive hepatorenal syndrome via modified Mercedes incision approach (at a median MELD of 37) without an additional kidney transplant incision, extraperitoneal exposure, or addition of wound retractors. Two out of the five patients experienced post-op wound complications, including one with delayed wound healing and superficial dehiscence in a diabetic patient. All patients have normal dual-allograft function with four out of five beyond six months and one at two months post-transplantation.

CONCLUSION

Modified Mercedes incision technique is safe and feasible. Lowering the subcostal incisions with unilateral, inferomedial extension allows adequate visualization of the lower abdominopelvic area without compromising exposure of the upper abdomen for both renal and liver allograft implantation, respectively. Further studies are needed to prove the theoretical benefits of this technique.

Pledgeted plication: A novel technique to treat dialysis access-related steal syndrome

Steal syndrome is a potential complication of surgically created arteriovenous fistulas that can result in sensory and/or motor deficits, or tissue loss in the affected limb. Several surgical techniques have been developed to treat steal syndrome, but all have potential drawbacks. We detail a novel, modified plication technique which involves sequential, longitudinal application of pledgets along the venous outflow to gradually narrow it, and consequently decrease flow. Its potential benefits include protection of the vein from bare suture, less turbulent flow, and thus lower risk of thrombosis. Implementation of this technique in two patients resulted in symptomatic relief and continuation of uninterrupted hemodialysis at 9- and 12-month follow-up, respectively.

Kidney Transplantation in United States Native Americans: Breaking Barriers

Advances in the field of solid-organ transplantation (SOT), namely evolution of surgical techniques, developments in immunosuppressive therapies and efforts to maximize utilization of donor allografts (deceased and living), have resulted in growing numbers of SOT performed annually in the United States (U.S.) (36,529 total organs and 21,167 kidneys transplanted in 2018). However, the Native American/American Indian (NA/AI) people of the U.S. experience enormous socioeconomic barriers such as poverty, lack of adequate healthcare, poor health literacy and geographic isolation which limit access to SOT resulting in low rates of organ donation and transplantation, poor quality of life and shorter life expectancy. The NA/AI population is at increased risk for end-stage renal disease secondary to the high prevalence of diabetes mellitus. We review existing challenges to kidney transplantation in NA/AI patients and discuss potential solutions which could improve equitable delivery of specialized healthcare to this underprivileged population.

Early Cardiopulmonary Cryptococcus neoformans Infection After Liver Transplant: A Case Report

Cryptococcal infection (CI) is an uncommon fungal disease that poses a particular fatal risk to liver transplant (LT) recipients because of the potential rapid development and dissemination of the disease. Depending on the pathophysiology, CI may manifest with a wide range of clinical presentations that may delay early diagnosis and timely treatment. Additionally, most anticryptococcal therapies may threaten LT recipients owing to the associated hepatotoxicity of these medications. We report a case of a 25-year-old woman who received an LT for cryptogenic cirrhosis and developed rapidly progressive CI with pulmonary, myocardial, and cerebral involvement within a month of transplantation. She presented with severe pulmonary hypertension refractory to medical management and subsequently died despite our efforts. Herein, we review the etiology of cryptococcosis, the natural history of cryptococcal disease, and standard treatments for CI, and we highlight peculiarities of Cryptococcus neoformans infection in solid organ transplant recipients.

Spontaneous Chylous Ascites After Liver Transplantation Secondary to Everolimus: A Case Report

Chylous ascites (CA) is an uncommon entity with several etiologies. Only a few cases of CA have been reported as a complication after liver transplantation (LT). Most of these cases occurred within 1 month after surgery and typically resulted from traumatic intraoperative injury leading to disruption of lymphatics. Although peripheral lymphedema has been frequently correlated with use of calcineurin inhibitors, associated spontaneous CA has only been reported in a few cases after renal transplantation. We report a case of delayed spontaneous CA after LT caused by the use of the mammalian target of rapamycin (mTOR) inhibitor everolimus. Everolimus was introduced in our patient early after transplantation because of tacrolimus-induced microangiopathy, and years later the patient presented with spontaneous CA. After excluding other causes of CA, everolimus was discontinued, and immunosuppression was maintained by increasing prednisone and continuing mycophenolate mofetil. Additionally, the patient was treated with percutaneous drain placement and began a low-fat, high-protein diet. One month later the patient had complete resolution of symptoms with no recurrence of ascites. To our knowledge, this is the first case of delayed-onset CA caused by everolimus after LT.

High-dose hydroxocobalamin in end-stage liver disease and liver transplantation

Distributive shock is a serious complication in patients with chronic or end-stage liver disease, and can be exacerbated by vasoplegia in this patient population. Vasoplegic syndrome (VS) is a state of shock refractory to catecholamines and vasopressin that is often multifactorial in liver failure patients, and can occur in any phase of liver transplantation (LT) [i.e., pre-transplantation, intraoperative, and post-transplantation]. Methylene blue (MB) has been a well-established pharmacologic therapy for VS. However, it has been known to cause dose-related toxicity. Hydroxocobalamin (HXC) is not currently FDA approved for the management of VS, but studies have demonstrated its ability to cause an increase in systolic blood pressure by hypothesized mechanisms with only minimal side effects. To date, only three other reports have demonstrated the use of HXC in LT patients, which highlighted its use both intraoperatively and post-transplantation. Our report illustrates the utility of HXC in four LT patients with VS. Two of these cases illustrate the usefulness of HXC in the pre-transplantation period, which has never been previously reported. HXC is a useful pharmaceutical agent in the management of VS, especially if contraindications to MB exist or in cases of MB-resistant vasoplegia. Further studies with large sample sizes are necessary to ascertain the optimal dosage of HXC in LT patients.

Utility of fiber-optic bronchoscopy in pulmonary infections among abdominal solid-organ transplant patients: A comprehensive review

Pulmonary infections are frequent complications in abdominal solid-organ transplantation (aSOT) which may threaten patient and allograft survival. Accurate diagnosis and treatment of pulmonary infections in this population can be challenging. Immunosuppressive therapy not only increases the risk of acquiring opportunistic and non-opportunistic infections, but it also impairs the inflammatory responses associated with microbial invasion which in an otherwise normal host produce clinical and radiologic responses that allow for early identification of the offending pathogen. Serologic testing is not a reliable diagnostic modality. Direct microbiological sampling is often necessary to make a definitive diagnosis early in the clinical course to optimize timely, targeted therapy while reducing the risk of developing antimicrobial resistance, and minimize adverse effects of therapy, if any. Fiber-optic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) or transbronchial lung biopsy (TBB) offers such diagnostic advantage and possesses a potential therapeutic value too. This comprehensive review discusses the potential benefits of FOB alongside its risks and complications, indications and contraindications, and techniques. Additionally, the essay highlights FOB's utility and yield specifically with regard to type and timing of infections in aSOT patients.