IntroductionFrameshift in medical management as well as in surgical thinking is putting the patient as a whole is the focus, rather than just the disease. To optimize the treatment of our pediatric transplant patients in our institution, we changed in 2013 the transplant program setting, treating, and operating all patients with pediatric transplant exclusively in a pediatric environment. The aim of this study was to analyze whether or not this change had an impact on patients safety, patient population, and patients and transplant outcome.MethodsIn the retrospective analysis, we compared transplant outcome of two eras. Era1 (2008–2012) solely included patients treated in the adult facilities, era 2 (2013–2017) patients were exclusively treated in the pediatric environment.ResultsThere were 53 patients with renal transplant, with era 1 (28 patients) and era 2 (25 patients). Overall mortality was 5.6%. Median recipient age at transplantation was 13.2 years in era 1 and 8.59 years in era 2, median recipient weight at transplantation was 41.7 kg in era 1 vs. 26 kg in era 2, median size 149. 5 cm (era 1) vs. 123 cm in era2 (p = 0.05). The direct recipient/donor weight ratio remained stable in both eras, for recipients below 20 kg we saw a larger weight mismatch in era 1 (0.84 vs. 0.66). In the subgroup of patients with congenital anomalies of the kidney and urinary tract (CAKUT) those were significantly younger at onset of dialysis (p < 0.001) and at time of transplantation (p < 0.001), also they were less in body weight (p < 0.01), and body size (p < 0.001), this subgroup was larger in era 2. HLA mismatch data, serum creatinine, and GFR yield comparable results in both groups. Median time to detection of DSA was 46.2 month (3.8 years).ConclusionSince children with ESRD at the time of transplant trend to be younger and smaller, it is crucial to ensure a medical environment that is able to address their particular challenges. Even in this recipient cohort, renal transplantation can be performed safely as outlined by our data.
IntroductionRenal allograft compartment syndrome (RACS) is a complication that infrequently occurs after renal transplantation. Tight muscle closure may lead to RACS due to compression of renal parenchyma or kinking of the renal vessels. Many techniques have been proposed in an attempt to achieve tension-free closure, which can be specially challenging in child recipients. We present our experience with Tutoplast® Fascia Lata (RTI Surgical Tutogen Medical GmbH Industriestrasse 6, 91077 Neunkirchen am Brand, Germany) closure.MethodsAll pediatric patients who underwent renal transplantation in our center between 2012 and 2021 were reviewed. Eight patients with Tutoplast® Fascia Lata placed at the time of initial transplantation were identified. Donor and recipient characteristics, Doppler ultrasound findings, and overall patient and graft survival rates were analyzed.ResultsDoppler ultrasound was performed intra-operatively after abdominal wall closure. If any sign of vascular compromise was seen, the abdominal wall was opened and the graft was revised. The Tutoplast® Fascia Lata implant was used to perform tension-free fascia closure and, afterwards, a Doppler ultrasound was performed to confirm the optimal renal artery perfusion and venous patency. Three of the renal transplantations were from a cadaver donor, with two of them en bloc. Living donor transplantation was performed in four cases. Among which, there was a case of auto-transplantation due to bilateral renal artery stenosis. None of the patients presented any complications of either short or long term that was derived from the abdominal closure with Tutoplast® Fascia Lata. There was also no record of graft failure till datum.ConclusionsRestricted volume of the recipient pelvic cavity and the size discrepancy between the recipient pelvic cavity space and the donor adult kidney may lead to RACS. Other situations that occur more infrequently, i.e., as en bloc or auto-transplantation, are prone to suffer the same problem. Tutoplast® Fascia Lata is a safe option for these patients.
Introduction A TCS after primary closure of meningomyeloceles is a known complication of the spina bifida disease. Data on the outcome after SSCU surgery is heterogeneous and lacking standardization. Thus we aimed to find a reliable system for assessment of the bladder function before and after SSCU surgery and document postoperative outcome. Methods A retrospective study was performed on a cohort of patients with spina bifida diagnosis. In total, 130 patients underwent 182 SSCU surgeries, 56 of those met our inclusion criteria. A classification system, including two different methods, was used. The AC system used baseline pressure and detrusor over activity to define three levels of bladder dysfunction, the second method ranked the severity of bladder dysfunction by awarding points from 0 to 2 for bladder capacity, maximal detrusor pressure during autonomous contractions, leak point pressure and vesicoureteral reflux A high score is correlated with a severe bladder dysfunction. Results Gender distribution was equally (male: n = 29; 51.8%; female: n = 27; 48.2%). The median age at SSCU was 902 years (range 0.5–22.8 years). After SSCU, the stage improved in 11 patients (19.6%), worsened in 11 (19.6%) patients and remained the same in 34 patients (60.7%) after intervention (AC score). Non-worsening was observed in a total of 45 cases (80.4%) (p < 0.001). MHS score (n = 27, 48.2%) improved, remained unchanged (n = 12, 21.4%), 17 patients worsened (30.4%). Non-worsening in postoperative bladder functional outcome was demonstrated in 39 cases (69.6%) over all (p < 0.005). Regardless of whether bladder function is categorized by AC or MHS, postoperative outcome worsened significantly when SSCU was performed due to increasing deterioration in motor function alone (p < 0.05). Of the 24 cases with NOD as indication, 22 (91.7%) had an unchanged (n = 10; 41.7%) or improved (n = 12; 50.0%), meaning positive neuro-orthopedic outcome, only 2 (8.3%) deteriorated (p < 0.001). Conclusion Our study presents reliable evaluation systems for bladder function in spina bifida patients. Since indications for SSCU surgery differ, it is important to know the possible effects on bladder function after this surgical procedure. Even a mild impairment of bladder function has a risk to deteriorate after SSCU surgery. Particularly interesting becomes this with regard to the fact that the prevalence of TCS might become more frequent with the rising numbers of prenatal closures of meningomyeloceles.
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