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Objective: To present the first Egyptian clinical practice guideline for kidney transplantation (KT). Methods: A panel of multidisciplinary subspecialties related to KT prepared this document. The sources of information included updates of six international guidelines, and review of several relevant international and Egyptian publications. All statements were graded according to the strength of clinical practice recommendation and the level of evidence. All recommendations were discussed by the panel members who represented most of the licensed Egyptian centres practicing KT. Results: Recommendations were given on preparation, surgical techniques and surgical complications of both donors and recipients. A special emphasis was made on the recipient’s journey with immunosuppression. It starts with setting the scene by covering the donor and recipient evaluations, medicolegal requirements, recipient’s protective vaccines, and risk assessment. It spans desensitisation and induction strategies to surgical approach and potential complications, options of maintenance immunosuppression, updated treatment of acute rejection and chemoprophylactic protocols. It ends with monitoring for potential complications of the recipient’s suppressed immunity and the short- and long-term complications of immunosuppressive drugs. It highlights the importance of individualisation of immunosuppression strategies consistent with pre-KT risk assessment. It emphasises the all-important role of anti-human leucocyte antigen antibodies, particularly the donor-specific antibodies (DSAs), in acute and chronic rejection, and eventual graft and patient survival. It addresses the place of DSAs across the recipient’s journey with his/her gift of life. Conclusion: This guideline introduces the first proposed standard of good clinical practice in the field of KT in Egypt. Abbreviations: Ab: antibody; ABMR: Ab-mediated rejection; ABO: ABO blood groups; BKV: BK polyomavirus; BMI: body mass index; BTS: British Transplantation Society; CAN: chronic allograft nephropathy; CDC: complement-dependent cytotoxicity; CKD: chronic kidney disease; CMV: cytomegalovirus; CNI: calcineurin inhibitor; CPRA: Calculated Panel Reactive Antibodies; (dn)DSA: (de novo) donor-specific antibodies; ECG: electrocardiogram; ESWL: extracorporeal shockwave lithotripsy; FCM: flow cytometry; GBM: glomerular basement membrane; GN: glomerulonephritis; HIV: human immunodeficiency virus; HLA: human leucocyte antigen; HPV: human papilloma virus; IL2-RA: interleukin-2 receptor antagonist; IVIg: intravenous immunoglobulin; KT(C)(R): kidney transplantation/transplant (candidate) (recipient); (L)(O)LDN: (laparoscopic) (open) live-donor nephrectomy; MBD: metabolic bone disease; MCS: Mean channel shift (in FCM-XM); MFI: mean fluorescence intensity; MMF: mycophenolate mofetil; mTOR(i): mammalian target of rapamycin (inhibitor); NG: ‘not graded’; PAP: Papanicolaou smear; PCN: percutaneous nephrostomy; PCNL: percutaneous nephrolithotomy; PKTU: post-KT urolithiasis; PLEX: plasma exchange; PRA: panel reactive antibodies; PSI: proliferation signal inhibitor; PTA: percutaneous transluminal angioplasty; RAS: renal artery stenosis; RAT: renal artery thrombosis;:rATG: rabbit anti-thymocyte globulin; RCT: randomised controlled trial; RIS: Relative MFI Score; RVT: renal vein thrombosis; TB: tuberculosis; TCMR: T-cell-mediated rejection; URS: ureterorenoscopy; (CD)US: (colour Doppler) ultrasonography; VCUG: voiding cystourethrogram; XM: cross match; ZN: Ziehl–Neelsen stain

Background To assess patients undergoing radical cystectomy using enhanced recovery protocol and standard protocol in terms of intraoperative and postoperative outcomes and complications. Results All operative and postoperative complications were recorded. In group B, time to normal bowel activity ranged from 1 to 4 days, and the mean was 1.8 days (± 1.02), while it ranged from 1 to 5 days, and the mean was 3.17 days (± 1.14) in group A which was statistically significant (p value p value = 0.033). Postoperative mortality was similar in both groups. Conclusion In patients undergoing radical cystectomy, enhanced recovery protocol is considered as a safe procedure and not associated with any increase in intraoperative and postoperative complications compared to standard protocol. The length of hospital stay and time to return to full diet are reduced.

INTRODUCTION AND OBJECTIVE:Operative surgical skills are among the most crucial competencies required for the independent practice in surgical specialties, yet they are rarely assessed as part of s...

Introduction: bipolar Transurethral Surgery of Prostate (BTUSP) is growing increasingly popular in the management of Benign prostatic hyperplasia related lower urinary tract symptoms (BPH-related LUTS). Compared to monopolar transurethral resection of the prostate (TURP), BTUSP has the potential advantages of less toxicity related to irrigation fluid absorption, and better hemostasis. However, there have been reports of BTUSP being associated with increased incidence of urethral stricture disease (USD). We aim at 2 years results of B-TUSP with special emphasis on USD and continence. Patients and methods: This is a retrospective study of patients who underwent BTUSP (resection, vaporization and enucleation) for BPH-related LUTS at Cairo University Hospital from January 2013 to December 2014. Perioperative parameters were assessed. Patients were evaluated 2 years postoperative to assess international prostate symptom score (IPSS), continence, urinary tract infection (UTI) uroflowmetry and post voiding residual urine (PVR). For patients with suspicion of USD (maximum flow rate “Qmax” ≤15 ml/s, PVR ≥100 cc,), retrograde and voiding cystourethrogram and/or cystoscopy were done. Results: A 2-years follow-up was available for 32 patients. Mean age was 66.2 ± 8.2 years. 16/32 patients were catheter dependent due to bladder outlet obstruction. Mean preoperative flowmetry, IPSS and adenoma size were 9.1 ± 3.02 ml/s, 23.1 ± 2.3 and 60.1 ± 28.1 g, respectively. Of our patients 11/32 (34%), 14/32 (44%) and 7/32 (22%) underwent BTU-enucleation, resection and vaporization of prostate, respectively. There was a difference in mean adenoma size for vaporization, enucleation and resection patients (29.57 ± 11.9 g, 83.36 ± 26.49 g and 58.71 ± 17.82 g, respectively) (p

Objectives To compare outcomes of renal transplantation (RTx) in children with end-stage renal disease (ESRD) resulting from lower urinary tract dysfunction (LUTD) vs other causes. Patients and Methods A database of children (

Objective To analyse the effect of preoperative clinical variables and comorbidity on the early, late and cumulative 90-day morbidity and mortality rates, as well as hospital re-admissions, after radical cystectomy (RC), in one centre. Patients and methods All patients undergoing RC over a period of 3 months were included. Preoperative investigations included measurements of serum albumin, a complete blood analysis, body mass index (BMI), Charlson comorbidity index (CCI) and the age-adjusted CCI (ACCI). We recorded the length of hospital stay (LOS) and all postoperative events for 90 days, and graded them according to the five-grade modification of the original Clavien system. Results In all there were 31 patients undergoing RC (mean age 58.4 years). The mean preoperative serum albumin and haemoglobin level, BMI, CCI and ACCI were 3.82 g/dL, 12.53 g/dL, 29.29 kg/m2, 3.0 and 4.58, respectively. The mean LOS was 20.03 days; seven patients needed re-admission and three died within the 90 days. There were postoperative complications in 20 patients. The age, CCI and ACCI were significantly associated with complications (P = 0.009, 0.001 and

OBJECTIVE To evaluate the clinicopathological outcomes for patients with clinical T2 (cT2) urothelial carcinoma treated with radical cystectomy (RC) without neoadjuvant chemotherapy (NC). PATIENTS AND METHODS We identified 212 patients with cT2 tumours who underwent RC at our institution without NC. Pathological assessment of RC specimens was correlated with clinical stage. The impact of various clinicopathological factors on the outcome of patients with cT2 disease was analysed. RESULTS In total, 153/212 (73.2%) patients with cT2 bladder cancer had either pT3/T4 or pN+ tumours at RC. Moreover, only 58/153 (37.9%) of these patients received adjuvant chemotherapy. The median follow-up was 28 (months 0.6-107.5) (range). The 5-year recurrence-free survival and cancer-specific survival (CSS) was 56.5% and 59.5%, respectively. On multivariate analysis, increasing age (hazard ratio [HR] 1.04; P= 0.04), advanced pathological stage (HR 1.83; P= 0.02), and positive lymph nodes (HR 3.72; P= 0.001) were adversely associated with CSS, while receipt of adjuvant chemotherapy was protective of disease-specific mortality (HR 0.45; P= 0.04). CONCLUSIONS Pathological upstaging is prevalent and survival remains modest in patients with cT2 tumours treated with RC without NC. Unfortunately, only 40% of patients that had locally advanced and/or regionally metastatic disease received adjuvant treatment. These data further support the value of NC for patients with muscle-invasive bladder cancer, even in those with apparent clinically organ-confined tumours.

We performed three cases of donor bladder trigone facilitated transplantation using pediatric en bloc kidneys into adult recipients. The donors were aged 11, 21, and 23 months; two of the donors were male, and the other was a female. In each case, the donor bladder was removed and the trigone was fashioned into a patch that contained both ureters, which was attached to the recipient anterior bladder wall. The recipients of the two male donor transplants healed and have normal voiding with no evidence of vesico-ureteral reflux. At 14 and 12 months, they have a creatinine of 1.2 and 1.0 mg/dL. The recipient of the female donor transplant developed a pelvic abscess, which necessitated reconstruction of the donor ureters and patch. She is now nine months with a creatinine of 1.2 mg/dL and voiding well. The use of the donor bladder trigone to facilitate pediatric en bloc transplantation can be carried out safely using the male donor urinary tract. However, the use of a female donor for this procedure may be a special circumstance requiring increased attention to sterilize the small donor introitus and avoiding devascularization of the bladder trigone that is adherent to the anterior vaginal wall.

Objective To prospectively compare the use of external ureteric stents with internal JJ stenting of the uretero-ileal anastomosis in patients undergoing laparoscopic radical cystectomy (LRC) with a Y-shaped ileal orthotopic neobladder (ON). Patients and methods The study included 69 patients undergoing LRC with ON. Patients were grouped according to the type of uretero-ileal stents used. An external ureteric stent was used in Group A (33 patients) and a JJ stent was used in Group B (36). We prospectively compared the duration of hospital stay, the incidence of short- and intermediate-term complications in the two study groups. Results The mean (SD) follow-up periods were 29.18 (3.94) and 28.19 (3.37) months for patients in Groups A and B, respectively. Perioperative patient characteristics were comparable in the two study groups. The use of JJ stenting was associated with a shorter hospital stay compared with external stenting, at a mean (SD) of 14.63 (3.74) and 6.8 (3.03) days in Groups A and B, respectively (P

INTRODUCTION AND OBJECTIVES: Patients with obstructive uropathy and voiding dysfunction (OUeVD), such as posterior urethral valves, neurogenic bladder dysfunction and vesicoureteral reflux represent 20% to 30% of kidney transplantation (KT) population. Historically, these patients were denied KT due to suboptimal lower urinary tract (LUT) and frequent UTI that may compromise graft survival. A number of series reported acceptable KT outcomes in these patients compared to patients with normal LUT. We aim to evaluate the outcome of KT in pediatric patients with ESRD due to OUeVD compared to patients with ESRD due to medical renal disease (MRD) METHODS: A retrospective review of patients’ records who underwent KT at Cairo University Pediatrics Hospital from January 2007 through January 2014. Outcomes of KT done for ESRD due OUeVD (Group I) were evaluated and compared with outcomes for KT done for ESRD due to MRD (Group II). Multiple perioperative parameters were examined including ancillary procedures performed to optimize the UT for KT in addition to graft survival. RESULTS: 103 patients underwent KT in the reviewed period with 74/103 (71.8%) males and 29/103 (28.2%) females. Mean patient age at KT was 5.05 12.4 (2.2e18) years. Group I patients included 29 patients while Group II included 74 patients. All patients in Group I needed ancillary procedure prior to KT with 55.2% in Group II. Mean follow up was 3.34 1.63 (1e7) years and 2.12 1.08 (1e5) years for Group I and II, respectively. Mean creatinine at 12 months was 0.94 0.24mg/dL and 0.97 0.36mg/dL for Group I and II respectively, with no statistically significant difference between the 2 groups (p1⁄40.8). All Group I patients were maintaned on TMPeSMX antibiotic prophylaxis. There was no signifant difference in posteKT UTI rates (7/29 (24%) in Group I and 9/74 (12.3%) in Group II (p1⁄40.05). The incidence of backepressure was comparable in both groups, 6/29 (20.69%) in Group I and 16/74 (21.62%) in Group II (P value1⁄40.92). CONCLUSIONS: KT can be safely performed in pediatric patients with OUeVD with/without reconstructed LUT, with results comparable to patients with ESRD due to MRD. Antibiotic prophylaxis helps maintain acceptable UTI rates.

The aim of this study was to detect possible risk factors for UC and UTI following pediatric renal Tx and effect of these complications on outcome. One hundred and eight children who underwent living donor Tx between 2009 and 2015 were retrospectively included. Extraperitoneal approach was used with stented tunneled extravesical procedure. Mean recipient age was 9.89 ± 3.46 years while mean weight was 25.22 ± 10.43 kg. Seventy-three (67.6%) recipients were boys while 92 (85.2%) were related to donors. Urological causes of ESRD were present in 33 (30.6%) recipients (14 [13%] posterior urethral valve, 16 [14.8%] VUR, and 3 [2.8%] neurogenic bladder). Augmentation ileocystoplasty was performed in 9 (8.3%) patients. Mean follow-up was 39.3 ± 17.33 months. UC were detected in 10 (9.3%) children (leakage 4 [3.7%], obstruction 3 [2.8%], and VUR 3 [2.8%]) while UTIs were reported in 40 (37%) children. After logistic regression analysis, UC were significantly higher in children with cystoplasty (44.4% vs 6.1%; P = .001). UTIs were significantly higher in girls (51.4% vs 30.1%; P = .001) and in children with urological causes of ESRD (51.5% vs 30.7%; P = .049). UC and UTI were not significantly associated with increased graft loss or mortality. UC were significantly higher in children with cystoplasty while UTIs were significantly higher in girls and children with urological causes of ESRD. Presence of UC did not affect the rate of graft loss or mortality due to its early detection and proper management.

We performed three cases of donor bladder trigone facilitated transplantation using pediatric en bloc kidneys into adult recipients. The donors were aged 11, 21, and 23 months; two of the donors were male, and the other was a female. In each case, the donor bladder was removed and the trigone was fashioned into a patch that contained both ureters, which was attached to the recipient anterior bladder wall. The recipients of the two male donor transplants healed and have normal voiding with no evidence of vesico-ureteral reflux. At 14 and 12 months, they have a creatinine of 1.2 and 1.0 mg/dL. The recipient of the female donor transplant developed a pelvic abscess, which necessitated reconstruction of the donor ureters and patch. She is now nine months with a creatinine of 1.2 mg/dL and voiding well. The use of the donor bladder trigone to facilitate pediatric en bloc transplantation can be carried out safely using the male donor urinary tract. However, the use of a female donor for this procedure may be a special circumstance requiring increased attention to sterilize the small donor introitus and avoiding devascularization of the bladder trigone that is adherent to the anterior vaginal wall.

Recent data demonstrate that age may be a significant independent prognostic variable following treatment for renal cell carcinoma. We analyzed data from the SEER (Surveillance, Epidemiology and End Results) database to evaluate the relative survival of patients treated surgically for localized renal cell carcinoma as related to tumor size and patient age.Patients in the SEER database with localized renal cell carcinoma were stratified into cohorts by age and tumor size. Three and 5-year relative survival, the ratio of observed survival in the cancer population to the expected survival of an age, sex and race matched cancer-free population, was calculated with SEER-Stat. Brown's method was used for hypothesis testing.A total of 8,578 patients with surgically treated, localized renal cell carcinoma were identified. While 3 and 5-year survival for patients with small (less than 4 cm) renal cell carcinoma was no different from that of matched cancer-free controls, patients treated for large (greater than 7 cm) localized renal cell carcinoma experienced decreased 5-year relative survival across all age groups. Therefore, age was not a significant predictor of relative survival for patients with small (less than 4 cm) or large (greater than 7 cm) tumors. However, a statistically significant trend toward lower relative survival with increasing age was demonstrated in patients with medium size tumors (4 to 7 cm). Hypothesis testing confirmed these findings.These data suggest that relative survival is high in patients with tumors less than 4 cm and lower in patients with tumors larger than 7 cm regardless of age. However, increasing age may be related to worse outcomes in patients with tumors 4 to 7 cm. The cause of this observation warrants further investigation.

We present a series of 400 patients with tumor in a solitary kidney who underwent open surgical partial nephrectomy performed by a single surgeon (ACN) with a primary focus on postoperative long-term kidney function.A total of 400 patients with sporadic nonfamilial kidney tumors in a solitary kidney underwent open partial nephrectomy between 1980 and 2002. In 323 patients (81%) the contralateral kidney had been surgically removed, while the remaining 77 (19%) had a congenital solitary kidney. Renal insufficiency was present preoperatively in 184 patients (46%). Adverse risk factors for partial nephrectomy were present in a large percent of patients. Intraoperative and postoperative parameters were evaluated at a mean followup of 44 months.In the overall series 5 and 10-year cancer specific survival was 89% and 82%, respectively. Surgical complications occurred in 52 patients (13%), most commonly urinary leakage. Early postoperative renal function was achieved in 398 patients (99.5%). Only 2 patients required permanent dialysis postoperatively. Satisfactory long-term renal function was achieved in 382 patients (95.5%). A total of 18 patients had progressed to renal failure a mean of 3.6 years after surgery. Patient age, the amount of renal parenchyma resected, a congenitally absent or atrophic contralateral kidney and the time of contralateral nephrectomy were noted to be significantly associated with postoperative renal function.Open surgical partial nephrectomy can be safely performed in patients with tumor in a solitary kidney. Long-term cancer-free survival with the preservation of renal function can be reliably expected in most of these cases.

patients. Recent data suggest that the development of metastatic disease is uncommon during active surveillance of SRMs over 3 to 5 years. Here we evaluate competing causes of non-cancer and cancer based death and compare these to death rates from RCC in age matched patients. METHODS: Mortality and survival rates in the United States were determined from the National Vital Statistics Reports. Patients