Nephro-Urology Monthly
Volume:1 Issue: 2, Dec 2009

Laparoscopic partial nephrectomy (LPN) is being practiced at several noted medical institutions worldwide. But, it is yet to be accepted as the standard level of care for many renal cancer patients for whom it is indicated. Due to several technical issues that are unique to LPN, there is a tendency to prolong the warm ischemia time due to renal artery occlusion beyond 30 minutes. It has been determined by several clinicians that a warm ischemia time of more than 32 minutes severely compromises the renal function post-operatively. This is primarily due to the prolonged ischemic insult with serious consequences as a result of severe hypoxia and/or anoxia in the affected kidney. In this review, a molecular approach is taken to describe the events that occur due to severe hypoxia and anoxia and to evaluate the reversibility of the injuries that follow with particular reference to alternative modes of renal cell death. Analyses of these molecular mechanisms suggest that it is possible to "pre-condition" the kidney pre-operatively by several strategies which are nutritional, biochemical, pharmacological and environmental in nature. An attempt is made to arrive at a common denominator in all these approaches, i.e., the ischemic insult to the renal mitochondria during hypoxia and the endoplasmic reticulum stress (ER-stress) during anoxia. It is hypothesized that lending a helping hand to the ischemic mitochondria and the anoxic ER in the affected renal cells (by either hypoxic and /or anoxic pre-conditioning) and empowering them by several ways may be the key to minimize the ischemic damage during LPN and thus may help enhance the warm ischemia time without compromising renal function.

Pelvic lymph node dissection (pLND) in patients undergoing radical retropubic prostatectomy (rRPE) is often associated with postoperative lymphocele formation. This can lead to consecutive complications such as abscesses and thrombosis. The aim of this study was to evaluate the possible risk of complications due to the lymph node dissection and to identify risk factors being associated with symptomatic lymphoceles
Between 02/2002 and 12/2003 all 504 patients who underwent pLND and rRPE were investigated on the 7th postoperative day by pelvic and lower abdominal ultrasound. Volumes of lymphoceles were determined. Complications related to pLND were described and evaluated statistically to explore the role of possible risk factors.
200ml. The mean volume of the lymphoceles was 111.6 ml (Median 80 ml). 13 patients developed complications such as thrombosis and abscesses. The mean volume of lymphoceles being clinically symptomatic was 227±125ml and in asymptomatic patients it was 87±65 ml. This difference was statistically significant (p<0.001).
Because of simple feasibility, universal availability as well as low costs, a pelvic ultrasound should be performed in the clinical setting after removal of all drains. Asymptomatic lymphoceles with a volume less than 100 ml do not need any particular close follow-up. Facing larger lymphoceles invasive means should be planned rather early to avoid complications.

Honeymoon impotence or first night erectile dysfunction (ED) is one kind of psychogenic ED which is not uncommon. Prevalence of this kind of ED is higher in conservative communities especially the Muslim population. We assessed the role of Sildenafil, a phosphodiesterase inhibitor (PDE-5) in the management of honeymoon (psychogenic) impotence.
All patients having erectile dysfunction (ED) after marriage with normal nocturnal erections were enrolled in this prospective study from 01-09-2006 to 31-08-2008. Reassurance & Sildenafil 100 mg at bed time was given to every patient and dose reduced to 50 mg after 3 successful intercourses. Patients who did not respond to PDE-5 inhibitor (3 doses), were given intracavernosal injection alprostadil and shifted to PDE-5 inhibitor after successful intercourse.
Total number of patients was 45 with age range of 20-39 years. Mean duration elapsed before seeking medical advice was 10±14 days. Eighty percent patients had successful intercourse on first dose of Sildenafil with 95% confidence interval (CI) and 13% patients responded to 2nd dose of Sildenafil. Twelve percent patients suffered mild, well tolerable complications.
Honeymoon impotence is not an uncommon condition in some special population. Sildenafil proved to be effective, with high success rate and few tolerable complications.

The aim of current study was to evaluate the efficacy of retroperitoneoscopic pyelolymphatic disconnection in the management of chyluria not responding to conservative therapy and two courses of retrograde pelvic instillation sclerotherapy (RPIS) that were considered as cases of intractable chyluria.
A total 21 patients of intractable chyluria underwent retroperitoneoscopic pyelolymphatic disconnection over a period of 30 months. They were then followed every three months for the history of absence or presence of milky urine. Every patient irrespective of the history of passing milky urine underwent biochemical test of urine to confirm the presence of chyle in their urine.
Mean operation time was 123 minutes (range 93 to 156 minutes) and mean hospital stay was 3 days. One patient had persistence of chyluria until third postoperative day that was managed successfully with RPIS. Another patient developed recurrence of chyluria after three months of operation from side opposite to the operated side as evident on cystoscopic view and was also successfully managed by RPIS. Our overall success rate was 95.3%.
Retroperitoneoscopic pyelolymphatic disconnection is a safe and effective procedure in the management of intractable chyluria not responding to conservative therapy or RPIS

Haemoglobin (Hb) decreases were associated with progression of nephropathy and it has been suggested that normal Hb levels may preserve renal function. Our aim was to investigate if this could be achieved by erythropoietin (EPO).
300 mg/l, and anaemia, Hb < 110 g/l. EPO was given in order to achieve Hb levels 115 g/l (low) or 130 g/l (normal). The patients were followed for one year and evaluated every third month with timed overnight urine collections, 24 hour blood pressure measurement and glomerular function (GFR) with iohexol clearance.
Twelve patients achieved 115 g/l and seven patients 130 g/l. The median GFR before treatment was 26 (12-50) and 29 (15-53) ml/min/1.73m2 (median and min-max, p=NS). The median decrease in GFR per month was faster in the patients with low Hb [- 1.0 (-2.89 to 0.25)] than in the normal Hb level group [-0.08 (-1.08 to 1.16] ml/min/1.73m2 per month (median and min-max, p= 0.015). Four patients were started on dialysis (n=2) or died (n=2), all in the low Hb group. Urine human complex (a-1-microglobulin) increased, i.e. proximal tubular function worsened, in the low Hb group with no change in the normal Hb group. Urine albumin, Immunoglobulin G, glycosaminoglycans, collagen IV non-collagenous part (NC1) and Tamm-Horsfall protein did not change in any of the groups. Glycated haemoglobin (HbA1c) and blood pressure levels were unchanged in both groups.
The present study infers that EPO treatment may preserve both glomerular filtration rate and proximal tubular function. Further studies are needed to confirm our findings.

The hemodialysis regimen required to treat end stage renal disease (ESRD) can be extremely strict, requiring individuals to deal with multiple acute and chronic stressors. The aim of this study was to assess relationships between compliance and therapeutic goals with marital status separately by sex in uremic patients receiving hemodialysis in Tehran province.
In December 2005, an observational study was performed that included the whole HD population (2630 patients; 1505 males and 1125 females) from 56 different units in the province of Tehran, an area encompassing 13.5 million inhabitants.
The mean age of patients in this study was 53.4±16.5 years. They were 1505 men (57.2%) and 1125 women (42.8%). Regarding marital status, it was shown that 1855 (72.5%) were married, 59 (2.3%) were divorced and 329 (12.9%) were widowed. A relationship between marital status and sex was found (80.2% of males were married versus 62.1% of females) (P=0.001). Mean hemoglobin level was not significantly different in two sexes (P=0.15) but was different significantly between married and singles (P=0.002). Even if there was no significant difference in achieving the numbers of K/DOQI guideline targets among different sex and marital status, the control was better in those with family support (P<0.05). The numbers of dialysis sessions and vaccination or preference for transplantation did not differ among the groups. As the marital status has a great impact on therapeutic goals achievements and that 38% of females versus 19.8% of males are single they may need more supervision. Higher rate of illiteracy mandates educational facilities to be appropriate to their capabilities.
The bottom line is that although patients with less support can get dialysis in adequate dose, they need more concentration regarding calcium and phosphorus metabolism and anemia management

End stage renal disease (ESRD) patients suffer from low health related quality of life (HRQoL) and according to a report presented at the 40th annual meeting of the American Society of Nephrology, it is predicted that by 2020, the number of patients with ESRD will increase to nearly 60% in comparison to that of 2005.
We measured HRQoL among 152 patients on dialysis by kidney disease quality of life-short form (KDQoL-SF) questionnaire and compared KDQoL scores by demographic factors such as gender, age, educational level, occupation and marital status.
Male gender, age <50 years, higher education level, marital status and employment status had a better Physical Component summary (PCS), Mental Component Summary (MCS) and Kidney Disease Component Summary (KDCS). The mean scores of PCS and MCS were significantly decreased by increasing the age (P=0.004 and 0.008, respectively). In addition, MCS and KDCS scores was significantly higher in employed and KDCS was significantly better in literate patients. The mean score of KDCS was higher than MCS and PCS (52.6 ± 13.5 vs 41.6 ± 20.9 and 39.06 ± 19.2, respectively with P<0.001).
Association of poorer HRQoL with preventable or controllable factors suggests that attention should be given to psychosocial and medical interventions to improve HRQoL in hemodialysis patients.

Non-calculus presentations of hyperoxaluria (HX) and Hyperuricosuria (HU) are not common. The aim of this study was to investigate the relationship of symptomatic non-calculous idiopathic HX, HU and both of them with dysuria, failure to thrive (FTT), recurrent urinary tract infection (UTI), dysmorphic RBCs, and abdominal pain in children.
A cross sectional study was done on 58 children who were age less than 14 years with history of persistent microscopic or macroscopic hematuria with HX and/or HU, regardless of having renal calculi, between October 2007 and October 2008. The patients were divided into three groups according to the type of crystalluria (I, 10 HX; II, 20 HU; and III, 28 HX).
The common presenting symptoms were abdominal pain (63%) and dysuria (45%). FTT was frequently occurred in female (68%). No significant relation was seen between the groups in terms of gender, macroscopic hematuria and recurrent UTI. We found that dysuria, positive family history, FTT, abdominal pain and dysmorphic RBCs in patients with HX were higher when compared to HU group. Moreover, logistic regression analysis showed the higher odds ratio of FTT, abdominal pain and dysmorphic RBCs in patients with HX group when compared to individuals with HU.
Although our study showed that non calculus symptoms and signs of crystaluria such as dysmorphic RBCs, FTT, abdominal pain and dysuria are frequently seen in children with HX, but further studies are needed.

Nephronophthisis (NPHP) is an autosomal recessive kidney disorder characterized by chronic tubulointerstitial nephritis that progresses eventually to end-stage kidney disease (ESKD). NPHP is often a part of a multisystem disorder such as Senior-Loken syndrome, Joubert syndrome, Senior-Boichis syndrome, Saldino-Mainzer syndrome, COACH syndrome, Arima syndrome, Alstrom syndrome, RHYNS syndrome and Jeune''s dystrophy with several associated extra renal manifestations. Positional cloning of nine genes (NPHP1-9) as mutated in NPHP and characterization of their coded proteins have contributed to the concept of "ciliopathies". The ciliary theory explains the multiple organ involvement in NPHP that may manifest as retinitis pigmentosa, liver fibrosis, ataxia, and mental retardation. The treatment of choice for ESKD due to NPHP is kidney transplantation. Positional cloning of additional genes of NPHP will elucidate further signaling mechanisms and pathways that are involved, thereby opening new potential therapeutic approaches.

Cytomegalovirus (CMV) is the leading cause of infectious complications after organ transplantation. Tuberculosis can occur in the early postoperative period and is potentially curable. We report here a 45-year-old renal transplant recipient with a rare coinfection of CMV infection and miliary tuberculosis, as early as 6 months after the transplant. In addition, HCV Ab was positive with normal liver function tests before kidney transplantation. The organism was isolated from sputum and broncoalveolar lavage (BAL) specimen cultures. The patient was given 12 months of quadruple anti-TB therapy. With antituberculous therapy, and reduction in the patient''s conventional immunosuppression, intravenous ganciclovir was also used. The patient remained disease-free after a follow-up period of 6 years.
To our knowledge, this is the first case report of a coinfection with cytomegalovirus and Mycobacterium tuberculosis presenting with pulmonary miliary pattern. In addition, administration of steroid boluses, CMV and HCV infections are important risk factors for TB in our patient.
Post-transplant TB is a serious problem worldwide, and must be always included in the differential diagnosis of fever and pulmonary disease in the renal transplant recipient. Early diagnosis and prompt initiation of treatment for TB among renal transplant patients is very important and vital.