Laparoscopic partial nephrectomy for renal tumor: Nagoya experience.

PubMed

Yoshikawa, Yoko; Ono, Yoshinari; Hattori, Ryohei; Gotoh, Momokazu; Yoshino, Yasushi; Katsuno, Satoshi; Katoh, Masashi; Ohshima, Shinichi

2004-08-01

To clarify the indication for a vascular clamp during laparoscopic partial nephrectomy, the clinical results of 17 patients who underwent the procedure for small renal tumors were reviewed. Seventeen patients with renal tumors were enrolled in our laparoscopic partial nephrectomy program between October 1999 and November 2003. During laparoscopy, a vascular clamp was used to remove the tumor mass and suture the incised renal parenchyma and urinary collecting system in 8 patients who had less-than-1-cm-thick renal parenchyma between the mass and the renal sinus or calices. In the remaining 9 patients, who had 1-cm-or-more-thick renal parenchyma between the mass and sinus or calices, renal bleeding was controlled using ultrasonic scissors, gauze tampon, argon beam coagulator, and fibrin glue. Sixteen patients were successfully treated with laparoscopy; one required conversion to open surgery because of uncontrollable bleeding. The average operative time was 4.5 hours, and average estimated bleeding volume was 301 mL. In the 8 patients requiring vascular clamping by forceps, the average ischemic time was 25 minutes. In all patients, the tumor mass was completely removed with negative surgical margins, and renal function was preserved. Three patients had prolonged urinary leakage for a mean of 21 days. Laparoscopic partial nephrectomy offers many advantages, including surgery that is both nephron sparing and minimally invasive. A vascular clamp was indicated for patients with less-than-1-cm-thick renal parenchyma between the tumor mass and renal sinus or calices.

A comparative cost analysis of robot-assisted versus traditional laparoscopic partial nephrectomy.

PubMed

Hyams, Elias; Pierorazio, Philip; Mullins, Jeffrey K; Ward, Maryann; Allaf, Mohamad

2012-07-01

Robot-assisted laparoscopic partial nephrectomy (RALPN) is supplanting traditional laparoscopic partial nephrectomy (LPN) as the technique of choice for minimally invasive nephron-sparing surgery. This evolution has resulted from potential clinical benefits, as well as proliferation of robotic systems and patient demand for robot-assisted surgery. We sought to quantify the costs associated with the use of robotics for minimally invasive partial nephrectomy. A cost analysis was performed for 20 consecutive robot-assisted partial nephrectomy (RPN) and LPN patients at our institution from 2009 to 2010. Data included actual perioperative and hospitalization costs as well as professional fees. Capital costs were estimated using purchase costs and amortization of two robotic systems from 2001 to 2009, as well as maintenance contract costs. The estimated cost/case was obtained using total robotic surgical volume during this period. Total estimated costs were compared between groups. A separate analysis was performed assuming "ideal" robotic utilization during a comparable period. RALPN had a cost premium of +$1066/case compared with LPN, assuming actual robot utilization from 2001 to 2009. Assuming "ideal" utilization during a comparable period, this premium decreased to +$334; capital costs per case decreased from $1907 to $1175. Tumor size, operative time, and length of stay were comparable between groups. RALPN is associated with a small to moderate cost premium depending on assumptions regarding robotic surgical volume. Saturated utilization of robotic systems decreases attributable capital costs and makes comparison with laparoscopy more favorable. Purported clinical benefits of RPN (eg, decreased warm ischemia time, increased utilization of nephron-sparing surgery) need further study, because these may have cost implications.

Zero ischemia anatomical partial nephrectomy: a novel approach.

PubMed

Gill, Inderbir S; Patil, Mukul B; Abreu, Andre Luis de Castro; Ng, Casey; Cai, Jie; Berger, Andre; Eisenberg, Manuel S; Nakamoto, Masahiko; Ukimura, Osamu; Goh, Alvin C; Thangathurai, Duraiyah; Aron, Monish; Desai, Mihir M

2012-03-01

We present a novel concept of zero ischemia anatomical robotic and laparoscopic partial nephrectomy. Our technique primarily involves anatomical vascular microdissection and preemptive control of tumor specific, tertiary or higher order renal arterial branch(es) using neurosurgical aneurysm micro-bulldog clamps. In 58 consecutive patients the majority (70%) had anatomically complex tumors including central (67%), hilar (26%), completely intrarenal (23%), pT1b (18%) and solitary kidney (7%). Data were prospectively collected and analyzed from an institutional review board approved database. Of 58 cases undergoing zero ischemia robotic (15) or laparoscopic (43) partial nephrectomy, 57 (98%) were completed without hilar clamping. Mean tumor size was 3.2 cm, mean ± SD R.E.N.A.L. score 7.0 ± 1.9, C-index 2.9 ± 2.4, operative time 4.4 hours, blood loss 206 cc and hospital stay 3.9 days. There were no intraoperative complications. Postoperative complications (22.8%) were low grade (Clavien grade 1 to 2) in 19.3% and high grade (Clavien grade 3 to 5) in 3.5%. All patients had negative cancer surgical margins (100%). Mean absolute and percent change in preoperative vs 4-month postoperative serum creatinine (0.2 mg/dl, 18%), estimated glomerular filtration rate (-11.4 ml/minute/1.73 m(2), 13%), and ipsilateral kidney function on radionuclide scanning at 6 months (-10%) correlated with mean percent kidney excised intraoperatively (18%). Although 21% of patients received a perioperative blood transfusion, no patient had acute or delayed renal hemorrhage, or lost a kidney. The concept of zero ischemia robotic and laparoscopic partial nephrectomy is presented. This anatomical vascular microdissection of the artery first and then tumor allows even complex tumors to be excised without hilar clamping. Global surgical renal ischemia is unnecessary for the majority of patients undergoing robotic and laparoscopic partial nephrectomy at our institution. Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Hybrid laparoscopic and robotic ultrasound-guided radiofrequency ablation-assisted clampless partial nephrectomy.

PubMed

Nadler, Robert B; Perry, Kent T; Smith, Norm D

2009-07-01

To describe a clampless approach made possible by creating an avascular plane of tissue with radiofrequency ablation. Laparoscopic partial nephrectomy is slowly gaining acceptance as a method to treat small (<4 cm) and select moderate (<7 cm) renal masses. The intricacies of laparoscopic suturing, which result in prolonged warm ischemia times, have delayed the widespread acceptance of this technique among urologists. Laparoscopic suturing to close the collecting system was done using the da Vinci robot. An avascular plane of tissue from coagulation necrosis was achieved with the Habib 4X radiofrequency ablation device and the Rita 1500X generator. Typically, we used a power setting of 50 W but have found settings as low as 25 W necessary to provide hemostasis for larger vessels. The tumor was then sharply excised with a negative margin using robotic scissors and electrocautery to facilitate tissue cutting. Retrograde injection of methylthioninium chloride and saline through an externalized ureteral catheter allowed for precise sutured closure of the collecting system. FloSeal and BioGlue were then applied, making surgical bolsters or parenchymal sutures unnecessary. Intraoperative histologic evaluation of the surgical margin and repeat resection of the tumor bed was possible because the renal hilum was not clamped, and no warm ischemia was used. This technique, which combines the improving technologies of robotic surgery, intraoperative laparoscopic ultrasonography, and radiofrequency ablation, might make more surgeons comfortable with the intricacies of laparoscopic suturing and eliminate prolonged warm ischemia times. Overall, this method should result in more patients being able to undergo minimally invasive laparoscopic partial nephrectomy.

Value of Nephrometry Score Constituents on Perioperative Outcomes and Split Renal Function in Patients Undergoing Minimally Invasive Partial Nephrectomy.

PubMed

Watts, Kara L; Ghosh, Propa; Stein, Solomon; Ghavamian, Reza

2017-01-01

To assess the relationship between individual nephrometry score (NS) constituents (RENAL) on perioperative outcomes and renal function of the surgical kidney in patients undergoing laparoscopic partial nephrectomy or robotic-assisted partial nephrectomy. Two hundred forty-five patients who underwent laparoscopic partial nephrectomy or robotic-assisted partial nephrectomy between 2005 and 2014 were retrospectively reviewed. Each renal mass' NS was calculated from preoperative computed tomography imaging. Multivariate regression analysis was used to evaluate the effect of NS variables on perioperative outcomes and change in overall renal function (as estimated by glomerular filtration rate) from preoperative to 1-year postoperative. A cohort analysis assessed the effect of NS variables on change in split renal function of the surgical kidney from pre- to postoperative based on nuclear medicine renal scintigraphy. Tumor radius (R), endophytic nature (E), and nearness to collecting system (N) variables significantly and incrementally predicted a longer operative time and warm ischemia time. Overall renal function based on glomerular filtration rate was not affected by any NS variable. However, percent function of the surgical kidney by renal scintigraphy significantly decreased postoperatively as R and E values increased. R, E, and N were associated with significant changes in warm ischemia time and operative time. R and E were associated with a significant decrease in split renal function of the surgical kidney at 1 year after surgery but not with overall renal function. R, E, and N are the NS constituents most relevant to perioperative outcomes and postoperative differential renal function after partial nephrectomy. Copyright © 2016. Published by Elsevier Inc.

Robotic surgery and hemostatic agents in partial nephrectomy: a high rate of success without vascular clamping.

PubMed

Morelli, Luca; Morelli, John; Palmeri, Matteo; D'Isidoro, Cristiano; Kauffmann, Emanuele Federico; Tartaglia, Dario; Caprili, Giovanni; Pisano, Roberta; Guadagni, Simone; Di Franco, Gregorio; Di Candio, Giulio; Mosca, Franco

2015-09-01

Robot-assisted partial nephrectomy has been proposed as a technique to overcome technical challenges of laparoscopic partial nephrectomy. We prospectively collected and analyzed data from 31 patients who underwent robotic partial nephrectomy with systematic use of hemostatic agents, between February 2009 and October 2014. Thirty-three renal tumors were treated in 31 patients. There were no conversions to open surgery, intraoperative complications, or blood transfusions. The mean size of the resected tumors was 27 mm (median 20 mm, range 5-40 mm). Twenty-seven of 33 lesions (82%) did not require vascular clamping and therefore were treated in the absence of ischemia. All margins were negative. The high partial nephrectomy success rate without vascular clamping suggests that robotic nephron-sparing surgery with systematic use of hemostatic agents may be a safe, effective method to completely avoid ischemia in the treatment of selected renal masses.

Application and analysis of retroperitoneal laparoscopic partial nephrectomy with sequential segmental renal artery clamping for patients with multiple renal tumor: initial experience.

PubMed

Zhu, Jundong; Jiang, Fan; Li, Pu; Shao, Pengfei; Liang, Chao; Xu, Aiming; Miao, Chenkui; Qin, Chao; Wang, Zengjun; Yin, Changjun

2017-09-11

To explore the feasibility and safety of retroperitoneal laparoscopic partial nephrectomy with sequential segmental renal artery clamping for the patients with multiple renal tumor of who have solitary kidney or contralateral kidney insufficiency. Nine patients who have undergone retroperitoneal laparoscopic partial nephrectomy with sequential segmental renal artery clamping between October 2010 and January 2017 were retrospectively analyzed. Clinical materials and parameters during and after the operation were summarized. Nineteen tumors were resected in nine patients and the operations were all successful. The operation time ranged from 100 to 180 min (125 min); clamping time of segmental renal artery was 10 ~ 30 min (23 min); the amount of blood loss during the operation was 120 ~ 330 ml (190 ml); hospital stay after the operation is 3 ~ 6d (5d). There was no complication during the perioperative period, and the pathology diagnosis after the surgery showed that there were 13 renal clear cell carcinomas, two papillary carcinoma and four perivascular epithelioid cell tumors with negative margins from the 19 tumors. All patients were followed up for 3 ~ 60 months, and no local recurrence or metastasis was detected. At 3-month post-operation follow-up, the mean serum creatinine was 148.6 ± 28.1 μmol/L (p = 0.107), an increase of 3.0 μmol/L from preoperative baseline. For the patients with multiple renal tumors and solitary kidney or contralateral kidney insufficiency, retroperitoneal laparoscopic partial nephrectomy with sequential segmental renal artery clamping was feasible and safe, which minimized the warm ischemia injury to the kidney and preserved the renal function effectively.

Hand-assisted laparoscopic versus robot-assisted laparoscopic partial nephrectomy: comparison of short-term outcomes and cost.

PubMed

Elsamra, Sammy E; Leone, Andrew R; Lasser, Michael S; Thavaseelan, Simone; Golijanin, Dragan; Haleblian, George E; Pareek, Gyan

2013-02-01

Robot-assisted laparoscopic partial nephrectomy (RALPN) and laparoscopic partial nephrectomy (LPN) have become standard for the surgical management of small renal masses (SRMs). However, no studies have evaluated the short-term outcomes or cost of RALPN as compared with hand-assisted laparoscopic partial nephrectomy (HALPN) in a standardized fashion. A retrospective review of all patients who underwent HALPN or RALPN from 2006 to 2010 were assessed for patient age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, radiographic tumor size, nephrometry (radius, endo/exophytic, nearness to collecting system, anterior/posterior, lines of polarity [RENAL]) scores, operative and room times, hospital length of stay (LOS), estimated blood loss (EBL), requirement of hilar vessel clamping, warm ischemia time (WIT), pre- and postprocedural creatinine and hemoglobin levels, and complications. Total costs of the procedures were estimated based on operating room component (operative staff time, anesthesia, and supply) and hospital stay cost (room and board, pharmacy). A robotic premium cost, estimated based on the yearly overall cost of the da Vinci S surgical system divided by the annual number of cases, was included in the RALPN cost. Cost figures were obtained from hospital administration and applied to the mean HALPN and RALPN patient. Forty-seven patients underwent HALPN since 2006 and 21 patients underwent RALPN since 2008. ASA, BMI, EBL, tumor size, nephrometry score, positive margin rate, change in creatinine, change in hemoglobin, morphine equivalents used, and complication rate were all similar in both groups (p>0.05). Room time and operative time were significantly shorter for the HALPN cohort (p=0.001) whereas LOS was significantly shorter in the RALPN cohort (p=0.019). Despite the shorter LOS, RALPN was associated with a $1165 increased cost, mainly due to increased operating room time and premium cost of the robot. While early in our experience, RALPN offered no significant advantage in short-term outcomes over HALPN and was associated with an increased cost of over $1150.

Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques in oncology: analysis of English secondary care data for radical prostatectomy and partial nephrectomy.

PubMed

Hughes, David; Camp, Charlotte; O'Hara, Jamie; Adshead, Jim

2016-06-01

To evaluate postoperative health resource utilisation and secondary care costs for radical prostatectomy and partial nephrectomy in National Health Service (NHS) hospitals in England, via a comparison of robot-assisted, conventional laparoscopic and open surgical approaches. We retrospectively analysed the secondary care records of 23 735 patients who underwent robot-assisted (RARP, n = 8 016), laparoscopic (LRP, n = 6 776) or open radical prostatectomy (ORP, n = 8 943). We further analysed 2 173 patients who underwent robot-assisted (RAPN, n = 365), laparoscopic (LPN, n = 792) or open partial nephrectomy (OPN, n = 1 016). Postoperative inpatient admissions, hospital bed-days, excess bed-days and outpatient appointments at 360 and 1 080 days after surgery were reviewed. Patients in the RARP group required significantly fewer inpatient admissions, hospital bed-days and excess bed-days at 360 and 1 080 days than patients undergoing ORP. Patients undergoing ORP had a significantly higher number of outpatient appointments at 1 080 days. The corresponding total costs were significantly lower for patients in the RARP group at 360 days (£1679 vs £2031 for ORP; P < 0.001) and at 1 080 days (£3461 vs £4208 for ORP; P < 0.001). In partial nephrectomy, Patients in the RAPN group required significantly fewer inpatient admissions and hospital bed-days at 360 days compared with those in the OPN group; no significant differences were observed in outcomes at 1 080 days. The corresponding total costs were lower for patients in the RAPN group at 360 days (£779 vs £1242 for OPN, P = 0.843) and at 1 080 days (£2122 vs £2889 for ORP; P = 0.570). For both procedure types, resource utilisation and costs for laparoscopic surgeries lay at the approximate midpoint of those for robot-assisted and open surgeries. Our analysis provides compelling evidence to suggest that RARP leads to reduced long-term health resource utilisation and downstream cost savings compared with traditional open and laparoscopic approaches. Furthermore, despite the limitations that arise from the inclusion of a small sample, these results also suggest that robot-assisted surgery may represent a cost-saving alternative to existing surgical options in partial nephrectomy. Further exploration of clinical cost drivers, as well as an extension of the analysis into subsequent years, could lend support to the wider commissioning of robot-assisted surgery within the NHS. © 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.

Intraoperative laparoscopic complications for urological cancer procedures.

PubMed

Montes, Sergio Fernández-Pello; Rodríguez, Ivan Gonzalez; Ugarteburu, Rodrigo Gil; Villamil, Luis Rodríguez; Mendez, Begoña Diaz; Gil, Patricio Suarez; Madera, Javier Mosquera

2015-05-16

To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution. We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications. We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery (radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery (radical prostatectomy and radical cystectomy). Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications.

Laparoscopic Donor Nephrectomy: Early Experience at a Single Center in Pakistan.

PubMed

Mohsin, Rehan; Shehzad, Asad; Bajracharya, Uspal; Ali, Bux; Aziz, Tahir; Mubarak, Muhammed; Hashmi, Altaf; Rizvi, Adibul Hasan

2018-04-01

Laparoscopic donor nephrectomy has become the criterion standard for kidney retrieval from living donors. There is no information on the experience and outcomes of laparoscopic donor nephrectomy in Pakistan. The objective of the study was to identify benefits and harms of using laparoscopic compared with open nephrectomy techniques for renal allograft retrieval. In this a retrospective study, patient files from May 2014 to September 2015 were analyzed. Patients were divided into 2 groups: those with open donor nephrectomy and those with laparoscopic donor nephrectomy. Donor case files and operative notes were analyzed for age, sex, laterality, body mass index, warm ischemia time, perioperative and postoperative complications, surgery time, and length of hospital stay. Finally, serum creatinine patterns of both donors and recipients were analyzed. Data were analyzed using SPSS version 10 (SPSS: An IBM Company, IBM Corporation, Armonk, NY, USA). Of 388 total donors, 190 (49%) had open donor nephrectomy and 198 (51%) had laparoscopic donor nephrectomy. For both groups, most donors were older than 25 years with male preponderance. Left-to-right kidney donation ratio was markedly higher in the laparoscopic group than in the open donor nephrectomy group, with 6 cases of double renal artery also included in this study. There were no significant differences in surgery times between the 2 groups, whereas the laparoscopic donor nephrectomy group had shorter hospital stay. Analgesic requirements were markedly shorter in the laparoscopic donor nephrectomy group. The 1-year graft function was not significantly different between the 2 groups. The results for laparoscopic donor nephrectomy were comparable to those for open donor nephrectomy, and its acceptability was high. Laparoscopic donor nephrectomy should be the preferred approach for procuring the kidney graft.

Intraoperative laparoscopic complications for urological cancer procedures

PubMed Central

Montes, Sergio Fernández-Pello; Rodríguez, Ivan Gonzalez; Ugarteburu, Rodrigo Gil; Villamil, Luis Rodríguez; Mendez, Begoña Diaz; Gil, Patricio Suarez; Madera, Javier Mosquera

2015-01-01

AIM: To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution. METHODS: We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications. RESULTS: We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery (radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery (radical prostatectomy and radical cystectomy). CONCLUSION: Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications. PMID:25984519

Protective response in renal transplantation: no clinical or molecular differences between open and laparoscopic donor nephrectomy.

PubMed

Machado, Christiano; Malheiros, Denise Maria Avancini Costa; Adamy, Ari; Santos, Luiz Sergio; Silva Filho, Agenor Ferreira da; Nahas, William Carlos; Lemos, Francine Brambate Carvalhinho

2013-04-01

Prolonged warm ischemia time and increased intra-abdominal pressure caused by pneumoperitoneum during a laparoscopic donor nephrectomy could enhance renal ischemia reperfusion injury. For this reason, laparoscopic donor nephrectomy may be associated with a slower graft function recovery. However, an adequate protective response may balance the ischemia reperfusion damage. This study investigated whether laparoscopic donor nephrectomy modified the protective response of renal tissue during kidney transplantation. Patients undergoing live renal transplantation were prospectively analyzed and divided into two groups based on the donor nephrectomy approach used: 1) the control group, recipients of open donor nephrectomy (n = 29), and 2) the study group, recipients of laparoscopic donor nephrectomy (n = 26). Graft biopsies were obtained at two time points: T-1 = after warm ischemia time and T+1 = 45 minutes after kidney reperfusion. The samples were analyzed by immunohistochemistry for the Bcl-2 and HO-1 proteins and by real-time polymerase chain reaction for the mRNA expression of Bcl-2, HO-1 and vascular endothelial growth factor. The area under the curve for creatinine and delayed graft function were similar in both the laparoscopic and open groups. There was no difference in the protective gene expression between the laparoscopic donor nephrectomy and open donor nephrectomy groups. The protein expression of HO-1 and Bcl-2 were similar between the open and laparoscopic groups. Furthermore, the gene expression of B-cell lymphoma 2 correlated with the warm ischemia time in the open group (p = 0.047) and that of vascular endothelial growth factor with the area under the curve for creatinine in the laparoscopic group (p = 0.01). The postoperative renal function and protective factor expression were similar between laparoscopic donor nephrectomy and open donor nephrectomy. These findings ensure laparoscopic donor nephrectomy utilization in renal transplantation.

Cost-utility analysis of radical nephrectomy versus partial nephrectomy in the management of small renal masses: Adjusting for the burden of ensuing chronic kidney disease

PubMed Central

Klinghoffer, Zachary; Tarride, Jean-Eric; Novara, Giacomo; Ficarra, Vincenzo; Kapoor, Anil; Shayegan, Bobby; Braga, Luis H.

2013-01-01

Objectives: We compare the cost-utility of laparoscopic radical nephrectomy (LRN), laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) in the management of small renal masses (SRMs) when the impact of ensuing chronic kidney disease (CKD) disease is considered. Methods: We designed a Markov decision analysis model with a 10-year time horizon. Estimates of costs, utilities, complication rates and probabilities of developing CKD were derived from the literature. The base case patient was assumed to be a 65-year-old patient with a <4-cm unilateral renal mass, a normal contralateral kidney and a normal preoperative serum creatinine. Univariate and probabilistic sensitivity analyses were conducted to address the uncertainty associated with the study parameters. Results: OPN was the least costly strategy at $25 941 USD and generated 7.161 quality-adjusted life years (QALYs) over 10 years. LPN yielded 0.098 additional QALYs at an additional cost of $888 for an incremental cost-effectiveness ratio of $9057 per QALY, well below a commonly cited willingness-to-pay threshold of $50 000 per QALY. LRN was more costly and yielded fewer QALYs than OPN and LPN. Sensitivity analyses demonstrated our model to be robust to changes to key parameters. Age had no effect on preferred strategy. Conclusions: Partial nephrectomy (PN) is the preferred treatment strategy for SRMs. In centres where LPN is not available, OPN remains considerably more cost-effective than LRN. Furthermore, our study demonstrates that there is no age at which PN is not preferred to LRN. Our study provides additional evidence to advocate PN for the management of all amenable SRMs. PMID:23671525

A rare case of acute presentation of trocar site hernia from robot-assisted laparoscopic partial nephrectomy.

PubMed

Ng, Zi Qin; Pemberton, Richard; Tan, Patrick

2018-02-15

Trocar site hernia is not a common acute complication encountered after robot-assisted surgery, especially in the urological cohort of patients. A few case reports of small bowel obstruction secondary to incarceration by trocar site hernia have been described in gynaecological surgery and prostatectomies. As the clinical presentation is non-specific, late diagnosis has significant implication on morbidity and mortality. Here, we present a rare case of a patient with recent robot-assisted laparoscopic partial nephrectomy for a renal cell carcinoma presented with features of impending bowel obstruction secondary to incarcerated small bowel in the trocar site. We also reviewed the literature focusing on clinical features of trocar site hernia and preventive measures.

Protective response in renal transplantation: no clinical or molecular differences between open and laparoscopic donor nephrectomy

PubMed Central

Machado, Christiano; Malheiros, Denise Maria Avancini Costa; Adamy, Ari; Santos, Luiz Sergio; da Silva Filho, Agenor Ferreira; Nahas, William Carlos; Lemos, Francine Brambate Carvalhinho

2013-01-01

OBJECTIVE: Prolonged warm ischemia time and increased intra-abdominal pressure caused by pneumoperitoneum during a laparoscopic donor nephrectomy could enhance renal ischemia reperfusion injury. For this reason, laparoscopic donor nephrectomy may be associated with a slower graft function recovery. However, an adequate protective response may balance the ischemia reperfusion damage. This study investigated whether laparoscopic donor nephrectomy modified the protective response of renal tissue during kidney transplantation. METHODS: Patients undergoing live renal transplantation were prospectively analyzed and divided into two groups based on the donor nephrectomy approach used: 1) the control group, recipients of open donor nephrectomy (n = 29), and 2) the study group, recipients of laparoscopic donor nephrectomy (n = 26). Graft biopsies were obtained at two time points: T-1 = after warm ischemia time and T+1 = 45 minutes after kidney reperfusion. The samples were analyzed by immunohistochemistry for the Bcl-2 and HO-1 proteins and by real-time polymerase chain reaction for the mRNA expression of Bcl-2, HO-1 and vascular endothelial growth factor. RESULTS: The area under the curve for creatinine and delayed graft function were similar in both the laparoscopic and open groups. There was no difference in the protective gene expression between the laparoscopic donor nephrectomy and open donor nephrectomy groups. The protein expression of HO-1 and Bcl-2 were similar between the open and laparoscopic groups. Furthermore, the gene expression of B-cell lymphoma 2 correlated with the warm ischemia time in the open group (p = 0.047) and that of vascular endothelial growth factor with the area under the curve for creatinine in the laparoscopic group (p = 0.01). CONCLUSION: The postoperative renal function and protective factor expression were similar between laparoscopic donor nephrectomy and open donor nephrectomy. These findings ensure laparoscopic donor nephrectomy utilization in renal transplantation. PMID:23778338

Feasibility of quantitative diffuse reflectance spectroscopy for targeted measurement of renal ischemia during laparoscopic partial nephrectomy.

PubMed

Goel, Utsav O; Maddox, Michael M; Elfer, Katherine N; Dorsey, Philip J; Wang, Mei; McCaslin, Ian Ross; Brown, J Quincy; Lee, Benjamin R

2014-01-01

Reduction of warm ischemia time during partial nephrectomy (PN) is critical to minimizing ischemic damage and improving postoperative kidney function, while maintaining tumor resection efficacy. Recently, methods for localizing the effects of warm ischemia to the region of the tumor via selective clamping of higher-order segmental artery branches have been shown to have superior outcomes compared with clamping the main renal artery. However, artery identification can prolong operative time and increase the blood loss and reduce the positive effects of selective ischemia. Quantitative diffuse reflectance spectroscopy (DRS) can provide a convenient, real-time means to aid in artery identification during laparoscopic PN. The feasibility of quantitative DRS for real-time longitudinal measurement of tissue perfusion and vascular oxygenation in laparoscopic nephrectomy was investigated in vivo in six Yorkshire swine kidneys (n=three animals ). DRS allowed for rapid identification of ischemic areas after selective vessel occlusion. In addition, the rates of ischemia induction and recovery were compared for main renal artery versus tertiary segmental artery occlusion, and it was found that the tertiary segmental artery occlusion trends toward faster recovery after ischemia, which suggests a potential benefit of selective ischemia. Quantitative DRS could provide a convenient and fast tool for artery identification and evaluation of the depth, spatial extent, and duration of selective tissue ischemia in laparoscopic PN.

Feasibility of quantitative diffuse reflectance spectroscopy for targeted measurement of renal ischemia during laparoscopic partial nephrectomy

NASA Astrophysics Data System (ADS)

Goel, Utsav O.; Maddox, Michael M.; Elfer, Katherine N.; Dorsey, Philip J.; Wang, Mei; McCaslin, Ian Ross; Brown, J. Quincy; Lee, Benjamin R.

2014-10-01

Reduction of warm ischemia time during partial nephrectomy (PN) is critical to minimizing ischemic damage and improving postoperative kidney function, while maintaining tumor resection efficacy. Recently, methods for localizing the effects of warm ischemia to the region of the tumor via selective clamping of higher-order segmental artery branches have been shown to have superior outcomes compared with clamping the main renal artery. However, artery identification can prolong operative time and increase the blood loss and reduce the positive effects of selective ischemia. Quantitative diffuse reflectance spectroscopy (DRS) can provide a convenient, real-time means to aid in artery identification during laparoscopic PN. The feasibility of quantitative DRS for real-time longitudinal measurement of tissue perfusion and vascular oxygenation in laparoscopic nephrectomy was investigated in vivo in six Yorkshire swine kidneys (n=three animals). DRS allowed for rapid identification of ischemic areas after selective vessel occlusion. In addition, the rates of ischemia induction and recovery were compared for main renal artery versus tertiary segmental artery occlusion, and it was found that the tertiary segmental artery occlusion trends toward faster recovery after ischemia, which suggests a potential benefit of selective ischemia. Quantitative DRS could provide a convenient and fast tool for artery identification and evaluation of the depth, spatial extent, and duration of selective tissue ischemia in laparoscopic PN.

Peritumoral Artery Scoring System: a Novel Scoring System to Predict Renal Function Outcome after Laparoscopic Partial Nephrectomy.

PubMed

Zhang, Ruiyun; Wu, Guangyu; Huang, Jiwei; Shi, Oumin; Kong, Wen; Chen, Yonghui; Xu, Jianrong; Xue, Wei; Zhang, Jin; Huang, Yiran

2017-06-06

The present study aimed to assess the impact of peritumoral artery characteristics on renal function outcome prediction using a novel Peritumoral Artery Scoring System based on computed tomography arteriography. Peritumoral artery characteristics and renal function were evaluated in 220 patients who underwent laparoscopic partial nephrectomy and then validate in 51 patients with split and total glomerular filtration rate (GFR). In particular, peritumoral artery classification and diameter were measured to assign arteries into low, moderate, and high Peritumoral Artery Scoring System risk categories. Univariable and multivariable logistic regression analyses were then used to determine risk factors for major renal functional decline. The Peritumoral Artery Scoring System and four other nephrometry systems were compared using receiver operating characteristic curve analysis. The Peritumoral Artery Scoring System was significantly superior to the other systems for predicting postoperative renal function decline (p < 0.001). In receiver operating characteristic analysis, our category system was a superior independent predictor of estimated glomerular filtration rate (eGFR) decline (area-under-the-curve = 0.865, p < 0.001) and total GFR decline (area-under-the-curve = 0.796, p < 0.001), and split GFR decline (area-under-the-curve = 0.841, p < 0.001). Peritumoral artery characteristics were independent predictors of renal function outcome after laparoscopic partial nephrectomy.

Reducing Operating Room Costs Through Real-Time Cost Information Feedback: A Pilot Study.

PubMed

Tabib, Christian H; Bahler, Clinton D; Hardacker, Thomas J; Ball, Kevin M; Sundaram, Chandru P

2015-08-01

To create a protocol for providing real-time operating room (OR) cost feedback to surgeons. We hypothesize that this protocol will reduce costs in a responsible way without sacrificing quality of care. All OR costs were obtained and recorded for robot-assisted partial nephrectomy and laparoscopic donor nephrectomy. Before the beginning of this project, costs pertaining to the 20 most recent cases were analyzed. Items were identified from previous cases as modifiable for replacement or omission. Timely feedback of total OR costs and cost of each item used was provided to the surgeon after each case, and costs were analyzed. A cost analysis of the robot-assisted partial nephrectomy before the washout period indicates expenditures of $5243.04 per case. Ten recommended modifiable items were found to have an average per case cost of $1229.33 representing 23.4% of the total cost. A postwashout period cost analysis found the total OR cost decreased by $899.67 (17.2%) because of changes directly related to the modifiable items. Therefore, 73.2% of the possible identified savings was realized. The same stepwise approach was applied to laparoscopic donor nephrectomies. The average total cost per case before the washout period was $3530.05 with $457.54 attributed to modifiable items. After the washout period, modifiable items costs were reduced by $289.73 (8.0%). No complications occurred in the donor nephrectomy cases while one postoperative complication occurred in the partial nephrectomy group. Providing surgeons with feedback related to OR costs may lead to a change in surgeon behavior and decreased overall costs. Further studies are needed to show equivalence in patient outcomes.

Gross intermittent hematuria after laparoscopic donor nephrectomy

PubMed Central

Gaurav, G; Santosh, K; Samiran, A; Ganesh, G

2008-01-01

Laparoscopic donor nephrectomy is a routine practice but still requires an intense level of attention to prevent complications. We report a rare case of gross hematuria in postoperative period after an uneventful laparoscopic donor nephrectomy. PMID:19547672

Diode laser supported partial nephrectomy in laparoscopic surgery: preliminary results

NASA Astrophysics Data System (ADS)

Sroka, Ronald; Hennig, Georg; Zillinberg, Katja; Khoder, Wael Y.

2011-07-01

Introduction: Warm ischemia and bleeding during laparoscopic partial nephrectomy place technical constraints on surgeons. Therefore it was the aim to develop a safe and effective laser assisted partial nephrectomy technique without need for ischemia. Patients and methods: A diode laser emitting light at 1318nm in cw mode was coupled into a bare fibre (core diameter 600 μm) thus able to transfer up to 100W to the tissue. After dry lab experience, a total of 8 patients suffering from kidney malformations underwent laparoscopic/retroperitoneoscopic partial nephrectomy. Clinically, postoperative renal function and serum c-reactive protein (CRP) were monitored. Laser induced coagulation depth and effects on resection margins were evaluated. Demographic, clinical and follow-up data are presented. Results: Overall interventions, the mean operative time was 116,5 minutes (range 60-175min) with mean blood loss of 238ml (range 50-600ml) while laser assisted resection of the kidney tissue took max 15min. After extirpation of the tumours all patients showed clinical favourable outcome during follow up period. The tumour size was measured to be 1.8 to 5cm. With respect to clinical safety and due to blood loos, two warm ischemia (19 and 24min) must be performed. Immediate postoperative serum creatinine and CRP were elevated within 0.1 to 0.6 mg/dl (mean 0.18 mg/dl) and 2.1-10 mg/dl (mean 6.24 mg/dl), respectively. The depth of the coagulation on the removed tissue ranged between <1 to 2mm without effect on histopathological evaluation of tumours or resection margin. As the surface of the remaining kidney surface was laser assisted coagulated after removal. The sealing of the surface was induced by a slightly larger coagulation margin, but could not measured so far. Conclusion: This prospective in-vivo feasibility study shows that 1318nm-diode laser assisted partial nephrectomy seems to be a safe and promising medical technique which could be provided either during open surgery as well as laparascopically. This application showed good haemostasis and minimal parenchymal damage. Oncological safety appears to be warranted by the use of diode laser. Further investigations and development are needed for on-line detection of the remain coagulation margin, optimisation of the treatment equipment, and finally to train the application technique.

Toward a Flexible Variable Stiffness Endoport for Single-Site Partial Nephrectomy.

PubMed

Amanov, E; Nguyen, T-D; Markmann, S; Imkamp, F; Burgner-Kahrs, J

2018-05-31

Laparoscopic partial nephrectomy for localized renal tumors is an upcoming standard minimally invasive surgical procedure. However, a single-site laparoscopic approach would be even more preferable in terms of invasiveness. While the manual approach offers rigid curved tools, robotic single-site systems provide high degrees of freedom manipulators. However, they either provide only a straight deployment port, lack of instrument integration, or cannot be reconfigured. Therefore, the current main shortcomings of single-site surgery approaches include limited tool dexterity, visualization, and intuitive use by the surgeons. For partial nephrectomy in particular, the accessibility of the tumors remains limited and requires invasive kidney mobilization (separation of the kidney from the surrounding tissue), resulting in patient stress and prolonged surgery. We address these limitations by introducing a flexible, robotic, variable stiffness port with several working channels, which consists of a two-segment tendon-driven continuum robot with integrated granular and layer jamming for stabilizing the pose and shape. We investigate biocompatible granules for granular jamming and demonstrate the stiffening capabilities in terms of pose and shape accuracy with experimental evaluations. Additionally, we conduct in vitro experiments on a phantom and prove that the visualization of tumors at various sites is increased up to 38% in comparison to straight endoscopes.

[Is laparoscopic surgery the technique of choice in nephrectomy?].

PubMed

Ribó, J M; García-Aparicio, L; Julià, V; Tarrado, X; Rovira, J; Morales, L

2003-01-01

Laparoscopic is performed in adults for the treatment of benign renal diseases. It is widely accepted that laparoscopic surgery has more advantages than open surgery in many procedures such as nephrectomy, but there is no further experience in this technique. In pediatric urology laparoscopy has become an accepted approach for varicocele, non palpable testis, bladder augmentation, adrenalectomy and urinary diversion. We report our experience with 25 laparoscopic nephrectomies in children.

Laparosopic hand-assisted living donor nephrectomy: the Niguarda experience.

PubMed

Maione, G; Sansalone, C V; Aseni, P; De Roberto, A; Soldano, S; Mangoni, I; Perrino, L; Minetti, E; Civati, G

2005-01-01

Perioperative donor morbidity, a barrier to living organ donation, may be mitigated by the laparoscopic approach. From September 2002 to September 2004, 15 living donors, of ages ranging from 36 to 59 years, underwent laparoscopic nephrectomy. We used a hand-assisted device to increase the safety of the procedure. The average operating time was 200 minutes. The average blood loss was about 100 mL. The patients resumed oral intake and started walking within 1 day. The average postoperative hospital stay was 6 days. Although laparoscopic operating times were longer than those for traditional surgery, we showed benefits to the laparoscopic donor to be less postoperative pain, better cosmesis, shorter recovery time, and faster return to normal activities. We therefore consider laparoscopic nephrectomy a good alternative to traditional surgery for selected patients. Despite a lack of strong evidence, such as large prospective randomized studies, laparoscopic donor nephrectomy is likely to become the gold standard for donor nephrectomy in the near future.

The financial impact of robotic technology for partial and radical nephrectomy.

PubMed

Kates, Max; Ball, Mark W; Patel, Hiten D; Gorin, Michael A; Pierorazio, Phillip M; Allaf, Mohamad E

2015-03-01

We sought to evaluate the financial impact of robotic technology for partial nephrectomy (PN) and radical nephrectomy (RN) in the state of Maryland. The Maryland Health Services Cost Review Commission (HSCRC) documents all acute care hospital charges data. This database was queried for patients who underwent laparoscopic or robot-assisted RN and PN from 2008 to 2012. Total hospital charge, subcharge, and length of stay (LOS) were analyzed separately for RN and PN. Overall, 2834 patients were identified. Of those, 282 were laparoscopic PN (LPN), 1078 robot-assisted PN (RPN), 1098 laparoscopic RN (LRN), and 376 robot-assisted RN (RRN). For PN, the total hospital charge was $19,062 for LPN and $18,255 for RPN (P=0.138), with a charge savings of $807 per case in favor of robotics. For RN, the total hospital charge was $23,391 for RRN and $18,280 for LRN (P=0.004), with a charge premium of $5111 for robotic cases. LOS was shorter for RPN compared with LPN (2.51 vs 2.99 days, P<0.0001) and for RRN compared with LRN (3.52 vs 3.98, P=0.0498). RPN is associated with lower hospital charges than LPN, while RRN is associated with higher hospital charges than LRN. Savings for RPN are driven by decreased room and board charge, while the premium for RRN is driven by higher operating room and supply charges. Because RRN use is increasing, the financial implications of RRN use for routine cases warrants further study.

Comparative Outcomes of Hand-assisted Laparoscopic Donor Nephrectomy Using Midline Incision or Low Transverse Incision for Hand-assisted Port Placement.

PubMed

Gwon, Jun Gyo; Jun, Heungman; Kim, Myung Gyu; Boo, Yoon Jung; Jung, Cheol Woong

2016-06-01

Hand-assisted laparoscopic donor nephrectomy is performed in many centers for donor nephrectomy. A midline incision for hand-assisted port placement is generally used but produces an unsightly scar. In this study, patients who had hand-assisted laparoscopic donor nephrectomy with low transverse incision were compared with those who received a midline incision. Our study group included patients who received hand-assisted laparoscopic donor nephrectomy from February 2012 to December 2014 at Korea University Anam Hospital. We retrospectively compared outcomes of these patients based on midline incision (45 patients) versus low transverse incision (17 patients). Risk factors, including age, sex, body mass index, creatinine level, glomerular filtration rate of allograft, side of graft kidney, number of renal arteries, duration of surgical procedure, and warm ischemic time, were compared between the midline and low transverse incision groups. When we compared the midline versus low transverse incision groups, duration of surgical procedure (P = .043), postoperative day 3 glomerular filtration rate (P = .017), and postoperative day 3 pain score (P = .049) were significantly higher in the low transverse incision group versus the midline incision group. Postoperative day 3 results for duration of hospitalization (P = .030) and pain score (P = .021) were also significantly higher in the low transverse versus midline incision groups when we focused on patients with left nephrectomy. Hand-assisted laparoscopic donor nephrectomy with low transverse incision is more painful and necessitates a longer hospital stay and longer surgical procedure. Despite these disadvantages, hand-assisted laparoscopic donor nephrectomy with low transverse incision can offer a better cosmetic outcome with no definitive differences regarding renal function compared with a midline incision. Surgeons should consider these aspects when deciding on the best method for donor nephrectomy.

Preoperative planning and real-time assisted navigation by three-dimensional individual digital model in partial nephrectomy with three-dimensional laparoscopic system.

PubMed

Wang, Dongwen; Zhang, Bin; Yuan, Xiaobin; Zhang, Xuhui; Liu, Chen

2015-09-01

To evaluate the feasibility and effectiveness of preoperative planning and real-time assisted surgical navigation for three-dimensional laparoscopic partial nephrectomy under the guidance of three-dimensional individual digital model (3D-IDM) created using three-dimensional medical image reconstructing and guiding system (3D-MIRGS). Between May 2012 and February 2014, 44 patients with cT1 renal tumors underwent retroperitoneal laparoscopic partial nephrectomy (LPN) using a three-dimensional laparoscopic system. The 3D-IDMs were created using the 3D-MIRGS in 21 patients (3D-MIRGS group) between February 2013 and February 2014. After preoperative planning, operations were real-time assisted using composite 3D-IDMs, which were fused with two-dimensional retrolaparoscopic images. The remaining 23 patients underwent surgery without 3D-MIRGS between May 2012 and February 2013; 14 of these patients were selected as a control group. Preoperative aspects and dimensions used for an anatomical score, "radius; exophytic/endophytic; nearness; anterior/posterior; location" nephrometry score, tumor size, operative time (OT), segmental renal artery clamping (SRAC) time, estimated blood loss (EBL), postoperative hospitalization, the preoperative serum creatinine level and ipsilateral glomerular filtration rate (GFR), as well as postoperative 6-month data were compared between groups. All the SRAC procedures were technically successful, and each targeted tumor was excised completely; final pathological margin results were negative. The OT was shorter (159.0 vs. 193.2 min; p < 0.001), and EBL (148.1 vs. 176.1 mL; p < 0.001) was reduced in the 3D-MIRGS group compared with controls. No statistically significant differences in SRAC time or postoperative hospitalization were found between the groups. Neither group showed any statistically significant increases in serum creatinine level or decreases in ipsilateral GFR postoperatively. Preoperative planning and real-time assisted surgical navigation using the 3D-IDM reconstructed from 3D-MIRGS and combined with the 3D laparoscopic system can facilitate LPN and result in precise SRAC and accurate excision of tumor that is both effective and safe.

Does robotic assistance confer an economic benefit during laparoscopic radical nephrectomy?

PubMed

Yang, David Y; Monn, M Francesca; Bahler, Clinton D; Sundaram, Chandru P

2014-09-01

While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit. From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique and those with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges. We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001). Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Robotic partial nephrectomy for complex renal tumors: surgical technique.

PubMed

Rogers, Craig G; Singh, Amar; Blatt, Adam M; Linehan, W Marston; Pinto, Peter A

2008-03-01

Laparoscopic partial nephrectomy requires advanced training to accomplish tumor resection and renal reconstruction while minimizing warm ischemia times. Complex renal tumors add an additional challenge to a minimally invasive approach to nephron-sparing surgery. We describe our technique, illustrated with video, of robotic partial nephrectomy for complex renal tumors, including hilar, endophytic, and multiple tumors. Robotic assistance was used to resect 14 tumors in eight patients (mean age: 50.3 yr; range: 30-68 yr). Three patients had hereditary kidney cancer. All patients had complex tumor features, including hilar tumors (n=5), endophytic tumors (n=4), and/or multiple tumors (n=3). Robotic partial nephrectomy procedures were performed successfully without complications. Hilar clamping was used with a mean warm ischemia time of 31 min (range: 24-45 min). Mean blood loss was 230 ml (range: 100-450 ml). Histopathology confirmed clear-cell renal cell carcinoma (n=3), hybrid oncocytic tumor (n=2), chromophobe renal cell carcinoma (n=2), and oncocytoma (n=1). All patients had negative surgical margins. Mean index tumor size was 3.6 cm (range: 2.6-6.4 cm). Mean hospital stay was 2.6 d. At 3-mo follow-up, no patients experienced a statistically significant change in serum creatinine or estimated glomerular filtration rate and there was no evidence of tumor recurrence. Robotic partial nephrectomy is safe and feasible for select patients with complex renal tumors, including hilar, endophytic, and multiple tumors. Robotic assistance may facilitate a minimally invasive, nephron-sparing approach for select patients with complex renal tumors who might otherwise require open surgery or total nephrectomy.

[Opened vs. laparoscopic radical nephrectomy in renal adenocarcinoma cost comparison].

PubMed

Herranz Amo, F; Subirá Ríos, D; Hernández Fernández, C; Martínez Salamanca, J I; Monzó, J I; Cabello Benavente, R

2006-10-01

To undertake a cost comparison (cost minimization) between transperitoneal laparoscopic and opened nephrectomy in renal adenocarcinoma treatment. Retrospective study on the first 26 patients submitted to LN without intra or postoperative complications in the period 2002-2003, using as control 22 patients treated with ON with the same characteristics and in the same period. Demographic variables were evaluated (age, sex, tumor size, etc.), intraoperative (operative time and fungible material used) and postoperative (length of stay in Postanaesthesic Care Unit, Acute Pain Unit needs and hospital stay). Our Hospital costs plus those imputed during year 2003 to the Urology Service, as well as the cost of fungible material for the same year were applied, carrying out a comparison of costs between both groups. There were no differences between the demographic variables between both groups except in the tumor, bigger size in the opened nephrectomy (p=0,001). Transperitoneal laparoscopic was 29,4% globally more expensive than opened nephrectomy. The transperitoneal laparoscopic intraoperative cost (operating room, anesthesia and fungibles) the exceeded in 151,6% to that of the opened nephrectomy, whereas in the opened nephrectomy the postoperative cost was a 63 % higher than in the transperitoneal laparoscopic cases. Transperitoneal laparoscopic in our Center is more expensive than opened nephrectomy due to a major occupation of operating room and that the specific fungible material used at the surgical act has a very high cost. It would be necessary to drastically reduce surgical time and decrease fungible material expenses, thus transperitoneal laparoscopic procedure could be competitive in our Hospital.

Correlation between CO2 storage at the last minute of gas insufflation and area of retroperitoneal lacuna during retroperitoneal laparoscopic radical nephrectomy.

PubMed

Hu, Jian-Jun; Liu, Ya-Hua; Yu, Chan-Juan; Jialielihan, Nuerbolati

2016-07-22

Adequate operation interspace is the premise of laparoscopy, and carbon dioxide (CO2) was an ideal gas for forming lacuna. A retroperitoneal space is used to form operation interspace in retroperitoneal laparoscopic radical nephrectomy by making ballooning, and the retroperitoneal space has no relative complete and airtight serous membrane, therefore CO2 absorption may be greater in retroperitoneal than transperitoneal laparoscopic radical nephrectomy. Excess CO2 absorption may induce hypercapnemia and further cause physiopathological change of respiratory and circulatory system. Therefore, exact evaluation of amount of CO2 which is eliminated from body via minute ventilation is important during retroperitoneal laparoscopic radical nephrectomy. The aim of the paper is to study the correlation between CO2 storage at the last minute of gas insufflation and area of retroperitoneal lacuna during retroperitoneal laparoscopic radical nephrectomy. Forty ASA I/II patients undergoing retroperitoneal laparoscopic radical nephrectomy were enrolled. CO2 storage at the last minute of gas insufflation and area of a retroperitoneal lacuna were observed. Linear correlation and regression were performed to determine the correlation between them. There was positive correlation between CO2 storage at the last minute of gas insufflation and area of retroperitoneal lacuna (r = 0.880, P = 0.000), and the equation of linear regression was y = -83.097 + 0.925x (R(2) = 0.780, t = 11.610, P = 0.000). Amount of CO2 which is eliminated from body via mechanical ventilation could be calculated by measuring the area of retroperitoneal lacuna during retroperitoneal laparoscopic radical nephrectomy, and an anesthetist should be aware of the size of lacuna to predict high CO2 storage at the last minute of gas insufflation.

Robotics applied in laparoscopic kidney surgery: the Yonsei University experience of 127 cases.

PubMed

Lorenzo, Enrique Ian S; Jeong, Wooju; Oh, Cheol Kyu; Chung, Byung Ha; Choi, Young Deuk; Rha, Koon Ho

2011-01-01

We report our experience on 127 kidney surgeries with the da Vinci surgical system and show the feasibility of a robotics application in a variety of kidney surgeries by both a laparoscopically-trained and a laparoscopically-naïve surgeon. Clinical data of patients who underwent kidney surgery with the da Vinci surgical system from September 2006 to April 2009 were reviewed. Data acquired from medical records included patient demographics, operative time, estimated blood loss (EBL), incidence of intraoperative complication, duration of hospital stay, blood transfusion rate, oncological outcomes, and follow-up results. One-hundred twenty-seven kidney surgeries have been conducted with the da Vinci surgical system at our institution. Three urologists--1 with formal endourology training, 1 with laparoscopic experience, and 1 laparoscopically naïve--have used it for a variety of procedures involving the kidney. The cases include 65 partial nephrectomies (RPN), 38 radical nephrectomies (RRN), and 24 nephroureterectomies with bladder cuff (RNU). Results on operative time, EBL, incidence of intraoperative injury, duration of hospital stay, and blood transfusion rate are comparable with contemporary studies. Robotics application in kidney surgery is a viable option for various procedures. Our experience shows it can be safely and effectively conducted by both laparoscopically-trained and laparoscopically-naïve surgeons once they are accustomed to the robotics system. Copyright © 2011 Elsevier Inc. All rights reserved.

American Confederation of Urology (CAU) experience in minimally invasive partial nephrectomy.

PubMed

Secin, Fernando P; Castillo, Octavio A; Rozanec, José J; Featherston, Marcelo; Holst, Pablo; Milfont, José Cocisfran Alves; García Marchiñena, Patricio; Jurado Navarro, Alberto; Autrán, Anamaría; Rovegno, Agustín R; Faba, Oscar Rodríguez; Palou, Joan; Teixeira Dubeux, Victor; Nuñez Bragayrac, Luciano; Sotelo, Rene; Zequi, Stenio; Guimarães, Gustavo Cardoso; Álvarez-Maestro, Mario; Martínez-Piñeiro, Luis; Villoldo, Gustavo; Villaronga, Alberto; Abreu Clavijo, Diego; Decia, Ricardo; Frota, Rodrigo; Vidal-Mora, Ivar; Finkelstein, Diana; Monzó Gardiner, Juan I; Schatloff, Oscar; Hernández-Porrás, Andres; Santaella-Torres, Félix; Quesada, Emilio T; Sánchez-Salas, Rodolfo; Dávila, Hugo; Mavric, Humberto Villavicencio

2017-01-01

To describe the perioperative and oncology outcomes in a series of laparoscopic or robotic partial nephrectomies (PN) for renal tumors treated in diverse institutions of Hispanic America from the beginning of their minimally invasive (MI) PN experience through December 2014. Seventeen institutions participated in the CAU generated a MI PN database. We estimated proportions, medians, 95 % confidence intervals, Kaplan-Meier curves, multivariate logistic and Cox regression analyses. Clavien-Dindo classification was used. We evaluated 1501 laparoscopic (98 %) or robotic (2 %) PNs. Median age: 58 years. Median surgical time, warm ischemia and intraoperative bleeding were 150, 20 min and 200 cc. 81 % of the lesions were malignant, with clear cell histology being 65 % of the total. Median maximum tumor diameter is 2.7 cm, positive margin is 8.2 %, and median hospitalization is 3 days. One or more postoperative complication was recorded in 19.8 % of the patients: Clavien 1: 5.6 %; Clavien 2: 8.4 %; Clavien 3A: 1.5 %; Clavien 3B: 3.2 %; Clavien 4A: 1 %; Clavien 4B: 0.1 %; Clavien 5: 0 %. Bleeding was the main cause of a reoperation (5.5 %), conversion to radical nephrectomy (3 %) or open partial nephrectomy (6 %). Transfusion rate is 10 %. In multivariate analysis, RENAL nephrometry score was the only variable associated with complications (OR 1.1; 95 % CI 1.02-1.2; p = 0.02). Nineteen patients presented disease progression or died of disease in a median follow-up of 1.37 years. The 5-year progression or kidney cancer mortality-free rate was 94 % (95 % CI 90, 97). Positive margins (HR 4.98; 95 % CI 1.3-19; p = 0.02) and females (HR 5.6; 95 % CI 1.7-19; p = 0.005) were associated with disease progression or kidney cancer mortality after adjusting for maximum tumor diameter. Laparoscopic PN in these centers of Hispanic America seem to have acceptable perioperative complications and short-term oncologic outcomes.

Retroperitoneal Laparoscopic Partial Nephrectomy Versus Radical Nephrectomy for Clinical T1 Renal Hilar Tumor: Comparison of Perioperative Characteristics and Short-Term Functional and Oncologic Outcomes.

PubMed

Yang, Chuance; Wang, Zhenlong; Huang, Shanlong; Xue, Li; Fu, Delai; Chong, Tie

2018-04-18

To present our single-center experience with retroperitoneal laparoscopic partial nephrectomy (LPN) and retroperitoneal laparoscopic radical nephrectomy (LRN) for T1 renal hilar tumors and evaluate which one is better. A retrospective review of 63 patients with hilar tumors undergoing retroperitoneal LPN or LRN was performed. The perioperative characteristics, change in estimated glomerular filtration rate (eGFR) from baseline to month 3, and oncologic outcomes were summarized. In total, 25 patients underwent LPN, and 38 patients underwent LRN. The mean tumor size in the LPN and LRN groups was 4.5 and 4.9 cm, respectively. The mean operation time was longer in the LPN group than that in the LRN group (212.5 minutes versus 160.7 minutes, respectively; P < .05). Patients undergoing the LPN had a longer median length of hospital stay after surgery (9 days versus 7 days, P < .05). Four percent of patients in the LPN group experienced postoperative complications compared with 5% of patients in the LRN group, which was not significantly different. Compared with preoperative eGFR, postoperative eGFR at 3 months decreased by 15.2 mL/min/1.73 m 2 and 27.8 mL/min/1.73 m 2 in the LPN and the LRN groups, respectively (P < .05). There was one local recurrence in the LPN group and three local or distant recurrences in the LRN group (P > .05). In experienced hands, although retroperitoneal LRN can result in shorter operation times and shorter lengths of stay, retroperitoneal LPN can preserve renal function better than LRN. Retroperitoneal LPN should be the priority in selected patients with T1 renal hilar tumors, especially for patients with renal insufficiency.

Flank muscle volume changes after open and laparoscopic partial nephrectomy.

PubMed

Crouzet, Sebastien; Chopra, Sameer; Tsai, Sheaumei; Kamoi, Kazumi; Haber, Georges-Pascal; Remer, Erick M; Berger, Andre K; Gill, Inderbir S; Aron, Monish

2014-10-01

To determine the occurrence of flank symptoms, flank muscle atrophy, bulge, and hernia formation after open and laparoscopic partial nephrectomy (LPN). Our prospective Institutional Review Board-approved database was queried to identify 50 consecutive patients who were treated with open partial nephrectomy (OPN) and 50 consecutive patients who were treated with LPN between September 2006 and May 2008. Study patients had: Solitary clinical T1 renal tumor, preoperative and ≥6 month postoperative CT scan performed at our institution, and a confirmed renal-cell carcinoma on the final pathology report. Patients with previous abdominal surgery and neuromuscular disorders were excluded. Oncocare software was used to measure abdominal wall musculature on preoperative and postoperative CT scan. Bilateral flanks were compared for muscle volume, bulge, and hernia. Patients were administered a phone questionnaire to assess postoperative flank symptoms. No statistical significant difference was found in the demographics between the two groups. Median age (range) was 59.9 years (20.6-80.7) in the OPN group and 57.5 years (25-78) in the LPN group (P=0.89). Median (range) body mass index and American Society of Anesthesiologists scores were similar between the two groups. On CT scans, median percent variation (range) in abdominal wall muscle volume was significantly greater in the OPN group: -1.03% (-31.4-1.5) vs-0.39% (-5.2-1.8) (P=0.006). The median extent of flank bulge on CT scans (range) was also greater in the OPN group: 0.75 cm (-1.9-7.6) vs 0 cm (-2.7-2.8) (P=0.0004). The OPN group was also more symptomatic, including paresthesia 48% vs 8% (P=0.0053); numbness 44% vs 0% (P=0.002); and flank bulge 57% vs 12% (P=0.007). Minimally invasive partial nephrectomy has lesser deleterious impact on flank muscle volume compared with OPN with fewer symptoms of flank bulge, paresthesia, and numbness.

A Comparison of Robotic, Laparoscopic and Open Partial Nephrectomy

PubMed Central

Lucas, Steven M.; Mellon, Matthew J.; Erntsberger, Luke

2012-01-01

Introduction: Comparison of treatments for partial nephrectomy is limited by case selection. We compared robotic (RPN), laparoscopic (LPN), and open partial nephrectomy (OPN), controlling for tumor size, patient age, sex, and nephrometry score. Methods: RPN, LPN, and OPN procedures between March 2003 and March 2010 were reviewed. All RPN and LPN were included, and 2 OPN were matched for each RPN in tumor size (±0.5cm), patient age (±10 y), sex, and nephrometry score. Perioperative outcomes were compared. Results: Ninety-six partial nephrectomy procedures were reviewed: 27 RPN, 15 LPN, and 54 OPN. RPN, LPN, and OPN had similar median tumor size (2.4, 2.2, and 2.3cm, respectively), nephrometry score (6.0 each), and preoperative glomerular filtration rate (71.5, 84.6, and 77.0 mL/min/1.73m2, respectively). Blood loss was higher for OPN (250 mL) than for RPN or LPN (100 mL), P < .001. Operative time was shorter in OPN (147 min) than in RPN (190 min) or LPN (195 min), P < .001. Median warm ischemia time was shorter for OPN (12.0 min) than for RPN (25.0 min) or LPN (29.5 min), P < .05. Cold ischemia time for OPN was 25.0 min. A 10% glomerular filtration rate decline occurred in 10 RPN, 5 LPN, and 29 OPN cases (P = .252). Median hospital stay for LPN and RPN was 2.0 d versus 3.0 d for OPN (P < .001). Urine leak occurred in 1 RPN and 3 OPN cases. Postoperative complications occurred in 4 RPN (3 were Clavien grade 2 or less), 1 LPN (grade 1), and 7 OPN (6 were grade 2 or less) cases. Conclusion: Renal function preservation and complications are similar for each treatment modality. OPN offers faster operative and ischemia times at the expense of greater blood loss and hospital stay. PMID:23484568

Iatrogenic diaphragmatic lesion: laparoscopic repair.

PubMed

Celia, A; Del Biondo, D; Zaccolini, G; Breda, G

2010-09-01

The increasing use of laparoscopy as first line surgical choice turned the iatrogenic diaphragmatic injury during transperitoneal nephrectomy from an unfrequent complication into a potential risk. We report the laparoscopic management of a iatrogenic diaphragmatic injury during a laparoscopic transperitoneal nephrectomy in a 66-year-old woman with a xantogranulomatous pyelonephritis due to an infected Staghorn stone.

Effectiveness of deep versus moderate muscle relaxation during laparoscopic donor nephrectomy in enhancing postoperative recovery: study protocol for a randomized controlled study.

PubMed

Bruintjes, Moira H D; Braat, Andries E; Dahan, Albert; Scheffer, Gert-Jan; Hilbrands, Luuk B; d'Ancona, Frank C H; Donders, Rogier A R T; van Laarhoven, Cornelis J H M; Warlé, Michiel C

2017-03-04

Postoperative recovery after live donor nephrectomy is largely determined by the consequences of postoperative pain and analgesia consumptions. The use of deep neuromuscular blockade has been shown to reduce postoperative pain scores after laparoscopic surgery. In this study, we will investigate whether deep neuromuscular blockade also improves the early quality of recovery after live donor nephrectomy. The RELAX-study is a phase IV, multicenter, double-blinded, randomized controlled trial, in which 96 patients, scheduled for living donor nephrectomy, will be randomized into two groups: one with deep and one with moderate neuromuscular blockade. Deep neuromuscular blockade is defined as a post-tetanic count of 1-2. Our primary outcome measurement will be the Quality of Recovery-40 questionnaire (overall score) at 24 h after extubation. This study is, to our knowledge, the first randomized study to assess the effectiveness of deep neuromuscular blockade during laparoscopic donor nephrectomy in enhancing postoperative recovery. The study findings may also be applicable for other laparoscopic procedures. clinicaltrials.gov, NCT02838134 . Registered on 29 June 2016.

Surgical planning and manual image fusion based on 3D model facilitate laparoscopic partial nephrectomy for intrarenal tumors.

PubMed

Chen, Yuanbo; Li, Hulin; Wu, Dingtao; Bi, Keming; Liu, Chunxiao

2014-12-01

Construction of three-dimensional (3D) model of renal tumor facilitated surgical planning and imaging guidance of manual image fusion in laparoscopic partial nephrectomy (LPN) for intrarenal tumors. Fifteen patients with intrarenal tumors underwent LPN between January and December 2012. Computed tomography-based reconstruction of the 3D models of renal tumors was performed using Mimics 12.1 software. Surgical planning was performed through morphometry and multi-angle visual views of the tumor model. Two-step manual image fusion superimposed 3D model images onto 2D laparoscopic images. The image fusion was verified by intraoperative ultrasound. Imaging-guided laparoscopic hilar clamping and tumor excision was performed. Manual fusion time, patient demographics, surgical details, and postoperative treatment parameters were analyzed. The reconstructed 3D tumor models accurately represented the patient's physiological anatomical landmarks. The surgical planning markers were marked successfully. Manual image fusion was flexible and feasible with fusion time of 6 min (5-7 min). All surgeries were completed laparoscopically. The median tumor excision time was 5.4 min (3.5-10 min), whereas the median warm ischemia time was 25.5 min (16-32 min). Twelve patients (80 %) demonstrated renal cell carcinoma on final pathology, and all surgical margins were negative. No tumor recurrence was detected after a media follow-up of 1 year (3-15 months). The surgical planning and two-step manual image fusion based on 3D model of renal tumor facilitated visible-imaging-guided tumor resection with negative margin in LPN for intrarenal tumor. It is promising and moves us one step closer to imaging-guided surgery.

Factors influencing the operating time for single-port laparoscopic radical nephrectomy: focus on the anatomy and distribution of the renal artery and vein.

PubMed

Matsumoto, Kazuhiro; Miyajima, Akira; Fukumoto, Keishiro; Komatsuda, Akari; Niwa, Naoya; Hattori, Seiya; Takeda, Toshikazu; Kikuchi, Eiji; Asanuma, Hiroshi; Oya, Mototsugu

2017-10-01

It is considered that laparoscopic single-site surgery should be performed by specially trained surgeons because of the technical difficulty in using special instruments through limited access. We investigated suitable patients for single-port laparoscopic radical nephrectomy, focusing on the anatomy and distribution of the renal artery and vein. This retrospective study was conducted in 52 consecutive patients who underwent single-port radical nephrectomy by the transperitoneal approach. In patients undergoing right nephrectomy, a 2-mm port was added for liver retraction. We retrospectively re-evaluated all of the recorded surgical videos and preoperative computed tomography images. The pneumoperitoneum time (PT) was used as an objective index of surgical difficulty. The PT was significantly shorter for right nephrectomy than left nephrectomy (94 vs. 123 min, P = 0.004). With left nephrectomy, dissection of the spleno-renal ligament to mobilize the spleen medially required additional time. Also, the left renal vein could only be divided after securing the adrenal, gonadal and lumbar veins. In patients whose renal artery was located cranial to the renal vein, PT tended to be longer than in the other patients (131 vs. 108 min, P = 0.070). In patients with a superior renal artery, the inferior renal vein invariably covered the artery and made it difficult to ligate the renal artery via the umbilical approach at the first procedure. These findings indicate that patients undergoing right nephrectomy in whom the renal artery is not located cranial to the renal vein are suitable for single-port laparoscopic radical nephrectomy. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Emergent Embolization of a Very Late Detected Pseudoaneurysm at a Lower Pole Subsegmental Artery of the Kidney after Clampless Laparoscopic Partial Nephrectomy

PubMed Central

Chiancone, Francesco; Fedelini, Maurizio; Pucci, Luigi; Di Lorenzo, Domenico; Meccariello, Clemente; Fedelini, Paolo

2017-01-01

Renal artery pseudoaneurysm is a rare but life-threatening condition. Its incidence is higher after minimally invasive partial nephrectomy (PN) than after the open approach. We reported a case of a renal artery pseudoaneurysm occurred about four months after a clampless laparoscopic PN. A 49-year-old female underwent a clampless laparoscopic PN for a right renal tumor with high surgical complexity. The patient experienced an intraoperative blood loss from renal bed and the surgeons performed a deep medullary absorbable suture. Three months after surgery the patient underwent a renal ultrasonography with good results. The patient came to our emergency department 115 days after surgery with a hypovolemic shock stage 3. Her CT scan showed a pseudoaneurysm of a lower pole vessel of the right kidney. She underwent a superselective embolization of the segmental renal artery. The surgical complexity of the tumor, the anatomical relationships with the renal sinus and the deep medullary suture could be responsible for the development of the pseudoaneurysm. The authors presented an unusual case of a very late detected pseudoaneurysm of a renal vessel, suggesting that all very complex renal tumors removed with a minimally invasive technique should be followed up closely at least during the first six-months in order to early detect this major complication. PMID:28785196

Cecal Volvulus Following Laparoscopic Nephrectomy and Renal Transplantation

PubMed Central

Ravindra, Kadiyala

2009-01-01

Cecal volvulus is a rare cause of bowel obstruction that carries a high mortality. Recent surgery is known to be a risk factor for the development of cecal volvulus. We present a case of cecal volvulus following laparoscopic nephrectomy and renal transplantation. PMID:20202405

Laparoscopic radical nephrectomy for a right renal tumor with renal vein tumor thrombus in a patient with situs inversus totalis.

PubMed

Ito, Jun; Kaiho, Yasuhiro; Iwamura, Hiromichi; Anan, Go; Sato, Makoto

2018-05-23

Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete inversion of the thoracic and abdominal organs. Many intra-abdominal and vessel anomalies have been reported in association with SIT. However, there have been no reports on the use of laparoscopic radical nephrectomy with thrombectomy for renal vein thrombus, which is considered as a safe and feasible procedure, in patients with SIT. We herein present the case of an 80-year-old man with SIT who was preoperatively diagnosed with a right renal tumor and renal vein tumor thrombus. The patient underwent laparoscopic right nephrectomy and tumor thrombectomy with no intraoperative complications. To ensure a safe procedure, the anatomy and vessels were carefully evaluated preoperatively using 3-D multiplanar reconstructed CT imaging. Assessing anatomical structures leads to safer laparoscopic radical nephrectomy for renal cell carcinoma with venous tumor thrombus in patients with SIT. © 2018 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.

Intraoperative evaluation of renal blood flow during laparoscopic partial nephrectomy with a novel Doppler system.

PubMed

Mues, Adam C; Okhunov, Zhamshid; Badani, Ketan; Gupta, Mantu; Landman, Jaime

2010-12-01

Hemostasis remains a major challenge associated with laparoscopic renal surgery. We evaluated a cost-effective novel Doppler probe (DP) for assessment of vascular control during laparoscopic partial nephrectomy (LPN). We prospectively collected data during LPN procedures. We documented tumor location and size as well as subjective quality of the hilar dissection. The DP was compared with our standard intraoperative ultrasound system (SUS) for the ability to detect blood flow during hilar dissection and to determine parenchymal ischemia around the tumor after clamping of the renal vessels. Twenty patients underwent LPN by a single surgeon. The mean tumor size was 3.0 cm (range: 1.2-6.3 cm). The times to assess the kidney using the SUS and DP were 68.6 seconds (range: 20-155) and 44.5 seconds (range: 15-180), respectively. Evaluation prior to renal hilar clamping demonstrated the presence of blood flow in all 20 patients (100%) using the SUS and in 17 of 20 (85%) using the DP. Similarly, cessation of blood flow with clamping was documented in 100% of cases with SUS and 85% with DP. Persistent flow was detected by both SUS and DP in two patients requiring further dissection and reclamping. Then, both systems detected the absence of flow before tumor resection. With blood flow interruption confirmation, no patient had significant bleeding at the time of renal parenchymal transection. Intraoperative Doppler ultrasound technologies minimize the risk of significant bleeding during LPN. The DP is a small, simple, effective probe that can be used to assess blood flow interruption to the kidney during laparoscopic renal surgery.

Hand-assisted Laparoscopic Nephrectomy in Living-donor Kidneys With Multiple Arteries: Experience of a Transplant Center.

PubMed

Bandín Musa, Alfonso Ricardo; Montes de Oca, Jorge

2016-04-01

Hand-assisted laparoscopic nephrectomy is a relatively new procedure in our country. This article reports on one of the largest number of this procedure in kidneys with multiple vessels. We reviewed all cases of hand-assisted laparoscopic nephrectomy from July 2002 to February 2009. Results were then descriptive, with statistical analyses performed with SPSS software (SPSS: An IBM Company, version 10.0, IBM Corporation, Armonk, NY, USA). From July 2002 to February 2009, 165 patients had hand-assisted laparoscopic nephrectomy, with 96.9% being the left kidney. We found a prevalence of 18.7% (n = 31) of kidneys with multiple arteries, with 8 of these having multiple principal arteries, 9 with superior polar artery, and 14 with inferior polar artery. Twenty-nine donors (17.57%) presented with more than 1 principal vein. Warm ischemia was longer in kidneys with multiple arteries (4.16 vs 3.96 min); recipient renal function (evaluated by creatinine levels at day 5 after transplant) was 1.63 mg/dL in kidneys with single artery versus 1.27 mg/dL in kidneys with multiple arteries. There were no significant differences for time of surgery, bleeding, and discharge of the donor. We found no differences in kidney function between single and multiple artery kidneys, resulting in the conclusion that hand-assisted laparoscopic nephrectomy offers an effective option for kidney donors, including those with multiple arteries.

Ginger Essence Effect on Nausea and Vomiting After Open and Laparoscopic Nephrectomies

PubMed Central

Hosseini, Fatemeh Sadat; Adib-Hajbaghery, Mohsen

2015-01-01

Background: Some studies reported that ginger was effective in prevention or treatment of post-surgical nausea and vomiting; however, there are controversies. In addition, no study compared the effects of ginger on nausea and vomiting after open and laparoscopic nephrectomies. Objectives: The current study aimed to compare the effect of ginger essence on nausea and vomiting after open versus laparoscopic nephrectomies. Patients and Methods: A randomized, placebo trial was conducted on two groups of patients, 50 open and 50 laparoscopic nephrectomy. Half of the subjects in each group received ginger essence and the other half received placebo. Using a visual analogue scale the severity of nausea was assessed every 15 minutes for the first two post-operative hours and the sixth hour. Frequency of vomiting was counted until the sixth hour. The placebo subgroups were treated similarly. Descriptive statistics were employed. Chi-square and Fisher’s exact tests, paired and independent samples t-test and repeated measure analysis of variance were used to analyze the data. Results: Repeated measure analysis of variance showed that the type of surgery and the type of intervention as factors had significant effects on the nausea severity scores in the nine successive measurements (P < 0.001). In the first two post-operative hours, the mean vomiting episodes was 2.92 ± 0.70 in the subjects who underwent open surgery and received placebo while it was 0.16 ± 0.37 in patients with the same surgery but receiving ginger essence (P = 0.001). The mean vomiting episodes was 6.0 ± 1.33 in the subjects who underwent laparoscopic surgery and received placebo while it was 1.39 ± 0.78 in patients with the same surgery but receiving ginger essence (P = 0.001). Conclusions: Using ginger essence was effective in reducing nausea and vomiting not only in the subjects who underwent open nephrectomy but also in the subjects of laparoscopic nephrectomy. Using ginger essence is suggested as a complementary remedy to prevent and treat post-operative nausea and vomiting in patients with nephrectomy. PMID:26339671

High-fidelity simulation-based team training in urology: evaluation of technical and nontechnical skills of urology residents during laparoscopic partial nephrectomy.

PubMed

Abdelshehid, Corollos S; Quach, Stephen; Nelson, Corey; Graversen, Joseph; Lusch, Achim; Zarraga, Jerome; Alipanah, Reza; Landman, Jaime; McDougall, Elspeth M

2013-01-01

The use of low-risk simulation training for resident education is rapidly expanding as teaching centers integrate simulation-based team training (SBTT) sessions into their education curriculum. SBTT is a valuable tool in technical and communication skills training and assessment for residents. We created a unique SBTT scenario for urology residents involving a laparoscopic partial nephrectomy procedure. Urology residents were randomly paired with a certified registered nurse anesthetists or an anesthesia resident. The scenario incorporated a laparoscopic right partial nephrectomy utilizing a unique polyvinyl alcohol kidney model with an embedded 3cm lower pole exophytic tumor and the high-fidelity SimMan3G mannequin. The Urology residents were instructed to pay particular attention to the patient's identifying information provided at the beginning of the case. Two scripted events occurred, the patient had an anaphylactic reaction to a drug and, after tumor specimen was sent for a frozen section, the confederate pathologist called into the operating room (OR) twice, first with the wrong patient name and subsequently with the wrong specimen. After the scenario was complete, technical performance and nontechnical performance were evaluated and assessed. A debriefing session followed the scenario to discuss and assess technical performance and interdisciplinary nontechnical communication between the team. All Urology residents (n = 9) rated the SBTT scenario as a useful tool in developing communication skills among the OR team and 88% rated the model as useful for technical skills training. Despite cuing to note patient identification, only 3 of 9 (33%) participants identified that the wrong patient information was presented when the confederate "pathologist" called in to report pathology results. All urology residents rated SBTT sessions as useful for the development of communication skills between different team members and making residents aware of unlikely but potential critical errors in the OR. We will continue to use SBTT as a useful method to develop resident technical and nontechnical skills outside of the high-risk operating environment. Copyright © 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Single-port laparoscopic and robotic partial nephrectomy.

PubMed

Kaouk, Jihad H; Goel, Raj K

2009-05-01

Partial nephrectomy (PN) for small renal masses provides effective oncologic outcomes. Single-port laparoscopic (SPL) and robotic surgeries are evolving approaches to advance minimally invasive surgery. To determine the feasibility of laparoscopic and robotic single-port PN. Since 2007, evaluation of patients undergoing SPL and single-port robotic (SPR) PN at a primary referral center was performed. Patients with small, solitary, exophytic-enhancing renal masses were selected. Patients with a solitary kidney, endophytic or hilar tumors, and previous abdominal and/or kidney surgery were excluded. Perioperative and pathologic data were entered prospectively into an institutional review board (IRB)-approved database. Tumor location determined either an open Hasson transperitoneal or retroperitoneal approach. A single multichannel port or Triport provided intra-abdominal access. The Harmonic Scalpel was used for tumor excision under normal renal perfusion. The da Vinci surgical robot was used for SPR cases. Patient demographics, perioperative, hematologic, and pathologic data as well as pain assessment using the Visual Analog Pain Scale (VAPS) were assessed. A total of seven patients underwent single-port PN (SPL=5, SPR=2). One patient with a right anterior upper-pole mass required conversion from SPL to standard laparoscopy following tumor excision because of intraoperative bleeding. Pathology revealed six lesions compatible with renal cell carcinoma (RCC) and one benign cyst. One negative frozen section came back focally positive on final histopathology. All other surgical margins were negative. A mean difference of 3.0+/-2.0 g/dl in hemoglobin was noted in all patients. Minimal pain was noted at discharge following both laparoscopic and robotic single-port surgery (VAPS=1.7+/-1.2 vs 1+/-0.5/10). SPL and SPR PN is feasible for select exophytic tumors. Robotics may improve surgical capabilities during single-port surgery.

Robot-Assisted Partial Nephrectomy for T1b Tumors: Strict Trifecta Outcomes.

PubMed

Tufek, Ilter; Mourmouris, Panagiotis; Doganca, Tunkut; Obek, Can; Argun, Omer Burak; Tuna, Mustafa Bilal; Keskin, Mehmet Selcuk; Kural, Ali Rıza

2017-01-01

"Trifecta" in partial nephrectomy consists of negative surgical margins, minimal renal function decrease and absence of complications. In the present article, our single-center robot-assisted partial nephrectomy (RAPN) experience in T1b renal masses is reported in terms of strict Trifecta outcomes. This is a retrospective analysis of patients with a tumor diameter between 4 and 7 cm (stage T1b), who underwent RAPN by a single surgeon. Preoperative, intraoperative, and postoperative data were recorded and analyzed to evaluate short-term functional and oncologic outcomes. Patients with absence of grade ≥ 2 Clavien-Dindo complications, warm ischemia time (WIT) ≤25 minutes, ≤15% postoperative estimated glomerular filtration rate (eGFR) decrease and negative surgical margins were reported to achieve strict Trifecta outcomes. P < .05 was indicated statistically significant. A total of 150 patients underwent RAPN, and 50 patients were identified with tumor size between 4 and 7 cm. Mean WIT was 20.8 ± 6.2 minutes and mean estimated blood loss (EBL) was 269 ± 191 mL. Surgical margins were negative in all patients. Eleven patients (22%) had a >15% eGFR decrease after surgery. Nine patients (18%) had WIT longer than 25 minutes. Four patients (8%) had grade ≥2 Clavien-Dindo complications. Twenty-nine (58%) patients had strict Trifecta outcomes. Mean follow-up was 44.2 ± 27.2 months. Tumor recurrence was not observed in any patient. Robot-assisted laparoscopic partial nephrectomy for T1b renal masses can be safely performed in experienced hands. Optimal strict Trifecta outcomes and recurrence rates can be achieved.

Renal artery aneurysm in hand-assisted laparoscopic donor nephrectomy: case report.

PubMed

Maciel, R F; Branco, A J; Branco, A W; Guterres, J C; Silva, A E; Ramos, L B; Rost, C; Vieira, C A; Cicogna, P E S; Daudt, C A; Deboni, L M; Vieira, M A; Luz, H A; Vieira, J A

2003-12-01

We report a living donor who underwent laparoscopic nephrectomy using a hand-assisted device (HALD). At preoperative arteriography the donor showed a renal artery aneurysm. The patient was a 37-year-old female, 166 cm height, white, weighing 87 kg, HLA identical to the recipient. HALD was indicated due to the better visualization of renal pedicle and greater security in an obese patient. Renal artery aneurysm is a rare condition, with many possible complications. The method proved to be adequate and safe for donor nephrectomy, despite a renal artery aneurysm.

A Mathematical Method to Calculate Tumor Contact Surface Area: An Effective Parameter to Predict Renal Function after Partial Nephrectomy.

PubMed

Hsieh, Po-Fan; Wang, Yu-De; Huang, Chi-Ping; Wu, Hsi-Chin; Yang, Che-Rei; Chen, Guang-Heng; Chang, Chao-Hsiang

2016-07-01

We proposed a mathematical formula to calculate contact surface area between a tumor and renal parenchyma. We examined the applicability of using contact surface area to predict renal function after partial nephrectomy. We performed this retrospective study in patients who underwent partial nephrectomy between January 2012 and December 2014. Based on abdominopelvic computerized tomography or magnetic resonance imaging, we calculated the contact surface area using the formula (2*π*radius*depth) developed by integral calculus. We then evaluated the correlation between contact surface area and perioperative parameters, and compared contact surface area and R.E.N.A.L. (Radius/Exophytic/endophytic/Nearness to collecting system/Anterior/Location) score in predicting a reduction in renal function. Overall 35, 26 and 45 patients underwent partial nephrectomy with open, laparoscopic and robotic approaches, respectively. Mean ± SD contact surface area was 30.7±26.1 cm(2) and median (IQR) R.E.N.A.L. score was 7 (2.25). Spearman correlation analysis showed that contact surface area was significantly associated with estimated blood loss (p=0.04), operative time (p=0.04) and percent change in estimated glomerular filtration rate (p <0.001). On multivariate analysis contact surface area and R.E.N.A.L. score independently affected percent change in estimated glomerular filtration rate (p <0.001 and p=0.03, respectively). On ROC curve analysis contact surface area was a better independent predictor of a greater than 10% change in estimated glomerular filtration rate compared to R.E.N.A.L. score (AUC 0.86 vs 0.69). Using this simple mathematical method, contact surface area was associated with surgical outcomes. Compared to R.E.N.A.L. score, contact surface area was a better predictor of functional change after partial nephrectomy. Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Retroperitoneal laparoscopic nephrectomy: the effect of the learning curve, and concentrating expertise, on operating times.

PubMed

Skinner, Adrian; Maoate, Kiki; Beasley, Spencer

2010-05-01

Laparoscopic nephrectomy is an accepted alternative to open nephrectomy. We analyzed our first 80 procedures of laparoscopic nephrectomy to evaluate the effect of experience and configuration of service on operative times. A retrospective review of 80 consecutive children who underwent retroperitoneal laparoscopic nephrectomy or heminephrectomy during an 11-year period from 1997 at Christchurch Hospital (Christchurch, New Zealand) was conducted. Operative times, in relation to the experience of the surgeon for this procedure, were analyzed. Four surgeons, assisted by an annually rotating trainee registrar, performed the procedure in 26 girls and 54 boys (range, 8 months to 15 years). Operating times ranged from 38 to 225 minutes (mean, 104). The average operative time fell from 105 to 90 minutes. One surgeon performed 40% of the procedures and assisted with a further 55%. The operative times for all surgeons showed a tendency to reduce, but this was not marked. Most procedures were performed by two surgeons working together, although one surgeon was involved in the majority of cases. The lead surgeon is often assisted by a fellow consultant colleague. Operative times were influenced by experience, but not markedly so. The shorter operative times and minimal "learning curve," compared with other reported series, may, in part, be due to the involvement of two surgeons experienced in laparoscopy for the majority of cases.

[Robotic assisted laparoscopic living donor nephrectomy: preoperative assessment and results of 100 cases].

PubMed

Laplace, B; Ladrière, M; Claudon, M; Eschwege, P; Kessler, M; Hubert, J

2014-04-01

To assess short term morbidity and renal function after robotic laparoscopic living donor nephrectomy. We performed a retrospective analysis of 100 consecutives patients undergoing a robotic laparoscopic living donors nephrectomy. We analyzed isotopic measure of the renal function before and 4 months after surgery, the side, the number of arteries, the blood loss, the operative time and warm ischemia time. In the outcomes, we collected the complications, the length of stay, and for the receiver, the renal function recovery time, dialysis, survival and renal function at one year. Left kidney nephrectomy was performed in 85 patients and we observed 25 multiples renal arteries. Mean estimated blood loss was 0,8 g/dL. Mean operative time and warm ischemia time were respectively 174 ± 30 and 4.8 ± 1.7 minutes. Seven complications occured, with 2 major (Clavien-Dindo System). Mean length of stay was 5.1 ± 1.9 days. Mean glomerular filtration decrease was 26% and remains stable at one year after surgery. Grafts had an immediate renal function recovery for 99%, and were all functional after one year, with mean MDRD clearance of 57 ± 14mL/min. Robotic procedure in laparoscopic living donor nephrectomy seems to guarantee low morbidity and the stability of the renal function decrease of 26%. Copyright © 2013. Published by Elsevier Masson SAS.

Comparison of Pfannenstiel or Extended Iliac Port Site Kidney Extraction in Laparoscopic Donor Nephrectomy: Do We Have Consensus?

PubMed

Iemsupakkul, Paiboon; Kongchareonsombat, Wisoot; Kijvikai, Kittinut

2017-04-01

Our objective was to compare the outcomes of the different extraction sites between extended iliac port site incision and Pfannenstiel incision during laparoscopic donor nephrectomy. We prospectively evaluated patients who underwent laparoscopic donor nephrectomy from June 2014 to March 2015 at our institution. Perioperative parameters were included, with particular reference to warm ischemic time. The other parameters recorded included operative time, blood loss, hospital stay, analgesic requirement, and cosmetic results. We analyzed a total of 41 patients. Kidney retrieval site of each patient was made randomly. Extraction sites were done by using extended iliac port site incisions in 23 patients and by Pfannenstiel incision in 18 patients. Mean warm ischemic time was 4.09 minutes with extended iliac port site incision versus 4.94 minutes with Pfannenstiel incision (P = .04). Mean operative time, blood loss, hospital stay, and analgesic requirements were comparable between the 2 groups. Mean cosmetic score was 10.39 with extended iliac port site versus 12.06 with Pfannenstiel incision. Extraction with extended iliac port site incision had significantly less warm ischemic time than Pfannenstiel incision in laparoscopic donor nephrectomy. It was also not inferior to Pfannenstiel incision regarding the other.

Intra-operative ultrasound-based augmented reality guidance for laparoscopic surgery.

PubMed

Singla, Rohit; Edgcumbe, Philip; Pratt, Philip; Nguan, Christopher; Rohling, Robert

2017-10-01

In laparoscopic surgery, the surgeon must operate with a limited field of view and reduced depth perception. This makes spatial understanding of critical structures difficult, such as an endophytic tumour in a partial nephrectomy. Such tumours yield a high complication rate of 47%, and excising them increases the risk of cutting into the kidney's collecting system. To overcome these challenges, an augmented reality guidance system is proposed. Using intra-operative ultrasound, a single navigation aid, and surgical instrument tracking, four augmentations of guidance information are provided during tumour excision. Qualitative and quantitative system benefits are measured in simulated robot-assisted partial nephrectomies. Robot-to-camera calibration achieved a total registration error of 1.0 ± 0.4 mm while the total system error is 2.5 ± 0.5 mm. The system significantly reduced healthy tissue excised from an average (±standard deviation) of 30.6 ± 5.5 to 17.5 ± 2.4 cm 3 ( p < 0.05) and reduced the depth from the tumor underside to cut from an average (±standard deviation) of 10.2 ± 4.1 to 3.3 ± 2.3 mm ( p < 0.05). Further evaluation is required in vivo, but the system has promising potential to reduce the amount of healthy parenchymal tissue excised.

Initial laboratory experience with a novel ultrasound probe for standard and single-port robotic kidney surgery: increasing console surgeon autonomy and minimizing instrument clashing.

PubMed

Yakoubi, Rachid; Autorino, Riccardo; Laydner, Humberto; Guillotreau, Julien; White, Michael A; Hillyer, Shahab; Spana, Gregory; Khanna, Rakesh; Isaac, Wahib; Haber, Georges-Pascal; Stein, Robert J; Kaouk, Jihad H

2012-06-01

The aim of this study was to evaluate a novel ultrasound probe specifically developed for robotic surgery by determining its efficiency in identifying renal tumors. The study was carried out using the Da Vinci™ surgical system in one female pig. Renal tumor targets were created by percutaneous injection of a tumor mimic mixture. Single-port and standard robotic partial nephrectomy were performed. Intraoperative ultrasound was performed using both standard laparoscopic probe and the new ProART™ Robotic probe. Probe maneuverability and ease of handling for tumor localization were recorded. The standard laparoscopic probe was guided by the assistant. Significant clashing with robotic arms was noted during the single-port procedure. The novel robotic probe was easily introduced through the assistant trocar, and held by the console surgeon using the robotic Prograsp™ with no registered clashing in the external operative field. The average time for grasping the new robotic probe was less than 10 s. Once inserted and grasped, no limitation was found in terms of instrument clashing during the single-port procedure. This novel ultrasound probe developed for robotic surgery was noted to be user-friendly when performing porcine standard and especially single-port robotic partial nephrectomy. Copyright © 2011 John Wiley & Sons, Ltd.

Comparison between magnetic anchoring and guidance system camera-assisted laparoendoscopic single-site surgery nephrectomy and conventional laparoendoscopic single-site surgery nephrectomy in a porcine model: focus on ergonomics and workload profiles.

PubMed

Han, Woong Kyu; Tan, Yung K; Olweny, Ephrem O; Yin, Gang; Liu, Zhuo-Wei; Faddegon, Stephen; Scott, Daniel J; Cadeddu, Jeffrey A

2013-04-01

To compare surgeon-assessed ergonomic and workload demands of magnetic anchoring and guidance system (MAGS) laparoendoscopic single-site surgery (LESS) nephrectomy with conventional LESS nephrectomy in a porcine model. Participants included two expert and five novice surgeons who each performed bilateral LESS nephrectomy in two nonsurvival animals using either the MAGS camera or conventional laparoscope. Task difficulty and workload demands of the surgeon and camera driver were assessed using the validated National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire. Surgeons were also asked to score 6 parameters on a Likert scale (range 1=low/easy to 5=high/hard): procedure-associated workload, ergonomics, technical challenge, visualization, accidental events, and instrument handling. Each step of the nephrectomy was also timed and instrument clashing was quantified. Scores for each parameter on the Likert scale were significantly lower for MAGS-LESS nephrectomy. Mean number of internal and external clashes were significantly lower for the MAGS camera (p<0.001). Mean task times for each procedure were shorter for experts than for novices, but this was not statistically significant. NASA-TLX workload ratings by the surgeon and camera driver showed that MAGS resulted in a significantly lower workload than the conventional laparoscope during LESS nephrectomy (p<0.05). The use of the MAGS camera during LESS nephrectomy lowers the task workload for both the surgeon and camera driver when compared to conventional laparoscope use. Subjectively, it appears to also improve surgeons' impressions of ergonomics and technical challenge. Pending approval for clinical use, further evaluation in the clinical setting is warranted.

Laparoscopic radical nephrectomy: incorporating advantages of hand assisted and standard laparoscopy.

PubMed

Ponsky, Lee E; Cherullo, Edward E; Banks, Kevin L W; Greenstein, Marc; Streem, Stevan B; Klein, Eric A; Zippe, Craig D

2003-06-01

We present an approach to laparoscopic radical nephrectomy and intact specimen extraction, which incorporates hand assisted and standard laparoscopic techniques. A refined approach to laparoscopic radical nephrectomy is described and our experience is reviewed. A low, muscle splitting Gibson incision is made just lateral to the rectus muscle and the hand port is inserted. A trocar is placed through the hand port and pneumoperitoneum is established. With the laparoscope in the hand port trocar 2 additional trocars are placed under direct vision. The laparoscope is then repositioned through the middle trocar and standard laparoscopic instruments are used through the other 2 trocars including the one in the hand port. If at any time during the procedure the surgeon believes the hand would be useful or needed, the trocar is removed from the hand port and the hand is inserted. This approach has been applied to 7 patients. Mean estimated blood loss was 200 cc (range 50 to 300) and mean operative time was 276.7 minutes (range 247 to 360). Mean specimen weight was 767 gm. (range 538 to 1,170). Pathologically 6 specimens were renal cell carcinoma (grades 2 to 4) and 1 was oncocytoma. Mean length of hospital stay was 3.71 days (range 2 to 7). There were no major complications. We believe that this approach enables the surgeon to incorporate the advantages of the hand assisted and standard laparoscopic approaches.

Surgical navigation in urology: European perspective.

PubMed

Rassweiler, Jens; Rassweiler, Marie-Claire; Müller, Michael; Kenngott, Hannes; Meinzer, Hans-Peter; Teber, Dogu

2014-01-01

Use of virtual reality to navigate open and endoscopic surgery has significantly evolved during the last decade. Current status of seven most interesting projects inside the European Association of Urology section of uro-technology is summarized with review of literature. Marker-based endoscopic tracking during laparoscopic radical prostatectomy using high-definition technology reduces positive margins. Marker-based endoscopic tracking during laparoscopic partial nephrectomy by mechanical overlay of three-dimensional-segmented virtual anatomy is helpful during planning of trocar placement and dissection of renal hilum. Marker-based, iPAD-assisted puncture of renal collecting system shows more benefit for trainees with reduction of radiation exposure. Three-dimensional laser-assisted puncture of renal collecting system using Uro-Dyna-CT realized in an ex-vivo model enables minimal radiation time. Electromagnetic tracking for puncture of renal collecting system using a sensor at the tip of ureteral catheter worked in an in-vivo model of porcine ureter and kidney. Attitude tracking for ultrasound-guided puncture of renal tumours by accelerometer reduces the puncture error from 4.7 to 1.8 mm. Feasibility of electromagnetic and optical tracking with the da Vinci telemanipulator was shown in vitro as well as using in-vivo model of oesophagectomy. Target registration error was 11.2 mm because of soft-tissue deformation. Intraoperative navigation is helpful during percutaneous puncture collecting system and biopsy of renal tumour using various tracking techniques. Early clinical studies demonstrate advantages of marker-based navigation during laparoscopic radical prostatectomy and partial nephrectomy. Combination of different tracking techniques may further improve this interesting addition to video-assisted surgery.

Visual enhancement of laparoscopic partial nephrectomy with 3-charge coupled device camera: assessing intraoperative tissue perfusion and vascular anatomy by visible hemoglobin spectral response.

PubMed

Crane, Nicole J; Gillern, Suzanne M; Tajkarimi, Kambiz; Levin, Ira W; Pinto, Peter A; Elster, Eric A

2010-10-01

We report the novel use of 3-charge coupled device camera technology to infer tissue oxygenation. The technique can aid surgeons to reliably differentiate vascular structures and noninvasively assess laparoscopic intraoperative changes in renal tissue perfusion during and after warm ischemia. We analyzed select digital video images from 10 laparoscopic partial nephrectomies for their individual 3-charge coupled device response. We enhanced surgical images by subtracting the red charge coupled device response from the blue response and overlaying the calculated image on the original image. Mean intensity values for regions of interest were compared and used to differentiate arterial and venous vasculature, and ischemic and nonischemic renal parenchyma. The 3-charge coupled device enhanced images clearly delineated the vessels in all cases. Arteries were indicated by an intense red color while veins were shown in blue. Differences in mean region of interest intensity values for arteries and veins were statistically significant (p >0.0001). Three-charge coupled device analysis of pre-clamp and post-clamp renal images revealed visible, dramatic color enhancement for ischemic vs nonischemic kidneys. Differences in the mean region of interest intensity values were also significant (p <0.05). We present a simple use of conventional 3-charge coupled device camera technology in a way that may provide urological surgeons with the ability to reliably distinguish vascular structures during hilar dissection, and detect and monitor changes in renal tissue perfusion during and after warm ischemia. Copyright © 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Pure retroperitoneal natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy using standard laparoscopic instruments: a safety and feasibility study in a porcine model.

PubMed

Wei, Dechao; Han, Yili; Li, Mingchuan; Wang, Yongxing; Chen, Yatong; Luo, Yong; Jiang, Yongguang

2016-06-11

Among the different organs used for NOTES (natural orifice translumenal endoscopic surgery) technique, the transvaginal approach may be the optimal choice because of a simple and secure closure of colpotomy site. Pure and hybrid NOTES transvaginal operations were routinely performed via transperitoneal access. In this study, we investigate the safety and feasibility of pure retroperitoneal natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy using conventional laparoscopic techniques in a porcine model. Six female pigs, weighing an average of 30 kg, were used in this study. Under general anesthesia, pure retroperitoneal NOTES transvaginal nephrectomy was conducted using standard laparoscopic instruments. Posterolateral colpotomy was performed, and the incision was enlarged laterally using blunt dissection and pneumatic dilation. A single-port device was inserted to construct the operative channel. The retroperitoneal space was created using sharp and blunt dissection under endoscopic guidance up to the level of the kidney. Dissection and removal of the kidney were performed according to standard surgical procedure, and the colpotomy site was closed using interrupted sutures. The survival and complications were observed 1 week postoperatively. Our results showed that two cases failed because of peritoneal rupture. One case was successful, but required the assistance of an extra 5 mm laparoscopic trocar inserted in the flank. Three cases of pure retroperitoneal NOTES transvaginal nephrectomy were completed, and survived 1 week after the operation. In these three cases, no intra- or postoperative complications were observed. All findings confirmed the safety and feasibility of the retroperitoneal pure retroperitoneal NOTES transvaginal nephrectomy using standard laparoscopic instruments, which suggested the possibility of clinical application in human beings in the future.

A multimodal imaging framework for enhanced robot-assisted partial nephrectomy guidance

NASA Astrophysics Data System (ADS)

Halter, Ryan J.; Wu, Xiaotian; Hartov, Alex; Seigne, John; Khan, Shadab

2015-03-01

Robot-assisted laparoscopic partial nephrectomies (RALPN) are performed to treat patients with locally confined renal carcinoma. There are well-documented benefits to performing partial (opposed to radical) kidney resections and to using robot-assisted laparoscopic (opposed to open) approaches. However, there are challenges in identifying tumor margins and critical benign structures including blood vessels and collecting systems during current RALPN procedures. The primary objective of this effort is to couple multiple image and data streams together to augment visual information currently provided to surgeons performing RALPN and ultimately ensure complete tumor resection and minimal damage to functional structures (i.e. renal vasculature and collecting systems). To meet this challenge we have developed a framework and performed initial feasibility experiments to couple pre-operative high-resolution anatomic images with intraoperative MRI, ultrasound (US) and optical-based surface mapping and kidney tracking. With these registered images and data streams, we aim to overlay the high-resolution contrast-enhanced anatomic (CT or MR) images onto the surgeon's view screen for enhanced guidance. To date we have integrated the following components of our framework: 1) a method for tracking an intraoperative US probe to extract the kidney surface and a set of embedded kidney markers, 2) a method for co-registering intraoperative US scans with pre-operative MR scans, and 3) a method for deforming pre-op scans to match intraoperative scans. These components have been evaluated through phantom studies to demonstrate protocol feasibility.

Laparoscopic nephrectomy using the harmonic scalpel.

PubMed

Helal, M; Albertini, J; Lockhart, J; Albrink, M

1997-08-01

Laparoscopic nephrectomy is gaining popularity. Improved instrumentation is making surgery easier with fewer complications. Our first three laparoscopic nephrectomies using the Harmonic Scalpel were performed on two women and one man. The surgical indications were nonfunctioning kidneys (two left, one right) with hypertension in one patient and stone disease in two. The three patients had a mean age of 46.3 years. The average hospital stay was 4 days, the average operative time 3.7 hours, and the average blood loss 160 mL. No complications occurred. Patients resumed oral intake within 8 hours postoperatively. We found the Harmonic Scalpel easy and safe to use. It saved time, was cost effective, and was capable of easily controlling small-vessel bleeding. In conclusion, the Harmonic Scalpel could be used effectively for both dissection and bleeding control without suction or other instrumentation.

Intraoperative Conversion From Partial to Radical Nephrectomy: Incidence, Predictive Factors, and Outcomes.

PubMed

Petros, Firas G; Keskin, Sarp K; Yu, Kai-Jie; Li, Roger; Metcalfe, Michael J; Fellman, Bryan M; Chang, Courtney M; Gu, Cindy; Tamboli, Pheroze; Matin, Surena F; Karam, Jose A; Wood, Christopher G

2018-06-01

To evaluate preoperative and intraoperative predictors of conversion to radical nephrectomy (RN) in a cohort of patients undergoing a planned partial nephrectomy (PN) for renal cell carcinoma (RCC). A single-center, retrospective review was conducted using our PN database that includes patients who were scheduled to undergo PN (regardless of the approach) but were converted to RN between August 1990 and December 2016. Reasons for conversion were collected from the operative report. Patient demographics and perioperative variables were compared with the successful PN group. Univariate and multivariate logistic regression analyses were conducted to assess predictors of conversion. A total of 1857 patients were scheduled to undergo PN. Of these patients, 90 (5%) were converted to RN. The multivariate model showed that larger tumor size (odds ratio [OR] = 1.20, P = .040), higher RENAL nephrometry score (OR = 1.41, P = .001), hilar tumor or renal sinus invasion (OR = 2.80, P = .004), laparoscopic PN (OR = 7.34, P <.001), intraoperative bleeding (OR = 19.62, P <.001), positive surgical margin (OR = 31.85, P <.001), and advanced pathologic tumor-stage (T3 or T4) (OR = 7.29, P <.001) were associated with increased odds of intraoperative conversion to RN. The rate of conversion to RN was low in patients who were scheduled to undergo PN in this series. Larger tumor size with increasing complexity, hilar tumor location or renal sinus invasion, locally advanced tumors, laparoscopic PN but not robotic PN, bleeding complication, and positive surgical margin were associated with intraoperative conversion from scheduled PN to RN. Copyright © 2018 Elsevier Inc. All rights reserved.

Can a Modified Bosniak Classification System Risk Stratify Pediatric Cystic Renal Masses?

PubMed

Saltzman, Amanda F; Carrasco, Alonso; Colvin, Alexandra N; Meyers, Mariana L; Cost, Nicholas G

2018-03-20

We characterize and apply the modified Bosniak classification system to a cohort of children with cystic renal lesions and known surgical pathology. We identified all patients at our institution with cystic renal masses who also underwent surgery for these lesions. Patients without available preoperative imaging or pathology were excluded. All radiological imaging was independently reviewed by a pediatric radiologist blinded to pathological findings. Imaging characteristics (size, border, septations, calcifications, solid components, vascularity) were recorded from the most recent preoperative ultrasounds and computerized tomograms. The modified Bosniak classification system was applied to these scans and then correlated with final pathology. A total of 22 patients met study criteria. Median age at surgery was 6.1 years (range 11 months to 16.8 years). Of the patients 12 (54.5%) underwent open nephrectomy, 6 (27.3%) open partial nephrectomy, 2 (9.1%) laparoscopic cyst decortication, 1 (4.5%) open renal biopsy and 1 (4.5%) laparoscopic partial nephrectomy. Final pathology was benign in 9 cases (41%), intermediate in 6 (27%) and malignant in 7 (32%). All malignant lesions were modified Bosniak class 4, all intermediate lesions were modified class 3 or 4 and 8 of 9 benign lesions (89%) were modified class 1 or 2. Cystic renal lesions in children with a modified Bosniak class of 1 or 2 were most often benign, while class 3 or 4 lesions warranted surgical excision since more than 90% of masses harbored intermediate or malignant pathology. The modified Bosniak classification system appears to allow for a reasonable clinical risk stratification of pediatric cystic renal masses. Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

[Anesthesia experiences on laparoscopic nephrectomy with da Vinci S robotics].

PubMed

Mou, Ling; Lan, Zhixun

2015-09-01

To summarize the clinical anesthesia experiences in 20 patients who underwent laparoscopic nephrectomy with da Vinci S robotics.
 Anesthesia data of 20 patients from Sichuan Provincial People's Hospital, who underwent laparoscopic nephrectomy with da Vinci S robotics from August 2014 to November 2014, were analyzed and summarized. The anesthesia time, operation time, CO(2) pneumoperitoneum time, PaCO(2) and PETCO(2) were recorded.
 All patients were anesthetized and underwent surgery with da Vinci S robotics. The anesthesia time was (220±14) min, the operation time was (187±11) min, and the CO(2) pneumoperitoneum time was (180±13) min. The PaCO(2) and PETCO(2) were significantly elevated at 1.5 h after operation compared with those at the baseline (before pneumoperitoneum) (P<0.05). The pH value was significantly decreased at 2.5 h after operation compared to that at the baseline (P<0.05). The peak airway pressure of inspiration was significantly elevated at 0.5 h after the beginning of pneumoperitoneum compared to that at the baseline (P<0.05).
 The hemodynamics is stable during the laparoscopic nephrectomy with da vinci S robotics. However, the duration of CO(2) pneumoperitoneum is significantly increased compared to that of other surgical procedures, resulting in high airway resistance and acid-base disturbance.

Laparoscopic nephrectomy in a patient with severe scoliosis: A case report.

PubMed

Tamura, Daichi; Ito, Ayato; Kikuchi, Daichi; Tsuyukubo, Takashi; Kato, Renpei; Kato, Yoichiro; Konari, Susumu; Omori, So; Obara, Wataru

2018-05-10

Although the role of laparoscopic nephrectomy (LN) has been established, few studies have reported cases of LN in individuals with scoliosis. Here we report a case of right LN in a patient with severe right convex scoliosis. A 26-year-old man presented with a fever. His medical history comprised severe right convex lumbar scoliosis. CT revealed right hydronephrosis and right kidney stones. Pyelonephritis requiring nephrectomy was diagnosed. Right LN was feasible with elaborate perioperative care. The postoperative course was uneventful with no relapse of urinary tract infection. © 2018 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.

Preoperative fiducial coil placement facilitates robot-assisted laparoscopic excision of retroperitoneal small solitary metastasis of kidney cancer.

PubMed

Agrawal, Vineet; Sharma, Ashwani; Wu, Guan

2014-11-01

Image-guided fiducial markers are being used in surgery, especially in spine and breast surgery, and radiotherapy, allowing localization of tumor sites precisely. We report a case of fiducial coil use in a man undergoing a robot-assisted laparoscopic resection of a metastatic nodule under the ipsilateral diaphragm after robot-assisted partial nephrectomy performed 2 years ago for a left upper pole renal tumor. The fiducial coil facilitated the localization of the lesion, which would otherwise have been challenging because of its small size and location. In addition, the fiducial coil was helpful to avoid cutting into the lesion directly. Copyright © 2014 Elsevier Inc. All rights reserved.

Early and late recipient graft function and donor outcome after laparoscopic vs open adult live donor nephrectomy for pediatric renal transplantation.

PubMed

Troppmann, Christoph; Pierce, Jonathan L; Wiesmann, Kevin M; Butani, Lavjay; Makker, Sudesh P; McVicar, John P; Wolfe, Bruce M; Perez, Richard V

2002-08-01

Laparoscopically procured live donor kidney grafts are increasingly transplanted into pediatric recipients. The safety and efficacy of this changed surgical practice are unknown. Outcomes of laparoscopic vs open donor grafts in recipients 18 years and younger are equivalent. Retrospective review at an academic tertiary care referral center. Eleven consecutive pediatric recipients of laparoscopically procured kidneys between April 1, 1997, and December 31, 2001, were pair matched for age with 11 recipients of openly procured kidneys between December 1, 1991, and March 31, 1997; the 22 adult donors were also studied. Recipients: surgical complications, graft function and survival. Donors: perioperative morbidity and length of hospital stay. Twenty (91%) of 22 kidneys were donated by a parent of the recipient. In recipients of laparoscopically procured grafts, we observed significantly lower creatinine clearances and higher creatinine levels on days 1, 4, and 6, but by 1 month, graft function was similar in both groups. No significant differences in surgical complications, delayed function, acute and chronic rejection, and graft survival rates were found. No laparoscopic or open donor required blood transfusion, reoperation, or hospital readmission. One laparoscopic donor (9%) was converted to open nephrectomy. For laparoscopic vs open donors, median operative time was longer (difference, 67 min; P =.08), but median postoperative length of stay was significantly shorter (3 vs 5 days; P =.02). Laparoscopic live donor nephrectomy has no adverse impact on pediatric recipient outcomes. For donors, the laparoscopic operation is safe and the hospital stay is shortened. These results support the continued use of laparoscopically procured live donor kidneys in pediatric renal transplantation.

Use of the holmium:YAG laser in urology.

PubMed

Johnson, D E; Cromeens, D M; Price, R E

1992-01-01

The tissue effects of a holmium:YAG (Ho:YAG) laser operating at a wavelength of 2.1 mu with a maximum power of 15 watts (W) and 10 different energy-pulse settings was systematically evaluated on kidney, bladder, prostate, ureteral, and vasal tissue in the dog. In addition, various urologic surgical procedures (partial nephrectomy, transurethral laser incision of the prostate, and laser-assisted vasovasostomy) were performed in the dog, and a laparoscopic pelvic lymph node dissection was carried out in a pig. Although the Ho:YAG laser has a strong affinity for water, precise tissue ablation was achieved in both the contact and non-contact mode when used endoscopically in a fluid medium to ablate prostatic and vesical tissue. Using the usual parameters for tissue destruction (blanching without charring), the depth of thermal injury in the bladder and ureter was kept superficial. In performing partial nephrectomies, a 2-fold reduction in the zone of coagulative necrosis was demonstrated compared to the use of the continuous wave Neodymium:YAG laser (Nd:YAG). When used through the laparoscope, the Ho:YAG laser provided precise cutting and, combined with electrocautery, allowed the dissection to proceed quickly and smoothly. Hemostatic control was adequate in all surgical procedures. Although the results of these investigations are preliminary, our initial experience with the Ho:YAG laser has been favorable and warrants further investigations.

Risk Factors Related with Retroperitoneal Laparoscopic Converted to Open Nephrectomy for Nonfunctioning Renal Tuberculosis.

PubMed

Xu, Bo; Hu, Jinghai; Chen, Anxiang; Hao, Yuanyuan; Liu, GuoHui; Wang, Chunxi; Wang, Xiaoqing

2017-06-01

The present study was designed to investigate the risk factors affecting the conversion to open surgery in retroperitoneal laparoscopic nephrectomy of nonfunctioning renal tuberculosis (TB). The records of 144 patients who underwent a retroperitoneal laparoscopic nephrectomy procedure by a single surgeon were retrospectively reviewed. The following factors, including age, sex, body mass index (BMI), diabetes status, hypertension status, side of kidney, size of kidney, degree of calcification, mild perirenal extravasation, contralateral hydronephrosis, the time of anti-TB, and surgeon experience were analyzed. Univariate and multivariate logistic regression analyses were used for statistical assessment. Twenty-three patients were converted to open surgery and the conversion rate was 15.97%. In univariate analysis, BMI ≥35 kg/m 2 (p = 0.023), hypertension (p = 0.011), diabetes (p = 0.003), and kidney size (p = 0.032) were the main factors of conversion to open surgery. Sex, age, side, anti-TB time, calcification, mild extravasation, and surgeon experience were not significantly related. In multivariate regression analysis, BMI ≥35 kg/m 2 , hypertension, diabetes, and enlargement of kidney were the most important factors for conversion to open surgery. Depending on the results achieved by a single surgeon, BMI ≥30 kg/m 2 , diabetes, hypertension, and enlargement of kidney significantly increased the conversion risk in retroperitoneal laparoscopic nephrectomy for nonfunctioning renal TB.

Renal histopathology features according to various warm ischemia times in porcine laparoscopic and open surgery model

PubMed Central

Sabbagh, Robert; Chawla, Arun; Tisdale, Britton; Kwan, Kevin; Chatterjee, Suman; Kwiecien, Jacek M.; Kapoor, Anil

2011-01-01

Background Thirty minutes has been considered as the threshold for tolerable warm ischemic time (WIT). Recent reports demonstrate recovery of renal function after longer WIT. We assessed renal histology according to different WIT in a 2-kidney porcine model. Methods Twelve female pigs were randomized to an open or laparoscopic group. Each pig was further randomized within each group to clamping the left renal artery for 5, 15, 30, 45, 60 or 180 minutes. Preclamping left renal biopsies were performed on each pig. The contralateral kidney in each animal was used as an individual control. On postoperative day 14, all animals underwent bilateral nephrectomies. Preclamping left renal biopsies and all renal specimens were evaluated by a blinded veterinary pathologist. Results One pig died in the open group after 180 minutes of clamping. Histopathology did not show any significant changes between the two groups and across clamp times from 5 to 60 minutes. After 180 minutes of laparoscopic clamping, there was evidence of diffuse necrosis. Interpretation Sixty minutes of ischemia did not show any permanent renal damage in both groups. Further studies are needed to verify these findings in humans. A prolonged ischemic time without permanent renal damage would be helpful in partial nephrectomy. Warm ischemic time of 180 minutes exceeded the renal ischemic burden based on histological features. PMID:21470513

Retroperitoneoscopic versus open surgical radical nephrectomy for 152 Chinese patients with large renal cell carcinoma in clinical stage cT2 or cT3a: A long-term retrospective comparison.

PubMed

Zhu, Xuhui; Yang, Xiaoyong; Hu, Xiaopeng; Zhang, Xiaodong

2016-01-01

To evaluate the feasibility, safety, and long-term efficacy of retroperitoneal laparoscopic radical nephrectomy for Chinese patients with a mean body mass index (BMI) of ≤24 and large renal cell carcinoma (RCC). A long-term retrospective analysis of clinical data of 152 Chinese patients with a mean BMI of ≤24 and large RCC. Totally, 84 patients who underwent retroperitoneal laparoscopic radical nephrectomy (RPNx) for tumor size >7 cm (group 1) were compared with 68 patients, who underwent open radical nephrectomy (group 2) for tumor with similar size characteristics. Moreover, their 10 years outcomes (or the number of patients) were divided into segments (e.g., the first 5 and last 5 years, the first 30 and last 30 patients, etc.) looking for the differences of learning curve. RPNx patients experienced significantly shorter hospital stay, less blood loss, and had a decreased analgesic requirement and more rapid convalescence. The incidence of intra- and post-operative complications was 6% and 13%, 7.2% and 16.1% in the two groups, respectively. The 5-year survival rates of the two groups were 86% and 82%, respectively. Retroperitoneal laparoscopic radical nephrectomy for patients with a mean BMI of ≤24 and large RCC is safe, feasible, and the efficacious procedure produced good long-term results.

Robotic partial nephrectomy for renal cell carcinomas with venous tumor thrombus.

PubMed

Abaza, Ronney; Angell, Jordan

2013-06-01

To describe the first report of robotic partial nephrectomies (RPNs) for renal cell carcinoma (RCC) with venous tumor thrombus (VTT). Partial nephrectomy for RCC extending into the renal vein has been described in limited fashion, but such a complex procedure has not previously been reported in minimally-invasive fashion. We demonstrate the feasibility of robotic nephron-sparing surgery despite vein thrombi and the results of the initial four highly-selected patients to have undergone this novel procedure. Two patients underwent RPN for RCC with VTT involving intraparenchymal vein branches, and 2 others had VTT involving the main renal vein. Mean patient age was 65 years (range 50-74 years). Mean tumor size was 7.75 cm (range 4.3-12.8 cm) with mean RENAL (radius, exophytic/endophytic, nearness to collecting system, anterior/posterior, and location) nephrometry score of 9.75 (range 8-12). Mean warm ischemia time was 24.2 minutes (range 19-27 minutes) and mean estimated blood loss was 168.8 mL (range 100-300 mL). No patients required transfusion, and there were no intraoperative complications. No patients required conversion to open or standard laparoscopic surgery. All 4 patients were discharged home on the first postoperative day. A single postoperative complication occurred in 1 patient who was readmitted with an ileus that resolved spontaneously. All patients had negative surgical margins. Two patients developed metastatic disease on surveillance imaging. RPN in patients with VTT is safe and feasible in selected patients. Given the risk of metastatic disease in patients with pathologic stage T3a RCC, the role of nephron sparing requires further evaluation such that radical nephrectomy remains the standard of care. Copyright © 2013 Elsevier Inc. All rights reserved.

Laparoscopic nephroureterectomy: making management of upper-tract transitional-cell carcinoma entirely minimally invasive.

PubMed

Keeley, F X; Tolley, D A

1998-04-01

Endoscopic treatment of upper-tract transitional-cell carcinoma (TCC) is well established. Nevertheless, many patients still required major ablative surgery. We have applied our experience with laparoscopic nephrectomy to the performance of laparoscopic nephroureterectomy in order to make the management of upper-tract TCC entirely minimally invasive. Since 1993, we have performed 22 laparoscopic nephroureterectomies for upper-tract TCC. Initially, we excluded patients with tumors below the pelvic brim, but we now offer a trial of laparoscopy to all patients. We describe the evolution of our technique, which involves resecting the ureteral orifice prior to laparoscopic dissection of the kidney and ureter. We have had to convert three cases to open surgery, one each for bleeding, failure to progress, and unappreciated tumor extent. Operative times averaged 156 minutes, which compares well with contemporary times for open nephroureterectomy. Complication rates, transfusion requirements, and length of stay, although higher than those of laparoscopic nephrectomy, were all reduced in comparison with open nephroureterectomy.

Laparoscopic donor nephrectomy: meeting the challenge of consumerism?

PubMed

Siddins, Mark; Hart, Gabrielle; He, Bulang; Kanchanabat, Burapa; Mohan Rao, M

2003-11-01

Despite the increasing adoption of laparoscopic donor nephrectomy, no study has examined donor perceptions following this procedure. In particular, it has been tacitly assumed that a less invasive procedure might in itself provide a more satisfactory donor experience. The present study reviews the experience of donors undergoing laparoscopic nephrectomy, and examines the extent to which contemporary management practice addresses issues relevant to consumerism. Forty-two donors participated in a structured telephone interview, and 33 (79%) returned a written questionnaire. Coming through the survey was a strong sense of commitment to donation, and most respondents were satisfied with the experience. The main criticisms related to hotel services, the duration of the preoperative investigations, the perceived quality of nursing care on the general wards, medical communication and the duration of postoperative follow up. The self-reported time to meet recovery goals was extremely broad. Considering the nature of criticisms offered by the respondents, it is concluded that the expectations of donors as health-care consumers will only be met through modification of existing protocols.

Anatomic partial nephrectomy: technique evolution.

PubMed

Azhar, Raed A; Metcalfe, Charles; Gill, Inderbir S

2015-03-01

Partial nephrectomy provides equivalent long-term oncologic and superior functional outcomes as radical nephrectomy for T1a renal masses. Herein, we review the various vascular clamping techniques employed during minimally invasive partial nephrectomy, describe the evolution of our partial nephrectomy technique and provide an update on contemporary thinking about the impact of ischemia on renal function. Recently, partial nephrectomy surgical technique has shifted away from main artery clamping and towards minimizing/eliminating global renal ischemia during partial nephrectomy. Supported by high-fidelity three-dimensional imaging, novel anatomic-based partial nephrectomy techniques have recently been developed, wherein partial nephrectomy can now be performed with segmental, minimal or zero global ischemia to the renal remnant. Sequential innovations have included early unclamping, segmental clamping, super-selective clamping and now culminating in anatomic zero-ischemia surgery. By eliminating 'under-the-gun' time pressure of ischemia for the surgeon, these techniques allow an unhurried, tightly contoured tumour excision with point-specific sutured haemostasis. Recent data indicate that zero-ischemia partial nephrectomy may provide better functional outcomes by minimizing/eliminating global ischemia and preserving greater vascularized kidney volume. Contemporary partial nephrectomy includes a spectrum of surgical techniques ranging from conventional-clamped to novel zero-ischemia approaches. Technique selection should be tailored to each individual case on the basis of tumour characteristics, surgical feasibility, surgeon experience, patient demographics and baseline renal function.

Anaesthesia for laparoscopic nephrectomy: Does end-tidal carbon dioxide measurement correlate with arterial carbon dioxide measurement?

PubMed

Jayan, Nithin; Jacob, Jaya Susan; Mathew, Mohan

2018-04-01

Not many studies have explored the correlation between arterial carbon dioxide tension (PaCO 2 ) and end-tidal carbon dioxide tension (ETCO 2 ) in surgeries requiring pneumoperitoneum of more than 1 hour duration with the patient in non-supine position. The aim of our study was to evaluate the correlation of ETCO 2 with PaCO 2 in patients undergoing laparoscopic nephrectomy under general anaesthesia. A descriptive study was performed in thirty patients undergoing laparoscopic nephrectomy from September 2014 to August 2015. The haemodynamic parameters, minute ventilation, PaCO 2 and ETCO 2 measured at three predetermined points during the procedure were analysed. Correlation was checked using Pearson's Correlation Coefficient Test. P <0.05 was considered statistically significant. Statistical analysis of the values showed a positive correlation between ETCO 2 and PaCO 2 ( P < 0.05). Following carbon dioxide insufflation, both ETCO 2 and PaCO 2 increased by 5.4 and 6.63 mmHg, respectively, at the end of the 1 st hour. The PaCO 2 -ETCO 2 gradient was found to increase during the 1 st hour following insufflation (4.07 ± 2.05 mmHg); it returned to the pre-insufflation values in another hour (2.93 ± 1.43 mmHg). Continuous ETCO 2 monitoring is a reliable indicator of the trend in arterial CO 2 fluctuations in the American Society of Anesthesiologists Grades 1 and 2 patients undergoing laparoscopic nephrectomy under general anaesthesia.

Day case laparoscopic nephrectomy with vaginal extraction: initial experience.

PubMed

Baldini, Arnaud; Golfier, François; Mouloud, Khaled; Bruge Ansel, Marie-Hélène; Navarro, Rémi; Ruffion, Alain; Paparel, Philippe

2014-12-01

To assess the feasibility of laparoscopic nephrectomy with vaginal extraction in an ambulatory setting. Two patients underwent a laparoscopic (1 was robot assisted) nephrectomy with vaginal extraction for a nonfunctioning kidney in an ambulatory setting. Both interventions were performed by the same surgical team comprising a urologic surgeon and a gynecologic surgeon. The operative specimen was vaginally extracted via an incision in the posterior fornix at the end of the intervention. Patients had to respect very strict socioenvironmental and clinical criteria. Anesthesia was achieved using short-acting agents. Only first- and second-step analgesics were used (morphine-free protocol). The main judgment criteria were visual analog scale assessment for postoperative pain, the Clavien-Dindo classification for surgical complications, and the hospital readmission rate. Two female patients (37 and 41 years old) have been successfully operated with this technique. No major perioperative or postoperative complications (Clavien-Dindo grade >2) were reported, and no patient readmission was required. Postoperative pain was well managed with visual analog scale scores ≤ 5. Both patients operated in the ambulatory setting had Chung scores of 10 before their discharge. Laparoscopic or robotic nephrectomy with vaginal extraction can be performed in an ambulatory setting in carefully selected patients. The association of fast-track surgical techniques and vaginal extraction by eliminating the abdominal wound extraction source of postoperative pain allows performing this operation in this setting with a high level of satisfaction. Copyright © 2014 Elsevier Inc. All rights reserved.

Intraoperative ultrasound control of surgical margins during partial nephrectomy.

PubMed

Alharbi, Feras M; Chahwan, Charles K; Le Gal, Sophie G; Guleryuz, Kerem M; Tillou, Xavier P; Doerfler, Arnaud P

2016-01-01

To evaluate a simple and fast technique to ensure negative surgical margins on partial nephrectomies, while correlating margin statuses with the final pathology report. This study was conducted for patients undergoing partial nephrectomy (PN) with T1-T2 renal tumors from January 2010 to the end of December 2015. Before tumor removal, intraoperative ultrasound (US) localization was performed. After tumor removal and before performing hemostasis of the kidney, the specimens were placed in a saline solution and a US was performed to evaluate if the tumor's capsule were intact, and then compared to the final pathology results. In 177 PN(s) (147 open procedures and 30 laparoscopic procedures) were performed on 147 patients. Arterial clamping was done for 32 patients and the mean warm ischemia time was 19 ± 6 min. The mean US examination time was 41 ± 7 s. The US analysis of surgical margins was negative in 172 cases, positive in four, and in only one case it was not possible to conclude. The final pathology results revealed one false positive surgical margin and one false negative surgical margin, while all other margins were in concert with US results. The mean tumor size was 3.53 ± 1.43 cm, and the mean surgical margin was 2.8 ± 1.5 mm. The intraoperative US control of resection margins in PN is a simple, efficient, and effective method for ensuring negative surgical margins with a small increase in warm ischemia time and can be conducted by the operating urologist.

Robotic assisted laparoscopic partial nephrectomy using contrast‐enhanced ultrasound scan to map renal blood flow

PubMed Central

Motiwala, Aamir; Eves, Susannah; Gray, Rob; Thomas, Asha; Meiers, Isabelle; Sharif, Haytham; Motiwala, Hanif; Laniado, Marc; Karim, Omer

2016-01-01

Abstract Objective The paper describes novel real‐time ‘in situ mapping’ and ‘sequential occlusion angiography’ to facilitate selective ischaemia robotic partial nephrectomy (RPN) using intraoperative contrast enhanced ultrasound scan (CEUS). Materials and methods Data were collected and assessed for 60 patients (61 tumours) between 2009 and 2013. 31 (50.8%) tumours underwent ‘Global Ischaemia’, 27 (44.3%) underwent ‘Selective Ischaemia’ and 3 (4.9%) were removed ‘Off Clamp Zero Ischaemia’. Demographics, operative variables, complications, renal pathology and outcomes were assessed. Results Median PADUA score was 9 (range 7–10). The mean warm ischaemia time in selective ischaemia was less and statistically significant than in global ischaemia (17.1 and 21.4, respectively). Mean operative time was 163 min. Postoperative complications (n = 10) included three (5%) Clavien grade 3 or above. Malignancy was demonstrated in 47 (77%) with negative margin in 43 (91.5%) and positive margin in four (8.5%). Long‐term decrease in eGFR post selective ischaemia robotic partial nephrectomy was less compared with global ischaemia (four and eight, respectively) but not statistically significant. Conclusions This technique is safe, feasible and cost‐effective with comparable perioperative outcomes. The technical aspects elucidate the role of intraoperative CEUS to facilitate and ascertain selective ischaemia. Further work is required to demonstrate long‐term oncological outcomes. © 2016 The Authors. The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons, Ltd. PMID:26948671

Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting.

PubMed

Stolzenburg, Jens-Uwe; Kallidonis, Panagiotis; Oh, Min-A; Ghulam, Nabi; Do, Minh; Haefner, Tim; Dietel, Anja; Till, Holger; Sakellaropoulos, George; Liatsikos, Evangelos N

2010-02-01

Laparoendoscopic single-site surgery (LESS) represents the latest innovation in laparoscopic surgery. We compare in dry and animal laboratory the efficacy of recently introduced pre-bent instruments with conventional laparoscopic and flexible instruments in terms of time requirement, maneuverability, and ease of handling. Participants of varying laparoscopic experience were included in the study and divided in groups according to their experience. The participants performed predetermined tasks in dry laboratory using all sets of instruments. An experienced laparoscopic surgeon performed 24 nephrectomies in 12 pigs using all sets of instruments. Single port was used for all instrument sets except for the conventional instruments, which were inserted through three ports. The time required for the performance of dry laboratory tasks and the porcine nephrectomies was recorded. Errors in the performance of dry laboratory tasks of each instrument type were also recorded. Pre-bent instruments had a significant advantage over flexible instruments in terms of time requirement to accomplish tasks and procedures as well as maneuverability. Flexible instruments were more time consuming in comparison to the conventional laparoscopic instruments during the performance of the tasks. There were no significant differences in the time required for the accomplishment of dry laboratory tasks or steps of nephrectomy using conventional instruments through appropriate number of ports in comparison to pre-bent instruments through single port. Pre-bent instruments were less time consuming and with better maneuverability in comparison to flexible instruments in experimental single-port access surgery. Further clinical investigations would elucidate the efficacy of pre-bent instruments.

Robot-assisted partial nephrectomy vs laparoscopic cryoablation for the small renal mass: redefining the minimally invasive 'gold standard'.

PubMed

Emara, Amr M; Kommu, Sashi S; Hindley, Richard G; Barber, Neil J

2014-01-01

To identify differences between the ablative and extirpative minimally invasive techniques of laparoscopic cryoablation (LC) and robot-assisted laparoscopic partial nephrectomy (RPN), respectively, in treating small renal tumours in terms of safety, peri-operative morbidity and early oncological outcomes. Between June 2008 and April 2012 56 patients underwent LC and from October 2010 to April 2012, 47 patients underwent RPN using the Da Vinci robotic platform (Intuitive Surgical, Sunnyvale, CA, USA). Data on intra-operative, postoperative and oncological outcomes were collected prospectively, and were analysed and compared for both groups. The median patient ages were 69 and 60 for the LC and RPN groups, respectively (P < 0.05). There was no significant difference in disease stage, but there was a significant difference in tumour size, with patients in the RPN group having larger tumours. The mean operating times were 146 and 159 min for the LC and RPN groups, respectively (P = 0.094) and the mean blood loss was 47 and 94 mL for the LC and the RPN groups, respectively (P = 0.251). The median length of hospital stay (1 day) was the same for both groups and the mean warm ischaemia time was 23 min in the RPN group. The marginal change in preoperative and 6-week postoperative renal function was recorded: the mean postoperative increase in serum creatinine was 5.4 mmol/L in the LC group and 9.2 mmol/L in the RPN group. Of the 47 patients in the RPN group, two (4.3%) were converted to laparoscopic radical nephrectomy because of difficulty in controlling bleeding during hilar dissection. Only two patients (3.6%) had recurrence in the LC group, both of whom were treated with re-cryoablation. A total of 5.4% of patients in the LC and 4.3% in the RPN group had Clavien grade I postoperative complications, one patient in the LC group had a Clavien grade II complication, while 1.8 and 4.3% of patients had Clavien IIIb in the LC and RPN groups, respectively. Our data confirm that LC is a successful, minimally invasive and safe treatment option for the management of small renal tumours, but the apparently similar characteristics of RPN suggest that an increasing proportion of patients, whatever their age or medical comorbidities, may be reasonably offered a robot-assisted extirpative procedure with the likely benefit of lower risk of local recurrence and need for retreatment. © 2013 The Authors. BJU International © 2013 BJU International.

Potassium-titanyl-phosphate laser assisted robotic partial nephrectomy in a porcine model: can robotic assistance optimize the power needed for effective cutting and hemostasis?

PubMed

Boris, Ronald S; Eun, Daniel; Bhandari, Akshay; Lyall, Kathryn; Bhandari, Mahendra; Rogers, Craig; Alassi, Osama; Menon, Mani

2007-01-01

A potassium-titanyl-phosphate (KTP) laser through robotic endo-wrist instrument has been evaluated as an ablative and hemostatic tool in robotic assisted laparoscopic partial nephrectomy (RALPN). Ten RALPN were performed in five domestic female pigs. The partial nephrectomies were performed with bulldog clamping of the pedicle. Flexible glass fiber carrying 532-nm green light laser was used through a robotic endowrist instrument in two cases. Power usage from 4 to 10 W was tested. The laser probe was explored both as a cutting knife and for hemostasis. The pelvicalyceal system was closed with a running suture. Partial nephrectomies using KTP laser were performed without complications. Mean operative times and warm ischemia times for laser cases were 96 and 18 min, respectively. Mean estimated blood loss was 60 ml compared with 50 ml for non-laser cases. Complete hemostasis with the laser alone could be achieved with a power of 4 W and was found to be effective. In our hands the laser fiber powered up to 10 W was not effective as a quick cutting agent. Histopathologic analysis of the renal remnant revealed a cauterized surface effect with average laser penetration depth less than 1 mm and minimal surrounding cellular injury. The new robotic endowrist instrument carrying flexible glass fiber transmitting 532-nm green light laser is a useful addition to the armamentarium of the robotic urologic setup. Its control by the console surgeon enables quicker and more complete hemostasis of the cut surface in renal sparing surgery using a porcine model. Histologically proven lased depth of less than 1 mm suggests minimal parenchyma damage in an acute setting. Laser application as a cutting agent, however, requires further investigation with interval power settings beyond the limits of this preliminary study. We estimate that effective cutting should be possible with a setting lower than traditionally recommended for solid organs.

The role of the assistant during robot-assisted partial nephrectomy: does experience matter?

PubMed

Potretzke, Aaron M; Knight, Brent A; Brockman, John A; Vetter, Joel; Figenshau, Robert S; Bhayani, Sam B; Benway, Brian M

2016-06-01

The objective of this study was to evaluate surgical outcomes with respect to the experience level of the bedside assistant during robot-assisted partial nephrectomy. A retrospective review was conducted of a prospectively maintained database of 414 consecutive robot-assisted laparoscopic partial nephrectomies performed by experienced robotic surgeons at our institution from April 2011 to September 2014. A senior-level assistant was defined as a resident in his or her post-graduate year (PGY) 4 or 5, or a fellow. Junior-level assistants were considered to be PGY-2, PGY-3, or a nurse first assistant. Multivariate analyses were performed using linear, Poisson, and logistic regression models. There were 115 junior-level cases and 299 senior-level cases. On univariate analysis, the experience level of the assistant had no impact on operative time (168 for junior level vs. 163 min for senior level, p = 0.656). Likewise, there were no differences between the junior- and senior-level groups with regard to warm ischemia time (21.3 vs. 20.9 min, p = 0.843), negative margin status (111/115 (96.5 %) vs. 280/299 (93.6 %), p = 0.340), or postoperative complications (17/115 (14.8 %) vs. 35/299 (11.7 %), p = 0.408). After multivariate analysis, operative time was associated with increased body mass index and tumor size (both p < 0.001), but not with resident experience level (p = 0.051). Estimated blood loss and postoperative complications were also not associated with the PGY of the assistant (p = 0.488 and p = 0.916, respectively). Despite common concern, the PGY status of a physician trainee serving as the bedside assistant does not appear to influence the outcomes of robot-assisted partial nephrectomy at a high-volume center.

Clinical use of a cordless laparoscopic ultrasonic device.

PubMed

Kim, Fernando J; Sehrt, David; Molina, Wilson R; Pompeo, Alexandre

2014-01-01

On April 25, 2012, the first laparoscopic cordless ultrasonic device (Sonicision, Covidien, Mansfield, Massachusetts) was used in a clinical setting. We describe our initial experience. The cordless device is assembled with a reusable battery and generator on a base hand-piece. It has a minimum and maximum power setting controlled by a single trigger for both coagulation and cutting. A laparoscopic radical nephrectomy was performed on a 56-year-old man with a 7-cm right renal mass. A laparoscopic pelvic lymphadenectomy was performed in a 51-year-old man with high-risk prostate cancer. Data on surgical team satisfaction, operative time, number of activations, and times the laparoscope was removed as a result of plume were collected. The surgical technician successfully assembled the device at the beginning of the cases with verbal instructions from the surgeon. Operative time for nephrectomy was 77 minutes, with 143 total activations (minimum = 86, maximum = 57). The operative time for the pelvic lymphadenectomy was 27 minutes, with 38 total activations (minimum = 27, maximum = 11). One battery was used in each case. The laparoscope was removed twice during the nephrectomy and once during the lymphadenectomy. Surgical staff satisfaction survey results revealed easier and faster assembly, more space in the operating room, ergonomic handle, and comparable cutting/coagulation, weight, and plume generation with other devices (Table 1). [Table: see text]. The first clinical application of the pioneering cordless dissector was successfully performed, resulting in surgeons' perceptions of comparable results with other devices of easier and safer use and faster assembly.

Laparoscopic partial nephrectomy for endophytic hilar tumors: feasibility and outcomes.

PubMed

Di Pierro, G B; Tartaglia, N; Aresu, L; Polara, A; Cielo, A; Cristini, C; Grande, P; Gentile, V; Grosso, G

2014-06-01

To analyze feasibility and outcomes of laparoscopic partial nephrectomy (LPN) for endophytic hilar tumors in low-intermediate (ASA I-II) risk patients. This is a single centre retrospective study. From May 2009 to September 2011, 208 LPNs were performed at our institution. Overall 11 (5.2%) elective LPNs were for hilar tumors not visible on kidney surface. Hilar tumor was defined as a mass located in the renal hilum and in contact with a major renal vessel on preoperative imaging. Procedures were carried out by a single experienced surgeon (G.G.) via retroperitoneal approach by clamping the only main renal artery. Mean (range) age of patients was 45.3 years (38.2-64.1), tumor size 1.6 cm (1.2-2.0), warm ischemia time 24 min (19-32), operative time 140 min (110-200) and estimated blood loss 270 ml (100-750). Two collecting system injuries were observed and repaired intraoperatively. No conversion to open surgery was required. Final pathological examination revealed 10 renal cell carcinomas and 1 oncocytoma. A negative surgical margin was obtained in 10/11 (91%) patients. Renal function and serum hemoglobin were nearly unaltered pre and post-surgery. No tumor recurrence was observed at mean (range) follow-up of 34 months (15-43). In experienced hands, LPN represents a feasible, safe and effective treatment for selected patients diagnosed with endophytic hilar masses. A larger number of patients and longer follow-up are required to draw definitive conclusions. Copyright © 2013 Elsevier Ltd. All rights reserved.

Retrograde renal hilar dissection and segmental arterial clamping: a simple modification to achieve super-selective robotic partial nephrectomy.

PubMed

Greene, Richard N; Sutherland, Douglas E; Tausch, Timothy J; Perez, Deo S

2014-03-01

Super-selective vascular control prior to robotic partial nephrectomy (also known as 'zero-ischemia') is a novel surgical technique that promises to reduce warm ischemia time. The technique has been shown to be feasible but adds substantial technical complexity and cost to the procedure. We present a simplified retrograde dissection of the renal hilum to achieve selective vascular control during robotic partial nephrectomy. Consecutive patients with stage 1 solid and complex cystic renal masses underwent robotic partial nephrectomies with selective vascular control using a modification to previously described super-selective robotic partial nephrectomy. In each case, the renal arterial branch supplying the mass and surrounding parenchyma was dissected in a retrograde fashion from the tumor. Intra-renal dissection of the interlobular artery was not performed. Intra-operative immunofluorescence was not utilized as assessment of parenchymal ischemia was documented before partial nephrectomy. Data was prospectively collected in an IRB-approved partial nephrectomy database. Operative variables between patients undergoing super-selective versus standard robotic partial nephrectomy were compared. Super-selective partial nephrectomy with retrograde hilar dissection was successfully completed in five consecutive patients. There were no complications or conversions to traditional partial nephrectomy. All were diagnosed with renal cell carcinoma and surgical margins were all negative. Estimated blood loss, warm ischemia time, operative time and length of stay were all comparable between patients undergoing super-selective and standard robotic partial nephrectomy. Retrograde hilar dissection appears to be a feasible and safe approach to super-selective partial nephrectomy without adding complex renovascular surgical techniques or cost to the procedure.

"Zero ischemia" partial nephrectomy: novel laparoscopic and robotic technique.

PubMed

Gill, Inderbir S; Eisenberg, Manuel S; Aron, Monish; Berger, Andre; Ukimura, Osamu; Patil, Mukul B; Campese, Vito; Thangathurai, Duraiyah; Desai, Mihir M

2011-01-01

Ischemic injury impacts renal function outcomes following partial nephrectomy. Efforts to minimize, better yet, eliminate renal ischemia are imperative. Describe a novel technique of "zero ischemia" laparoscopic (LPN) and robotic-assisted (RAPN) partial nephrectomy. Data were prospectively collected into an institutional review board-approved database. Fifteen consecutive patients underwent zero ischemia procedures: LPN (n=12), RAPN (n=3). Included were all candidates for LPN or RAPN, irrespective of tumor complexity, including tumors that were central (n=9; 60%), hilar (n=1), in solitary kidney (n=1), in patients with chronic kidney disease grade 3 or greater (n=3). Anesthesia-related monitoring included pulmonary artery catheter (ie, Swan-Ganz), transesophageal echocardiography, cerebral oximetry, electroencephalographic bispectral index, mixed venous oxygen measurements, and vigorous hydration/diuresis. Pharmacologically induced hypotension was carefully timed to correspond with excision of the deepest aspect of the tumor. Renal parenchymal reconstruction was completed under normotension, ensuring complete hemostasis. Intraoperative and early postoperative data were collected prospectively. All cases were successfully completed without hilar clamping. Ischemia time was zero in all cases. Median tumor size was 2.5 cm (range: 1-4); operative time was 3 h (range: 1.3-6); blood loss was 150 ml (range: 20-400); and hospital stay was 3 d (range: 2-19). Nadir mean arterial pressure ranged from 52-65 mm Hg (median: 60), typically for 1-5 min. No patient had intraoperative transfusion or complication, acute or delayed renal hemorrhage, or hypotension-related sequelae. Postoperative complications (n=5) included urine retention (n=1), septicemia from presumed prostatitis (n=1), atrial fibrillation (n=1), urine leak (n=2). Pathology confirmed renal cell carcinoma in 13 patients (87%), all with negative margins. Median pre- and postoperative serum creatinine (0.9 mg/dl and 0.95 mg/dl, respectively) and estimated glomerular filtration rate (eGFR) (75.3 and 72.9, respectively) were comparable. Median absolute and percent change in discharge serum creatinine and eGFR were 0 and 0%, respectively. A novel zero ischemia technique for RAPN and LPN for substantial renal tumors is presented. The initial experience is encouraging. Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.

[Which surgical technique should we perform for benign renal disease in children?].

PubMed

Saura, L; Aparicio, L García; Julià, V; Ribó, J M; Rovira, J; Rodó, J; Tarrado, X; Prat, J; Cáceres, F; Morales, L

2007-01-01

The aim of this paper is to analyze our experience in different surgical techniques to perform a nephrectomy for benign renal diseases in children. From 1993 to 2005 we have performed 98 nephrectomies. We have three groups of patients depending on the surgical technique: open nephrectomy (ON), transperitoneal laparoscopic nephrectomy (TLN) and retroperitoneal laparoscopic nephrectomy (RLN). ON was performed in 36 patients. Mean age was 3.3 years. TLN was performed in 39 patients. Mean age was 4.7 years old. RLN was performed in 23 patients. Mean age was 3.6 years old. Criteria to nephrectomy was a renographic function under 19%. We have compared the three surgical techniques in relation with surgical time and mean hospital stay. Mean operative time was 126.2 minutes in ON, 132.3 minutes in TLN and 134.1 minutes in RLN. Mean stay was 5.02 days in ON, 2.35 days in TLN and 1.86 days in RLN. The median hospital stay of the ON group is significantly longer than that of NLT and NR groups (p < 0.05). However, there are no differences related to surgical time between all the groups. Nephrectomy may be performed for benign disease in children using less invasive surgical techniques. They are associated with minimal morbidity, minimal postoperative discomfort, improve cosmesis and a shorter hospital stay. However, we haven't found differences between TLN and RLN.

Impact of parenchymal loss on renal function after laparoscopic partial nephrectomy under warm ischemia.

PubMed

Bagheri, Fariborz; Pusztai, Csaba; Farkas, László; Kallidonis, Panagiotis; Buzogány, István; Szabó, Zsuzsanna; Lantos, János; Imre, Marianna; Farkas, Nelli; Szántó, Árpád

2016-12-01

To elucidate the impact of renal parenchymal loss and the ischemic reperfusion injury (RI) on the renal function after laparoscopic partial nephrectomy (LPN) under warm ischemia (WI). Thirty-five patients with a single polar renal mass ≤4 cm and normal contralateral kidney underwent LPN. Transperitoneal LPN with WI using en bloc hilar occlusion was performed. The total differential renal function (T-DRF) using 99m Tc-dimercaptosuccinic acid was evaluated preoperatively and postoperatively over a period of 1 year. A special region of interest (ROI) was selected on the non-tumorous pole of the involved kidney, and was compared with the same ROI in the contralateral kidney. The latter comparison was defined as partial differential renal function (P-DRF). Any postoperative decline in the P-DRF of the operated kidney was attributed to the RI. Subtraction of the P-DRF decline from the T-DRF decline was attributed to the parenchymal loss caused by the resection of the tumor and suturing of the normal parenchyma. The mean WI time was 22 min, and the mean weight of resected specimen was 18 g. The mean postoperative eGFR declined to 87 ml/min/1.73 m 2 from its baseline mean value of 97 ml/min/1.73 m 2 (p value = 0.075). Mean postoperative T-DRF and P-DRF of the operated kidney declined by 7 and 3 %, respectively. After LPN of small renal mass, decline in renal function is primarily attributed to parenchymal loss caused by tumor resection and suturing of the normal parenchyma rather than the RI.

Obesity, hypertension and diabetes mellitus affect complication rate of different nephrectomy techniques.

PubMed

Hua, X; Ying-Ying, C; Zu-Jun, F; Gang, X; Zu-Quan, X; Qiang, D; Hao-Wen, J

2014-12-01

To investigate whether obesity, hypertension, and diabetes mellitus (DM) would increase post-nephrectomy complication rates using standardized classification method. We retrospectively included 843 patients from March 2006 to November 2012, of whom 613 underwent radical nephrectomy (RN) and 229 had partial nephrectomy (PN). Modified Clavien classification system was applied to quantify complication severity of nephrectomy. Fisher's exact or chi-square test was used to assess the relationship between complication rates and obesity, hypertension, as well as DM. The prevalence of obesity, hypertension, and DM was 11.51%, 30.84%, 8.78%, respectively. The overall complication rate was 19.31%, 30.04%, 35.71% and 36.36% for laparoscopic radical nephrectomy (LRN), open-RN, LPN and open-PN respectively. An increasing trend of low grade complication rate as BMI increased was observed in LRN (P=.027) and open-RN (P<.001). Obese patients had greater chance to have low grade complications in LRN (OR=4.471; 95% CI: 1.290-17.422; P=0.031) and open-RN (OR=2.448; 95% CI: 1.703-3.518; P<.001). Patients with hypertension were more likely to have low grade complications, especially grade ii complications in open-RN (OR=1.526; 95% CI: 1.055-2.206; P=.026) and open PN (OR=2.032; 95% CI: 1.199-3.443; P=.009). DM was also associated with higher grade i complication rate in open-RN (OR=2.490; 95% CI: 331-4.657; P=.016) and open-PN (OR=4.425; 95% CI: 1.815-10.791; P=.013). High grade complication rates were similar in comparison. Obesity, hypertension, and DM were closely associated with increased post-nephrectomy complication rates, mainly low grade complications. Copyright © 2013 AEU. Published by Elsevier Espana. All rights reserved.

Long-term survival following partial vs radical nephrectomy among older patients with early-stage kidney cancer.

PubMed

Tan, Hung-Jui; Norton, Edward C; Ye, Zaojun; Hafez, Khaled S; Gore, John L; Miller, David C

2012-04-18

Although partial nephrectomy is the preferred treatment for many patients with early-stage kidney cancer, recent clinical trial data, which demonstrate better survival for patients treated with radical nephrectomy, have generated new uncertainty regarding the comparative effectiveness of these treatment options. To compare long-term survival after partial vs radical nephrectomy among a population-based patient cohort whose treatment reflects contemporary surgical practice. We performed a retrospective cohort study of Medicare beneficiaries with clinical stage T1a kidney cancer treated with partial or radical nephrectomy from 1992 through 2007. Using an instrumental variable approach to account for measured and unmeasured differences between treatment groups, we fit a 2-stage residual inclusion model to estimate the treatment effect of partial nephrectomy on long-term survival. Overall and kidney cancer-specific survival. Among 7138 Medicare beneficiaries with early-stage kidney cancer, we identified 1925 patients (27.0%) treated with partial nephrectomy and 5213 patients (73.0%) treated with radical nephrectomy. During a median follow-up of 62 months, 487 (25.3%) and 2164 (41.5%) patients died following partial or radical nephrectomy, respectively. Kidney cancer was the cause of death for 37 patients (1.9%) treated with partial nephrectomy, and 222 patients (4.3%) treated with radical nephrectomy. Patients treated with partial nephrectomy had a significantly lower risk of death (hazard ratio [HR], 0.54; 95% CI, 0.34-0.85). This corresponded with a predicted survival increase with partial nephrectomy of 5.6 (95% CI, 1.9-9.3), 11.8 (95% CI, 3.9-19.7), and 15.5 (95% CI, 5.0-26.0) percentage points at 2, 5, and 8 years posttreatment (P < .001). No difference was noted in kidney cancer-specific survival (HR, 0.82; 95% CI, 0.19-3.49). Among Medicare beneficiaries with early-stage kidney cancer who were candidates for either surgery, treatment with partial rather than radical nephrectomy was associated with improved survival.

Inferior vena cava tumor thrombus after partial nephrectomy for renal cell carcinoma.

PubMed

Akatsuka, Jun; Suzuki, Yasutomo; Hamasaki, Tsutomu; Shindo, Takao; Yanagi, Masato; Kimura, Go; Yamamoto, Yoichiro; Kondo, Yukihiro

2014-03-29

Partial nephrectomy is now the gold standard treatment for small renal tumors. Local recurrence is a major problem after partial nephrectomy, and local recurrence in the remnant kidney after partial nephrectomy is common. A 77-year-old man underwent right partial nephrectomy for a T1 right renal cell carcinoma. Microscopic examination revealed a clear cell renal carcinoma, grade 2, stage pT3a. Although the surgical margin was negative, the carcinoma invaded the perirenal fat, and vascular involvement was strongly positive. Thirty months after partial nephrectomy, an enhanced computed tomographic scan showed local recurrence of the renal cell carcinoma extending into the inferior vena cava without renal mass. Hence, we performed right radical nephrectomy and intracaval thrombectomy. Microscopic examination revealed a clear cell carcinoma grade 2, stage pT3a + b. The patient is still alive with no evidence of recurrence 10 months post-procedure. To our knowledge, local recurrence of renal cell carcinoma extending into the inferior vena cava after partial nephrectomy has not been reported in the literature. Our case report emphasizes the importance of strict surveillance of patients after partial nephrectomy, especially for those with renal cell carcinoma positive for microvessel involvement.

Robotic assisted laparoscopic partial nephrectomy using contrast-enhanced ultrasound scan to map renal blood flow.

PubMed

Alenezi, Ahmad; Motiwala, Aamir; Eves, Susannah; Gray, Rob; Thomas, Asha; Meiers, Isabelle; Sharif, Haytham; Motiwala, Hanif; Laniado, Marc; Karim, Omer

2017-03-01

The paper describes novel real-time 'in situ mapping' and 'sequential occlusion angiography' to facilitate selective ischaemia robotic partial nephrectomy (RPN) using intraoperative contrast enhanced ultrasound scan (CEUS). Data were collected and assessed for 60 patients (61 tumours) between 2009 and 2013. 31 (50.8%) tumours underwent 'Global Ischaemia', 27 (44.3%) underwent 'Selective Ischaemia' and 3 (4.9%) were removed 'Off Clamp Zero Ischaemia'. Demographics, operative variables, complications, renal pathology and outcomes were assessed. Median PADUA score was 9 (range 7-10). The mean warm ischaemia time in selective ischaemia was less and statistically significant than in global ischaemia (17.1 and 21.4, respectively). Mean operative time was 163 min. Postoperative complications (n = 10) included three (5%) Clavien grade 3 or above. Malignancy was demonstrated in 47 (77%) with negative margin in 43 (91.5%) and positive margin in four (8.5%). Long-term decrease in eGFR post selective ischaemia robotic partial nephrectomy was less compared with global ischaemia (four and eight, respectively) but not statistically significant. This technique is safe, feasible and cost-effective with comparable perioperative outcomes. The technical aspects elucidate the role of intraoperative CEUS to facilitate and ascertain selective ischaemia. Further work is required to demonstrate long-term oncological outcomes. © 2016 The Authors. The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons, Ltd. © 2016 The Authors. The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons, Ltd.

Laparoscopic nephrectomy for giant staghorn calculus with non-functioning kidneys: Is associated unsuspected urothelial carcinoma responsible for conversion? Report of 2 cases

PubMed Central

Shah, Hemendra Navinchandra; Jain, Pritesh; Chibber, Percy Jal

2006-01-01

Background- Neglected renal stones remain a major cause of morbidity in developing countries. They not only result in functional impairment of affected kidney, but also act as an important predisposing factor for development of urothelial neoplasms. It is not uncommon to miss an associated urothelial tumor in a patient of nephrolithiasis preoperatively. Case presentation- In last 3 years, we came across two patients with giant staghorn calculus and poorly functioning kidneys who underwent laparoscopic nephrectomy. In view of significant perirenal adhesions & loss of normal tissue planes both these patients were electively converted to open surgery. The pathological examination of specimen revealed an unsuspected urothelial carcinoma in both these patients. The summary of our cases and review of literature is presented. Conclusion- It is important to keep a differential diagnosis of associated urothelial malignancy in mind in patient presenting with long standing renal calculi. The exact role of a computerized tomography and cytology in preoperative workup for detection of possible associated malignancy in such condition is yet to be defined. Similarly if laparoscopic dissection appears difficult during nephrectomy for a renal calculus with non-functional kidney, keeping a possibility of associated urothelial malignancy in mind it is advisable to dissect in a plane outside gerotas fascia as for radical nephrectomy. PMID:16398940

Long-term survival following partial versus radical nephrectomy among older patients with early-stage kidney cancer

PubMed Central

Tan, Hung-Jui; Norton, Edward C.; Ye, Zaojun; Hafez, Khaled S.; Gore, John L.; Miller, David C.

2013-01-01

Context Although partial nephrectomy is the preferred treatment for many patients with early-stage kidney cancer, recent clinical trial data demonstrating better survival for patients treated with radical nephrectomy has generated new uncertainty regarding the comparative effectiveness of these treatment options. Objective We sought to clarify this issue by performing an instrumental variable analysis comparing long-term survival after partial versus radical nephrectomy among a population-based patient cohort whose treatment reflects contemporary surgical practice. Design, Setting, and Patients We performed a retrospective cohort study of Medicare beneficiaries with clinical stage T1a kidney cancer treated from 1992 through 2007 with partial or radical nephrectomy. Using an instrumental variable approach to account for measured and unmeasured differences between treatment groups, we fit a two-stage residual inclusion model to estimate the treatment effect of partial nephrectomy on long-term survival. Main outcome measures Overall and kidney cancer-specific survival. Results Among 7,138 Medicare beneficiaries with early-stage kidney cancer, we identified 1,925 (27.0%) patients treated with partial nephrectomy, and 5,213 (73.0%) patients treated with radical nephrectomy. During a median follow-up of 62 months, 487 (25.3%) and 2,164 (41.5%) patients died following partial or radical nephrectomy, respectively. Kidney cancer was the cause of death for 37 (1.9%) patients treated with partial nephrectomy, and 222 (4.3%) patients treated with radical nephrectomy. Patients treated with partial nephrectomy had a significantly lower risk of death (HR 0.54, 95% CI 0.34-0.85). This corresponded to a predicted survival increase with partial nephrectomy of 5.6 (95% CI 1.9-9.3), 11.8 (95% CI 3.9-19.7), and 15.5 (95% CI 5.0-26.0) percentage points at 2-, 5-, and 8-years post-treatment (p<0.001). No difference was noted in kidney cancer-specific survival (HR 0.82, 95% CI 0.19-3.49). Conclusions Among Medicare beneficiaries with early-stage kidney cancer who were candidates for either surgery, treatment with partial rather than radical nephrectomy was associated with improved survival. PMID:22511691

Single surgeon's experience with laparoscopic versus robotic partial nephrectomy: perioperative outcomes/complications and influence of tumor characteristics on choice of therapy.

PubMed

Lee, Nora G; Zampini, Anna; Tuerk, Ingolf

2012-10-01

Laparoscopic (LPN) and robotic partial nephrectomy (RPN) may offer similar advantages for nephron-sparing surgery (NSS). We evaluated the perioperative outcomes and complications of LPN versus RPN and sought to evaluate if one technique may have more favorable outcomes over another based on tumor characteristics. All patients who underwent LPN and RPN by a single surgeon were retrospectively reviewed. The surgeon almost exclusively performed LPN from February 2009 to January 2011 and RPN from January 2011 to January 2012. Patient demographics, tumor characteristics, perioperative outcomes, short term renal functional data, and complications were reviewed. Operative time (OT), warm ischemia time (WIT), and estimated blood loss (EBL) were evaluated for each technique when tumor characteristics were divided by size, location, distance to collecting system, and overall tumor complexity based on nephrometry scoring. Of 39 laparoscopic cases and 30 robotic cases, there were no significant differences in perioperative outcomes, short term renal functional data, or complications between the two groups except for WIT which was shorter in the LPN group (p = 0.006). For medium complexity tumors, OT was less for LPN compared to RPN (p = 0.04); for high complexity tumors, EBL was reduced for RPN compared to LPN cases (p = 0.003). When tumor characteristics were individualized, LPN may be superior to RPN for WIT for small, anterior and exophytic tumors, and tumors located > 5 mm from the collecting system. LPN and RPN appear more equivocal for WIT in posteriorly located tumors. Reduced EBL may be a benefit with RPN for larger tumors. Although WIT was less in patients undergoing LPN compared to RPN, perioperative outcomes and complications remain similar. RPN may be beneficial for approaching more difficult, posterior tumors, whereas LPN may be a better technique for WIT for simple, accessible renal tumors. Reduced EBL may be a benefit for RPN for highly complex tumors.

Laparoscopic partial nephrectomy for hilar tumors: oncologic and renal functional outcomes.

PubMed

George, Arvin K; Herati, Amin S; Rais-Bahrami, Soroush; Waingankar, Nikhil; Kavoussi, Louis R

2014-01-01

To present our experience with laparoscopic partial nephrectomy (LPN) for hilar tumors and evaluate intermediate oncologic and renal functional outcomes. A retrospective review of LPN cases performed in 488 patients was performed. Hilar lesions were defined as renal cortical tumors in direct physical contact with the renal artery, vein, or both, as identified on preoperative imaging and confirmed intraoperatively. The clinicopathologic parameters, perioperative course, complications, and oncologic and 6-month renal functional outcomes were analyzed. A total of 488 patients underwent LPN, of which 43 were hilar. The mean tumor size for hilar and nonhilar tumors was 3.6 cm and 3.1 cm, respectively. The mean operative time was shorter for hilar as compared with nonhilar tumors (129.1 minutes vs 141.8 minutes). Mean estimated blood loss was greater in LPN for hilar tumors (311.65 mL vs 298.4 mL). There were no statistically significant differences noted in any of the perioperative parameters investigated despite a higher nephrometry complexity score in the hilar group. Change in estimated glomerular filtration rate at 6 months showed a decrease of 10.9 mL/min and 8.8 mL/min for hilar and nonhilar tumors, respectively (P = NS). There was 1 recurrence detected in the hilar group, with a median follow-up of 41.6 months. In the hands of an experienced laparoscopist, LPN can safely be performed for hilar tumors, with preservation of perioperative outcomes and durable renal functional and oncologic outcomes. Copyright © 2014 Elsevier Inc. All rights reserved.

Robotic partial nephrectomy shortens warm ischemia time, reducing suturing time kinetics even for an experienced laparoscopic surgeon: a comparative analysis.

PubMed

Faria, Eliney F; Caputo, Peter A; Wood, Christopher G; Karam, Jose A; Nogueras-González, Graciela M; Matin, Surena F

2014-02-01

Laparoscopic and robotic partial nephrectomy (LPN and RPN) are strongly related to influence of tumor complexity and learning curve. We analyzed a consecutive experience between RPN and LPN to discern if warm ischemia time (WIT) is in fact improved while accounting for these two confounding variables and if so by which particular aspect of WIT. This is a retrospective analysis of consecutive procedures performed by a single surgeon between 2002-2008 (LPN) and 2008-2012 (RPN). Specifically, individual steps, including tumor excision, suturing of intrarenal defect, and parenchyma, were recorded at the time of surgery. Multivariate and univariate analyzes were used to evaluate influence of learning curve, tumor complexity, and time kinetics of individual steps during WIT, to determine their influence in WIT. Additionally, we considered the effect of RPN on the learning curve. A total of 146 LPNs and 137 RPNs were included. Considering renal function, WIT, suturing time, renorrhaphy time were found statistically significant differences in favor of RPN (p < 0.05). In the univariate analysis, surgical procedure, learning curve, clinical tumor size, and RENAL nephrometry score were statistically significant predictors for WIT (p < 0.05). RPN decreased the WIT on average by approximately 7 min compared to LPN even when adjusting for learning curve, tumor complexity, and both together (p < 0.001). We found RPN was associated with a shorter WIT when controlling for influence of the learning curve and tumor complexity. The time required for tumor excision was not shortened but the time required for suturing steps was significantly shortened.

The role of hemostatic agents in preventing complications in laparoscopic partial nephrectomy

PubMed Central

y Gregorio, Sergio Alonso; Rivas, Juan Gómez; Bazán, Alfredo Aguilera; Sebastián, Jesús Díez; Martínez-Piñeiro, Luis

2017-01-01

Introduction Nephron-sparing surgery is currently the treatment of choice for renal cell carcinoma stage T1a. During the past years, several hemostatic agents (HA) have been developed in order to reduce surgical complications. We present the results of our series and the impact of the use of HA in the prevention of surgical complications in laparoscopic partial nephrectomies (LPNs). Material and methods We retrospectively analyzed all LPN performed in our center from 2005 to 2012. A total of 77 patients were included for analysis. Patients were divided into two groups: Group A (no use of HA) and Group B (use of HA). HA used included gelatin matrix thrombin (FloSeal) and oxidized regenerated cellulose (Surgicel). Demographics, perioperative variables, and complications were analyzed with a special interest in postoperative bleeding and urinary leakage. Results Median age was 57.17 years old (±12.1), 72.7% were male, most common comorbidities were hypertension (33.8%) and diabetes mellitus (18.2%). All patients had one solitary tumor, and 87% had a tumor ≤4 cm. Renal cell carcinoma was found in 79.2% of cases, and 78.7% were stage pT1a. and were used in 36 cases (46.8%). No differences were found in demographics, perioperative variables, and complications between groups. No conversions to open surgery or perioperative mortality were reported. Conclusions We conclude that in our series the use of a hemostatic agent did not offer benefit in reducing the complication rate over sutures over a bolster. PMID:29410886

Feasibility study for image guided kidney surgery: assessment of required intraoperative surface for accurate image to physical space registrations

NASA Astrophysics Data System (ADS)

Benincasa, Anne B.; Clements, Logan W.; Herrell, S. Duke; Chang, Sam S.; Cookson, Michael S.; Galloway, Robert L.

2006-03-01

Currently, the removal of kidney tumor masses uses only direct or laparoscopic visualizations, resulting in prolonged procedure and recovery times and reduced clear margin. Applying current image guided surgery (IGS) techniques, as those used in liver cases, to kidney resections (nephrectomies) presents a number of complications. Most notably is the limited field of view of the intraoperative kidney surface, which constrains the ability to obtain a surface delineation that is geometrically descriptive enough to drive a surface-based registration. Two different phantom orientations were used to model the laparoscopic and traditional partial nephrectomy views. For the laparoscopic view, fiducial point sets were compiled from a CT image volume using anatomical features such as the renal artery and vein. For the traditional view, markers attached to the phantom set-up were used for fiducials and targets. The fiducial points were used to perform a point-based registration, which then served as a guide for the surface-based registration. Laser range scanner (LRS) obtained surfaces were registered to each phantom surface using a rigid iterative closest point algorithm. Subsets of each phantom's LRS surface were used in a robustness test to determine the predictability of their registrations to transform the entire surface. Results from both orientations suggest that about half of the kidney's surface needs to be obtained intraoperatively for accurate registrations between the image surface and the LRS surface, suggesting the obtained kidney surfaces were geometrically descriptive enough to perform accurate registrations. This preliminary work paves the way for further development of kidney IGS systems.

Cost effectiveness of open versus laparoscopic living-donor nephrectomy.

PubMed

Hamidi, Vida; Andersen, Marit Helen; Oyen, Ole; Mathisen, Lars; Fosse, Erik; Kristiansen, Ivar Sønbø

2009-03-27

Kidney transplantation is an essential part of care for patients with end-stage renal disease. The introduction of laparoscopic living-donor nephrectomy (LLDN) has made live donation more advantageous because of less postoperative pain, earlier return to normal activities, and a consequent potential to increase the pool of kidney donors. However, the cost effectiveness of LLDN remains unknown. The aim of this study was to explore the health and cost consequences of replacing open-donor nephrectomy by LLDN. Kidney donors were randomized to laparoscopic (n=63) or open surgery (n=59). We obtained data on operating time, personnel costs, length of stay, cost of analgesic, disposable instruments and complications, and indirect costs. Quality of life was captured before the operation and at 1, 6, and 12 months postdonation by means of short form-36. The scores were translated into utilities by means of Brazier's 6D algorithm. The cost per patient was U.S. $55,292 with laparoscopic and U.S. $29,886 with open surgery. The greatest cost difference was in costs attributed to complications (U.S. $33,162 vs. U.S. $4,573). The 1-year quality-adjusted life years (QALYs) were 0.780 and 0.765, respectively for laparoscopic and open surgery. This implies a cost of U.S. $1,693,733 per QALY at 12 months follow-up. Sensitivity analyses indicated that the cost of the major complications in the laparoscopic group and magnitude of QALY gain had the greatest impact on cost effectiveness. The LLDN is an attractive alternative because it, in general, entails less postoperative pain than open surgery, but it is cost effective only with relatively low rates of complications.

Laparoscopic donor nephrectomy increases the supply of living donor kidneys: a center-specific microeconomic analysis.

PubMed

Kuo, P C; Johnson, L B

2000-05-27

A tenet of microeconomics is that new technology will shift the supply curve to the right. Laparoscopic donor nephrectomy (LDN) is a new technique for removal of living donor kidneys. Centers performing this procedure have noted an increased number of patients presenting for donor evaluation. This has not been previously studied. The records of all LDN performed from May 1998 to February 1999 were reviewed. The following variables were examined: sex, age, related vs. unrelated donation, estimated blood loss, i.v. analgesia, length of stay, and time out of work. Donors undergoing traditional open donor nephrectomy during January 1997 to May 1998 served as the control group. A composite cost index was constructed. LDN significantly decreased length of stay, pain, and time out of work; the supply function shifted to the right. Telephone interviews revealed that 47% donated solely because of the LDN procedure. LDN increases the supply of living donor kidneys.

Feasibility and accuracy of computational robot-assisted partial nephrectomy planning by virtual partial nephrectomy analysis.

PubMed

Isotani, Shuji; Shimoyama, Hirofumi; Yokota, Isao; China, Toshiyuki; Hisasue, Shin-ichi; Ide, Hisamitsu; Muto, Satoru; Yamaguchi, Raizo; Ukimura, Osamu; Horie, Shigeo

2015-05-01

To evaluate the feasibility and accuracy of virtual partial nephrectomy analysis, including a color-coded three-dimensional virtual surgical planning and a quantitative functional analysis, in predicting the surgical outcomes of robot-assisted partial nephrectomy. Between 2012 and 2014, 20 patients underwent virtual partial nephrectomy analysis before undergoing robot-assisted partial nephrectomy. Virtual partial nephrectomy analysis was carried out with the following steps: (i) evaluation of the arterial branch for selective clamping by showing the vascular-supplied area; (ii) simulation of the optimal surgical margin in precise segmented three-dimensional model for prediction of collecting system opening; and (iii) detailed volumetric analyses and estimates of postoperative renal function based on volumetric change. At operation, the surgeon identified the targeted artery and determined the surgical margin according to the virtual partial nephrectomy analysis. The surgical outcomes between the virtual partial nephrectomy analysis and the actual robot-assisted partial nephrectomy were compared. All 20 patients had negative cancer surgical margins and no urological complications. The tumor-specific renal arterial supply areas were shown in color-coded three-dimensional model visualization in all cases. The prediction value of collecting system opening was 85.7% for sensitivity and 100% for specificity. The predicted renal resection volume was significantly correlated with actual resected specimen volume (r(2) = 0.745, P < 0.001). The predicted estimated glomerular filtration rate was significantly correlated with actual postoperative estimated glomerular filtration rate (r(2) = 0.736, P < 0.001). Virtual partial nephrectomy analysis is able to provide the identification of tumor-specific renal arterial supply, prediction of collecting system opening and prediction of postoperative renal function. This technique might allow urologists to compare various arterial clamping methods and resection margins with surgical outcomes in a non-invasive manner. © 2015 The Japanese Urological Association.

MDCT evaluation of potential living renal donor, prior to laparoscopic donor nephrectomy: What the transplant surgeon wants to know?

PubMed Central

Ghonge, Nitin P; Gadanayak, Satyabrat; Rajakumari, Vijaya

2014-01-01

As Laparoscopic Donor Nephrectomy (LDN) offers several advantages for the donor such as lesser post-operative pain, fewer cosmetic concerns and faster recovery time, there is growing global trend towards LDN as compared to open nephrectomy. Comprehensive pre-LDN donor evaluation includes assessment of renal morphology including pelvi-calyceal and vascular system. Apart from donor selection, evaluation of the regional anatomy allows precise surgical planning. Due to limited visualization during laparoscopic renal harvesting, detailed pre-transplant evaluation of regional anatomy, including the renal venous anatomy is of utmost importance. MDCT is the modality of choice for pre-LDN evaluation of potential renal donors. Apart from appropriate scan protocol and post-processing methods, detailed understanding of surgical techniques is essential for the Radiologist for accurate image interpretation during pre-LDN MDCT evaluation of potential renal donors. This review article describes MDCT evaluation of potential living renal donor, prior to LDN with emphasis on scan protocol, post-processing methods and image interpretation. The article laid special emphasis on surgical perspectives of pre-LDN MDCT evaluation and addresses important points which transplant surgeons want to know. PMID:25489130

Migrated Hem-o-Lok clips in the ureter: a rare cause of recurrent urinary tract infection.

PubMed

Shrivastava, Prashant; Nayak, Brusabhanu; Singh, Prabhjot

2017-02-15

Erosion of surgical materials into the adjacent organs following surgical procedures is a rare complication. Migrations of these surgical materials into the urinary tract like pelvicalyceal system, ureter and bladder have been reported following various urological procedures. We present a case of migrated Hem-o-Lok clips into the ureter following a laparoscopic partial nephrectomy for angiomyolipoma of the left kidney presented with recurrent urinary tract infection. The case was managed with ureteroscopic removal of clips. The patient is asymptomatic on last follow-up. 2017 BMJ Publishing Group Ltd.

[Hybrid operating room: For what?

PubMed

Benoit, M; Bouvier, A; Bigot, P

2017-11-01

Hybrid operating rooms (HOR) are rooms that mix interventional radiology and surgical equipments. They are usually used in heart, vascular, orthopedic and neurosurgery, and make it possible to consider new minimally invasive procedures in urology. Thanks to these, we developed a new partial nephrectomy technique without renal pedicle clamping and without ischemia. Renal cancer is now diagnosed at localized stage in most of the cases, and its treatment is mostly based on nephron sparing surgery. However, the hemorrhagic character of this intervention requires a renal pedicle clamping whose long-term consequences on renal function are discussed. It also exposes to a classical complication: the renal artery pseudoaneurysm. Therefore, we developed a new laparoscopic partial nephrectomy technique without clamping or approach of renal pedicle, by a selective embolization of tumor vessels through an endovascular route, immediately before the surgery. HOR allowed the combination of the two procedures in the same time and space unit. Tumor staining by Bleu Patenté also aids the surgeon in its spotting. HOR allow a new approach in localized renal cancer management, and should be used in many other urologic surgeries in years to come. They represent a technological advancement by combining interventional radiologists and surgeons' expertise. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Localized renal cell carcinoma management: an update.

PubMed

Heldwein, Flavio L; McCullough, T Casey; Souto, Carlos A V; Galiano, Marc; Barret, Eric

2008-01-01

To review the current modalities of treatment for localized renal cell carcinoma. A literature search for keywords: renal cell carcinoma, radical nephrectomy, nephron sparing surgery, minimally invasive surgery, and cryoablation was performed for the years 2000 through 2008. The most relevant publications were examined. New epidemiologic data and current treatment of renal cancer were covered. Concerning the treatment of clinically localized disease, the literature supports the standardization of partial nephrectomy and laparoscopic approaches as therapeutic options with better functional results and oncologic success comparable to standard radical resection. Promising initial results are now available for minimally invasive therapies, such as cryotherapy and radiofrequency ablation. Active surveillance has been reported with acceptable results, including for those who are poor surgical candidates. This review covers current advances in radical and conservative treatments of localized kidney cancer. The current status of nephron-sparing surgery, ablative therapies, and active surveillance based on natural history has resulted in great progress in the management of localized renal cell carcinoma.

Laparoscopic Partial Nephrectomy with Diode Laser: A Promising Technique

PubMed Central

Knezevic, Nikola; Maric, Marjan; Grkovic, Marija Topalovic; Krhen, Ivan; Kastelan, Zeljko

2014-01-01

Abstract Objective: The aim of this study was to evaluate application of diode laser in laparoscopic partial nephrectomy (LPN), and to question this technique in terms of ease of tumor excision and reduction of warm ischemia time (WIT). Background data: LPN is the standard operative method for small renal masses. The benefits of LPN are numerous, including preserving renal function and prolonging overall survival. However, reduction of WIT remains main challenge in this operation. In order to shorten WIT, many techniques have been developed, with variable results. Patients and methods: We performed a prospective collection and analysis of health records for patients who were operated on between March 2011 and August 2012. Inclusion criteria were single tumor ≤4 cm, predominant exophytic growth and intraparenchymal depth ≤1.5 cm, with a minimum distance of 5 mm from the urinary collecting system. Results: We operated on 17 patients. Median operative time was 170 min. In all but two patients, we had to perform hilar clamping. Median duration of WIT was 16 min. Pathohistological evaluation revealed clear cell renal cancer and confirmed margins negative for tumor in all cases. Median size of the tumor was 3 cm. Median postoperative hospitalization was 5 days. Average follow up was 11.5 months. There were no intraoperative complications. One postoperative complication was noted: perirenal hematoma. Conclusions: Laser LPN is feasible, and offers the benefit of shorter WIT, with effective tissue coagulation and hemostasis. With operative experience and technical advances, WIT will be reduced or even eliminated, and a solution to some technical difficulties, such as significant smoke production, will be found. PMID:24460067

Benefits and shortcomings of superselective transarterial embolization of renal tumors before zero ischemia laparoscopic partial nephrectomy.

PubMed

D'Urso, L; Simone, G; Rosso, R; Collura, D; Castelli, E; Giacobbe, A; Muto, G L; Comelli, S; Savio, D; Muto, G

2014-12-01

To report feasibility, safety and effectiveness of "zero-ischemia" laparoscopic partial nephrectomy (LPN) following preoperative superselective transarterial embolization (STE) for clinical T1 renal tumors. We retrospectively reviewed perioperative data of 23 consecutive patients, who underwent STE prior LPN between March 2010 and November 2012 for incidental clinical T1 renal mass. STE was performed by two experienced radiologists the day before surgery. Surgical procedures were performed in extended flank position, transperitoneally, by a single surgeon. Mean patients age was 68 years (range 56-74), mean tumor size was 3.5 cm (range 2.2-6.3 cm). STE was successfully completed in 16 patients 12-15 h before surgery. In 4 cases STE failed to provide a complete occlusion of all feeding arteries, while in 3 cases the ischemic area was larger than expected. LPN was successfully completed in all patients but one where open conversion was necessary; a "zero-ischemia" approach was performed in 19/23 patients (82.6%) while hilar clamp was necessary in 4 cases, with a mean warm-ischemia time of 14.8 min (range 5-22). Mean operative time was 123 min (range 115-130) and mean intraoperative blood loss was 250 mL (range 20-450). No patient experienced postoperative acute renal failure and no patient developed new onset IV stage chronic kidney disease at 1-yr follow-up. STE is a viable option to perform "zero-ischemia" LPN at beginning of learning curve; however, hilar clamp was necessary to achieve a relatively blood-less field in 17.4% of cases. Copyright © 2014 Elsevier Ltd. All rights reserved.

A retrospective analysis of laparoscopic partial nephrectomy with segmental renal artery clamping and factors that predict postoperative renal function.

PubMed

Li, Pu; Qin, Chao; Cao, Qiang; Li, Jie; Lv, Qiang; Meng, Xiaoxin; Ju, Xiaobing; Tang, Lijun; Shao, Pengfei

2016-10-01

To evaluate the feasibility and efficiency of laparoscopic partial nephrectomy (LPN) with segmental renal artery clamping, and to analyse the factors affecting postoperative renal function. We conducted a retrospective analysis of 466 consecutive patients undergoing LPN using main renal artery clamping (group A, n = 152) or segmental artery clamping (group B, n = 314) between September 2007 and July 2015 in our department. Blood loss, operating time, warm ischaemia time (WIT) and renal function were compared between groups. Univariable and multivariable linear regression analyses were applied to assess the correlations of selected variables with postoperative glomerular filtration rate (GFR) reduction. Volumetric data and estimated GFR of a subset of 60 patients in group B were compared with GFR to evaluate the correlation between these functional variables and preserved renal function after LPN. The novel technique slightly increased operating time, WIT and intra-operative blood loss (P < 0.001), while it provided better postoperative renal function (P < 0.001) compared with the conventional technique. The blocking method and tumour characteristics were independent factors affecting GFR reduction, while WIT was not an independent factor. Correlation analysis showed that estimated GFR presented better correlation with GFR compared with kidney volume (R(2) = 0.794 cf. R(2) = 0.199) in predicting renal function after LPN. LPN with segmental artery clamping minimizes warm ischaemia injury and provides better early postoperative renal function compared with clamping the main renal artery. Kidney volume has a significantly inferior role compared with eGFR in predicting preserved renal function. © 2016 The Authors BJU International © 2016 BJU International Published by John Wiley & Sons Ltd.

The Piezo Actuator-Driven Pulsed Water Jet System for Minimizing Renal Damage after Off-Clamp Laparoscopic Partial Nephrectomy.

PubMed

Kamiyama, Yoshihiro; Yamashita, Shinichi; Nakagawa, Atsuhiro; Fujii, Shinji; Mitsuzuka, Koji; Kaiho, Yasuhiro; Ito, Akihiro; Abe, Takaaki; Tominaga, Teiji; Arai, Yoichi

2017-09-01

In the setting of partial nephrectomy (PN) for renal cell carcinoma, postoperative renal dysfunction might be caused by surgical procedure. The aim of this study was to clarify the technical safety and renal damage after off-clamp laparoscopic PN (LPN) with a piezo actuator-driven pulsed water jet (ADPJ) system. Eight swine underwent off-clamp LPN with this surgical device, while off-clamp open PN was also performed with radio knife or soft coagulation. The length of the removed kidney was 40 mm, and the renal parenchyma was dissected until the renal calyx became clearly visible. The degree of renal degeneration from the resection surface was compared by Hematoxylin-Eosin staining and immunostaining for 1-methyladenosine, a sensitive marker for the ischemic tissue damage. The mRNA levels of neutrophil gelatinase-associated lipocalin (Ngal), a biomarker for acute kidney injury, were measured by quantitative real-time PCR. Off-clamp LPN with ADPJ system was successfully performed while preserving fine blood vessels and the renal calix with little bleeding. In contrast to other devices, the resection surface obtained with the ADPJ system showed only marginal degree of ischemic changes. Indeed, the expression level of Ngal mRNA was lower in the resection surface obtained with the ADPJ system than that with soft coagulation (p = 0.02). Furthermore, using the excised specimens of renal cell carcinoma, we measured the breaking strength at each site of the human kidney, suggesting the applicability of this ADPJ to clinical trials. In conclusion, off-clamp LPN with the ADPJ system could be safely performed with attenuated renal damage.

Current controversies in pediatric urologic robotic surgery.

PubMed

Trevisani, Lorenzo F M; Nguyen, Hiep T

2013-01-01

Minimally invasive surgeries such as conventional laparoscopic surgery and robotic assisted laparoscopic surgery (RALS) have significant advantages over the traditional open surgical approach including lower pain medication requirements and decreased length of hospitalization. However, open surgery has demonstrated better success rates and shorter surgery time when compared to the other modalities. Currently, it is unclear which approach has better long-term clinical outcomes, greater benefits and less cost. There are limited studies in the literature comparing these three different surgical approaches. In this review, we will evaluate the advantages and disadvantages of RALS compared to conventional laparoscopic surgery and open surgery for commonly performed pediatric urological procedures such as pyeloplasty, ureteral reimplantation, complete and partial nephrectomy, bladder augmentation and creation of continent catheterizable channels. Although it is not yet possible to demonstrate the superiority of one single surgical modality over another, RALS has been shown to be feasible, well tolerated and advantageous in reconstructive urological procedures. With experience, the outcomes of RALS are improving, justifying its usage. However, cost remains a significant issue, limiting the accessibility of RALS, which in the future may improve with market competition and device innovation.

A Randomized, Prospective, Parallel Group Study of Laparoscopic vs. Laparoendoscopic Single Site Donor Nephrectomy for Kidney Donation

PubMed Central

Aull, Meredith J.; Afaneh, Cheguevara; Charlton, Marian; Serur, David; Douglas, Melissa; Christos, Paul J.; Kapur, Sandip; Del Pizzo, Joseph J.

2014-01-01

Few prospective, randomized studies have assessed benefits of laparoendoscopic single site donor nephrectomy (LESS-DN) over laparoscopic donor nephrectomy (LDN). Our center initiated such a trial in January 2011, following subjects randomized to LESS-DN vs. LDN from surgery through 5 years post-donation. Subjects complete recovery/satisfaction questionnaires at 2, 6, and 12 months post-donation; transplant recipient outcomes are also recorded. 100 subjects (49 LESS-DN, 51 LDN) underwent surgery; donor demographics were similar between groups, and included a predominance of female, living unrelated donors, mean age of 47 years who underwent left donor nephrectomy. Operative parameters (overall time, time to extraction, warm ischemia time, blood loss) were similar between groups. Conversion to hand-assist laparoscopy was required in 3 LESS-DN (6.1%) vs. 2 LDN (3.9%; P=0.67). Questionnaires revealed 97.2% of LESS-DN vs. 79.5% of LDN (P=0.03) were 100% recovered by two months after donation. No significant difference was seen in satisfaction scores between the groups. Recipient outcomes were similar between groups. Our randomized trial comparing LESS donor nephrectomy to LDN confirms that LESS-DN offers a safe alternative to conventional LDN in terms of intra- and post-operative complications. LDN and LESS-DN offer similar recovery and satisfaction after donation. PMID:24934732

[Living kidney donation].

PubMed

Timsit, M-O; Kleinclauss, F; Mamzer Bruneel, M F; Thuret, R

2016-11-01

To review ethical, legal and technical aspects of living kidney donor surgery. An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords: Donor nephrectomy; Kidney paired donation; Kidney transplantation; Laparoscopic nephrectomy; Living donor; Organs trafficking; Robotic assisted nephrectomy; Vaginal extraction. French legal documents have been reviewed using the government portal (http://www.legifrance.gouv.fr). Articles were selected according to methods, language of publication and relevance. A total of 6421 articles were identified; after careful selection, 161 publications were considered of interest and were eligible for our review. The ethical debate focuses on organ shortage, financial incentive, organ trafficking and the recent data suggesting a small but significant increase risk for late renal disease in donor population. Legal decisions aim to increase the number of kidneys available for donation, such as kidney-paired donation that faces several obstacles in France. Laparoscopic approach became widely used, while robotic-assisted donor nephrectomy failed to demonstrate improved outcome as compared with other minimal invasive techniques. Minimally invasive living donor nephrectomy aims to limit side effects in the donor without increasing the morbidity in this specific population of healthy persons; long term surveillance to prevent the onset of renal disease in mandatory. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Trends and perioperative outcomes for laparoscopic and robotic nephrectomy using the National Surgical Quality Improvement Program (NSQIP) database.

PubMed

Liu, Jen-Jane; Leppert, John T; Maxwell, Bryan G; Panousis, Periklis; Chung, Benjamin I

2014-05-01

We sought to examine the trends in perioperative outcomes of kidney cancer surgery stratified by type (radical nephrectomy [RN] vs. partial nephrectomy [PN]) and approach (open vs. minimally invasive). We queried the National Surgical Quality Improvement Program database to identify kidney cancer operations performed from 2005 to 2011. We examined 30-day perioperative outcomes including operative time, transfusion rate, length of stay, major morbidity (cardiovascular, pulmonary, renal, and infectious), and mortality. A total of 2,902 PN and 5,459 RN cases were identified. The use of PN increased over time, accounting for 39% of all nephrectomies in 2011. Minimally invasive approaches also increased over time for both RN and PN. Open surgery was associated with increased length of stay, receipt of transfusion, major complications, and perioperative mortality. Resident involvement and open approach were independent predictors of major complications for both PN and RN. Additionally, the presence of a medical comorbidity was also a risk factor for complications after RN. The overall complication rates decreased for all approaches over the study period. Minimally invasive approaches to kidney cancer renal surgery have increased with favorable outcomes. The safety of open and minimally invasive PN improved significantly over the study period. Although pathologic features cannot be determined from this data set, these data show that complications from renal surgical procedures are decreasing in an era of increasing use. © 2013 Published by Elsevier Inc.

A Prospective Randomized Study of Pfannenstiel Versus Expanded Port Site Incision for Intact Specimen Extraction in Laparoscopic Radical Nephrectomy.

PubMed

Binsaleh, Saleh; Madbouly, Khaled; Matsumoto, Edward D; Kapoor, Anil

2015-08-01

To compare intra- and postoperative outcome of patients undergoing laparoscopic radical nephrectomy with intact specimen extraction through a Pfannenstiel (PFN) transverse suprapubic or expanded port site (EPS) incision in a prospective randomized fashion. Patients undergoing laparoscopic transperitoneal radical nephrectomies for suspected renal tumors were randomized for intact renal specimen extraction via a PFN or EPS incision. Operative, perioperative, 1 week, 6 weeks, and 6 months postoperative parameters were prospectively recorded and analyzed including specimen weight, size in maximum diameter, incision length, total operative time, extraction time, estimated blood loss, length of hospital stay, pain score in the postoperative holding area and on the first post operative day, narcotic consumption, time to fluid intake/full diet intake, unassisted ambulation, cosmesis, and wound-related complications. A postoperative quality-of-life questionnaire was also filled out by all the patients. Our series included 51 patients: 26 in the PFN group and 25 in the EPS group. The two groups were similar in demographic characteristics and intraoperative and postoperative parameters apart from a longer PFN incision (P<0.00). First postoperative day pain score was significantly less in the PFN group than in the EPS group (P=0.023). Complication rate was less in the PFN group, although not statistically significant. Hospital stay was significantly shorter in the PFN than in the EPS group (P=0.01). Mean cosmesis and operative satisfaction scores at week 1, week 6, and 6 month visits were not significantly different between both groups. Compared with the EPS group, PFN group patients significantly will choose the same operation if they would do it again (P=0.004). PFN incision has less morbidity, pain score, and hospital stay compared with EPS incision for intact specimen extraction after transperitoneal laparoscopic radical nephrectomy. Both incisions are associated with high operative satisfaction, good cosmesis, and a low rate of wound complications.

Characteristics and clinical outcomes of living renal donors in Hong Kong.

PubMed

Hong, Y L; Yee, C H; Leung, C B; Teoh, J Yc; Kwan, B Ch; Li, P Kt; Hou, S Sm; Ng, C F

2018-02-01

In Asia, few reports are available on the outcomes for living renal donors. We report the short- and long-term clinical outcomes of individuals following living donor nephrectomy in Hong Kong. We retrospectively reviewed the characteristics and clinical outcomes of all living renal donors who underwent surgery from January 1990 to December 2015 at a teaching hospital in Hong Kong. Information was obtained from hospital records and territory-wide electronic patient records. During the study period, 83 individuals underwent donor nephrectomy. The mean (± standard deviation) follow-up time was 12.0 ± 8.3 years, and the mean age at nephrectomy was 37.3 ± 10.0 years. A total of 44 (53.0%), four (4.8%), and 35 (42.2%) donors underwent living donor nephrectomy via an open, hand-port assisted laparoscopic, and laparoscopic approach, respectively. The overall incidence of complications was 36.6%, with most being grade 1 or 2. There were three (9.4%) grade 3a complications; all were related to open donor nephrectomy. The mean glomerular filtration rate was 96.0 ± 17.5 mL/min/1.73 m 2 at baseline and significantly lower at 66.8 ± 13.5 mL/min/1.73 m 2 at first annual follow-up (P<0.01). The latest mean glomerular filtration rate was 75.6% ± 15.1% of baseline. No donor died or developed renal failure. Of the donors, 14 (18.2%) developed hypertension, two (2.6%) had diabetes mellitus, and three (4.0%) had experienced proteinuria. The overall perioperative outcomes are good, with very few serious complications. The introduction of a laparoscopic approach has decreased perioperative blood loss and also shortened hospital stay. Long-term kidney function is satisfactory and no patients developed end-stage renal disease. The incidences of new-onset medical diseases and pregnancy-related complications were also low.

Mini-flank supra-12th rib incision for open partial nephrectomy for renal tumor with RENAL nephrometry score ≥10: an innovation of traditional open surgery.

PubMed

Wang, Hang; Sun, Li-an; Wang, Yiwei; Xiang, Zhuoyi; Zhou, Lin; Guo, Jianming; Wang, Guomin

2015-04-01

The skill of supra-12th rib mini-flank approach for open partial nephrectomy (MI-OPN) provides an advanced operative method for renal tumor. Compared with laparoscopic and robotic surgery, it may be a feasible selection for the complex renal tumors. We describe our techniques and results of MI-OPN in complex renal tumors with high RENAL nephrometry score (RENAL nephrometry score ≥10). Fifty-five patients diagnosed with renal tumors between January 2009 and July 2013 were included in this study. Eligibility criteria comprised of patients with complex renal tumor (RENAL score ≥10) being candidates for partial nephrectomy (PN). All patients received MI-OPN and all surgeries were performed by a single urologist. The preoperative workup comprised of medical history, physical examination, and routine laboratory tests. Serum creatinine was recorded preoperatively and 2 to 3 months after operation. Operative time, ischemia time, blood loss, operative and postoperative complications, renal function, and pathology parameters were recorded. MI-OPN was successfully performed in all cases. Mean tumor size was 4.7 cm (range: 2.5-8.1). Mean warm ischemia time was 28.1 minutes (range: 21-39), mean operative time was 105 minutes (range: 70-150) and mean estimated blood loss was 68 mL (range: 10-400). Mean postoperative hospital stay was 6.5 days (range: 5-12). Postoperative complications were found in 3 patients (5.5%). The mean pre- and postoperative serum creatinine levels were 76.2 μmol/L (range: 47-132) and 87.1 μmol/L (range: 61-189) with significant difference (P = 0.004). The mean pre- and postoperative estimated glomerular filtration rate (eGFR) were 91.5 (range: 34-133) and 82.5 (range: 22-126.5), respectively with significant difference (P = 0.024). In an average follow-up of 19.9 months (range: 8-50), no local recurrence or systemic progression occurred. In conclusion, MI-OPN can combine the benefits of both minimal invasive and traditional open partial nephrectomy (OPN) techniques with a smaller incision. It is an innovation of traditional OPN and suitable for the complex renal tumors with high RENAL nephrometry score safely and effectively.

Two-year analysis for predicting renal function and contralateral hypertrophy after robot-assisted partial nephrectomy: A three-dimensional segmentation technology study.

PubMed

Kim, Dae Keun; Jang, Yujin; Lee, Jaeseon; Hong, Helen; Kim, Ki Hong; Shin, Tae Young; Jung, Dae Chul; Choi, Young Deuk; Rha, Koon Ho

2015-12-01

To analyze long-term changes in both kidneys, and to predict renal function and contralateral hypertrophy after robot-assisted partial nephrectomy. A total of 62 patients underwent robot-assisted partial nephrectomy, and renal parenchymal volume was calculated using three-dimensional semi-automatic segmentation technology. Patients were evaluated within 1 month preoperatively, and postoperatively at 6 months, 1 year and continued up to 2-year follow up. Linear regression models were used to identify the factors predicting variables that correlated with estimated glomerular filtration rate changes and contralateral hypertrophy 2 years after robot-assisted partial nephrectomy. The median global estimated glomerular filtration rate changes were -10.4%, -11.9%, and -2.4% at 6 months, 1 and 2 years post-robot-assisted partial nephrectomy, respectively. The ipsilateral kidney median parenchymal volume changes were -24%, -24.4%, and -21% at 6 months, 1 and 2 years post-robot-assisted partial nephrectomy, respectively. The contralateral renal volume changes were 2.3%, 9.6% and 12.9%, respectively. On multivariable linear analysis, preoperative estimated glomerular filtration rate was the best predictive factor for global estimated glomerular filtration rate change on 2 years post-robot-assisted partial nephrectomy (B -0.452; 95% confidence interval -0.84 to -0.14; P = 0.021), whereas the parenchymal volume loss rate (B -0.43; 95% confidence interval -0.89 to -0.15; P = 0.017) and tumor size (B 5.154; 95% confidence interval -0.11 to 9.98; P = 0.041) were the significant predictive factors for the degree of contralateral renal hypertrophy on 2 years post-robot-assisted partial nephrectomy. Preoperative estimated glomerular filtration rate significantly affects post-robot-assisted partial nephrectomy renal function. Renal mass size and renal parenchyma volume loss correlates with compensatory hypertrophy of the contralateral kidney. Contralateral hypertrophy of the renal parenchyma compensates for the functional loss of the ipsilateral kidney. © 2015 The Japanese Urological Association.

A single overnight stay is possible for most patients undergoing robotic partial nephrectomy.

PubMed

Abaza, Ronney; Shah, Ketul

2013-02-01

To evaluate establishment of overnight stay only as sufficient after robotic partial nephrectomy (RPN). Stated benefits of minimally invasive surgery include reduced hospitalization, but published hospital stays after laparoscopic or robotic partial nephrectomy are not significantly less than with open surgery. We developed a clinical pathway targeting discharge on postoperative day (POD) 1 after RPN of any complexity. We reviewed all RPNs by a single surgeon since instituting our clinical pathway, including ambulation and diet the night of surgery, avoidance of intravenous narcotics and drains, and catheter removal on POD 1 before discharge. Targeted discharge was not modified regardless of RPN complexity. A total of 150 consecutive patients underwent 160 RPNs with 35 hilar tumors and 26 with segmental, and 33 with no artery clamping. Three had solitary kidneys, and 8 underwent multiple (range, 2-4) RPNs. Mean patient age was 57 years (range, 22-89 years), and body mass index was 32 kg/m(2) (range, 18-54 kg/m(2)). Mean tumor size was 3.6 cm (range, 1.0-11.0; median, 3.2 cm), and the RENAL (radius, exophytic/endophytic, nearness to collecting system, anterior/posterior, and location) nephrometry score was 8 (range, 4-12; median, 8). Mean warm ischemia time was 12.1 minutes (range, 0-30.0 minutes). Mean preoperative and discharge creatinine were 0.9 mg/dL (range, 0.43-2.79 mg/dL) and 1.13 mg/dL (range, 0.56-2.93 mg/dL). All patients ambulated on POD 0. One patient required one dose of intravenous narcotic. Mean length of stay was 1.1 days, with 145 (97%) discharged on POD 1, of which only 4 (2.7%) were readmitted within 30 days. Discharge on POD 1 is feasible in most RPN patients regardless of complexity. Readmission rate was low, indicating that longer admissions may not prevent complications when patients meeting discharge criteria go home on POD 1. Copyright © 2013 Elsevier Inc. All rights reserved.

Sutureless laparoscopic heminephrectomy using laser tissue soldering.

PubMed

Ogan, Kenneth; Jacomides, Lucas; Saboorian, Hossein; Koeneman, Kenneth; Li, Yingming; Napper, Cheryl; Hoopman, John; Pearle, Margaret S; Cadeddu, Jeffrey A

2003-06-01

Widespread application of laparoscopic partial nephrectomy has been limited by the lack of a reliable means of attaining hemostasis. We describe laser tissue welding using human albumin as a solder to control bleeding and seal the collecting system during laparoscopic heminephrectomy in a porcine model. Laparoscopic left lower-pole heminephrectomy was performed in five female domestic pigs after occluding the hilar vessels. Using an 810-nm pulsed diode laser (20 W), a 50% liquid albumin-indocyanine green solder was welded to the cut edge of the renal parenchyma to seal the collecting system and achieve hemostasis. Two weeks later, an identical procedure was performed on the right kidney, after which, the animals were sacrificed and both kidneys were harvested for ex vivo retrograde pyelograms and histopathologic analysis. All 10 heminephrectomies were performed without complication. The mean operative time was 82 minutes, with an average blood loss of 43.5 mL per procedure. The mean warm ischemia time was 11.7 minutes. For each heminephrectomy, a mean of 4.2 mL of solder was welded to the cut parenchymal surface. In three of the five acute kidneys and all five 2-week kidneys, ex vivo retrograde pyelograms demonstrated no extravasation. In addition, no animal had clinical evidence of urinoma or delayed hemorrhage. Histopathologic analysis showed preservation of the renal parenchyma immediately beneath the solder. Laser tissue welding provided reliable hemostasis and closure of the collecting system while protecting the underlying parenchyma from the deleterious effect of the laser during porcine laparoscopic heminephrectomy.

Partial nephrectomy in a patient with dwarfism.

PubMed

Farber, Nicholas J; Dubin, Justin; Parihar, Jaspreet; Han, Chris; Lasser, Michael S

2016-08-01

We describe the case of a 50-year-old male with achondroplastic dwarfism who presents with a renal mass in his left kidney concerning for renal cell carcinoma. The patient successfully underwent a robotic partial nephrectomy, which revealed a T1a renal cell carcinoma. The tumor was excised successfully without any intraoperative complications demonstrating that a robotic partial nephrectomy is technically both safe and effective in patients with achondroplastic dwarfism.

Impact of early incentive spirometry in an enhanced recovery program after laparoscopic donor nephrectomy.

PubMed

Rollins, K E; Aggarwal, S; Fletcher, A; Knight, A; Rigg, K; Williams, A R; Bhattacharjya, S

2013-05-01

This study aimed to assess the impact of early incentive spirometry on the incidence of chest infection in patients undergoing laparoscopic donor nephrectomy. A retrospective review on all consecutive laparoscopic donor nephrectomies (LDN) performed at a single institution from January 2008 to August 2012 was performed. We performed 84 LDN. Seventy patients had epidural analgesia continued for 48 hours postoperatively and 14 had a combination of spinal followed by oral analgesia. Incentive spirometry was introduced from July 2010 and 45 of the 84 donors used the spirometer as taught, both pre- and postoperatively. We performed 84 LDN; 39 patients did not receive incentive spirometers and had postoperative chest physiotherapy started on postoperative day 1. Of the 45 patients given incentive spirometers, 44 started using their spirometers as taught, after recovery once they were settled in the ward, 1 patient started the exercises the following day. In the group who received no spirometer, 5 patients had a chest infection. In the group of patients who started using their spirometers in the early perioperative period (44/45), no patient developed a chest infection. One patient in this group was excluded from the analysis because he started spirometer exercises on postoperative day 1. This patient did develop a chest infection. Our results suggest that early introduction of incentive spirometry after LDN significantly reduces the incidence of chest infection (P < .05); however, this benefit may be lost if the introduction of spirometry is delayed. Copyright © 2013 Elsevier Inc. All rights reserved.

Retroperitoneal versus transperitoneal robotic-assisted laparoscopic partial nephrectomy: a matched-pair, bicenter analysis with cost comparison using time-driven activity-based costing.

PubMed

Laviana, Aaron A; Tan, Hung-Jui; Hu, Jim C; Weizer, Alon Z; Chang, Sam S; Barocas, Daniel A

2018-03-01

To perform a bicenter, retrospective study of perioperative outcomes of retroperitoneal versus transperitoneal robotic-assisted laparoscopic partial nephrectomy (RALPN) and assess costs using time-driven activity-based costing (TDABC). We identified 355 consecutive patients who underwent RALPN at University of California Los Angeles and the University of Michigan during 2009-2016. We matched according to RENAL nephrometry score, date, and institution for 78 retroperitoneal versus 78 transperitoneal RALPN. Unadjusted analyses were performed using McNemar's Chi-squared or paired t test, and adjusted analyses were performed using multivariable repeated measures regression analysis. From multivariable models, predicted probabilities were derived according to approach. Cost analysis was performed using TDABC. Patients treated with retroperitoneal versus transperitoneal RALPN were similar in age (P = 0.490), sex (P = 0.715), BMI (P = 0.273), and comorbidity (P = 0.393). Most tumors were posterior or lateral in both the retroperitoneal (92.3%) and transperitoneal (85.9%) groups. Retroperitoneal RALPN was associated with shorter operative times (167.0 versus 191.1 min, P = 0.001) and length of stay (LOS) (1.8 versus 2.7 days, P < 0.001). There were no differences in renal function preservation or cancer control. In adjusted analyses, retroperitoneal RALPN was 17.6-min shorter (P < 0.001) and had a 76% lower probability of LOS at least 2 days (P < 0.001). Utilizing TDABC, transperitoneal RALPN added $2337 in cost when factoring in disposable equipment, operative time, LOS, and personnel. In two high-volume, tertiary centers, retroperitoneal RALPN is associated with reduced operative times and shortened LOS in posterior and lateral tumors, whereas sharing similar clinicopathologic outcomes, which may translate into lower healthcare costs. Further investigation into anterior tumors is needed.

Laparoscopic partial nephrectomy: A series of one hundred cases performed by the same surgeon.

PubMed

Campero, José M; Ramos, Christián G; Valdevenito, Raúl; Mercado, Alejandro; Fullá, Juan

2012-09-01

Laparoscopic partial nephrectomy (LPN) has become the first-line surgical technique for the management of renal tumors smaller than 4 cm. Its main advantages are an excellent oncologic control together with the preservation of nephron units. Moreover, it implies a shorter length of hospital stay, less postoperative pain, and shorter recovering times for patients. We included 100 patients who consecutively underwent LPN between years 2000 and 2010 in our institution. The aim was to present our experience and to compare it with the results reported in the literature by other centers. This was a prospective study. One hundred consecutive patients (67 men and 33 women) who underwent LPN within years 2000 and 2010 were included in the study. In all cases, surgery was performed by the same surgeon (JMC). Data were collected retrospectively, including clinical and histopathologic information, as well as surgical and functional results. Statistical analysis was performed using the chi-square test and SPSS v17 software. A P-value < 0.05 was considered significant in all the analyses. The indication for LPN was a renal tumor or a complex renal cyst in the 96% of the cases. A retroperitoneal or transperitoneal approach was performed in the 62% and 38% of the cases, respectively. The average size of the tumor was 3.3 cm (range 1-8). The mean surgical time was 103.5 min (range 40-204). The mean estimated blood loss was 193.7 cc. The average hospital length of stay was 50.2 h. Six (6%) patients had complications related to the surgery. The majority (n = 2) was due to intraoperative bleeding. With an average follow-up time of 42.1 months, there is no tumor recurrence reported up to now. Our results are similar to those reported in the international literature. LPN is a challenging surgical technique that in hands of a trained and experienced surgeon has excellent and reproducible results for the management of small renal masses and cysts.

Renal mass anatomic characteristics and perioperative outcomes of laparoscopic partial nephrectomy: a critical analysis.

PubMed

Tsivian, Matvey; Ulusoy, Said; Abern, Michael; Wandel, Ayelet; Sidi, A Ami; Tsivian, Alexander

2012-10-01

Anatomic parameters determining renal mass complexity have been used in a number of proposed scoring systems despite lack of a critical analysis of their independent contributions. We sought to assess the independent contribution of anatomic parameters on perioperative outcomes of laparoscopic partial nephrectomy (LPN). Preoperative imaging studies were reviewed for 147 consecutive patients undergoing LPN for a single renal mass. Renal mass anatomy was recorded: Size, growth pattern (endo-/meso-/exophytic), centrality (central/hilar/peripheral), anterior/posterior, lateral/medial, polar location. Multivariable models were used to determine associations of anatomic parameters with warm ischemia time (WIT), operative time (OT), estimated blood loss (EBL), intra- and postoperative complications, as well as renal function. All models were adjusted for the learning curve and relevant confounders. Median (range) tumor size was 3.3 cm (1.5-11 cm); 52% were central and 14% hilar. While 44% were exophytic, 23% and 33% were mesophytic and endophytic, respectively. Anatomic parameters did not uniformly predict perioperative outcomes. WIT was associated with tumor size (P=0.068), centrality (central, P=0.016; hilar, P=0.073), and endophytic growth pattern (P=0.017). OT was only associated with tumor size (P<0.001). No anatomic parameter predicted EBL. Tumor centrality increased the odds of overall and intraoperative complications, without reaching statistical significance. Postoperative renal function was not associated with any of the anatomic parameters considered after adjustment for baseline function and WIT. Learning curve, considered as a confounder, was independently associated with reduced WIT and OT as well as reduced odds of intraoperative complications. This study provides a detailed analysis of the independent impact of renal mass anatomic parameters on perioperative outcomes. Our findings suggest diverse independent contributions of the anatomic parameters to the different measures of outcomes (WIT, OT, EBL, complications, and renal function) emphasizing the importance of the learning curve.

Renal Arterial Pseudoaneurysm and Renal Arteriovenous Fistula Following Partial Nephrectomy.

PubMed

Chen, Jinchao; Yang, Min; Wu, Pengjie; Li, Teng; Ning, Xianghui; Peng, Shuanghe; Wang, Jiangyi; Qi, Nienie; Gong, Kan

2018-01-01

Renal arterial pseudoaneurysm (RAP) and renal arteriovenous fistula (RAVF) are rare but can cause fatal bleeding. A retrospective review was conducted for patients undergoing partial nephrectomy (PN) in our department. The clinical features and treatment methods were analysed, and the relationships between RAP/RAVF and the surgical methods and R.E.N.A.L. score were investigated. Eleven patients were diagnosed with RAP/RAVF (9 with RAP and 2 with RAVF). The incidence of RAP/RAVF after laparoscopic PN showed no significant difference compared to that after open PN (p = 0.47). A low R.E.N.A.L. score was present in 6 patients, while an intermediate/high score was present in the other 5 patients. The major clinical manifestations included haematuria and haemorrhagic shock, and the median time of occurrence was 8 days after the operation. Six patients underwent an ultrasound examination. Of the 4 patients who underwent enhanced CT, 2 patients were diagnosed with RAP. All 11 patients were diagnosed by renal angiography and were cured after super-selective arterial embolization. The serum creatinine levels before and after embolization showed no significant differences (p = 0.14). RAP/RAVF may not have any relationship with the surgical procedure or R.E.N.A.L. score. Renal angiography and super-selective arterial embolization are the preferred methods for diagnosing and treating RAP/RAVF. © 2016 S. Karger AG, Basel.

Small-Incision Laparoscopy-Assisted Surgery Under Abdominal Cavity Irrigation in a Porcine Model

PubMed Central

Ishii, Takuro; Aoe, Tomohiko; Yu, Wen-Wei; Ebihara, Yuma; Kawahira, Hiroshi; Isono, Shiro; Naya, Yukio

2016-01-01

Abstract Background: Laparoscopic and robot-assisted surgeries are performed under carbon dioxide insufflation. Switching from gas to an isotonic irrigant introduces several benefits and avoids some adverse effects of gas insufflation. We developed an irrigating device and apparatus designed for single-incision laparoscopic surgery and tested its advantages and drawbacks during surgery in a porcine model. Materials and Methods: Six pigs underwent surgical procedures under general anesthesia. A 30-cm extracorporeal cistern was placed over a 5–6-cm abdominal incision. The abdomen was irrigated with warm saline that was drained via a suction tube placed near the surgical field and continuously recirculated through a closed circuit equipped with a hemodialyzer as a filter. Irrigant samples from two pigs were cultured to check for bacterial and fungal contamination. Body weight was measured before and after surgery in four pigs that had not received treatments affecting hemodynamics or causing diuresis. Results: One-way flow of irrigant ensured laparoscopic vision by rinsing blood from the surgical field. Through a retroperitoneal approach, cystoprostatectomy was successfully performed in three pigs, nephrectomy in two, renal excision in two, and partial nephrectomy in one, under simultaneous ultrasonographic monitoring. Through a transperitoneal approach, liver excision and hemostasis with a bipolar sealing device were performed in three pigs, and bladder pedicle excision was performed in one pig. Bacterial and fungal contamination of the irrigant was observed on the draining side of the circuit, but the filter captured the contaminants. Body weight increased by a median of 2.1% (range, 1.2–4.4%) of initial weight after 3–5 hours of irrigation. Conclusions: Surgery under irrigation is feasible and practical when performed via a cistern through a small abdominal incision. This method is advantageous, especially in the enabling of continuous and free-angle ultrasound observation of parenchymal organs. Adverse effects of abdominal irrigation need further assessment before use in humans. PMID:26745012

Laparoscopic Nephrectomy for a Nonfunctioning Pelvic Kidney in Preparation for Renal Transplantation

PubMed Central

Milhoua, Paul M.; Knoll, Abraham; Koi, Philip T.; Hoenig, David M.

2006-01-01

Pelvic kidneys pose a problem for any planned surgical intervention given their anomalous blood supply. Although minimally invasive approaches have been described for the management of benign conditions, only a handful of reports have described the use of laparoscopy for removal of ectopic or fused kidneys. We describe the laparoscopic removal of a symptomatic pelvic kidney in a patient before renal transplantation. PMID:17575778

Successful Embolization of a Renal Artery Pseudoaneurysm with Arteriovenous Fistula and Extravasations Using Onyx After Partial Nephrectomy for Renal Cell Carcinoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zelenak, Kamil, E-mail: zelenak@mfn.s; Sopilko, Igor; Svihra, Jan

2009-01-15

Partial nephrectomy can be associated with vascular complications. Computed tomography (CT) with CT angiography is ideal for noninvasive imaging of this process. The treatment of choice is selective embolization. Successful transcatheter embolization of right renal subsegmental artery pseudoaneurysm with arteriovenous fistula and extravasations using Onyx was performed in a 66-year-old woman with macrohematuria 12 days after partial nephrectomy for renal cell carcinoma.

[Vascular anatomy of donor and recipient in living kidney transplantation].

PubMed

Zhang, Jiqing; Zhang, Xiaodong

2009-09-01

To review the vascular anatomy of the donor and the recipient for the living kidney transplantation. The recent literature about the vessels of donor and recipient in clinical applications was extensively reviewed. The pertinent vascular anatomy of the donor and recipient was essential for the screening of the proper candidates, surgical planning and long-term outcome. Early branching and accessory renal artery of the donor were particularly important to deciding the side of nephrectomy, surgical technique and anastomosing pattern, and their injuries were the most frequent factor of the conversion from laparoscopic to open surgery. With increase of laparoscopic nephrectomy in donors, accurate venous anatomy was paid more and more attention to because venous bleeding could also lead to conversion to open nephrectomy. Multidetector CT (MDCT) could supplant the conventional excretory urography and renal catheter angiography and could accurately depict the donors' vessels, vascular variations. In addition, MDCT can excellently evaluate the status of donor kidney, collecting system and other pertinent anatomy details. Accurate master of related vascular anatomy can facilitate operation plan and success of operation and can contribute to the rapid development of living donor kidney transplantation. MDCT has become the choice of preoperative one-stop image assessment for living renal donors.

Relative to open surgery, minimally-invasive renal and ureteral pediatric surgery offers no improvement in 30-day complications, yet requires longer operative time: Data from the National Surgical Quality Improvement Program Pediatrics.

PubMed

Colaco, Marc; Hester, Austin; Visser, William; Rasper, Alison; Terlecki, Ryan

2018-05-01

Performance of minimally-invasive surgery (MIS) is increasing relative to open surgery. We sought to compare the contemporary rates of short-term complications of open versus laparoscopic renal and ureteral surgery in pediatric patients. A retrospective cross-sectional analysis of the National Surgical Quality Improvement Program Pediatrics database was performed of all cases in 2014 identified using CPT procedure codes for nephrectomy, partial nephrectomy (PN), ureteroneocystostomy (UNC), and pyeloplasty, and reviewed for postoperative complications. Univariate analysis was performed to determine 30-day complications, with comparison between open and MIS approaches. Receiver operator curve (ROC) analysis was performed to determine differences in body surface area (BSA) and age for open versus MIS. Review identified 207 nephrectomies, 72 PN, 920 UNC, and 625 pyeloplasties. MIS was associated with older age and larger BSA except for cases of UNC. Apart from PN, operative durations were longer with MIS. However, only PN was associated with significantly longer length of hospital stay (LOS). There was no difference in incidence of all other 30-day complications. When evaluating BSA via ROC, the area under the curve (AUC) was found to be 0.730 and was significant. Children with a BSA greater than 0.408 m 2 were more likely to have MIS (sensitivity, 66.9%; specificity, 69.3%). Regarding age, the AUC was 0.732. Children older than 637.5 days were more likely to have MIS (sensitivity, 72.8%; specificity, 63.3%). Pediatric MIS is associated with longer operative time for nephrectomy, but shorter LOS following PN. Surgical approach was not associated with difference in short-term complications.

Laparoendoscopic single-site surgery versus standard laparoscopic simple nephrectomy: a prospective randomized study.

PubMed

Tugcu, Volkan; Ilbey, Yusuf Ozlem; Mutlu, Bircan; Tasci, Ali Ihsan

2010-08-01

Laparoendoscopic single-site surgery (LESS), an attempt to further enhance the cosmetic benefits of minimally invasive surgery while minimizing the potential morbidity associated with multiple incisions, has been developed recently. Our aim was to compare LESS simple nephrectomy (LESS-SN) and conventional transperitoneal laparoscopic simple nephrectomy (CTL-SN). In this randomized study that was conducted between December 2008 and September 2009, 27 patients who needed simple nephrectomy were randomized to either LESS-SN or CTL-SN. All procedures in both groups were performed by the first author, who is experienced in laparoscopic surgery. Patient characteristics, perioperative details, and time to return to work were recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. There was no difference in median operative time (117.5 vs 114 min, P = 0.52), blood loss (50.71 vs 47.15 mL, P = 0.60), transfusion rates (0% for both), and hospitalization time (2.07 vs 2.11 days, P = 0.74) between the LESS-SN and CTL-SN groups. Time to return to normal activities was shorter in the LESS-SN group compared with the CTL-SN group (10.7 vs 13.5 days, P = 0.001). Both the visual analogue scale and the postoperative use of analgesics were significantly lower during postoperative days 1, 2, and 3 in patients who underwent LESS-SN, compared with patients who underwent CTL-SN. There were no intraoperative or postoperative complications in both groups. Compared with CTL-SN, LESS-SN was more expensive, but all patients undergoing LESS-SN were very pleased with the cosmetic outcome (no visible scars). The early experience described in this study suggests that LESS-SN is a safe and effective alternative to CTL-SN that provides surgeons with a minimally invasive surgical option and the ability to hide the surgical incision within the umbilicus; however, a larger series is necessary to confirm these findings and to determine if there are any benefits in pain, recovery, or cosmesis.

When Partial Nephrectomy is Unsuccessful: Understanding the Reasons for Conversion from Robotic Partial to Radical Nephrectomy at a Tertiary Referral Center.

PubMed

Kara, Önder; Maurice, Matthew J; Mouracade, Pascal; Malkoç, Ercan; Dagenais, Julien; Nelson, Ryan J; Chavali, Jaya Sai S; Stein, Robert J; Fergany, Amr; Kaouk, Jihad H

2017-07-01

We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event. Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion. The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p <0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p <0.01) and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar location) score (9 vs 8, p <0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96-0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22-1.7, p <0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short-term oncologic outcomes but better renal functional preservation (p <0.01). At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion. Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Urological procedures in Central Europe and the current reality based on the national registries of Czech Republic, Hungary, and Poland (2012 status).

PubMed

Adamczyk, Przemysław; Juszczak, Kajetan; Drewa, Tomasz; Hora, Milan; Nyirády, Peter; Sosnowski, Marek

2016-01-01

In recent years, the laparoscopic approach in oncologic urology seems more attractable to the surgeons. It is considered to have the same oncologic quality as open surgery, but is less invasive in patients. It is used widely in all of Europe, but with various frequency. The aim of the study was to present a various amount of oncourological procedures from three neighbouring countries - Poland, Czech Republic and Hungary. Prostatectomy, cystectomy, nephrectomy and tumorectomy (Nephron Sparing Procedures - NSS) were presented as a list of procedures prepared from the national registry. The total amount of procedures was presented, as well as the LO (Lap to Open procedures) index, P/P (procedures/population) index, ratio of cystectomy/population, and cystectomy/TURBT. In the Czech Republic, the most complex procedures are performed (laparoscopic/robotic prostatectomy, NSS LAP, LAP nephrectomy) in the majority when analysing the country's population. In Hungary and Czech Republic, there are more laparoscopic/robotic radical prostatectomies performed, than open ones. In Poland the largest number of cystectomies is performed when analysing the country's population, but it is difficult to explain the much higher ratio of 6.57 TUR/one cystectomy. In the Czech Republic this procedure is performed in almost one quarter of the patients (23.36%). Interestingly, in Hungary the cystectomy with pouch creation is performed in about 67.65% cases. The highest reimbursement for surgical procedure is present in the Czech Republic with approximately 20-40% more than when compared to Poland or Hungary. The definitive leader in Central Europe (based on the national registry) is the Czech Republic, where the most complex procedures are performed (laparoscopic/robotic prostatectomy, NSS LAP, LAP nephrectomy) in biggest amounts when analysing the country's population. Explanation of such circumstances, can be the higher reimbursement rate for surgical procedure in this country.

Laparoscopic telesurgery between the United States and Singapore.

PubMed

Lee, B R; Png, D J; Liew, L; Fabrizio, M; Li, M K; Jarrett, J W; Kavoussi, L R

2000-09-01

Telemedicine is the use of electronic digital signals to transfer information from one site to another. With the advent of a telepresence operative system and development of remote robotic arms to hold and manoeuvre the laparoscope, telemedicine is finding its role in surgery, especially laparoscopic surgery. CLINICAL FEATURES AND TREATMENT: We report two successful cases of laparoscopic surgery--radical nephrectomy and varicocelectomy for a 3-cm renal tumour and for bilateral varicoceles causing pain, where a less experienced laparoscopic surgeon in Singapore was telementored by an experienced laparoscopic surgeon located remotely in the United States. Both patients recovered uneventfully and returned home on postoperative day 4 and on the day of surgery, respectively. This study demonstrates that telementored laparoscopic systems are feasible and safe, between countries halfway across the world. As the Internet expands in utility and the cost of higher bandwidth telecommunication lines decreases, even to remote countries, telementoring systems will become more affordable and may potentially pave the way for advanced surgical and laparoscopic applications and training for the future.

The Auckland experience with laparoscopic donor nephrectomy.

PubMed

Muthu, Carl; McCall, John; Windsor, John; Harman, Richard; Dittmer, Ian; Smith, Pat; Munn, Stephen

2003-07-25

To examine the initial experience of laparoscopic donor nephrectomy (LDN) in New Zealand and compare it with open donor nephrectomy (ODN). All LDNs performed between June 2000 and June 2002 were reviewed. An equal number of ODNs were reviewed. Data were also collected on the recipients of the grafts. Key clinical data were prospectively collected; remaining data were collected by retrospectively reviewing patient charts. Auckland Hospital databases were accessed for costing analysis. Thirty five cases of each procedure had been performed. There has been 100% LDN graft survival. There was no significant difference in graft function (serum creatinine) at one and 12 months (p = 0.25 and 0.35) between the two groups. There was no significant difference in donor morbidity (26% vs 31%, p = 0.59). LDN resulted in a shorter hospital stay (3 vs 6.5 days, p <0.0001) and convalescence period (3 vs 6 weeks, p <0.0001). LDN was significantly more expensive (13 357 dollars vs 6713 dollars, p <0.0001). LDN in the New Zealand setting provides effective grafts for renal transplant recipients and is safe for the donor. Advantages for the donor are a shorter hospital stay and convalescence period. The major disadvantage of LDN is its higher cost compared with ODN.

Zero ischemia robotic-assisted partial nephrectomy in Alberta: Initial results of a novel approach.

PubMed

Forbes, Ellen; Cheung, Douglas; Kinnaird, Adam; Martin, Blair St

2015-01-01

Partial nephrectomy remains the standard of care in early stage, organ-confined renal tumours. Recent evidence suggests that minimally invasive surgery can proceed without segmental vessel clamping. In this study, we review our experience at a Canadian centre with zero ischemia robotic-assisted partial nephrectomy (RAPN). A retrospective chart review of zero ischemia RAPN was performed. All surgeries were consecutive partial nephrectomies performed by the same surgeon at a tertiary care centre in Northern Alberta. The mean follow-up period was 28 months. These outcomes were compared against the current standards for zero ischemia (as outlined by the University of Southern California Institute of Urology [USC]). We included 21 patients who underwent zero ischemia RAPN between January 2012 and June 2013. Baseline data were similar to contemporary studies. Twelve (57.1%) required no vascular clamping, 7 (33.3%) required clamping of a single segmental artery, and 2 (9.5%) required clamping of two segmental arteries. We achieved an average estimated blood loss of 158 cc, with a 9.2% average increase in creatinine postoperatively. Operating time and duration of hospital stay were short at 153 minutes and 2.2 days, respectively. Zero ischemia partial nephrectomy was a viable option at our institution with favourable results in terms of intra-operative blood loss and postoperative creatinine change compared to results from contemporary standard zero ischemia studies (USC). To our knowledge, this is the first study to review an initial experience with the zero ischemia protocol in robotic-assisted partial nephrectomies at a Canadian hospital.

Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases.

PubMed

Dulabon, Lori M; Kaouk, Jihad H; Haber, Georges-Pascal; Berkman, Douglas S; Rogers, Craig G; Petros, Firas; Bhayani, Sam B; Stifelman, Michael D

2011-03-01

Minimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon. We compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients. We retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions. Patient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded. Forty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2 cm vs 2.6 cm; p=0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3±7.4 min vs 19.6±10.0 min; p=<0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons' prior robotic experience. The data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons. Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Delayed Partial Nephrectomy for Hydronephrosis After Renal Trauma.

PubMed

Setia, Shaan; Jackson, Jessica Nicole; Herndon, C D Anthony; Corbett, Sean T

2017-03-01

Delayed sequelae following conservative management of renal trauma in the pediatric population are uncommon. Reports of delayed operations to manage these sequelae are even less common. Here we present the case of a 16-year-old male patient who had delayed development of upper urinary tract obstruction with recurrent infections following high-grade renal trauma managed conservatively. Ultimately, he required a robotic-assisted partial nephrectomy 2 years after initial nonoperative management. This is unique as no prior studies to our knowledge have described delayed hydronephrosis and delayed partial nephrectomy over a year following renal trauma. Copyright © 2016 Elsevier Inc. All rights reserved.

Introduction of hand-assisted retroperitoneoscopic living donor nephrectomy at Karolinska University Hospital Huddinge.

PubMed

Gjertsen, H; Sandberg, A-K A; Wadström, J; Tydén, G; Ericzon, B-G

2006-10-01

Living donor kidney transplantation accounts for about 50% of the total number of renal transplantations at our center. From 1999 through 2005, 75 out of 220 living donor nephrectomies were performed with a laparoscopic technique (LLDN). In June 2005, we introduced the technique of hand-assisted retroperitoneoscopic nephrectomy (HARS) for living donors. Since the introduction until the end of 2005, 11 out of 18 living donor nephrectomies (LDN) were performed with HARS. Reduced operation time was observed for the HARS group (mean, 166 minutes) compared with the LLDN (mean, 244 minutes). Two grafts showed delayed function, one in the LLND group and one in the HARS group. No major perioperative or postoperative complications were observed in the HARS group, whereas one patient who underwent LLDN developed severe pancreatitis. So far in our hands HARS is a fast and safe procedure with results comparable with open LDN. Compared to LLDN, we experienced reduced operation time together with the advantage of retroperitoneal access.

Nephrectomy for benign disease in the UK: results from the British Association of Urological Surgeons nephrectomy database.

PubMed

Zelhof, Bachar; McIntyre, Iain G; Fowler, Sarah M; Napier-Hemy, Richard D; Burke, Daniel M; Grey, Ben R

2016-01-01

To summarize the practice of UK urologists with regard to nephrectomy for benign disease, documenting the indications, procedural techniques and outcomes. All patients undergoing nephrectomy for a benign condition in 2012 were identified from the British Association of Urological Surgeons (BAUS) nephrectomy database. Recorded variables included the technique of surgery, the type of minimally invasive procedure, operating time, blood loss, transfusion rate, conversion rate, intra- and postoperative complications and mortality rate. Cases were also sub-analysed according to their pathologies to determine the differences in complication rate between stone disease, pyelonephritis, non-functioning kidney and other benign lesions. To contextualize procedural complexity, the simple nephrectomy data were compared with those obtained from the BAUS stage T1 radical nephrectomy audit. A total of 1 093 nephrectomies were performed (537 non-functioning kidneys, 142 stone disease, 129 nephrectomies secondary to pyelonephritis and 285 cases with other benign conditions). Of these, 76% were performed laparoscopically. Blood loss >500 mL was noted in 74 cases with a 4.8% blood transfusion rate. The intra- and postoperative complication rates were 5.2 and 11.9%, respectively. Of the 847 minimally invasive procedures, the conversion rate was 5.9%. Patients with stone disease have the highest intra- and postoperative complications (9.9 and 23.9%, respectively) compared with other benign pathologies. The total number of T1 radical nephrectomies performed was 1 095. In comparison with T1 radical nephrectomy, simple nephrectomy carries an increased risk of conversion to an open procedure (1.8 times), a higher rate of blood transfusion (4.8 vs 2.8%), and a higher risk of intra- and postoperative complications (5.2 vs 3.7% and 11.9 vs 10%, respectively). The present study reports the largest series of nephrectomies performed for benign disease and the resultant data now support the bespoke preoperative counselling of patients. Furthermore, it confirms the commonly held view that simple nephrectomy can be more difficult than its radical counterpart. The authors suggest that the term 'simple nephrectomy' is changed to 'benign nephrectomy'. © 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.

The natural history of renal function after surgical management of renal cell carcinoma: Results from the Canadian Kidney Cancer Information System.

PubMed

Mason, Ross; Kapoor, Anil; Liu, Zhihui; Saarela, Olli; Tanguay, Simon; Jewett, Michael; Finelli, Antonio; Lacombe, Louis; Kawakami, Jun; Moore, Ronald; Morash, Christopher; Black, Peter; Rendon, Ricardo A

2016-11-01

Patients who undergo surgical management of renal cell carcinoma (RCC) are at risk for chronic kidney disease and its sequelae. This study describes the natural history of renal function after radical and partial nephrectomy and explores factors associated with postoperative decline in renal function. This is a multi-institutional cohort study of patients in the Canadian Kidney Cancer Information System who underwent partial or radical nephrectomy for RCC. Estimated glomerular filtration rate (eGFR) and stage of chronic kidney disease were determined preoperatively and at 3, 12, and 24 months postoperatively. Linear regression was used to determine the association between postoperative eGFR and type of surgery (radical vs. partial), duration of ischemia, ischemia type (warm vs. cold), and tumor size. With a median follow-up of 26 months, 1,379 patients were identified from the Canadian Kidney Cancer Information System database including 665 and 714 who underwent partial and radical nephrectomy, respectively. Patients undergoing radical nephrectomy had a lower eGFR (mean = 19ml/min/1.73m 2 lower) at 3, 12, and 24 months postoperatively (P<0.001). Decline in renal function occurred early and remained stable throughout follow-up. A lower preoperative eGFR and increasing age were also associated with a lower postoperative eGFR (P<0.01). Ischemia type and duration were not predictive of postoperative decline in eGFR (P>0.05). Severe renal failure (eGFR<30ml/min/1.73m 2 ) developed postoperatively in 12.5% and 4.1% of radical and partial nephrectomy patients, respectively (P<0.001). After the initial postoperative decline, renal function remains stable in patients undergoing surgery for RCC. Patients undergoing radical nephrectomy have a greater long-term reduction in renal function compared with those undergoing partial nephrectomy. Ischemia duration and type are not predictive of postoperative renal function when adhering to generally short ischemia durations. Copyright © 2016 Elsevier Inc. All rights reserved.

Deep neuromuscular blockade improves surgical conditions during low-pressure pneumoperitoneum laparoscopic donor nephrectomy.

PubMed

Özdemir-van Brunschot, D M D; Braat, A E; van der Jagt, M F P; Scheffer, G J; Martini, C H; Langenhuijsen, J F; Dam, R E; Huurman, V A; Lam, D; d'Ancona, F C; Dahan, A; Warlé, M C

2018-01-01

Evidence indicates that low-pressure pneumoperitoneum (PNP) reduces postoperative pain and analgesic consumption. A lower insufflation pressure may hamper visibility and working space. The aim of the study is to investigate whether deep neuromuscular blockade (NMB) improves surgical conditions during low-pressure PNP. This study was a blinded randomized controlled multicenter trial. 34 kidney donors scheduled for laparoscopic donor nephrectomy randomly received low-pressure PNP (6 mmHg) with either deep (PTC 1-5) or moderate NMB (TOF 0-1). In case of insufficient surgical conditions, the insufflation pressure was increased stepwise. Surgical conditions were rated by the Leiden-Surgical Rating Scale (L-SRS) ranging from 1 (extremely poor) to 5 (optimal). Mean surgical conditions were significantly better for patients allocated to a deep NMB (SRS 4.5 versus 4.0; p < 0.01). The final insufflation pressure was 7.7 mmHg in patients with deep NMB as compared to 9.1 mmHg with moderate NMB (p = 0.19). The cumulative opiate consumption during the first 48 h was significantly lower in patients receiving deep NMB, while postoperative pain scores were similar. In four patients allocated to a moderate NMB, a significant intraoperative complication occurred, and in two of these patients a conversion to an open procedure was required. Our data show that deep NMB facilitates the use of low-pressure PNP during laparoscopic donor nephrectomy by improving the quality of the surgical field. The relatively high incidence of intraoperative complications indicates that the use of low pressure with moderate NMB may compromise safety during LDN. Clinicaltrials.gov identifier: NCT 02602964.

Diagnostic accuracy of a volume-rendered computed tomography movie and other computed tomography-based imaging methods in assessment of renal vascular anatomy for laparoscopic donor nephrectomy.

PubMed

Yamamoto, Shingo; Tanooka, Masao; Ando, Kumiko; Yamano, Toshiko; Ishikura, Reiichi; Nojima, Michio; Hirota, Shozo; Shima, Hiroki

2009-12-01

To evaluate the diagnostic accuracy of computed tomography (CT)-based imaging methods for assessing renal vascular anatomy, imaging studies, including standard axial CT, three-dimensional volume-rendered CT (3DVR-CT), and a 3DVR-CT movie, were performed on 30 patients who underwent laparoscopic donor nephrectomy (10 right side, 20 left side) for predicting the location of the renal arteries and renal, adrenal, gonadal, and lumbar veins. These findings were compared with videos obtained during the operation. Two of 37 renal arteries observed intraoperatively were missed by standard axial CT and 3DVR-CT, whereas all arteries were identified by the 3DVR-CT movie. Two of 36 renal veins were missed by standard axial CT and 3DVR-CT, whereas 1 was missed by the 3DVR-CT movie. In 20 left renal hilar anatomical structures, 20 adrenal, 20 gonadal, and 22 lumbar veins were observed during the operation. Preoperatively, the standard axial CT, 3DVR-CT, and 3DVR-CT movie detected 11, 19, and 20 adrenal veins; 13, 14, and 19 gonadal veins; and 6, 11, and 15 lumbar veins, respectively. Overall, of 135 renal vascular structures, the standard axial CT, 3DVR-CT, and 3DVR-CT movie accurately detected 99 (73.3%), 113 (83.7%), and 126 (93.3%) vessels, respectively, which indicated that the 3DVR-CT movie demonstrated a significantly higher detection rate than other CT-based imaging methods (P < 0.05). The 3DVR-CT movie accurately provides essential information about the renal vascular anatomy before laparoscopic donor nephrectomy.

A case study of metastatic Xp11.2 translocation renal cell carcinoma effectively treated with sunitinib.

PubMed

Numakura, Kazuyuki; Tsuchiya, Norihiko; Yuasa, Takeshi; Saito, Mitsuru; Obara, Takashi; Tsuruta, Hiroshi; Narita, Shintaro; Horikawa, Yohei; Satoh, Shigeru; Habuchi, Tomonori

2011-10-01

We report a case of Xp11.2 translocation renal cell carcinoma (RCC) whose lung metastases were effectively treated with sunitinib. A 43-year-old woman presenting with upper abdominal pain was diagnosed with a left renal tumor. Laparoscopic left radical nephrectomy was performed. Histopathological examination of the surgical specimen revealed a clear-cell carcinoma of the left kidney. Two years later, multiple lung metastases were detected and the patient was treated daily with 50 mg sunitinib. A computed tomography scan performed after 2 cycles of sunitinib treatment revealed partial regression of these metastases. The partial regression has been maintained for >3 years. In retrospective evaluation of the primary RCC, tumor cells showed strong nuclear staining for transcription factor E3 (TFE3) protein and TFE3 split-fluorescence in-situ hybridization revealed translocation involving the TFE3 gene. These findings strongly support diagnosis of Xp11.2 translocation RCC.

[Cost comparison of open and robot-assisted partial nephrectomy in treatment of renal tumor].

PubMed

Abd El Fattah, V; Chevrot, A; Meusy, A; Mercier, G; Wagner, L; Soustelle, L; Boukaram, M; Thuret, R; Costa, P; Droupy, S

2016-04-01

Robot-assisted partial nephrectomy rapidly took on among urologists, even though studies showing its superiority over other techniques are still scarce and its costs hard to evaluate, especially in the French medical system. To evaluate the cost overrun of robot-assisted partial nephrectomy compared to that of open partial nephrectomy. From January 2010 to December 2013, 77 patients underwent a partial nephrectomy, 46 of which by robot-assisted laparoscopy and the remaining 31 by lombotomy. The two groups were similar in composition. Economic data regarding the staff, the consumables and the premises involved have been analyzed. Costs are significantly higher in the NPR group (9253.21 euros vs. 7448.42 euros) due to higher consumable expenses as well as the costs pertaining to the amortization and maintenance of the robot. Yet, that difference tends to diminish as the duration of the experiment increases. No significant difference was found in warm ischemia times, operation duration and renal function a month after the operation. On the other hand, patients from the NPR group spent a significantly smaller amount of time in recovery room (159 minutes vs. 205 minutes, P=0.004), presented fewer complications and were discharged faster (6.1 days vs. 8.1 days, P=0.04). To be profitable for the hospital in the French GHS system, robot-assisted partial nephrectomy must take place in a complex where at least 300 robot-assisted interventions are performed annually, in the framework of a hospitalization lasting four days or less, the use of a single needle holder and no systematic use of a haemostatic agent. 4. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Prospective clinical trial of preoperative sunitinib in patients with renal cell carcinoma.

PubMed

Hellenthal, Nicholas J; Underwood, Willie; Penetrante, Remedios; Litwin, Alan; Zhang, Shaozeng; Wilding, Gregory E; Teh, Bin T; Kim, Hyung L

2010-09-01

Sunitinib is an approved treatment for metastatic renal cell carcinoma. We performed a prospective clinical trial to evaluate the safety and clinical response to sunitinib administered before nephrectomy in patients with localized or metastatic clear cell renal cell carcinoma. Patients with biopsy proven clear cell renal cell carcinoma were enrolled in the study and treated with 37.5 mg sunitinib malate daily for 3 months before nephrectomy. The primary end point was safety. In an 18-month period 20 patients were enrolled. The most common toxicities were gastrointestinal symptoms and hematological effects. Grade 3 toxicity developed in 6 patients (30%). No surgical complications were attributable to sunitinib treatment. Of the 20 patients 17 (85%) experienced reduced tumor diameter (mean change -11.8%, range -27% to 11%) and cross-sectional area (mean change -27.9%, range -43% to 23%). Enhancement on contrast enhanced computerized tomography decreased in 15 patients (mean HU change -22%, range -74% to 29%). After tumor reduction 8 patients with cT1b disease underwent laparoscopic partial nephrectomy. Surgical parameters, such as blood loss, transfusion rate, operative time and complications, were similar to those in patients who underwent surgery during the study period and were not enrolled in the trial. Preoperative treatment with sunitinib is safe. Sunitinib decreased the size of primary renal cell carcinoma in 17 of 20 patients. Future trials can be considered to evaluate neoadjuvant sunitinib to maximize nephron sparing and decrease the recurrence of high risk, localized renal cell carcinoma. 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Prospective clinical trial of preoperative sunitinib in patients with renal cell carcinoma.

PubMed Central

Hellenthal, Nicholas J.; Underwood, Willie; Penetrante, Remedios; Litwin, Alan; Zhang, Shaozeng; Wilding, Gregory E.; Teh, Bin T.; Kim, Hyung L.

2011-01-01

Introduction Sunitinib is an approved treatment for metastatic renal cell carcinoma (RCC). A prospective clinical trial was conducted to evaluate the safety and clinical response to sunitinib administered prior to nephrectomy in patients with localized or metastatic clear cell RCC. Methods Patients with biopsy-proven clear cell RCC were enrolled and treated with sunitinib malate, 37.5 mg daily, for 3 months prior to nephrectomy. The primary endpoints was safety. Results Twenty patients were enrolled during an 18 month period. The most common toxicities were GI symptoms and hematologic. Grade 3 toxicities occurred in 6 patients (30%). No surgical complications were attributable to treatment with sunitinib. Seventeen of the 20 patients (85%) experienced a decrease in tumor diameter (mean change −11.8%, range −27% to 11%) and cross-sectional area (mean change −27.9%, range −43% to 23%). Enhancement on contrast-enhanced CT decreased in 15 patients, with a mean change in Hounsfield units of −22% (range −74% to 29%). Following a decrease in tumor size, 8 patients with cT1b tumors underwent laparoscopic partial nephrectomy. Surgical parameters such as blood loss, transfusion rate, operative time, and complications were similar to those who underwent surgery during the study period and were not enrolled on the trial. Conclusions Preoperative treatment with sunitinib is safe. Sunitinib decreased the size of primary RCC in 17 of 20 patients, and future trials can be considered to evaluate the use of neoadjuvant sunitinib to maximize nephron-sparing and decrease recurrence risk for high-risk, localized RCC. PMID:20643461

Drain placement can be safely omitted after the majority of robotic partial nephrectomies.

PubMed

Abaza, Ronney; Prall, David

2013-03-01

Drain placement after partial nephrectomy is considered standard but it is based on routine and not on evidence. With experience we performed robotic partial nephrectomy and routinely omitted a drain even with significant collecting system violation. We have rarely used drains after robotic partial nephrectomy for several years, and we report our outcomes. We reviewed a single surgeon, prospective database of all robotic partial nephrectomies from February 2008 to March 2012, including the characteristics of those with and without a drain. The 150 patients underwent a total of 160 robotic partial nephrectomy procedures with a drain used in 11 patients and omitted in 93%. Mean patient age was 57 years (range 22 to 89), mean American Society of Anesthesiologists score was 2.8 (range 2 to 4) and mean body mass index was 32 kg/m(2) (range 18 to 54). Values were similar in patients with and without a drain. In patients without a drain and in those with a drain mean tumor size was 3.5 cm (range 1.0 to 11.0) and 4.6 cm (range 1.1 to 8.6), and mean R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines, hilar tumor touching main renal artery or vein) nephrometry score was 7.8 (range 4 to 12) and 8.8 (range 6 to 11), respectively. Collecting system violation occurred in 88 patients (59%), including 78 without a drain. Two patients (1.3%) required transfusion with no intervention for bleeding. All except 5 patients (97%) were discharged home on postoperative day 1 with all drains removed before discharge. In 2 patients (1.3%) without a drain small urinomas without infection developed more than 2 weeks postoperatively, which were treated with a week of Foley catheter drainage and percutaneous drainage, respectively. Drain placement after robotic partial nephrectomy can be routinely omitted with a low rate of urine leaks, which can be managed safely when they rarely occur. Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Hilar control during laparoscopic donor nephrectomy: Practice patterns in Canada.

PubMed

Mcgregor, Thomas B; Patel, Premal; Chan, Gabriel; Sener, Alp

2017-10-01

In recent years, the method of vascular control during laparoscopic donor nephrectomy (LDN) has come under scrutiny due to catastrophic consequences of a device failure. This study sought to examine the surgical preferences of Canadian donor surgeons with regards to vascular control and their perception on the safety of these modalities. We also surveyed the experience with device malfunction and their subsequent management during LDN. An online survey was sent out to donor surgeons registered with the Canadian Society of Transplantation. Surveys were anonymous and voluntary. Descriptive statistics were used to analyze the collected responses. Recollection of the sequelae and outcomes from device malfunction were also queried. Twenty-eight of 37 surgeons (76% response rate) responded to the survey. At least one surgeon from every institution in Canada performing LDN responded to the survey. Laparoscopic stapler is the most commonly used device for securing the renal artery (61%) and renal vein (67%). Overall, surgeons felt the stapler was the safest method of securing the renal artery. Stapler misfire and clip slippage were reported by eight (28.5%) and 12 (43%) surgeons, respectively. Most cases were salvageable: laparoscopically (30%), open conversion (30%), and by hand port (5%). Slippage of a plastic locking clip resulted in one emergent laparotomy on POD#1 and one stapler misfire was converted to open resulting in donor death. Although rare, hemorrhagic complications can occur from device malfunction resulting in poor outcomes for healthy volunteers undergoing LDN. Surgeons need to remain vigilant when selecting the appropriate modality for vascular control.

Development of a human cadaver model for training in laparoscopic donor nephrectomy.

PubMed

Sutton, Erica R H; Billeter, Adrian; Druen, Devin; Roberts, Henry; Rice, Jonathan

2017-06-01

The organ procurement network recommends a surgeon record 15 cases as surgeon or assistant for laparoscopic donor nephrectomies (LDN) prior to independent practice. The literature suggests that the learning curve for improved perioperative and patient outcomes is closer to 35 cases. In this article, we describe our development of a model utilizing fresh tissue and objective, quantifiable endpoints to document surgical progress, and efficiency in each of the major steps involved in LDN. Phase I of model development focused on the modifications necessary to maintain visualization for laparoscopic surgery in a human cadaver. Phase II tested proposed learner-based metrics of procedural competency for multiport LDN by timing procedural steps of LDN in a novice learner. Phases I and II required 12 and nine cadavers, with a total of 35 kidneys utilized. The following metrics improved with trial number for multiport LDN: time taken for dissection of the gonadal vein, ureter, renal hilum, adrenal and lumbrical veins, simulated warm ischemic time (WIT), and operative time. Human cadavers can be used for training in LDN as evidenced by improvements in timed learner-based metrics. This simulation-based model fills a gap in available training options for surgeons. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Prospective analysis of laparoscopic versus open radical nephrectomy for renal tumours more than 7 cm.

PubMed

Khan, Mohd Mubashir Ali; Patel, Rajkumar Ashokkumar; Jain, Nitesh; Balakrishnan, Arunkumar; Venkataraman, Murali

2018-03-23

To analyse the feasibility of laparoscopic radical nephrectomy (LRN) for renal tumours> 7 cm and to compare the operative and oncologic outcomes with open radical nephrectomy (ORN). This was a prospective, observational, comparative study. The study was conducted at a tertiary care super-speciality hospital. All the patients who underwent radical nephrectomy for> 7 cm renal tumours during a period of 2 years (April 2012 to May 2014) were included in the study. Thirty patients were included in each ORN and LRN group. Pre-operative, intra-operative and post-operative data for all these patients were collected and analysed. Statistical Package for the Social Sciences (SPSS, version 11.0 for Windows, Chicago, IL). Mean age of patients in ORN and LRN groups was 57.3 ± 6.1 years and 54.9 ± 5.7 years, respectively (P = 0.220). As compared to ORN, LRN had less drop in post-operative haemoglobin (1.39 ± 0.55 g/dl vs. 4.07 ± 1.023 g/dl, P < 0.05), less drop in haematocrit value (4.7 ± 3.25% vs. 9.5 ± 5.13%, P < 0.05), less analgesic requirement for tramadol hydrochloride (165 ± 74.5 mg vs. 260 ± 181.66 mg) and less mean hospital stay (4.2 days vs. 6.1 days, P < 0.05). There was no statistically significant difference in post-operative complication rate and recurrence-free survival over a median follow-up of 17 months (93.9% - LRN vs. 90% - ORN) Conclusions: LRN for large renal tumours is feasible and achieves oncologic outcomes similar to that obtained with ORN.

A randomized, prospective study of laparoendoscopic single-site plus one-port versus mini laparoscopic technique for live donor nephrectomy.

PubMed

Lee, Kyu Won; Choi, Sae Woong; Park, Yong Hyun; Bae, Woong Jin; Choi, Yong Sun; Ha, U-Syn; Hong, Sung-Hoo; Lee, Ji Youl; Kim, Sae Woong; Cho, Hyuk Jin

2018-04-01

To compare the clinical outcomes of laparoendoscopic single-site plus one-port donor nephrectomy (LESSOP-DN) and mini laparoscopic donor nephrectomy (MLDN). A prospective randomized controlled trial was conducted from December 2014 to February 2016 in donors scheduled for left donor nephrectomy. Donor and recipient demographics and clinical outcomes including pain scores and questionnaires (BIQ: body image questionnaire, SF-36, patient-reported overall convalescence) were also compared. A total of 121 eligible donors were recruited, of which 99 donors who were scheduled to undergo an operation on their left side were randomized into LESSOP-DN (n = 50) and MLDN (n = 49) groups. There were no significant demographic differences between the two groups. The renal extraction time in the LESS-DN group was shorter than that in the MLDN group (75.89 ± 13.01 vs. 87.31 ± 11.38 min, p < 0.001). Other perioperative parameters and complication rates were comparable between the two groups. The LESSOP-DN group had a smaller incision length than the MLDN group (4.89 ± 0.68 vs. 6.21 ± 1.11 cm, p < 0.001), but cosmetic scores and body image scores were similar in the two groups (p = 0.905, 0.217). Donor quality of life (SF-36) and recovery and satisfaction data were comparable between the two groups. Delayed graft function (DGF) occurred in one recipient undergoing MLDN procedure (2.1%) and progressed to graft failure. There were no differences in cosmetic satisfaction between groups despite the smaller incision size of LESSOP-DN. Safety parameters and subjective measures of postoperative morbidity were similar between the two groups.

Current status of cryotherapy for prostate and kidney cancer.

PubMed

Cho, Seok; Kang, Seok Ho

2014-12-01

In terms of treating diseases, minimally invasive treatment has become a key element in reducing perioperative complications. Among the various minimally invasive treatments, cryotherapy is often used in urology to treat various types of cancers, especially prostate cancer and renal cancer. In prostate cancer, the increased incidence of low-risk, localized prostate cancer has made minimally invasive treatment modalities an attractive option. Focal cryotherapy for localized unilateral disease offers the added benefit of minimal morbidities. In renal cancer, owing to the increasing utilization of cross-sectional imaging, nearly 70% of newly detected renal masses are stage T1a, making them more susceptible to minimally invasive nephron-sparing therapies including laparoscopic and robotic partial nephrectomy and ablative therapies. This article reviews the various outcomes of cryotherapy compared with other treatments and the possible uses of cryotherapy in surgery.

Current Status of Cryotherapy for Prostate and Kidney Cancer

PubMed Central

Cho, Seok

2014-01-01

In terms of treating diseases, minimally invasive treatment has become a key element in reducing perioperative complications. Among the various minimally invasive treatments, cryotherapy is often used in urology to treat various types of cancers, especially prostate cancer and renal cancer. In prostate cancer, the increased incidence of low-risk, localized prostate cancer has made minimally invasive treatment modalities an attractive option. Focal cryotherapy for localized unilateral disease offers the added benefit of minimal morbidities. In renal cancer, owing to the increasing utilization of cross-sectional imaging, nearly 70% of newly detected renal masses are stage T1a, making them more susceptible to minimally invasive nephron-sparing therapies including laparoscopic and robotic partial nephrectomy and ablative therapies. This article reviews the various outcomes of cryotherapy compared with other treatments and the possible uses of cryotherapy in surgery. PMID:25512811

Diffusion of robotics into clinical practice in the United States: process, patient safety, learning curves, and the public health.

PubMed

Mirheydar, Hossein S; Parsons, J Kellogg

2013-06-01

Robotic technology disseminated into urological practice without robust comparative effectiveness data. To review the diffusion of robotic surgery into urological practice. We performed a comprehensive literature review focusing on diffusion patterns, patient safety, learning curves, and comparative costs for robotic radical prostatectomy, partial nephrectomy, and radical cystectomy. Robotic urologic surgery diffused in patterns typical of novel technology spreading among practicing surgeons. Robust evidence-based data comparing outcomes of robotic to open surgery were sparse. Although initial Level 3 evidence for robotic prostatectomy observed complication outcomes similar to open prostatectomy, subsequent population-based Level 2 evidence noted an increased prevalence of adverse patient safety events and genitourinary complications among robotic patients during the early years of diffusion. Level 2 evidence indicated comparable to improved patient safety outcomes for robotic compared to open partial nephrectomy and cystectomy. Learning curve recommendations for robotic urologic surgery have drawn exclusively on Level 4 evidence and subjective, non-validated metrics. The minimum number of cases required to achieve competency for robotic prostatectomy has increased to unrealistically high levels. Most comparative cost-analyses have demonstrated that robotic surgery is significantly more expensive than open or laparoscopic surgery. Evidence-based data are limited but suggest an increased prevalence of adverse patient safety events for robotic prostatectomy early in the national diffusion period. Learning curves for robotic urologic surgery are subjective and based on non-validated metrics. The urological community should develop rigorous, evidence-based processes by which future technological innovations may diffuse in an organized and safe manner.

Renal functional and perioperative outcomes of off-clamp versus clamped robot-assisted partial nephrectomy: matched cohort study.

PubMed

Tanagho, Youssef S; Bhayani, Sam B; Sandhu, Gurdarshan S; Vaughn, Nicholas P; Nepple, Kenneth G; Figenshau, R Sherburne

2012-10-01

To evaluate the potential benefit of performing off-clamp robot-assisted partial nephrectomy as it relates to renal functional outcomes, while assessing the safety profile of this unconventional surgical approach. Twenty-nine patients who underwent off-clamp robot-assisted partial nephrectomy for suspected renal cell carcinoma at Washington University between March 2008 and September 2011 (group 1) were matched to 29 patients with identical nephrometry scores and comparable baseline renal function who underwent robot-assisted partial nephrectomy with hilar clamping during the same period (group 2). The matched cohorts' perioperative and renal functional outcomes were compared at a mean 9-month follow-up. Mean estimated blood loss was 146.4 mL in group 1, versus 103.9 mL in group 2 (P = .039). Mean hilar clamp time was 0 minutes in group 1 and 14.7 minutes in group 2. No perioperative complications were encountered in group 1; 1 Clavien-2 complication (3.4%) occurred in group 2 (P = 1.000). At 9-month follow-up, mean estimated glomerular filtration rate in group 1 was 79.9 versus 84.8 mL/min/1.73 m(2) preoperatively (P = .013); mean estimated glomerular filtration rate in group 2 was 74.1 versus 85.8 mL/min/1.73 m(2) preoperatively (P < .001). Hence, estimated glomerular filtration rate declined by a mean of 4.9 mL/min/1.73 m(2) in group 1 versus 11.7 mL/min/1.73 m(2) in group 2 (P = .033). Off-clamp robot-assisted partial nephrectomy is associated with a favorable morbidity profile and relatively greater renal functional preservation compared to clamped robot-assisted partial nephrectomy. Nevertheless, the benefit is small in renal functional terms and may have very limited clinical relevance. Copyright © 2012 Elsevier Inc. All rights reserved.

Robot-assisted approach improves surgical outcomes in obese patients undergoing partial nephrectomy.

PubMed

Malkoc, Ercan; Maurice, Matthew J; Kara, Onder; Ramirez, Daniel; Nelson, Ryan J; Caputo, Peter A; Mouracade, Pascal; Stein, Robert; Kaouk, Jihad H

2017-02-01

To assess the impact of approach on surgical outcomes in otherwise healthy obese patients undergoing partial nephrectomy for small renal masses. Using our institutional partial nephrectomy database, we abstracted data on otherwise healthy (Charlson comorbidity score ≤1 and bilateral kidneys), obese patients (body mass index >30 kg/m 2 ) with small renal masses (<4 cm) treated between 2011 and 2015. The primary outcomes were intra-operative transfusion, operating time, length of hospital stay (LOS), and postoperative complications. The association between approach, open (OPN) vs robot-assisted partial nephrectomy (RAPN), and outcomes was assessed by univariable and multivariable logistic regression analyses. Covariates included age, gender, obesity severity, tumour size and tumour complexity. Of 237 obese patients undergoing partial nephrectomy, 25% underwent OPN and 75% underwent RAPN. Apart from larger tumour size in the OPN group (2.8 vs 2.5 cm; P = 0.02), there was no significant difference between groups. The rate of intra-operative blood transfusion (1.1 vs 10%; P = 0.01), the median operating time (180 vs 207 min; P < 0.01) and the median ischaemia time (19.5 vs 27 min; P < 0.01) were all greater for OPN. The LOS was significantly shorter for RAPN (3 vs 4 days; P < 0.01). While the overall complication rate was higher for OPN (15.8 vs 31.7%; P < 0.01), major complications were not significantly different (5.6 vs 1.7%; P = 0.20). On multivariable analyses, OPN independently predicted longer operating time, longer length of stay, and more overall complications. At a high-volume centre, the robot-assisted approach offers less blood transfusion, shorter operating time, faster recovery, and fewer peri-operative complications compared with the open approach in obese patients undergoing partial nephrectomy for small renal masses. In this setting, RAPN may be a preferable treatment option. © 2016 The Authors BJU International © 2016 BJU International Published by John Wiley & Sons Ltd.

Yonsei nomogram: A predictive model of new-onset chronic kidney disease after on-clamp partial nephrectomy in patients with T1 renal tumors.

PubMed

Abdel Raheem, Ali; Shin, Tae Young; Chang, Ki Don; Santok, Glen Denmer R; Alenzi, Mohamed Jayed; Yoon, Young Eun; Ham, Won Sik; Han, Woong Kyu; Choi, Young Deuk; Rha, Koon Ho

2018-06-19

To develop a predictive nomogram for chronic kidney disease-free survival probability in the long term after partial nephrectomy. A retrospective analysis was carried out of 698 patients with T1 renal tumors undergoing partial nephrectomy at a tertiary academic institution. A multivariable Cox regression analysis was carried out based on parameters proven to have an impact on postoperative renal function. Patients with incomplete data, <12 months follow up and preoperative chronic kidney disease stage III or greater were excluded. The study end-points were to identify independent risk factors for new-onset chronic kidney disease development, as well as to construct a predictive model for chronic kidney disease-free survival probability after partial nephrectomy. The median age was 52 years, median tumor size was 2.5 cm and mean warm ischemia time was 28 min. A total of 91 patients (13.1%) developed new-onset chronic kidney disease at a median follow up of 60 months. The chronic kidney disease-free survival rates at 1, 3, 5 and 10 year were 97.1%, 94.4%, 85.3% and 70.6%, respectively. On multivariable Cox regression analysis, age (1.041, P = 0.001), male sex (hazard ratio 1.653, P < 0.001), diabetes mellitus (hazard ratio 1.921, P = 0.046), tumor size (hazard ratio 1.331, P < 0.001) and preoperative estimated glomerular filtration rate (hazard ratio 0.937, P < 0.001) were independent predictors for new-onset chronic kidney disease. The C-index for chronic kidney disease-free survival was 0.853 (95% confidence interval 0.815-0.895). We developed a novel nomogram for predicting the 5-year chronic kidney disease-free survival probability after on-clamp partial nephrectomy. This model might have an important role in partial nephrectomy decision-making and follow-up plan after surgery. External validation of our nomogram in a larger cohort of patients should be considered. © 2018 The Japanese Urological Association.

Commentary on "Detailed analysis of morbidity following nephrectomy for renal cell carcinoma in octogenarians." Berger J, Fardoun T, Brassart E, Capon G, Bigot P, Bernhard JC, Rigaud J, Patard JJ, Descazeaud A, Department of Urology, Dupuytren University Hospital, Limoges, France: J Urol 2012;188(3):736-40 (Epub 2012 Jul 19).

PubMed

Boorjian, Stephen

2013-01-01

We evaluated the morbidity of nephrectomy in patients older than 80 years of age. Between June 2002 and March 2011, 2,530 patients underwent surgery for renal tumor at 5 French academic centers. Of these patients, 180 (7.1%) were 80 years of age or older; 22 (12%) and 158 (88%) patients underwent partial and radical nephrectomy, respectively, and 47 (26.1%) of whom were treated with a laparoscopic approach. Mean patient age was 82.3 years. Median Charlson score was 4. Mean preoperative glomerular filtration rate was 47 ml/min. A total of 136 complications were recorded in 70 patients (38.8% of all patients). Of these patients, 28 (15.5%), 25 (13.9%), and 17 (9.4%) experienced 1, 2, and 3 or more complications, respectively. According to the modified Clavien classification grade I, II, III, IV, and V complications were observed in 7, 81, 19, 23, and 6 patients, respectively. The transfusion rate was 31.1% (56). On logistic regression analysis, the parameters of Eastern Cooperative Oncology Group Performance Status 2 to 4 (P = 0.035) and preoperative glomerular filtration rate less than 30 ml/min (P = 0.03) were independent predictive factors of morbidity. Morbidity and mortality are significant in the octogenarian population. The risk of complications should be considered in decision making for patients with renal cell carcinoma who were older than age 80 years. Copyright © 2013 Elsevier Inc. All rights reserved.

A discrete mechanics framework for real time virtual surgical simulations with application to virtual laparoscopic nephrectomy.

PubMed

Zhou, Xiangmin; Zhang, Nan; Sha, Desong; Shen, Yunhe; Tamma, Kumar K; Sweet, Robert

2009-01-01

The inability to render realistic soft-tissue behavior in real time has remained a barrier to face and content aspects of validity for many virtual reality surgical training systems. Biophysically based models are not only suitable for training purposes but also for patient-specific clinical applications, physiological modeling and surgical planning. When considering the existing approaches for modeling soft tissue for virtual reality surgical simulation, the computer graphics-based approach lacks predictive capability; the mass-spring model (MSM) based approach lacks biophysically realistic soft-tissue dynamic behavior; and the finite element method (FEM) approaches fail to meet the real-time requirement. The present development stems from physics fundamental thermodynamic first law; for a space discrete dynamic system directly formulates the space discrete but time continuous governing equation with embedded material constitutive relation and results in a discrete mechanics framework which possesses a unique balance between the computational efforts and the physically realistic soft-tissue dynamic behavior. We describe the development of the discrete mechanics framework with focused attention towards a virtual laparoscopic nephrectomy application.

Robot-assisted Partial Nephrectomy: 5-yr Oncological Outcomes at a Single European Tertiary Cancer Center.

PubMed

Vartolomei, Mihai Dorin; Matei, Deliu Victor; Renne, Giuseppe; Tringali, Valeria Maria; Crisan, Nicolae; Musi, Gennaro; Mistretta, Francesco Alessandro; Russo, Andrea; Cozzi, Gabriele; Cordima, Giovani; Luzzago, Stefano; Cioffi, Antonio; Di Trapani, Ettore; Catellani, Michele; Delor, Maurizio; Bottero, Danilo; Imbimbo, Ciro; Mirone, Vincenzo; Ferro, Matteo; de Cobelli, Ottavio

2017-10-27

Nowadays, there is a debate about which surgical treatment should be best for clinical T1 renal tumors. If the oncological outcomes are considered, there are many open and laparoscopic series published. As far as robotic series are concerned, only a few of them report 5-yr oncological outcomes. The aim of this study was to analyze robot-assisted partial nephrectomy (RAPN) midterm oncological outcomes achieved in a tertiary robotic reference center. Between April 2009 and September 2013, 123 consecutive patients with clinical T1-stage renal masses underwent RAPN in our tertiary cancer center. Inclusion criteria were as follows: pathologically confirmed renal cell carcinomas (RCCs) and follow-up for >12 mo. Eighteen patients were excluded due to follow-up of <12 mo and 15 due to benign final pathology. Median follow-up was 59 mo (interquartile range 44-73 mo). Patients were followed according to guideline recommendations and institutional protocol. Outcomes were measured by time to disease progression, overall survival, or time to cancer-specific death. Kaplan-Meier method was used to estimate survival; log-rank tests were applied for pair-wise comparison of survival. From the 90 patients included, 66 (73.3%) had T1a, 12 (13.3%) T1b, three (3.3%) T2a, and nine (10%) T3a tumors. Predominant histological type was clear cell carcinoma: 67 (74.5%). Fuhrmann grade 1 and 2 was found in 73.3% of all malignant tumors. Two patients (2.2%) had positive surgical margins, and complication rate was 17.8%. Relapse rate was 7.7%, including two cases (2.2%) of local recurrences and five (5.5%) distant metastasis. Five-year disease-free survival was 90.9%, 5-yr cancer-specific survival was 97.5%, and 5-yr overall survival was 95.1%. Midterm oncological outcomes after RAPN for localized RCCs (predominantly T1a tumors of low anatomic complexity) were shown to be good, adding significant evidence to support the oncological efficacy and safety of RAPN for the treatment of this type of tumors. Robot-assisted partial nephrectomy seems to be the most promising minimally invasive approach in the treatment of renal masses suitable for organ-sparing surgery as midterm (5 yr) oncological outcomes are excellent. Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Return to normal activities and work after living donor laparoscopic nephrectomy.

PubMed

Larson, Dawn B; Jacobs, Cheryl; Berglund, Danielle; Wiseman, Jennifer; Garvey, Catherine; Gillingham, Kristen; Ibrahim, Hassan N; Matas, Arthur J

2017-01-01

Transplant programs inform potential donors that they should be able to return to normal activities within ~2 weeks and to work by 6 weeks after laparoscopic nephrectomy. We studied actual time. Between 10/2004 and 9/2014, 911 donors having laparoscopic nephrectomy were surveyed 6 months post-donation. Surveys asked questions specific to their recovery experience, including time to return to normal activities and work and a description of their recovery time relative to pre-donation expectations. Of the 911, 646 (71%) responded: mean age at donation was 43.5±10.6 years; 65% were female, 95% were white, 51% were biologically related to their recipient, and 83% reported education beyond high school. Of the 646 respondents, a total of 35% returned to normal activities by 2 weeks post-donation; 79% by 4 weeks post-donation; 94% by 5-6 weeks; however, 6% took >6 weeks. Of the 646, 551 (85%) were working for pay; of these, mean time to return to work was 5.3±2.8 weeks; median, 5 weeks. Of the 551, a total of 14% returned to work in 1-2 weeks, 46% by 3-4 weeks, and 76% by 5-6 weeks. Importantly, 24% required >6 weeks before returning to work with the highest rates for donors in manual labor or a skilled trade. Significantly longer return to work was reported by females (vs males; P=.01), those without (vs those with) post-high school education (P=.010, those with longer hospital stay (P=.01), and those with a postoperative complication (P=.02). Of respondents, 37% described their recovery time as longer than expected. During the donor informed consent process, additional emphasis on realistic expectations around recovery to baseline activities and return to work is warranted. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Robotic-assisted laparoscopic radical nephrectomy using the Da Vinci Si system: how to improve surgeon autonomy. Our step-by-step technique.

PubMed

Davila, Hugo H; Storey, Raul E; Rose, Marc C

2016-09-01

Herein, we describe several steps to improve surgeon autonomy during a Left Robotic-Assisted Laparoscopic Radical Nephrectomy (RALRN), using the Da Vinci Si system. Our kidney cancer program is based on 2 community hospitals. We use the Da Vinci Si system. Access is obtained with the following trocars: Two 8 mm robotic, one 8 mm robotic, bariatric length (arm 3), 15 mm for the assistant and 12 mm for the camera. We use curved monopolar scissors in robotic arm 1, Bipolar Maryland in arm 2, Prograsp Forceps in arm 3, and we alternate throughout the surgery with EndoWrist clip appliers and the vessel sealer. Here, we described three steps and the use of 3 robotic instruments to improve surgeon autonomy. Step 1: the lower pole of the kidney was dissected and this was retracted upwards and laterally. This maneuver was performed using the 3rd robotic arm with the Prograsp Forceps. Step 2: the monopolar scissors was replaced (robotic arm 1) with the robotic EndoWrist clip applier, 10 mm Hem-o-Lok. The renal artery and vein were controlled and transected by the main surgeon. Step 3: the superior, posterolateral dissection and all bleeders were carefully coagulated by the surgeon with the EndoWrist one vessel sealer. We have now performed 15 RALRN following these steps. Our results were: blood loss 300 cc, console time 140 min, operating room time 200 min, anesthesia time 180 min, hospital stay 2.5 days, 1 incisional hernia, pathology: (13) RCC clear cell, (1) chromophobe and (1) papillary type 1. Tumor Stage: (5) T1b, (8) T2a, (2) T2b. We provide a concise, step-by-step technique for radical nephrectomy (RN) using the Da Vinci Si robotic system that may provide more autonomy to the surgeon, while maintaining surgical outcome equivalent to standard laparoscopic RN.

[Post-operative pain after ultrasound transversus abdominis plane block versus trocar site infiltration in laparoscopic nephrectomy: a prospective study].

PubMed

Araújo, Ana M; Guimarães, Joana; Nunes, Catarina S; Couto, Paula S; Amadeu, Eduarda

Transversus abdominis plane (TAP) block is useful in reducing post-operative pain in laparoscopic nephrectomy compared to placebo. The purpose of this work is to compare post-operative pain and recovery after TAP block or trocar site infiltration (TSI) in this surgery. A prospective, single blinded study on patients scheduled for laparoscopic nephrectomy. Patients were assigned to two groups: TSI Group: trocar site infiltration at the end of surgery; TAP Group: unilateral ultrasound-guided TAP block after induction. Sevoflurane and remifentanil, in a target controlled infusion mode, were used for maintenance of general anesthesia. Before the end of surgery paracetamol, tramadol and morphine were administered. Visual analogue scale (VAS 0-100mm) at rest and with cough was applied in three moments: in recovery room (T1 at admission and T2 before discharge) and 24h after surgery (T3). Pain scores with incentive spirometer were also evaluated at T3. In recovery, morphine was administered as a rescue drug whenever VAS>30mm. Time to oral intake, chair sitting, ambulation and length of hospital stay were evaluated 24h after surgery. Student's t-test and Chi-square test, and linear regression models. A p-value<0.05 was considered significant. Data are presented as mean (SD). Forty patients were enrolled in the study. The primary outcome variable, VAS pain scores did not show a statistical significant difference between groups (p>0.05). VAS at rest (TAP vs. TSI groups) was: T1=33±29 vs. 39±32, T2=10±9 vs. 17±18 and T3=7±12 vs. 10±18. VAS with cough (TAP vs. TSI groups) was: T1=51±34 vs. 45±32, T2=24±24 vs. 33±23 and T3=20±23 vs. 23±23. VAS with incentive spirometer (TAP vs. TSI groups) was: T3=21±27 vs. 21±25. Intraoperative remifentanil consumption was similar between TAP (0.16±0.07mcg.kg -1 .min -1 ) and TSI (0.18±0.9mcg.kg -1 .min -1 ) groups. There were no differences in opioid consumption between TAP (4.4±3.49mg) and TSI (6.87±4.83mg) groups during recovery. Functional recovery parameters were not statistically different between groups. Multimodal analgesia with TAP block did not show a significant clinical benefit compared with trocar site infiltration in laparoscopic nephrectomies. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Drain placement can safely be omitted for open partial nephrectomy: Results from a prospective randomized trial.

PubMed

Kriegmair, Maximilian C; Mandel, Philipp; Krombach, Patrick; Dönmez, Hasan; John, Axel; Häcker, Axel; Michel, Maurice S

2016-05-01

To examine the benefit of drain placement during open partial nephrectomy. Overall, 106 patients treated with open partial nephrectomy were enrolled in a prospective randomized trial. Based on the randomization, a drain was placed or omitted. Complications were assessed according to the Clavien classification. Pain level and requirement for analgesics was evaluated according to a customized pattern. There was no significant difference in the two groups regarding age, body mass index, American Society of Anesthesiologists score, tumor size and nephrometry (preoperative aspects and dimensions used for an anatomical classification). In terms of overall and drain-related complications, no advantage of placing a drain could be proven (P = 0.249). Patients with a drain suffered from a significantly higher pain level (P = 0.01) and showed prolonged mobilization (P < 0.001). There was no difference in bowel movements and requirement of additional analgesics (P = 0.347 and 0.11). The results of the study suggest that drain placement during open partial nephrectomy can safely be omitted, even in cases with violation of the collecting system. © 2016 The Japanese Urological Association.

[A new technique for ensuring negative surgical margins during partial nephrectomy: the ex vivo ultrasound control].

PubMed

Desmonts, A; Tillou, X; Le Gal, S; Secco, M; Orczyk, C; Bensadoun, H; Doerfler, A

2013-10-01

To evaluate the feasibility and the efficiency of intraoperative ex vivo ultrasound of resection margins in patients undergoing partial nephrectomy by urologist. Patients undergoing partial nephrectomy from July 2010 to November 2012 for T1-T2 renal tumors were included in analysis. Tumor margin status was immediately determined by ex vivo ultrasound done by the surgeon himself. Results were compared with margin status on definitive pathological evaluation. A total of 26 men and 15 women with a median age of 61 (30-82) years old were included in analysis. Intraoperative ex vivo ultrasound revealed negative surgical margins in 38 cases and positive margins in two. Final pathological results revealed negative margins in all except one case. Ultrasound sensitivity and specificity were 100% and 97%, respectively. Mean ultrasound duration was 1minute±1. Mean tumor and margin sizes were 3.4±1.8cm and 2.38±1.76mm, respectively. Intraoperative ex vivo ultrasound of resection margins in patients undergoing partial nephrectomy by a urologist seemed to be feasible, efficient and easy. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Evidence of a heterogeneous tissue oxygenation: renal ischemia/reperfusion injury in a large animal model

NASA Astrophysics Data System (ADS)

Crane, Nicole J.; Huffman, Scott W.; Alemozaffar, Mehrdad; Gage, Frederick A.; Levin, Ira W.; Elster, Eric A.

2013-03-01

Renal ischemia that occurs intraoperatively during procedures requiring clamping of the renal artery (such as renal procurement for transplantation and partial nephrectomy for renal cancer) is known to have a significant impact on the viability of that kidney. To better understand the dynamics of intraoperative renal ischemia and recovery of renal oxygenation during reperfusion, a visible reflectance imaging system (VRIS) was developed to measure renal oxygenation during renal artery clamping in both cooled and warm porcine kidneys. For all kidneys, normothermic and hypothermic, visible reflectance imaging demonstrated a spatially distinct decrease in the relative oxy-hemoglobin concentration (%HbO2) of the superior pole of the kidney compared to the middle or inferior pole. Mean relative oxy-hemoglobin concentrations decrease more significantly during ischemia for normothermic kidneys compared to hypothermic kidneys. VRIS may be broadly applicable to provide an indicator of organ ischemia during open and laparoscopic procedures.

Staged Hand-Assisted Bilateral Native Nephrectomy for Management of Posttransplant Polyuria in an Adult with Dent's Disease

PubMed Central

Montero, Rosa M.; Olsburgh, Jonathon

2015-01-01

Polyuria after kidney transplantation causes graft dysfunction and increased thrombotic risk. We present a case of a polyuric adult with Dent's disease who underwent staged bilateral native nephrectomies, the first operation before transplant and the second four months after transplant. This led to improved allograft function maintained during four years of follow-up. The retroperitoneal laparoscopic approach was well tolerated and allowed continuation of peritoneal dialysis before transplantation. A staged approach helps regulate fluid balance perioperatively and may be tailored to individual need according to posttransplant urine output. This novel approach should be considered for polyuric patients with tubular dysfunction including Dent's disease. PMID:25649339

Surgical complications associated with robotic urologic procedures in elderly patients.

PubMed

Cusano, Antonio; Haddock, Peter; Staff, Ilene; Jackson, Max; Abarzua-Cabezas, Fernando; Dorin, Ryan; Meraney, Anoop; Wagner, Joseph; Shichman, Steven; Kesler, Stuart

2015-02-01

Urologic malignancies are often diagnosed at an older age, and are increasingly managed utilizing robotic-assisted surgical techniques. As such, we assessed and compared peri-postoperative complication rates following robotic urologic surgery in elderly and younger patients. A retrospective analysis of IRB-approved databases and electronic medical records identified patients who underwent robotic-assisted urologic surgery between December 2003-September 2013. Patients were grouped according to surgical procedure (partial nephrectomy, radical cystectomy, radical prostatectomy) and age at surgery (≤ 74 or ≥ 75 years old). Associations between age, comorbidities, Charlson comorbidity index (CCI), and patient outcomes were evaluated within each surgery type. 97.5% and 2.5% of patients were ≤ 74 or ≥ 75 years old, respectively. Cystectomies, partial nephrectomies and prostatectomies accounted for 3.5%, 9.5% and 87.1% of surgeries, respectively. Within cystectomy, nephrectomy and prostatectomy groups, 24.4%, 12.5% and 0.6% patients were ≥ 75 years old. Within each surgical type, elderly patients had significantly elevated CCI scores. Length of stay was significantly prolonged in elderly patients undergoing partial nephrectomy or prostatectomy. In elderly cystectomy, partial nephrectomy and prostatectomy patients, 36.7%, 14.3% and 5.9% suffered ≥ 1 Clavien grade 3-5 complication, respectively. Major complications were not significantly different between age groups. A qualitatively similar pattern was observed regarding Clavien grade 1-2 complications. The risks of robotic-assisted urologic surgery in elderly patients are not significantly elevated compared to younger patients.

Development and Validity of a Silicone Renal Tumor Model for Robotic Partial Nephrectomy Training.

PubMed

Monda, Steven M; Weese, Jonathan R; Anderson, Barrett G; Vetter, Joel M; Venkatesh, Ramakrishna; Du, Kefu; Andriole, Gerald L; Figenshau, Robert S

2018-04-01

To provide a training tool to address the technical challenges of robot-assisted laparoscopic partial nephrectomy, we created silicone renal tumor models using 3-dimensional printed molds of a patient's kidney with a mass. In this study, we assessed the face, content, and construct validity of these models. Surgeons of different training levels completed 4 simulations on silicone renal tumor models. Participants were surveyed on the usefulness and realism of the model as a training tool. Performance was measured using operation-specific metrics, self-reported operative demands (NASA Task Load Index [NASA TLX]), and blinded expert assessment (Global Evaluative Assessment of Robotic Surgeons [GEARS]). Twenty-four participants included attending urologists, endourology fellows, urology residents, and medical students. Post-training surveys of expert participants yielded mean results of 79.2 on the realism of the model's overall feel and 90.2 on the model's overall usefulness for training. Renal artery clamp times and GEARS scores were significantly better in surgeons further in training (P ≤.005 and P ≤.025). Renal artery clamp times, preserved renal parenchyma, positive margins, NASA TLX, and GEARS scores were all found to improve across trials (P <.001, P = .025, P = .024, P ≤.020, and P ≤.006, respectively). Face, content, and construct validity were demonstrated in the use of a silicone renal tumor model in a cohort of surgeons of different training levels. Expert participants deemed the model useful and realistic. Surgeons of higher training levels performed better than less experienced surgeons in various study metrics, and improvements within individuals were observed over sequential trials. Future studies should aim to assess model predictive validity, namely, the association between model performance improvements and improvements in live surgery. Copyright © 2018 Elsevier Inc. All rights reserved.

Impact of preoperative calculation of nephron volume loss on future of partial nephrectomy techniques; planning a strategic roadmap for improving functional preservation and securing oncological safety.

PubMed

Rha, Koon H; Abdel Raheem, Ali; Park, Sung Y; Kim, Kwang H; Kim, Hyung J; Koo, Kyo C; Choi, Young D; Jung, Byung H; Lee, Sang K; Lee, Won K; Krishnan, Jayram; Shin, Tae Y; Cho, Jin-Seon

2017-11-01

To assess the correlation of the resected and ischaemic volume (RAIV), which is a preoperatively calculated volume of nephron loss, with the amount of postoperative renal function (PRF) decline after minimally invasive partial nephrectomy (PN) in a multi-institutional dataset. We identified 348 patients from March 2005 to December 2013 at six institutions. Data on all cases of laparoscopic (n = 85) and robot-assisted PN (n = 263) performed were retrospectively gathered. Univariable and multivariable linear regression analyses were used to identify the associations between various time points of PRF and the RAIV, as a continuous variable. The mean (sd) RAIV was 24.2 (29.2) cm 3 . The mean preoperative estimated glomerular filtration rate (eGFR) and the eGFRs at postoperative day 1, 6 and 36 months after PN were 91.0 and 76.8, 80.2 and 87.7 mL/min/1.73 m 2 , respectively. In multivariable linear regression analysis, the amount of decline in PRF at follow-up was significantly correlated with the RAIV (β 0.261, 0.165, 0.260 at postoperative day 1, 6 and 36 months after PN, respectively). This study has the limitation of its retrospective nature. Preoperatively calculated RAIV significantly correlates with the amount of decline in PRF during long-term follow-up. The RAIV could lead our research to the level of prediction of the amount of PRF decline after PN and thus would be appropriate for assessing the technical advantages of emerging techniques. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

Surgeons' preferences and practice patterns regarding intraoperative frozen section during partial nephrectomy.

PubMed

Sidana, Abhinav; Donovan, James F; Gaitonde, Krishnanath

2014-08-01

Intraoperative frozen section (FS) evaluation for tumor margin during partial nephrectomy (PN) is a matter of controversy in urologic oncology. We evaluated the preferences and practice patterns of urologists regarding intraoperative FS during PN. A 17-item questionnaire was designed to collect information on surgeons' preferences and practice patterns regarding FS during PN. The survey was sent to the members of the Society of Urologic Oncology and Endourological Society. A total of 197 responses were received. Overall, 69% and 58% of respondents chose to obtain FS (always or sometimes) during open PN (OPN) and laparoscopic PN (LPN), respectively. There was a strong correlation between the surgeons' preferences during OPN and LPN. Younger surgeons are less likely to obtain FS during OPN. For surgeons who did not routinely obtain FS, "confidence about complete resection" was the most common reason (79%), followed by "no change in management with positive margins" (35%). Most surgeons (75%) believed the margins to be negative, if surgical margin was free of tumor microscopically by a single cell layer. Older surgeons considered negative margins to be free of tumor microscopically by ≥5 mm. Overall, 54% and 42% of respondents would repeat FS for positive microscopic margins during OPN and LPN, respectively. Of the respondents, 95% would not recommend additional treatment for positive margins on final pathology. Despite recent literature pointing to low clinical utility of FS, most surgeons still obtain FS during PN. Older surgeons tend to obtain FS more often. Fellowship training and practice type do not appear to influence preferences and practice patterns in regard to FS. Copyright © 2014 Elsevier Inc. All rights reserved.

Computed Tomography Perfusion, Magnetic Resonance Imaging, and Histopathological Findings After Laparoscopic Renal Cryoablation: An In Vivo Pig Model.

PubMed

Nielsen, Tommy Kjærgaard; Østraat, Øyvind; Graumann, Ole; Pedersen, Bodil Ginnerup; Andersen, Gratien; Høyer, Søren; Borre, Michael

2017-08-01

The present study investigates how computed tomography perfusion scans and magnetic resonance imaging correlates with the histopathological alterations in renal tissue after cryoablation. A total of 15 pigs were subjected to laparoscopic-assisted cryoablation on both kidneys. After intervention, each animal was randomized to a postoperative follow-up period of 1, 2, or 4 weeks, after which computed tomography perfusion and magnetic resonance imaging scans were performed. Immediately after imaging, open bilateral nephrectomy was performed allowing for histopathological examination of the cryolesions. On computed tomography perfusion and magnetic resonance imaging examinations, rim enhancement was observed in the transition zone of the cryolesion 1week after laparoscopic-assisted cryoablation. This rim enhancement was found to subside after 2 and 4 weeks of follow-up, which was consistent with the microscopic examinations revealing of fibrotic scar tissue formation in the peripheral zone of the cryolesion. On T2 magnetic resonance imaging sequences, a thin hypointense rim surrounded the cryolesion, separating it from the adjacent renal parenchyma. Microscopic examinations revealed hemorrhage and later hemosiderin located in the peripheral zone. No nodular or diffuse contrast enhancement was found in the central zone of the cryolesions at any follow-up stage on neither computed tomography perfusion nor magnetic resonance imaging. On microscopic examinations, the central zone was found to consist of coagulative necrosis 1 week after laparoscopic-assisted cryoablation, which was partially replaced by fibrotic scar tissue 4 weeks following laparoscopic-assisted cryoablation. Both computed tomography perfusion and magnetic resonance imaging found the renal collecting system to be involved at all 3 stages of follow-up, but on microscopic examination, the urothelium was found to be intact in all cases. In conclusion, cryoablation effectively destroyed renal parenchyma, leaving the urothelium intact. Both computed tomography perfusion and magnetic resonance imaging reflect the microscopic findings but with some differences, especially regarding the peripheral zone. Magnetic resonance imaging seems an attractive modality for early postoperative follow-up.

Commentary on "Laparoendoscopic single-site (LESS) partial nephrectomy short-term outcomes." Rais-Bahrami S, George AK, Montag S, Okhunov Z, Richstone L, The Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY: BJU Int 2012 (Epub ahead of print).

PubMed

Meng, Maxwell V

2013-01-01

Study type-therapy (case series). Level of evidence 4. What's known on the subject and what does the study add? Laparoendoscopic single-site (LESS) surgery has been used by urologists for a broad-range of operations including LESS partial nephrectomy (LESS-PN). To date, experiences of LESS-PN have been presented as small series or as a subset of larger heterogeneous operative experiences, which have shown the overall feasibility and safety of this novel technique. We report our experience with LESS-PN with complete pathologic resection and excellent short-term oncologic and renal functional outcomes in the select patient-population who underwent this minimally invasive approach. To present our experience of transumbilical LESS-PN with pathologic and short-term oncologic and renal functional outcomes. In all, 15 LESS-PNs were performed for cT1a tumors between July 2008 and August 2011 by 1 surgeon. All patients underwent transumbilical LESS using a 5mm flexible-tip laparoscope and a combination of flexible and conventional laparoscopic instruments. The technique for transperitoneal LESS-PN otherwise replicated conventional laparoscopic PN. Demographic, perioperative, and postoperative variables were recorded and analyzed. Of the 14 patients (8 men), undergoing 15 distinct LESS-PN, the mean (sd) age was 57.9 (8.7) years and the mean (sd, range) tumor size resected was 2.4 (0.8; 1.2-4.0). There were 12 renal cell carcinomas, 2 angiomyolipomas, and 2 metanephric adenomas on final pathology, all with negative margins. The mean (sd) operative duration was 169 (47) minutes with a mean (sd, range) warm ischemia time of 14.7 (13.4; 0-37) minutes; bull-dog clamps were used for hilar-control in 9 cases with the remaining 6 cases done without hilar vascular clamping. The mean (sd) estimated blood loss in this series was 293 (325)ml (median 200ml) and no cases required intraoperative or postoperative blood transfusions. The mean (sd) hospital stay was 2.7 (0.8) days and mean inpatient analgesic requirement in morphine equivalents was 21.7 (11.6)mg. Follow-up surveillance imaging showed no recurrence at a mean (sd, range) follow-up of 18.3 (12.2; 6-36) months and a negligible change in serum creatinine (<0.1mg/dl) at a mean (sd, range) follow-up of 17.1 (11.9; 1-36) months. LESS-PN is a feasible and effective operation, providing complete oncologic resection along with excellent short-term oncologic and renal functional outcomes. Copyright © 2013 Elsevier Inc. All rights reserved.

External Validation of Contact Surface Area as a Predictor of Postoperative Renal Function in Patients Undergoing Partial Nephrectomy.

PubMed

Haifler, Miki; Ristau, Benjamin T; Higgins, Andrew M; Smaldone, Marc C; Kutikov, Alexander; Zisman, Amnon; Uzzo, Robert G

2017-09-20

We sought to externally validate a mathematical formula for tumor contact surface area as a predictor of postoperative renal function in patients undergoing partial nephrectomy for renal cell carcinoma. We queried a prospectively maintained kidney cancer database for patients who underwent partial nephrectomy between 2014 and 2016. Contact surface area was calculated using data obtained from preoperative cross-sectional imaging. The correlation between contact surface area and perioperative variables was examined. The correlation between postoperative renal functional outcomes, contact surface area and the R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and tumor touches main renal artery or vein) nephrometry score was also assessed. A total of 257 patients who underwent partial nephrectomy had sufficient data to enter the study. Median contact surface area was 14.5 cm 2 (IQR 6.2-36) and the median nephrometry score was 9 (IQR 7-10). Spearman correlation analysis showed that contact surface area correlated with estimated blood loss (r s = 0.42, p <0.001), length of stay (r s = 0.18, p = 0.005), and percent and absolute change in the estimated glomerular filtration rate (r s = -0.77 and -0.78, respectively, each p <0.001). On multivariable analysis contact surface area and nephrometry score were independent predictors of the absolute change in the estimated glomerular filtration rate (each p <0.001). ROC curve analysis revealed that contact surface area was a better predictor of a greater than 20% postoperative decline in the estimated glomerular filtration rate compared with the nephrometry score (AUC 0.94 vs 0.80). Contact surface area correlated with the change in postoperative renal function after partial nephrectomy. It can be used in conjunction with the nephrometry score to counsel patients about the risk of renal functional decline after partial nephrectomy. Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

R-LESS partial nephrectomy trifecta outcome is inferior to multiport robotic partial nephrectomy: comparative analysis.

PubMed

Komninos, Christos; Shin, Tae Young; Tuliao, Patrick; Yoon, Young Eun; Koo, Kyo Chul; Chang, Chien-Hsiang; Kim, Sang Woon; Ha, Ji Yong; Han, Woong Kyu; Rha, Koon Ho

2014-09-01

Trifecta achievement in partial nephrectomy (PN) is defined as the combination of warm ischemia time ≤ 20 min, negative surgical margins, and no surgical complications. To compare trifecta achievement between robotic, laparoendoscopic, single-site (R-LESS) PN and multiport robotic PN (RPN). Data from 167 patients who underwent RPN from 2006 to 2012 were retrospectively analyzed. Primary outcome measurement was trifecta achievement; secondary outcome was the perioperative and postoperative comparison between groups. The measurements were estimated and analyzed with SPSS v.18 using univariable, multivariable, and subgroup analyses. Eighty-nine patients were treated with RPN and 78 were treated with R-LESS PN. Baseline characteristics of both groups were similar. Trifecta was achieved in 38 patients (42.7%) in the multiport RPN group and 20 patients (25.6%) in the R-LESS PN group (p=0.021). Patients in the R-LESS PN group had longer mean operative time, warm ischemia time, and increased estimated glomerular filtration rate (eGFR) percentage change. No significant differences were found between the two groups in days of hospitalization, blood loss, postoperative eGFR, positive surgical margins, and surgical complications. Patients with increased PADUA and RENAL scores, infiltration of the collecting system, and renal sinus involvement had an increased probability of not achieving the trifecta. In regression analysis, the type of procedure and the tumor size could predict trifecta accomplishment (p=0.019 and 0.043, respectively). The retrospective study, the low number of series, and the controversial definition of trifecta were the main limitations. The trifecta was achieved in significantly more patients who underwent multiport RPN than those who underwent R-LESS PN. R-LESS PN could be an alternative option for patients with decreased tumor size, low PADUA and RENAL scores, and without renal sinus or collecting system involvement. In this study, we looked at the outcomes of patients who had undergone robotic partial nephrectomy. We found that conventional robotic partial nephrectomy is superior to R-LESS partial nephrectomy with regard to the accomplishment of negative margins, reduced warm ischemia time, and minimal surgical complications. Copyright © 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Quality of Recovery After Low-Pressure Laparoscopic Donor Nephrectomy Facilitated by Deep Neuromuscular Blockade: A Randomized Controlled Study.

PubMed

Özdemir-van Brunschot, Denise M D; Scheffer, Gert J; van der Jagt, Michel; Langenhuijsen, Hans; Dahan, Albert; Mulder, Janneke E E A; Willems, Simone; Hilbrands, Luuk B; Donders, Rogier; van Laarhoven, Cees J H M; d'Ancona, Frank A; Warlé, Michiel C

2017-11-01

The use of low intra-abdominal pressure (<10 mmHg) reduces postoperative pain scores after laparoscopic surgery. To investigate whether low-pressure pneumoperitoneum with deep neuromuscular blockade improves the quality of recovery after laparoscopic donor nephrectomy (LDN). In a single-center randomized controlled trial, 64 live kidney donors were randomly assigned to 6 or 12 mmHg insufflation pressure. A deep neuromuscular block was used in both groups. Surgical conditions were rated by the five-point Leiden-surgical rating scale (L-SRS), ranging from 5 (optimal) to 1 (extremely poor) conditions. If the L-SRS was insufficient, the pressure was increased stepwise. The primary outcome measure was the overall score on the quality of recovery-40 (QOR-40) questionnaire at postoperative day 1. The difference in the QOR-40 scores on day 1 between the low- and standard-pressure group was not significant (p = .06). Also the overall pain scores and analgesic consumption did not differ. Eight procedures (24%), initially started with low pressure, were converted to a standard pressure (≥10 mmHg). A L-SRS score of 5 was significantly more prevalent in the standard pressure as compared to the low-pressure group at 30 min after insufflation (p < .01). Low-pressure pneumoperitoneum facilitated by deep neuromuscular blockade during LDN does not reduce postoperative pain scores nor improve the quality of recovery in the early postoperative phase. The question whether the use of deep neuromuscular blockade during laparoscopic surgery reduces postoperative pain scores independent of the intra-abdominal pressure should be pursued in future studies. The trial was registered at clinicaltrial.gov before the start of the trial (NCT02146417).

Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre.

PubMed

Schroeder, R P J; Chrzan, R J; Klijn, A J; Kuijper, C F; Dik, P; de Jong, T P V M

2015-10-01

Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons. To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU). The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients' ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12 kg. Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and 1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children ≥2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation. There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre. Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential. Copyright © 2015. Published by Elsevier Ltd.

Different methods of hilar clamping during partial nephrectomy: Impact on renal function.

PubMed

Lee, Jeong Woo; Kim, Hwanik; Choo, Minsoo; Park, Yong Hyun; Ku, Ja Hyeon; Kim, Hyeon Hoe; Kwak, Cheol

2014-03-01

To evaluate the impact of different hilar clamping methods on changes in renal function after partial nephrectomy. We analyzed the clinical data of 369 patients who underwent partial nephrectomy for a single renal tumor of size ≤4.0 cm and a normal contralateral kidney. Patients were separated into three groups depending on hilar clamping method: non-clamping, cold ischemia and warm ischemia. Estimated glomerular filtration rate was examined at preoperative, nadir and 1 year postoperatively. Percent change in estimated glomerular filtration rate was used as the parameter to assess the renal functional outcome. Percent change in nadir estimated glomerular filtration rate in the non-clamping group was significantly less compared with the cold ischemia and warm ischemia groups (P < 0.001). However, no significant differences among the groups were noted in percent change of estimated glomerular filtration rate at 1 year (P = 0.348). The cold ischemia group had a similar serial change of postoperative renal function compared with the warm ischemia group. Percent change in 1-year estimated glomerular filtration rate increased with increasing ischemia time in the cold ischemia (P for trend = 0.073) and warm ischemia groups (P for trend = 0.010). On multivariate analysis, hilar clamping (both warm ischemia and cold ischemia) were significantly associated with percent change in nadir estimated glomerular filtration rate, but not in 1-year estimated glomerular filtration rate. Non-clamping partial nephrectomy results in a lower percent change in nadir estimated glomerular filtration rate, whereas it carries an estimated glomerular filtration rate change at 1 year that is similar to partial nephrectomy with cold ischemia and warm ischemia. Cold ischemia and warm ischemia provide a similar effect on renal function. Therefore, when hilar clamping is required, minimization of ischemia time is necessary. © 2013 The Japanese Urological Association.

Adaptive functional change of the contralateral kidney after partial nephrectomy.

PubMed

Choi, Se Young; Yoo, Sangjun; You, Dalsan; Jeong, In Gab; Song, Cheryn; Hong, Bumsik; Hong, Jun Hyuk; Ahn, Hanjong; Kim, Choung-Soo

2017-08-01

Partial nephrectomy aims to maintain renal function by nephron sparing; however, functional changes in the contralateral kidney remain unknown. We evaluate the functional change in the contralateral kidney using a diethylene triamine penta-acetic acid (DTPA) renal scan and determine factors predicting contralateral kidney function after partial nephrectomy. A total of 699 patients underwent partial nephrectomy, with a DTPA scan before and after surgery to assess the separate function of each kidney. Patients were divided into three groups according to initial contralateral glomerular filtration rate (GFR; group 1 : <30 ml·min -1 ·1.73 m -2 , group 2 : 30-45 ml·min -1 ·1.73 m -2 , and group 3 : ≥45 ml·min -1 ·1.73 m -2 ). Multiple-regression analysis was used to identify the factors associated with increased GFR of the contralateral kidney over a 4-yr postoperative period. Patients in group 1 had a higher mean age and hypertension history, worse American Society of Anesthesiologists score, and larger tumor size than in the other two groups. The ipsilateral GFR changes at 4 yr after partial nephrectomy were -18.9, -3.6, and 3.9% in groups 1 , 2 , and 3 , respectively, whereas the contralateral GFR changes were 10.8, 25.7, and 38.8%. Age [β: -0.105, 95% confidence interval (CI): -0.213; -0.011, P < 0.05] and preoperative contralateral GFR (β: -0.256, 95% CI: -0.332; -0.050, P < 0.01) were significant predictive factors for increased GFR of the contralateral kidney after 4 yr. The contralateral kidney compensated for the functional loss of the ipsilateral kidney. The increase of GFR in contralateral kidney is more prominent in younger patients with decreased contralateral renal function. Copyright © 2017 the American Physiological Society.

30-day hospital readmission after robotic partial nephrectomy--are we prepared for Medicare readmission reduction program?

PubMed

Brandao, Luis Felipe; Zargar, Homayoun; Laydner, Humberto; Akca, Oktay; Autorino, Riccardo; Ko, Oliver; Samarasekera, Dinesh; Li, Jianbo; Rabets, John; Krishnan, Jayram; Haber, Georges-Pascal; Kaouk, Jihad; Stein, Robert J

2014-09-01

After CMS introduced the concept of the Hospital Readmissions Reduction Program, hospitals and health care centers became financially penalized for exceeding specific readmission rates. We retrospectively reviewed our institutional review board approved database of patients undergoing robotic partial nephrectomy at our institution and included in our analysis patients who were readmitted to any hospital as an inpatient stay within 30 days from discharge home after robotic partial nephrectomy. From March 2006 to March 2013 a total of 627 patients underwent robotic partial nephrectomy at our center and 28 (4.46%) were readmitted within 30 days of surgery. Postoperative bleeding was responsible for 8 (28.5%) readmissions. Pulmonary embolism was reported in 3 cases and retroperitoneal abscess was diagnosed in 2. Urinary leak requiring surgical intervention developed in 2 patients, pneumonia was diagnosed in 2 and 2 patients were readmitted for chest pain. Overall 9 (32.1%) patients presented with major complications requiring intervention. On multivariable analysis Charlson comorbidity index score was the only factor significantly associated with a higher 30-day readmission rate (p = 0.03). If the Charlson score was 5 or greater the chance of hospital readmission would be 2.7 times higher. Increased comorbidity, specifically a Charlson score of 5 or greater, was the only significant predictor of a higher incidence of 30-day readmission. This information can be useful in counseling patients regarding robotic partial nephrectomy and in determining baseline rates if CMS expands the number of conditions they evaluate for excess 30-day readmissions. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Application of modified R.E.N.A.L. nephrometry score system in evaluating the retroperitoneal partial nephrectomy for T1 renal cell carcinoma.

PubMed

Wang, Qinzhang; Qian, Biao; Li, Qiang; Ni, Zhao; Li, Yinglong; Wang, Xinmin

2015-01-01

This study aims to investigate the application of the modified R.E.N.A.L. nephrometry score system in evaluating the operation difficulty of retroperitoneal partial nephrectomy in T1 renal cell carcinoma patients. A total of 52 patients with T1 renal cell carcinoma were enrolled. They all had retroperitoneal partial nephrectomy. Their clinical data was retrospectively analyzed. R.E.N.A.L. nephrometry score system was modified based on the features of retroperitoneal partial nephrectomy. The specificity, sensitivity and Youden index were compared between R.E.N.A.L. nephrometry score system and the modified R.E.N.A.L. nephrometry score system. The effect of the modified R.E.N.A.L. nephrometry score system on perioperative outcomes was analyzed. Three degrees of operation difficulty were defined by the modified R.E.N.A.L. nephrometry score system, which included the low, medium and high degree of operation difficulty. The specificity, sensitivity and Youden index of the modified R.E.N.A.L. nephrometry score system were better than those of the original R.E.N.A.L. nephrometry score system. Compared with low degree of operation difficulty, patients with medium and high degree of operation difficulty had significantly higher levels of operative time, warm ischemia time, and intraoperative blood loss (P < 0.05). And, the levels of operative time, warm ischemia time, and intraoperative blood loss in patients with high degree were significantly higher than those in patients with medium degree (P < 0.05). The modified R.E.N.A.L. nephrometry score system has a good effect in evaluating the operation difficulty of retroperitoneal partial nephrectomy.

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy.

PubMed

Ng, Casey K; Gill, Inderbir S; Patil, Mukul B; Hung, Andrew J; Berger, Andre K; de Castro Abreu, Andre Luis; Nakamoto, Masahiko; Eisenberg, Manuel S; Ukimura, Osamu; Thangathurai, Duraiyah; Aron, Monish; Desai, Mihir M

2012-01-01

Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped. Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors. A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n=22) or without anatomic VMD (group 2; n=22) performed by a single surgeon from April 2010 to January 2011. Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary. Baseline, perioperative, and postoperative data were collected prospectively. Group 1 tumors were larger (4.3 vs 2.6 cm; p=0.011), were more often hilar (41% vs 9%; p=0.09), were medial (59% and 23%; p=0.017), were closer to the hilum (1.46 vs 3.26 cm; p=0.0002), and had a lower C index score (2.1 vs 3.9; p=0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p=0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1h), median blood loss (200 and 100ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3mg/dl). The study was limited by the relatively small sample size. Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution. Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Comparison between laparoscopic and open radical nephrectomy for the treatment of primary renal tumors in children: single-center experience over a 5-year period.

PubMed

Romao, R L P; Weber, B; Gerstle, J T; Grant, R; Pippi Salle, J L; Bägli, D J; Figueroa, V H; Braga, L H P; Farhat, W A; Koyle, M A; Lorenzo, A J

2014-06-01

To compare the outcomes of laparoscopic nephrectomy (LN) with open radical nephrectomy (ORN) in the management of consecutive pediatric neoplasms. Retrospective cohort study of consecutive children treated for primary renal tumors between 2006 and 2011, segregated based on surgical modality (LN/ORN). Pre-, intra- and postoperative data and outcomes were collected. Demographics from the 45 patients (13 LN, 32 ORN) were similar, and tumors in the LN group were smaller [6.59 ± 1.8 cm vs. 10.99 ± 2.99 cm ORN (p < 0.05)]. Six patients had preoperative chemotherapy (two LN, four ORN). No tumor ruptures occurred with either technique. Wilms tumor (seven LN, 24 ORN) was the most common diagnosis, followed by renal cell carcinoma (four LN, four ORN). Procedure length was similar between groups (282 ± 79 LN, 263 ± 81 min ORN). Mean length of stay was significantly shorter for LN (2.9 vs. 5.9 days; p = 0.002). Postoperative narcotic requirements and use of nasogastric tube were higher in the ORN group. After a median follow-up of 18 (LN) and 33 months (ORN), 1 and 4 recurrences occurred, respectively. LN is an attractive alternative to open surgery in carefully selected cases of pediatric renal tumors. Procedure length and incidence of intra-operative rupture were not increased, while post-operative recovery and hospital stay were shorter for LN. Longer follow-up is mandatory to confirm comparable oncological outcomes to ORN. Copyright © 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Randomized clinical trial of transversus abdominis plane block versus placebo control in live-donor nephrectomy.

PubMed

Hosgood, Sarah A; Thiyagarajan, Umasanker M; Nicholson, Harriet F L; Jeyapalan, Inthira; Nicholson, Michael L

2012-09-15

Laparoscopic surgery reduces pain after donor nephrectomy; however, most patients still require a significant amount of postoperative parenteral opiate analgesia. Therefore, there is a need to investigate techniques that might further reduce postoperative pain. This study assessed the safety and efficacy of using a transversus abdominis plane (TAP) block in a randomized, double-blind, placebo-controlled trial. Forty-six patients were analyzed in the trial and were randomized to undergo the TAP block procedure with either bupivacaine (n=24) or saline placebo (Control n=22) injected into the muscle plane. Prefilled syringes were dispensed with the group allocation concealed to maintain blinding. After surgery, the amount of morphine, level of pain, and measures of recovery were recorded. The amount of morphine used 6 hr after surgery was significantly lower in patients receiving TAP block with bupivacaine compared with the control (presented as mean [SD], 12.4 [8.4] vs. 21.2 [14.0] mg; P=0.015). However, the total amount of morphine used was similar in both groups 45.6 [31.4] vs. 52.7 [28.8] mg; P=0.771. Patients in the bupivacaine group experienced significantly less pain on postoperative days 1 (score, 19 [15] vs. 37 [20]; P=0.003) and 2 (score, 11 [10] vs. 19 [13]; P=0.031). Recovery and postoperative hospital stay were similar in both groups. There were no complications associated with the procedure. The TAP block procedure is beneficial in reducing postoperative pain and early morphine requirements in laparoscopic live-donor nephrectomy.

Lymph node non-Hodgkin's lymphoma incidentally discovered during a nephrectomy for renal cell carcinoma.

PubMed

Fernandez-Pello, Sergio; Rodriguez Villamil, Luis; Gonzalez Rodriguez, Ivan; Venta, Victoria; Cuervo, Javier; Menéndez, Carmen Luz

2013-06-16

We report the case of a left laparoscopic nephroureterectomy with the incidental discovery of a non-Hodgkin's lymphoma in one of the lymph nodes of the renal hilum. A laparoscopic nephroureterectomy was decided on for a 64-year-old man. Renal cell carcinoma in the kidney and one lymph node of the renal hilum with non-Hodgkin's lymphoma was found. Chemotherapy was not started for the lymphoma discovery. There are no signs of relapse after two years of follow up. Coexistence in the same patient is an extremely rare condition. We review the literature about this issue to clarify this association.

Early laparoscopic management of acute postoperative hemorrhage after initial laparoscopic surgery.

PubMed

Gong, Edward M; Zorn, Kevin C; Gofrit, Ofer N; Lucioni, Alvaro; Orvieto, Marcelo A; Zagaja, Gregory P; Shalhav, Arieh L

2007-08-01

The use of laparoscopic surgery has been well established for the management of abdominal emergencies. However, the value of this technique for postoperative hemorrhage in urology has not been characterized. We present our favorable experience with laparoscopic exploration after urologic surgery and suggest guidelines for laparoscopic management of post-laparoscopy bleeding. Three patients who developed hemorrhage shortly after laparoscopic urologic surgery and were managed by laparoscopic exploration were identified from a series of 910 laparoscopic urologic procedures performed at our institution from October 2002 to June 2006. Three patients, who were hemodynamically stable (two after robot-assisted laparoscopic prostatectomy, one after laparoscopic radical nephrectomy), required prompt surgical exploration for postoperative hemorrhage not stabilized by blood transfusion (mean 2.7 units) at a mean of 19.4 hours after initial surgery. Clots were evacuated with a 10-mm suction-irrigator. Two patients were found to have abdominal-wall arterial bleeding and were managed with suture ligation. The third patient demonstrated diffuse bleeding from the prostatic bed, which was controlled with Surgicel and FloSeal. Bleeding was efficiently controlled in all patients, and none required post-exploration transfusion. The mean post-exploration hospital stay was 2.3 days. Significant hemorrhage after urologic laparoscopy is a rare event. We found laparoscopic exploration to be an excellent way to diagnose and correct such hemorrhage in certain patients. Early diagnosis with clinical and hematologic studies, a lowered threshold for surgical exploration, and specific operative equipment may decrease patient morbidity and the need for open surgical exploration.

Robotic partial nephrectomy for duplex kidney with ectopic ureter draining in the vagina in an adult patient with urinary incontinence.

PubMed

Mahmood, Humza; Hadjipavlou, Marios; Das, Raj; Anderson, Chris

2017-02-06

A duplex kidney system with an ectopic ureter draining into the vagina is a congenital malformation that typically presents as refractory urinary incontinence. Diagnosis is often difficult to establish and delayed due to a low incidence. We present the case of a patient aged 26 years with a life-long history of persistent urinary incontinence. Initial presentation was at childhood; however, the diagnosis went undetermined for 22 years. CT urography revealed a duplex kidney with an atrophic upper pole associated with an ectopic ureter that drained into the vaginal vault. This is the first description of such a case being managed successfully via a robot-assisted partial nephrectomy approach. Ectopic ureteral duplication should be considered in the differential diagnosis for young women with refractory urinary incontinence. Robotic partial nephrectomy is a safe and effective technique to manage such cases. 2017 BMJ Publishing Group Ltd.

Safety and efficacy of transarterial nephrectomy as an alternative to surgical nephrectomy.

PubMed

Choe, Jooae; Shin, Ji Hoon; Yoon, Hyun-Ki; Ko, Gi-Young; Gwon, Dong Il; Ko, Heung Kyu; Kim, Jin Hyoung; Sung, Kyu-Bo

2014-01-01

To evaluate the safety and efficacy of transarterial nephrectomy, i.e., complete renal artery embolization, as an alternative to surgical nephrectomy. This retrospective study included 11 patients who underwent transarterial nephrectomy due to a high risk of surgical nephrectomy or their refusal to undergo surgery during the period from April 2002 to February 2013. Medical records and radiographic images were reviewed retrospectively to collect information regarding underlying etiologies, clinical presentations and embolization outcomes. The underlying etiologies for transarterial nephrectomy included recurrent hematuria (chronic transplant rejection [n = 3], arteriovenous malformation or fistula [n = 3], angiomyolipoma [n = 1], or end-stage renal disease [n = 1]), inoperable renal or ureteral injury (n = 2), and ectopic kidney with urinary incontinence (n = 1). The technical success rate was 100%, while clinical success was achieved in eight patients (72.7%). Subsequent surgical nephrectomy was required for three patients due to an incomplete nephrectomy effect (n = 2) or necrotic pyelonephritis (n = 1). Procedure-related complications were post-infarction syndrome in one patient and necrotic pyelonephritis in another patient. Of four patients with follow-up CT, four showed renal atrophy and two showed partial renal enhancement. No patient developed a procedure-related hypertension. Transarterial nephrectomy may be a safe and effective alternative to surgical nephrectomy in patients with high operative risks.

Robotic-assisted single-port donor nephrectomy using the da Vinci single-site platform.

PubMed

LaMattina, John C; Alvarez-Casas, Josue; Lu, Irene; Powell, Jessica M; Sultan, Samuel; Phelan, Michael W; Barth, Rolf N

2018-02-01

Although single-port donor nephrectomy offers improved cosmetic outcomes, technical challenges have limited its application to selected centers. Our center has performed over 400 single-port donor nephrectomies. The da Vinci single-site robotic platform was utilized in an effort to overcome the steric, visualization, ergonomic, and other technical limitations associated with the single-port approach. Food and Drug Administration device exemption was obtained. Selection criteria for kidney donation included body mass index <35, left kidney donors, and ≤2 renal arteries. After colonic mobilization using standard single-port techniques, the robotic approach was utilized for ureteral complex and hilar dissection. Three cases were performed using the robotic single-site platform. Average total operative time was 262 ± 42 min including 82 ± 16 min of robotic use. Docking time took 20 ± 10 min. Blood loss averaged 77 ± 64 mL. No intraoperative complications occurred, and all procedures were completed with our standard laparoscopic single-port approach. This is the first clinical experience of robotic-assisted donor nephrectomy utilizing the da Vinci single-site platform. Our experience supported the safety of this approach but found that the technology added cost and complexity without tangible benefit. Development of articulating instruments, energy, and stapling devices will be necessary for increased application of robotic single-site surgery for donor nephrectomy. Copyright © 2017 Elsevier Inc. All rights reserved.

Development and Validation of a Novel Robotic Procedure Specific Simulation Platform: Partial Nephrectomy.

PubMed

Hung, Andrew J; Shah, Swar H; Dalag, Leonard; Shin, Daniel; Gill, Inderbir S

2015-08-01

We developed a novel procedure specific simulation platform for robotic partial nephrectomy. In this study we prospectively evaluate its face, content, construct and concurrent validity. This hybrid platform features augmented reality and virtual reality. Augmented reality involves 3-dimensional robotic partial nephrectomy surgical videos overlaid with virtual instruments to teach surgical anatomy, technical skills and operative steps. Advanced technical skills are assessed with an embedded full virtual reality renorrhaphy task. Participants were classified as novice (no surgical training, 15), intermediate (less than 100 robotic cases, 13) or expert (100 or more robotic cases, 14) and prospectively assessed. Cohort performance was compared with the Kruskal-Wallis test (construct validity). Post-study questionnaire was used to assess the realism of simulation (face validity) and usefulness for training (content validity). Concurrent validity evaluated correlation between virtual reality renorrhaphy task and a live porcine robotic partial nephrectomy performance (Spearman's analysis). Experts rated the augmented reality content as realistic (median 8/10) and helpful for resident/fellow training (8.0-8.2/10). Experts rated the platform highly for teaching anatomy (9/10) and operative steps (8.5/10) but moderately for technical skills (7.5/10). Experts and intermediates outperformed novices (construct validity) in efficiency (p=0.0002) and accuracy (p=0.002). For virtual reality renorrhaphy, experts outperformed intermediates on GEARS metrics (p=0.002). Virtual reality renorrhaphy and in vivo porcine robotic partial nephrectomy performance correlated significantly (r=0.8, p <0.0001) (concurrent validity). This augmented reality simulation platform displayed face, content and construct validity. Performance in the procedure specific virtual reality task correlated highly with a porcine model (concurrent validity). Future efforts will integrate procedure specific virtual reality tasks and their global assessment. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Comparison of clamping technique in robotic partial nephrectomy: does unclamped partial nephrectomy improve perioperative outcomes and renal function?

PubMed

Krane, L Spencer; Mufarrij, Patrick W; Manny, Theodore B; Hemal, Ashok K

2013-02-01

Partial nephrectomy without renal vascular occlusion has been introduced to improve outcomes in patients undergoing robotic partial nephrectomy (RPN). We prospectively evaluated unclamped RPN at our institution and compared this to other clamping techniques in a non-randomized fashion. Ninety-five consecutive patients who successfully completed RPN between June 2010 and October 2011 are included in this analysis. All RPNs were performed by a single surgeon. Clamping technique was artery and vein (AV), artery alone (AO) or unclamped (U) without hypotensive anesthesia. Clamping decision was based on surgeon preference and feasibility of minimizing ischemia. All patients had bilateral functional renal units. Eighteen (19%), 58 (61%) and 19 (20%) patients had AV, AO and U technique respectively. Preoperative characteristics including age (p = 0.43), body mass index (p = 0.40) and RENAL nephromety distribution (p = 0.10) were similar. In AV and AO, mean warm ischemia time were 19 and 17 minutes and similar between the two cohorts (p = 0.39). Mean glomerular filtration rate (GFR) and overall percentage decrease in GFR at time of at last follow up were (64, 69, 81, p = 0.12) and (6%, 6%,and 2%,p = 0.79) for AV, AO and U respectively. Median follow up for last serum creatinine was 113 days and was similar between all cohorts (p = 0.37). Complication rate (p = 0.37), positive margin rate (p = 0.84), and change in hemoglobin concentration postoperatively (p = 0.94) were similar between cohorts. Unclamped partial nephrectomy is possible in patients undergoing RPN. In this study, it does not significantly alter perioperative or postoperative renal function or change rate of complications. Minimal ischemia, irrespective of clamping technique, in patients with bilateral renal units does not appear to adversely effect intermediate term renal function in these patients.

Update on contemporary management of clinically localized renal cell carcinoma.

PubMed

Jorns, J J; Thiel, D D; Castle, E P

2012-12-01

Renal cell carcinoma (RCC) continues to increase in incidence with the largest increase manifesting in small, organ-confined tumors. This review outlines the epidemiology and current data pertaining to the management of clinically-localized RCC. In this manuscript, the current data outlining the benefit of nephron sparing to the overall survival of the patient is described. The data pertaining to minimally invasive nephron sparing is also explained in detail. From laparoscopic and robotic partial nephrectomy to watchful waiting and percutaneous ablation, the urologist is continually assaulted with new data for the management of clinically-localized RCC. The data can be confusing, and much of it is conflicting. The addition of new scoring systems or nomograms may aid in predicting which therapy would be most beneficial in certain patient groups. New scoring systems may also predict the difficulty of surgical resection and predict surgical complications. The limitations of the data pertaining to the management of clinically-localized RCC are also outlined.

A Case Report of Partial Nephrectomy of Mucinous Cystadenocarcinoma in Kidney and Its Literature Review

PubMed Central

Kim, Sung Han; Yuk, Heong Dong; Park, Weon Seo; Kim, Sun Ho; Joung, Jae Young; Seo, Ho Kyung; Lee, Kang Hyun; Chung, Jinsoo

2016-01-01

Mucinous cystadenocarcinoma (MC) of the kidney is a rare epithelial tumor originating from the renal pelvic urothelium and few study cases have been reported. Because of the rarity of these tumors and their unknown histogenesis, its diagnosis is difficult until surgical exploration. We report here on a 55-year-old man referred to the urology department from the hepatology department because of a cystic renal mass measuring approximately 5 cm in size, which was detected incidentally under ultrasonography during the routine examination of liver. The renal mass was finally diagnosed as MC originating from kidney after partial nephrectomy and the patient still showed no evidence of recurrence until 12 months postoperatively. This is the first report on a case of renal MC in a patient who underwent partial nephrectomy. The aim of this report is to present our unusual case of MC and also review the previous literature on the pathological and radiological aspects of MC of kidney. PMID:25687861

Hospitalization for partial nephrectomy was not associated with intrathecal opioid analgesia: Retrospective analysis.

PubMed

Weingarten, Toby N; Del Mundo, Serena B; Yeoh, Tze Yeng; Scavonetto, Federica; Leibovich, Bradley C; Sprung, Juraj

2014-10-01

The aim of this retrospective study is to test the hypothesis that the use of spinal analgesia shortens the length of hospital stay after partial nephrectomy. We reviewed all patients undergoing partial nephrectomy for malignancy through flank incision between January 1, 2008, and June 30, 2011. We excluded patients who underwent tumor thrombectomy, used sustained-release opioids, or had general anesthesia supplemented by epidural analgesia. Patients were grouped into "spinal" (intrathecal opioid injection for postoperative analgesia) versus "general anesthetic" group, and "early" discharge group (within 3 postoperative days) versus "late" group. Association between demographics, patient physical status, anesthetic techniques, and surgical complexity and hospital stay were analyzed using multivariable logistic regression analysis. Of 380 patients, 158 (41.6%) were discharged "early" and 151 (39.7%) were "spinal" cases. Both spinal and early discharge groups had better postoperative pain control and used less postoperative systemic opioids. Spinal analgesia was associated with early hospital discharge, odds ratio 1.52, (95% confidence interval 1.00-2.30), P = 0.05, but in adjusted analysis was no longer associated with early discharge, 1.16 (0.73-1.86), P = 0.52. Early discharge was associated with calendar year, with more recent years being associated with early discharge. Spinal analgesia combined with general anesthesia was associated with improved postoperative pain control during the 1(st) postoperative day, but not with shorter hospital stay following partial nephrectomy. Therefore, unaccounted practice changes that occurred during more recent times affected hospital stay.

Perioperative outcomes of 6042 nephrectomies in 2012: surgeon-reported results in the UK from the British Association of Urological Surgeons (BAUS) nephrectomy database.

PubMed

Henderson, John M; Fowler, Sarah; Joyce, Adrian; Dickinson, Andrew; Keeley, Francis X

2015-01-01

To present the perioperative outcomes from the British Association of Urological Surgeons (BAUS) nephrectomy dataset for 2012, the first year of public reporting of individual surgeon outcomes in the UK. All nephrectomies performed in the year 2012 and recorded in the database were analysed. These were divided into simple nephrectomy (SN), partial nephrectomy (PN), radical nephrectomy (RN), and nephroureterectomy (NU). The estimated capture rate for nephrectomy was 80%. The outcomes measured were 30-day mortality (30-DM), Clavien-Dindo complications grade ≥III, blood transfusion, conversion to open, and length of stay. The overall 30-DM was 0.55% (SN 0.53%; PN 0.10%; RN 0.52%; NU 1.27%). Clavien-Dindo complications grade ≥III were recorded in 3.9% of nephrectomies (SN 4.3%; PN 5.4%; RN 3.1%; NU 4.5%). Blood transfusion was required during surgical admission for 8.4% of nephrectomies (SN 5.2%; PN 3.4%; RN 11.1%; NU 8.3%). Conversion to open was carried out in 5.5% of minimally invasive nephrectomies (SN 6.1%; PN 4.0%; RN 5.5%; NU 5.6%). Open nephrectomy patients remained in hospital for a median of 6 days (SN 7; PN 5; RN 7; NU 8 days), which was higher than the median 4-day stay (SN 3; PN 4; RN 4; NU 5 days) for minimally invasive surgery. Nephrectomy in 2012 was a safe procedure with morbidity and mortality rates comparable with or less than published series. The collection of surgeon-specific data should be iterative with further refinement of data categories, support for the collection process and independent validation of results. © 2014 The Authors. BJU International © 2014 BJU International.

Laparoscopic versus open nephrectomy for live kidney donors.

PubMed

Wilson, Colin H; Sanni, Aliu; Rix, David A; Soomro, Naeem A

2011-11-09

Waiting lists for kidney transplantation continue to grow and live organ donation has become more important as the number of brain stem dead cadaveric organ donors continues to fall. The major disincentive to potential kidney donors is the pain and morbidity associated with open surgery. To identify the benefits and harms of using laparoscopic compared to open nephrectomy techniques to recover kidneys from live organ donors. We searched the online databases CENTRAL (in The Cochrane Library 2010, Issue 2), MEDLINE (January 1966 to January 2010) and EMBASE (January 1980 to January 2010) and handsearched textbooks and reference lists. Randomised controlled trials comparing laparoscopic donor nephrectomy (LDN) with open donor nephrectomy (ODN). Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. Six studies were identified that randomised 596 live kidney donors to either LDN or ODN arms. All studies were assessed as having low or unclear risk of bias for selection bias, allocation bias, incomplete outcome data and selective reporting bias. Four of six studies had high risk of bias for blinding. Various different combinations of techniques were used in each study, resulting in heterogeneity in the results. The conversion rate from LDN to ODN ranged from 1% to 1.8%. LDN was generally found to be associated with reduced analgesia use, shorter hospital stay, and faster return to normal physical functioning. The extracted kidney was exposed to longer warm ischaemia periods (2 to 17 minutes) with no associated short-term consequences. ODN was associated with shorter duration of procedure. For those outcomes that could be meta-analysed there were no significant differences between LDN or ODN for perioperative complications (RR 0.87, 95% CI 0.47 to 4.59), reoperations (RR 0.57, 95% CI 0.09 to 3.64), early graft loss (RR 0.31, 95% CI 0.06 to 1.48), delayed graft function (RR 1.09, 95% CI 0.52 to 2.30), acute rejection (RR 1.41, 95 % CI 0.87 to 2.27), ureteric complications (RR 1.51, 95% CI 0.69 to 3.31), kidney function at one year (SMD 0.15, 95% CI -0.11 to 0.41) or graft loss at one year (RR 0.76, 95% CI 0.15 to 3.85). LDN is associated with less pain compared with open surgery; however, there are equivalent numbers of complications and occurrences of perioperative events that require further intervention. Kidneys obtained using LDN procedures were exposed to longer warm ischaemia periods than ODN-acquired grafts, although this has not been reported as being associated with short-term consequences.

Predicted versus observed 30-day perioperative outcomes using the ACS NSQIP surgical risk calculator in patients undergoing partial nephrectomy for renal cell carcinoma.

PubMed

Blair, Brian M; Lehman, Erik B; Jafri, Syed M; Kaag, Matthew G; Raman, Jay D

2018-06-04

The purpose of the study was to evaluate the accuracy of the American College of Surgeons NSQIP Surgical Risk Calculator for predicting risk-adjusted 30-day outcomes for patients undergoing partial nephrectomy (PN) for renal cell carcinoma (RCC). A single institution, multi-surgeon, prospectively maintained database was queried for patients undergoing PN for RCC from 1998 to 2015. 21 preoperative factors were analyzed for each patient with predicted risk for 30-day complications, mortality, and length of stay (LOS) calculated. Differences between the mean predicted risk and observed rate of surgical outcomes were determined using two-sided one-sample t test with significance at p < 0.05. Subgroup analyses of outcomes stratified by surgical approach were also performed. 470 patients undergoing PN for RCC were analyzed. Comparing NSQIP predicted to observed outcomes, clinically significant underestimations occurred with rates of overall complications (9.16 vs. 16.81%, p < 0.001), surgical site infections [SSI] (1.65 vs. 2.77%, p < 0.001), urinary tract infection [UTI] (1.41 vs. 3.40%, p < 0.001), and LOS (3.25 vs. 3.73 days, p < 0.001). On subgroup analysis, 209 open PN and 261 minimally invasive PN (MIPN) were performed. The NSQIP calculator consistently underestimated overall complications, SSI, UTI, and LOS (p < 0.001) among both surgical approaches, while overestimating MIPN severe complications (p < 0.001). Clinically important differences persisted when stratifying the MIPN group by laparoscopic (N = 111) and robotic (N = 150) approaches. The ACS NSQIP Surgical Risk Calculator had significant discrepancies among observed and predicted outcomes. Additional analyses confirmed these differences remained significant irrespective of surgical approach. These findings emphasize the need for urologic oncology-specific calculators to better predict surgical outcomes in this complex patient population.

Need for intraoperative ultrasound and surgical recommendation for partial nephrectomy: correlation with tumor imaging features and urologist practice patterns.

PubMed

Sun, Maryellen R M; Wagner, Andrew A; San Francisco, Ignacio F; Brook, Alexander; Kavoussi, Louis; Russo, Paul; Steele, Graeme; Viterbo, Rosalia; Pedrosa, Ivan

2012-03-01

This study aimed to evaluate the need for intraoperative ultrasound (IOUS) and recommendation for surgical approach in the resection of renal tumors through a survey of practicing urologists, with correlation to tumor imaging features and urologist practice pattern. An institutional review board-approved retrospective review, compliant with the Health Insurance Portability and Accountability Act, of 44 renal tumors that underwent laparoscopic partial nephrectomy at the study institution was performed. The numeric component of the RENAL nephrometry score (radius [diameter], % exophytic, nearness [to collecting system/renal sinus], location) was calculated for each case using preoperative computed tomography/magnetic resonance imaging. Five anonymized images of each tumor were presented to 4 academic urologists with varying practice patterns. Reviewers independently scored each case for its need for IOUS, for recommendation of a surgical technique, and for the difficulty of the proposed surgery. The RENAL scores were as follows: RENAL 1 (low complexity, score 4-6; n = 19); RENAL 2 (moderate complexity, score 7-9; n = 23); RENAL 3 (high complexity, score 10-12; n = 2). The only RENAL score component significantly influencing need for IOUS was percentage exophytic (P = 0.00002). There was an inverse relationship between normalized and averaged need for IOUS and percentage exophytic (P < 0.0001). The predominant influence for recommendation of surgical method was the reviewer him/herself, with each reviewer's recommendations closely matching his/her practice pattern. Size and percentage exophytic represented the only tumor features significantly (P = 0.03) influencing surgical recommendation. There was a significant difference in the perceived need for IOUS and surgical recommendation when 4 academic urologists reviewed a series of renal masses requiring resection. Percentage exophytic correlated inversely with need for IOUS. Urologist's practice pattern and tumor size and percentage exophytic were most predictive of surgical recommendation.

Provider-based research networks and diffusion of surgical technologies among patients with early-stage kidney cancer.

PubMed

Tan, Hung-Jui; Meyer, Anne-Marie; Kuo, Tzy-Mey; Smith, Angela B; Wheeler, Stephanie B; Carpenter, William R; Nielsen, Matthew E

2015-03-15

Provider-based research networks such as the National Cancer Institute's Community Clinical Oncology Program (CCOP) have been shown to facilitate the translation of evidence-based cancer care into clinical practice. This study compared the utilization of laparoscopy and partial nephrectomy among patients with early-stage kidney cancer according to their exposure to CCOP-affiliated providers. With linked Surveillance, Epidemiology, and End Results-Medicare data, patients with T1aN0M0 kidney cancer who had been treated with nephrectomy from 2000 to 2007 were identified. For each patient, the receipt of care from a CCOP physician or hospital and treatment with laparoscopy or partial nephrectomy were determined. Adjusted for patient characteristics (eg, age, sex, and marital status) and other organizational features (eg, community hospital and National Cancer Institute-designated cancer center), multivariate logistic regression was used to estimate the association between each surgical innovation and CCOP affiliation. During the study interval, 1578 patients (26.8%) were treated by a provider with a CCOP affiliation. Trends in the utilization of laparoscopy and partial nephrectomy remained similar between affiliated and nonaffiliated providers (P ≥ .05). With adjustments for patient characteristics, organizational features, and clustering, no association was noted between CCOP affiliation and the use of laparoscopy (odds ratio [OR], 1.11; 95% confidence interval [CI], 0.81-1.53) or partial nephrectomy (OR, 1.04; 95% CI, 0.82-1.32) despite the more frequent receipt of these treatments in academic settings (P < .05). At a population level, patients treated by providers affiliated with CCOP were no more likely to receive at least 1 of 2 surgical innovations for treatment of their kidney cancer, indicating perhaps a more limited scope to provider-based research networks as they pertain to translational efforts in cancer care. © 2014 American Cancer Society.

Renal function following xenon anesthesia for partial nephrectomy-An explorative analysis of a randomized controlled study.

PubMed

Stevanovic, Ana; Schaefer, Patrick; Coburn, Mark; Rossaint, Rolf; Stoppe, Christian; Boor, Peter; Pfister, David; Heidenreich, Axel; Christ, Hildegard; Hellmich, Martin; Fahlenkamp, Astrid V

2017-01-01

Perioperative preservation of renal function has a significant impact on morbidity and mortality in kidney surgery. Nephroprotective effects of the anesthetic xenon on ischemia-reperfusion injury were found in several experimental studies. We aimed to explore whether xenon anesthesia can reduce renal damage in humans undergoing partial nephrectomy and to gather pilot data of possible nephroprotection in these patients. A prospective randomized, single-blinded, controlled study. Single-center, University Hospital of Aachen, Germany between July 2013-October 2015. Forty-six patients with regular renal function undergoing partial nephrectomy. Patients were randomly assigned to receive xenon- (n = 23) or isoflurane (n = 23) anesthesia. Primary outcome was the maximum postoperative glomerular filtration rate (GFR) decline within seven days after surgery. Secondary outcomes included intraoperative and tumor-related data, assessment of further kidney injury markers, adverse events and optional determination of renal function after 3-6 months. Unexpected radical nephrectomy was performed in 5 patients, thus they were excluded from the per-protocol analysis, but included in the intention-to-treat analysis. The maximum postoperative GFR decline was attenuated by 45% in the xenon-group (10.9 ml min-1 1.73 cm-2 versus 19.7 ml min-1 1.73 cm-2 in the isoflurane group), but without significance (P = 0.084). Occurrence of adverse events was reduced (P = 0.003) in the xenon group. Renal function was similar among the groups after 3-6 months. Xenon anesthesia was feasible and safe in patients undergoing partial nephrectomy with regard to postoperative renal function. We found no significant effect on early renal function but less adverse events in the xenon group. Larger randomized controlled studies in more heterogeneous collectives are required, to confirm or refute the possible clinical benefit on renal function by xenon. ClinicalTrials.gov NCT01839084 and EudraCT 2012-005698-30.

Utility of 16-MDCT angiography for comprehensive preoperative vascular evaluation of laparoscopic renal donors.

PubMed

Raman, Steven S; Pojchamarnwiputh, Suwalee; Muangsomboon, Kobkun; Schulam, Peter G; Gritsch, H Albin; Lu, David S K

2006-06-01

Our objective was to determine the efficacy of 16-MDCT angiography in preoperative evaluation of vascular anatomy of laparoscopic renal donors. Fifty-five consecutive renal donors (25 men and 30 women) underwent 16-MDCT angiography followed by donor nephrectomy. In the arterial and nephrographic phases, images were acquired with 60% overlap and 0.6-mm reconstruction in both phases after 120 mL of iohexol was injected at 4 mL/sec. On a 3D workstation, images were evaluated retrospectively by two abdominal imagers blinded to surgical results with respect to number and branching pattern of renal arteries and major and minor renal veins. These CT angiography results were compared with surgical findings. The surgically confirmed sensitivity of both reviewers (1 and 2) using the MDCT data for detection of renal arteries was 98.5% (65 of 66), and accuracies were 97.0% for reviewer 1 and 95.5% for reviewer 2. Sensitivity and accuracy detection of renal veins was 97% (61 of 63) and 98% (62 of 63) for reviewer 1 and reviewer 2, respectively. Sensitivity and accuracy detection of early arterial bifurcation (< 2 cm from aorta) was 100% (14 of 14), and sensitivity in detection of late venous confluence (< 1.5 cm from aorta) was 100% (8 of 8). All major renal venous variants were identified; reviewer 1 identified 78% (18 of 23) minor venous variants, and reviewer 2 identified 83% (19 of 23) minor venous variants. There were no hemorrhagic complications at surgery. Excellent agreement between reviewers (kappa = 0.92-0.97) was achieved for detection of normal and variant anatomy. 16-MDCT angiography enabled excellent preoperative detection of arterial anatomy and venous laparoscopic donor nephrectomy.

Prospective randomized controlled trial of conventional laparoscopic versus laparoendoscopic single-site radical nephrectomy for localized renal cell carcinoma: a preliminary report regarding quality of life.

PubMed

Park, Yong Hyun; Kim, Kwang Taek; Ko, Kyungtae; Kim, Hyeon Hoe

2015-03-01

The safety and efficacy of laparoendoscopic single-site surgery (LESS) for renal cell carcinoma (RCC) have not been clearly demonstrated. We aimed to present preliminary data from a prospective randomized controlled trial of LESS versus conventional laparoscopic radical nephrectomy for localized RCC. Patients with cT1-2 RCC were randomized to LESS (n = 17) or conventional laparoscopy (n = 18) group. The short-term outcome measures assessed were perioperative morbidity, postoperative pain, and quality of recovery as determined using QoR-40. No significant differences were observed between the LESS and conventional laparoscopy groups with respect to operative time (143.5 vs. 126.1 min, p = 0.218), blood loss (143.6 vs. 118.2 ml, p = 0.121), hospital stay (3.8 vs. 3.1 day s, p = 0.170), analgesic requirements (63.2 vs. 60.0 mg, p = 0.956), and complication rates (26.7 vs. 22.2 %, p = 0.767). However, postoperative quality of recovery was better in the LESS group (176.4 vs. 152.6, p = 0.005). Furthermore, quality of recovery, as measured using the QoR-40 dimensions of emotional state (39.9 vs. 34.0, p = 0.003), physical comfort (51.9 vs. 46.7, p = 0.034), psychological support (32.2 vs. 25.8, p = 0.003), and physical independence (20.7 vs. 17.5, p = 0.047), but not pain (31.8 vs. 29.6, p = 0.259), was significantly better in the LESS group. The preliminary results from this prospective trial suggest that LESS could be a safe and effective treatment option for localized RCC with equivalent surgical outcomes and improved postoperative quality of recovery compared with conventional laparoscopic surgery.

Hospitalization for partial nephrectomy was not associated with intrathecal opioid analgesia: Retrospective analysis

PubMed Central

Weingarten, Toby N.; Del Mundo, Serena B.; Yeoh, Tze Yeng; Scavonetto, Federica; Leibovich, Bradley C.; Sprung, Juraj

2014-01-01

Background: The aim of this retrospective study is to test the hypothesis that the use of spinal analgesia shortens the length of hospital stay after partial nephrectomy. Materials and Methods: We reviewed all patients undergoing partial nephrectomy for malignancy through flank incision between January 1, 2008, and June 30, 2011. We excluded patients who underwent tumor thrombectomy, used sustained-release opioids, or had general anesthesia supplemented by epidural analgesia. Patients were grouped into “spinal” (intrathecal opioid injection for postoperative analgesia) versus “general anesthetic” group, and “early” discharge group (within 3 postoperative days) versus “late” group. Association between demographics, patient physical status, anesthetic techniques, and surgical complexity and hospital stay were analyzed using multivariable logistic regression analysis. Results: Of 380 patients, 158 (41.6%) were discharged “early” and 151 (39.7%) were “spinal” cases. Both spinal and early discharge groups had better postoperative pain control and used less postoperative systemic opioids. Spinal analgesia was associated with early hospital discharge, odds ratio 1.52, (95% confidence interval 1.00-2.30), P = 0.05, but in adjusted analysis was no longer associated with early discharge, 1.16 (0.73-1.86), P = 0.52. Early discharge was associated with calendar year, with more recent years being associated with early discharge. Conclusion: Spinal analgesia combined with general anesthesia was associated with improved postoperative pain control during the 1st postoperative day, but not with shorter hospital stay following partial nephrectomy. Therefore, unaccounted practice changes that occurred during more recent times affected hospital stay. PMID:25422611

The Effect of Patient and Surgical Characteristics on Renal Function After Partial Nephrectomy.

PubMed

Winer, Andrew G; Zabor, Emily C; Vacchio, Michael J; Hakimi, A Ari; Russo, Paul; Coleman, Jonathan A; Jaimes, Edgar A

2018-06-01

The purpose of the study was to identify patient and disease characteristics that have an adverse effect on renal function after partial nephrectomy. We conducted a retrospective review of 387 patients who underwent partial nephrectomy for renal tumors between 2006 and 2014. A line plot with a locally weighted scatterplot smoothing was generated to visually assess renal function over time. Univariable and multivariable longitudinal regression analyses incorporated a random intercept and slope to evaluate the association between patient and disease characteristics with renal function after surgery. Median age was 60 years and most patients were male (255 patients [65.9%]) and white (343 patients [88.6%]). In univariable analysis, advanced age at surgery, larger tumor size, male sex, longer ischemia time, history of smoking, and hypertension were significantly associated with lower preoperative estimated glomerular filtration rate (eGFR). In multivariable analysis, independent predictors of reduced renal function after surgery included advanced age, lower preoperative eGFR, and longer ischemia time. Length of time from surgery was strongly associated with improvement in renal function among all patients. Independent predictors of postoperative decline in renal function include advanced age, lower preoperative eGFR, and longer ischemia time. A substantial number of subjects had recovery in renal function over time after surgery, which continued past the 12-month mark. These findings suggest that patients who undergo partial nephrectomy can experience long-term improvement in renal function. This improvement is most pronounced among younger patients with higher preoperative eGFR. Copyright © 2017 Elsevier Inc. All rights reserved.

National Utilization of Partial Nephrectomy Pre- and Post- AUA Guidelines: Is This as Good as It Gets?

PubMed

Sorokin, Igor; Feustel, Paul J; O'Malley, Rebecca L

2017-10-01

The purpose of the study was to compare utilization and predictors of partial nephrectomy (PN) in the pre- and post-guideline eras. American Board of Urology certification/recertification operative logs were reviewed from 2003 to 2014. Nephrectomy cases were extracted using Current Procedural Terminology codes. The cases were then stratified according to pre-guidelines (2003-October 2009) and post-guidelines (November 2009-2014). Multivariable logistic regression was used to evaluate patient, surgeon, and practice characteristics as predictors of PN. A general linear model with regression analysis was used to evaluate the change in PN over time relative to the incidence of renal cell carcinoma (RCC). We identified 20,402 and 20,729 nephrectomies in the pre- and post-guidelines eras, respectively. In multivariable analysis, the post-guidelines group was more likely to undergo PN (odds ratio, 1.87; P < .001). The pre- as well as post-guidelines groups had a higher likelihood of undergoing PN with an open approach, higher-volume surgeons, and younger patient age (P < .05). Surgeon subspecialty and US region were no longer significant factors after guidelines publication. Number of PN normalized to the incidence of RCC continued to increase over time (0.14%/y; R 2  = 0.77; P < .001). Partial nephrectomy in the post-guidelines era is no longer confined to urological subspecialists or certain densely populated US regions. Although rates of PN continue to increase relative to the recently decreasing overall incidence of RCC, the slope has leveled off somewhat. This is likely related to clinical intricacies of the best treatment modality and technologic advances rather than changes related to guidelines publication. Published by Elsevier Inc.

Robotic partial nephrectomy with selective parenchymal compression (Simon clamp).

PubMed

Castillo, O A; Rodriguez-Carlin, A; Lopez-Fontana, G; Aleman, E

2013-01-01

To present our initial experience using selective renal parenchymal ischemia, without hilar clamping, in robotic-assisted partial nephrectomy. In four patients with T1a renal tumor we performed robotic-assisted partial nephrectomy, using the Simon's clamp (Aesculap). It provides selective parenchymal compression without the need of vascular clamping. All patients had exofitic renal tumors in polar location. Renal parenchymal reconstruction was done as the standard technique. The median age was 49.6 years (42-59), 3 male and 1 female patient. Median operative time was 71,6 minutes (40-120). Mean stimated bleeding was 250 ml (50-400). Average tumor size was 3,25 cm (1,5-5,3). There were no complications and the average hospital stay was 3,5 days (1-7). The pathology was informed as renal cell carcinoma in three patients and one hemorrhagic cyst. The surgical margins were negative. Our preliminary results shows that selective renal parenchymal compression, with the Simon's clamp, provides an alternative to vascular control in selected patients with polar renal tumors. Copyright © 2012 AEU. Published by Elsevier Espana. All rights reserved.

Indications for nephrectomy in children: what has changed?

PubMed

Nouira, Faouzi; Sarrai, Nadia; Ghorbel, Soufiane; Sghair, Yacoub Ould Med; Khemakhem, Rachid; Chariag, Awatef; Jlidi, Said; Chaouachi, Beji

2010-04-01

The last decade has witnessed significant refinements in preoperative diagnostic evaluation and an improvement in surgical techniques and postoperative management for paediatric patients. There has been an improvement in our understanding of the natural history of some congenital renal anomalies which has caused some changes in management approach. To review the indications for nephrectomy in children between 1996 and 2008, at the departement of paediatric surgery, children's hospital in Tunis. There were 80 nephrectomies. A retrospective review of the patients' notes was performed. The 13-year period was divided into two halves (1996-2000 and 2001-2008) which were then compared. The total number of nephrectomies per year significantly increased over the period of the study (4, 6 and 8 nephrectomies per year for 1996-2000 and 2001-2008, respectively; P < 0.05), as did the number of nephrectomies for Multicystic dysplastic kidney (MCDK) (zero and 5 for 1996-2000 and 2001-2008, respectively) and wilms'tumour (8.3% and 29,16% for 1996 - 2000 and 2001 - 2008, respectively). Wilms' tumour, vesico-ureteric reflux (VUR) and pelvi-ureteric junction (PUJ) obstruction accounted for more than half of the nephrectomies (80% and 58% for 1996-2000 and 2001-2008, respectively). The proportion of nephrectomies performed for VUR did not change (15% and 12% for 1996-2000 and 2001-2008, respectively) but fewer nephrectomies were performed for pelvi-ureteric junction (PUJ) obstruction in the second half of the study period (44% and 4,16% for 1996-2000 and 2001-2008, respectively ; P < 0.05). The total number of nephrectomies, including partial nephrectomies, has increased significantly. The decrease in nephrectomies for PUJ obstruction could be accounted for by a more aggressive approach in the management and follow up of prenatally diagnosed hydronephrosis. Of note is that there was no significant change in the proportion of nephrectomies performed for VUR. On the contrary, the proportion of nephrectomies increased for neoplastic lesions and MCDK.

Treatment options for renal cell carcinoma in renal allografts: a case series from a single institution.

PubMed

Swords, Darden C; Al-Geizawi, Samer M; Farney, Alan C; Rogers, Jeffrey; Burkart, John M; Assimos, Dean G; Stratta, Robert J

2013-01-01

Renal cell carcinoma (RCC) is more common in renal transplant and dialysis patients than the general population. However, RCC in transplanted kidneys is rare, and treatment has previously consisted of nephrectomy with a return to dialysis. There has been recent interest in nephron-sparing procedures as a treatment option for RCC in allograft kidneys in an effort to retain allograft function. Four patients with RCC in allograft kidneys were treated with nephrectomy, partial nephrectomy, or radiofrequency ablation. All of the patients are without evidence of recurrence of RCC after treatment. We found nephron-sparing procedures to be reasonable initial options in managing incidental RCCs diagnosed in functioning allografts to maintain an improved quality of life and avoid immediate dialysis compared with radical nephrectomy of a functioning allograft. However, in non-functioning renal allografts, radical nephrectomy may allow for a higher chance of cure without the loss of transplant function. Consequently, radical nephrectomy should be utilized whenever the allograft is non-functioning and the patient's surgical risk is not prohibitive. © 2013 John Wiley & Sons A/S.

The best option: Umbilical LESS radical nephrectomy with vaginal extraction.

PubMed

Andrés, G; García-Mediero, J M; García-Tello, A; Arance, I; Cabrera, P M; Angulo, J C

2015-04-01

Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages. We present a 34-year-old patient with a solid mesorenal lesion measuring 8 cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instrument's double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision. After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bag's thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180 min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications. Umbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result. Copyright © 2014 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.

Multiple Renal Artery Pseudoaneurysms in Patients Undergoing Renal Artery Embolization Following Partial Nephrectomy: Correlation with RENAL Nephrometry Scores

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gupta, Nakul; Patel, Anish; Ensor, Joe

PurposeTo describe the incidence of multiple renal artery pseudoaneurysms (PSA) in patients referred for renal artery embolization following partial nephrectomy and to study its relationship to RENAL nephrometry scores.Materials and MethodsThe medical records of 25 patients referred for renal artery embolization after partial nephrectomy were retrospectively reviewed for the following parameters: size and number of tumors, RENAL nephrometry scores, angiographic abnormalities, technical and clinical outcomes, and estimated glomerular filtration rates (eGFRs) after embolization.ResultsTwenty-four patients had primary renal tumors, while 1 patient had a pancreatic tumor invading the kidney. Multiple tumors were resected in 4 patients. Most patients (92 %) were symptomatic,more » presenting with gross hematuria, flank pain, or both. Angiography revealed PSA with (n = 5) or without (n = 20) AV fistulae. Sixteen patients (64 %) had multiple PSA involving multiple renal vessels. Higher RENAL nephrometry scores were associated with an increasing likelihood of multiple PSA. Multiple vessels were embolized in 14 patients (56 %). Clinical success was achieved after one (n = 22) or two (n = 3) embolization sessions in all patients. Post-embolization eGFR values at different time points after embolization were not significantly different from the post-operative eGFR.ConclusionA majority of patients requiring renal artery embolization following partial nephrectomy have multiple pseudoaneurysms, often requiring selective embolization of multiple vessels. Higher RENAL nephrometry score is associated with an increasing likelihood of multiple pseudoaneurysms. We found transarterial embolization to be a safe and effective treatment option with no long-term adverse effect on renal function in all but one patient with a solitary kidney.« less

Nephron-sparing surgery for treatment of reninoma: a rare renin secreting tumor causing secondary hypertension.

PubMed

Torricelli, Fabio Cesar Miranda; Marchini, Giovanni Scala; Colombo, Jose Roberto; Coelho, Rafael Ferreira; Nahas, Willian Carlos; Srougi, Miguel

2015-01-01

A 25-year-old hypertensive female patient was referred to our institution. Initial workup exams demonstrated a 2.8 cm cortical lower pole tumor in the right kidney. She underwent laparoscopic partial nephrectomy without complications. Histopathologic examination revealed a rare juxtaglomerular cell tumor known as reninoma. After surgery, she recovered uneventfully and all medications were withdrawn. Case hypothesis: Secondary arterial hypertension is a matter of great interest to urologists and nephrologists. Renovascular hypertension, primary hyperadosteronism and pheocromocytoma are potential diagnosis that must not be forgotten and should be excluded. Although rare, chronic pyelonephritis and renal tumors as rennin-producing tumors, nephroblastoma, hypernephroma, and renal cell carcinoma might also induce hypertension and should be in the diagnostic list of clinicians. Promising future implications: Approximately 5% of patients with high blood pressure have specific causes and medical investigation may usually identify such patients. Furthermore, these patients can be successfully treated and cured, most times by minimally invasive techniques. This interesting case might expand knowledge of physicians and aid better diagnostic care in future medical practice.

The utility of 64 channel multidetector CT angiography for evaluating the renal vascular anatomy and possible variations: a pictorial essay.

PubMed

Kumar, Sheo; Neyaz, Zafar; Gupta, Archna

2010-01-01

The increased use of laparoscopic nephrectomy and nephron-sparing surgery has prompted the need for a more detailed radiological evaluation of the renal vascular anatomy. Multidetector CT angiography is a fast and accurate modality for assessing the precise anatomy of the renal vessels. In this pictorial review, we present the multidetector CT angiography appearances of the normal renal vascular anatomy and a spectrum of various anomalies that require accurate vascular depiction before undergoing surgical treatment.

Effect of Regional Hospital Competition and Hospital Financial Status on the Use of Robotic-Assisted Surgery.

PubMed

Wright, Jason D; Tergas, Ana I; Hou, June Y; Burke, William M; Chen, Ling; Hu, Jim C; Neugut, Alfred I; Ananth, Cande V; Hershman, Dawn L

2016-07-01

Despite the lack of efficacy data, robotic-assisted surgery has diffused rapidly into practice. Marketing to physicians, hospitals, and patients has been widespread, but how this marketing has contributed to the diffusion of the technology remains unknown. To examine the effect of regional hospital competition and hospital financial status on the use of robotic-assisted surgery for 5 commonly performed procedures. A cohort study of 221 637 patients who underwent radical prostatectomy, total nephrectomy, partial nephrectomy, hysterectomy, or oophorectomy at 1370 hospitals in the United States from January 1, 2010, to December 31, 2011, was conducted. The association between hospital competition, hospital financial status, and performance of robotic-assisted surgery was examined. The association between hospital competition was measured with the Herfindahl-Hirschman Index (HHI), hospital financial status was estimated as operating margin, and performance of robotic-assisted surgery was examined using multivariate mixed-effects regression models. We identified 221 637 patients who underwent one of the procedures of interest. The cohort included 30 345 patients who underwent radical prostatectomy; 20 802, total nephrectomy; 8060, partial nephrectomy; 134 985, hysterectomy; and 27 445, oophorectomy. Robotic-assisted operations were performed for 20 500 (67.6%) radical prostatectomies, 1405 (6.8%) total nephrectomies, 2759 (34.2%) partial nephrectomies, 14 047 (10.4%) hysterectomies, and 1782 (6.5%) oophorectomies. Use of robotic-assisted surgery increased for each procedure from January 2010 through December 2011. For all 5 operations, increased market competition (as measured by the HHI) was associated with increased use of robotic-assisted surgery. For prostatectomy, the risk ratios (95% CIs) for undergoing a robotic-assisted procedure were 2.20 (1.50-3.24) at hospitals in moderately competitive markets and 2.64 (1.84-3.78) for highly competitive markets compared with noncompetitive markets. For hysterectomy, patients at hospitals in moderately (3.75 [2.26-6.25]) and highly (5.30; [3.27-8.57]) competitive markets were more likely to undergo a robotic-assisted surgery. Increased hospital profitability was associated with use of robotic-assisted surgery only for partial nephrectomy in facilities with medium-high (1.67 [1.13-2.48]) and high (1.50 [0.98-2.29]) operating margins. With analysis limited to patients treated at a hospital that had performed robotic-assisted surgery, there was no longer an association between competition and use of robotic-assisted surgery. Patients undergoing surgery in a hospital in a competitive regional market were more likely to undergo a robotic-assisted procedure. These data imply that regional competition may influence a hospital's decision to acquire a surgical robot.

[Comparison of validity and safety between holmium: YAG laser and traditional surgery in partial nephrectomy].

PubMed

Bi, Sheng; Xia, Ming

2015-08-11

To compare the validity and safety between holmium: YAG laser and traditional surgery in partial nephrectomy. A total of 28 patients were divided into two groups (holmium: YAG laser group without renal artery clamping and traditional surgery group with renal artery clamping). The intraoperative blood loss, total operative time, renal artery clamping time, postoperative hospital stay, separated renal function, postoperative complications and depth of tissue injury were recorded. The intraoperative blood loss, total operative time, renal artery clamping time, postoperative hospital stay, separated renal function, postoperative complications and depth of tissue injury were 80 ml, 77 min, 0 min, 7.4 days, 35 ml/min, 0, 0.9 cm, respectively, in holmium: YAG laser group. And in traditional surgery group were 69 ml, 111 min, 25.5 min, 7.3 days, 34 ml/min, 0, 2.0 cm, respectively. The differences of total operative time, renal artery clamping time and depth of tissue injury between two groups were statistically significant. The others were not statistically significant. Holmium: YAG laser is effective and safe in partial nephrectomy. It can decrease the total operative time, minimize the warm ischemia time and enlarge the extent of surgical excision.

Laparoscopic kidney orthotopic transplant: preclinical study in the pig model.

PubMed

He, B; Musk, G C; Mou, L; Waneck, G L; Delriviere, L

2013-06-01

Laparoscopic surgery has rapidly expanded in clinical practice replacing conventional open surgery over the last three decades. Laparoscopic donor nephrectomy has been favored due to its multiple benefits. The aim of this study was to explore the safety and feasibility of kidney transplantation by a laparoscopic technique in a pig model. The study was approved by the university animal ethics committee. Eight female pigs (Sus Scrofra, weighing 45-50 kg) were divided into 2 groups: group I included 4 animals that underwent laparoscopic kidney orthotopic transplantation on the left side. The right kidney was remained functional in situ. The pigs recovered and were observed for 1 week. In the 4 hosts group II pigs underwent a laparoscopic kidney transplantation on the left side. With simultaneous clipping of the right ureter. After recovery, the pigs were observed for 4 weeks. A laparotomy for examination was performed prior to euthanasia. All 4 group I pigs survived for 1 week. The laparotomy showed normal graft perfusion with wall patent renal artery and vein as well as satisfactory urine output upon transection of ureter in 3 hosts. Renal artery stenosis occurred in one pig. In The Immediate kidney graft function was achieved in 3 group II pigs. The fourth died following extubation due to laryngospasm despite a functional graft. The average creatinine levels were 195.5 μmol/L on day 3; 224.5 μmol/L at week 1; 127 μmol/L at week 2; 182.7 umol/L at week 3; and 154.7 umol/L at week 4. Laparoscopic kidney transplantation was feasible and safe in a pig model with immediate graft function. This study will provide further evidence to support application of laparoscopic technique to human kidney transplant. Copyright © 2013 Elsevier Inc. All rights reserved.

Contrast enhancement for in vivo visible reflectance imaging of tissue oxygenation.

PubMed

Crane, Nicole J; Schultz, Zachary D; Levin, Ira W

2007-08-01

Results are presented illustrating a straightforward algorithm to be used for real-time monitoring of oxygenation levels in blood cells and tissue based on the visible spectrum of hemoglobin. Absorbance images obtained from the visible reflection of white light through separate red and blue bandpass filters recorded by monochrome charge-coupled devices (CCDs) are combined to create enhanced images that suggest a quantitative correlation between the degree of oxygenated and deoxygenated hemoglobin in red blood cells. The filter bandpass regions are chosen specifically to mimic the color response of commercial 3-CCD cameras, representative of detectors with which the operating room laparoscopic tower systems are equipped. Adaptation of this filter approach is demonstrated for laparoscopic donor nephrectomies in which images are analyzed in terms of real-time in vivo monitoring of tissue oxygenation.

Feasibility of telementoring between Baltimore (USA) and Rome (Italy): the first five cases.

PubMed

Micali, S; Virgili, G; Vannozzi, E; Grassi, N; Jarrett, T W; Bauer, J J; Vespasiani, G; Kavoussi, L R

2000-08-01

Telemedicine is the use of telecommunication technology to deliver healthcare. Telementoring has been developed to allow a surgeon at a remote site to offer guidance and assistance to a less-experienced surgeon. We report on our experience during laparoscopic urologic procedures with mentoring between Rome, Italy, and Baltimore, USA. Over a period of 3 months, two laparoscopic left spermatic vein ligations, one retroperitoneal renal biopsy, one laparoscopic nephrectomy, and one percutaneous access to the kidney were telementored. Transperitoneal laparoscopic cases were performed with the use of AESOP, a robotic for remote manipulation of the endoscopic camera. A second robot, PAKY, was used to perform radiologically guided needle orientation and insertion for percutaneous renal access. In addition to controlling the robotic devices, the system provided real-time video display for either the laparoscope or an externally mounted camera located in the operating room, full duplex audio, telestration over live video, and access to electrocautery for tissue cutting or hemostasis. All procedures were accomplished with an uneventful postoperative course. One technical failure occurred because the robotic device was not properly positioned on the operating table. The round-trip delay of image transmission was less than 1 second. International telementoring is a feasible technique that can enhance surgeon education and decrease the likelihood of complications attributable to inexperience with new operative techniques.

Single-port laparoscopic partial splenectomy: a case report.

PubMed

Hong, Tae Ho; Lee, Sang Kuon; You, Young Kyoung; Kim, Jun Gi

2010-10-01

With the better understanding of the importance of the spleen as a primary organ of the human immune system, there has been an increased interest in performing the partial splenectomy for a number of indications such as nonparasitic cysts, benign tumors, staging of lymphomas, etc. Moreover, laparoscopic partial splenectomy has been gaining more interest as the recommended approach for benign splenic disorders to preserve the splenic function with very low recurrence rates. Meanwhile, many surgeons have attempted to reduce the number and size of the ports in laparoscopic surgery with the aim of inducing less parietal trauma and fewer scars. One of these efforts is single-port laparoscopic surgery, which is a rapidly evolving field all over the world. Here, we describe a feasible method of single-port laparoscopic partial splenectomy for treating a benign splenic cyst that was located in the upper medial aspect of the spleen.

Single center experience with percutaneous and laparoscopic cryoablation of small renal masses.

PubMed

Malcolm, John B; Berry, Tristan T; Williams, Michael B; Logan, Joshua E; Given, Robert W; Lance, Raymond S; Barone, Bethany; Shaves, Sarah; Vingan, Harlan; Fabrizio, Michael D

2009-06-01

While partial nephrectomy remains the gold standard for the management of most small renal masses, increasing experience with renal cryoablation has suggested a viable alternative with a favorable morbidity profile and good efficacy. We report intermediate-term oncologic outcomes from a single-center experience with laparoscopic and percutaneous renal cryoablation. We performed a retrospective review of our laparoscopic renal cryoablation (LRC) and percutaneous renal cryoablation (PRC) experience between January 2003 and April 2007. Patients with at least 12 months of follow-up were included in the analysis. Follow-up consisted of imaging and laboratory studies at regular intervals. Persistent mass enhancement or interval tumor growth was considered a treatment failure. Sixty-six patients (44% women/56% men; 42% African-American/58% Caucasian/other; mean body mass index, 29.7) with 72 tumors underwent either LRC (n = 52) or PRC (n = 20) with a mean follow-up of 30 months (median 25.1 mos; range 13-63 mos). Average patient age was 66.5 years (range 34-82 yrs). Mean tumor size was 2.33 cm (range 1-4.6 cm). Comorbid conditions were prevalent: 76% hypertension, 36% hyperlipidemia, 24% chronic kidney disease, 29% diabetes mellitus, 36% tobacco use, and 32% heart disease. RESULTS of pretreatment biopsy were 62% renal-cell carcinoma and 38% benign or nondiagnostic. Overall cancer-specific and cancer-free survival were 100% and 97%, respectively. There were two treatment failures (3.8%) in the LRC group and five primary failures in the PRC group (25%) (P = 0.015), four of which were salvaged with repeated PRC with no evidence of recurrence at 6 to 36 months of follow-up. There has been no significant local or metastatic progression. LRC and PRC achieved good oncologic control with minimal morbidity at a mean follow-up of 30 months in a patient cohort characterized by numerous comorbid conditions. PRC had a significantly higher primary treatment failure rate than LRC, but re-treatment offered salvage oncologic control with no significant complications.

Current Status of Nephron-Sparing Surgery (NSS) in the Management of Renal Tumours.

PubMed

Venkatramani, Vivek; Swain, Sanjaya; Satyanarayana, Ramgopal; Parekh, Dipen J

2017-06-01

Nephron-sparing surgery has emerged as the surgical treatment of choice for small renal masses over the past two decades, replacing the traditional teaching of radical nephrectomy for renal cell carcinoma. With time, there has been an evolution in the techniques and indications for partial nephrectomy. This review summarizes the current status of nephron-sparing surgery for renal carcinoma and also deals with the future of this procedure.

Operative safety and oncologic outcome of laparoscopic radical nephrectomy for renal cell carcinoma >7 cm: a multicenter study of 222 patients.

PubMed

Luciani, Lorenzo G; Porpiglia, Francesco; Cai, Tommaso; D'Elia, Carolina; Vattovani, Valentino; Giusti, Guido; Tiscione, Daniele; Chiodini, Stefano; Peschechera, Roberto; Fiori, Christian; Spina, Rosa; Parma, Paolo; Celia, Antonio; Malossini, Gianni

2013-06-01

To evaluate the safety of laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) >7 cm, addressing the issue of modality and risk factors for complications and open conversion, and to assess the oncologic outcome. The data of 222 patients undergoing LRN for RCC >7 cm prospectively enrolled from 2002 to 2010 at 5 urologic centers were reviewed. Transperitoneal LRN was performed by 5 experienced laparoscopic surgeons. The Clavien-Dindo classification was used to assess complications. Multivariable analysis of factors predictive of conversions was performed. Oncologic outcomes for survival were estimated using the Kaplan-Meier method. Median tumor size was 8.5 cm, operative time was 180 minutes, and blood loss was 280 mL. Forty-two patients (19%) received a blood transfusion. Six (2.7%) patients had grade III-IV complications: 2 with postoperative bleeding requiring abdominal re-exploration and 1 each with adrenal injury, splenic injury, wound diastasis, and respiratory insufficiency. Twelve patients (5.4%) were converted to open surgery. The diameter was 11.9 in converted groups and 8.5 cm in nonconverted groups (P = .001). Multivariable analysis revealed that pathologic stage was the only independent predictor of conversion (P = .002). The 5-year overall (OS), cancer-specific (CSS), and progression-free (PFS) survival was 74%, 78%, and 66%, respectively. The 5-year stage-adjusted CSS was 89% in pT2 and 40% in pT3 patients (P <.0001). Limitations of this study were its retrospective nature and the relatively short follow-up period for oncologic outcome. LRN for large RCC is a safe operation. Stage pT3 is a risk factor for open conversion and is associated to significantly lower cancer-specific survival compared with pT2 stage. Copyright © 2013 Elsevier Inc. All rights reserved.

Wilms Tumor in a Child With Bilateral Polycystic Kidneys and PHACE Syndrome: Successful Treatment Outcome Using Partial Nephrectomy and Chemotherapy.

PubMed

Thankamony, Priyakumari; Sivarajan, Venugopal; Mony, Rari P; Muraleedharan, Venugopal

2016-01-01

Congenital anomalies may be associated with Wilms tumor either as isolated anomalies or as part of a congenital malformation syndrome. Nephroblastoma occurring in association with polycystic kidneys is very rare. The optimal surgical management of nephroblastoma in the setting of polycystic kidneys is not defined because of the rarity of this presentation. PHACE syndrome includes posterior fossa anomalies, hemangioma, arterial lesions, cardiac abnormalities/coarctation of aorta, and eye abnormalities. We report a 17-month-old baby with bilateral polycystic kidneys and PHACE syndrome who developed nephroblastoma in the right polycystic kidney which was treated successfully with nephron-sparing partial nephrectomy and chemotherapy.

Human error identification for laparoscopic surgery: Development of a motion economy perspective.

PubMed

Al-Hakim, Latif; Sevdalis, Nick; Maiping, Tanaphon; Watanachote, Damrongpan; Sengupta, Shomik; Dissaranan, Charuspong

2015-09-01

This study postulates that traditional human error identification techniques fail to consider motion economy principles and, accordingly, their applicability in operating theatres may be limited. This study addresses this gap in the literature with a dual aim. First, it identifies the principles of motion economy that suit the operative environment and second, it develops a new error mode taxonomy for human error identification techniques which recognises motion economy deficiencies affecting the performance of surgeons and predisposing them to errors. A total of 30 principles of motion economy were developed and categorised into five areas. A hierarchical task analysis was used to break down main tasks of a urological laparoscopic surgery (hand-assisted laparoscopic nephrectomy) to their elements and the new taxonomy was used to identify errors and their root causes resulting from violation of motion economy principles. The approach was prospectively tested in 12 observed laparoscopic surgeries performed by 5 experienced surgeons. A total of 86 errors were identified and linked to the motion economy deficiencies. Results indicate the developed methodology is promising. Our methodology allows error prevention in surgery and the developed set of motion economy principles could be useful for training surgeons on motion economy principles. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

A critical incident report: Propofol triggered anaphylaxis

PubMed Central

Koul, Archna; Jain, Rashmi; Sood, Jayashree

2011-01-01

Although propofol is one of the most commonly used drugs for induction of anaesthesia, it is not devoid of anaphylactic potential. Early detection of any suspected anaphylactic reaction during anaesthesia, prompt management, identification of the offending agent and prevention of exposure to the offending agent in the future is the responsibility of the anaesthesiologist. This is a case report of anaphylaxis to propofol at the induction of anaesthesia in a previously non-allergic 56 year-old man, planned to undergo laparoscopic nephrectomy, who responded to epinephrine infusion. PMID:22174476

Positive surgical margins in robot-assisted partial nephrectomy: a multi-institutional analysis of oncologic outcomes (leave no tumor behind).

PubMed

Khalifeh, Ali; Kaouk, Jihad H; Bhayani, Sam; Rogers, Craig; Stifelman, Michael; Tanagho, Youssef S; Kumar, Ramesh; Gorin, Michael A; Sivarajan, Ganesh; Samarasekera, Dinesh; Allaf, Mohamad E

2013-11-01

Expanding indications for robot-assisted partial nephrectomy raise major oncologic concerns for positive surgical margins. Previous reports showed no correlation between positive surgical margins and oncologic outcomes. We report a multi-institutional experience with the oncologic outcomes of positive surgical margins on robot-assisted partial nephrectomy. Pathological and clinical followup data were reviewed from an institutional review board approved, prospectively maintained joint database from 5 institutions. Tumors with malignant pathology were isolated and statistically analyzed for demographics and oncologic followup. The log rank test was used to compare recurrence-free and metastasis-free survival between patients with positive and negative surgical margins. The proportional hazards method was used to assess the influence of multiple factors, including positive surgical margins, on recurrence and metastasis. A total of 943 robot-assisted partial nephrectomies for malignant tumors were successfully completed. Of the patients 21 (2.2%) had positive surgical margins on final pathological assessment, resulting in 2 groups, including the 21 with positive surgical margins and 922 with negative surgical margins. Positive surgical margin cases had higher recurrence and metastasis rates (p<0.001). As projected by the Kaplan-Meier method in the population as a whole at followup out to 63.6 months, 5-year recurrence-free and metastasis-free survival was 94.8% and 97.5%, respectively. There was a statistically significant difference in recurrence-free and metastasis-free survival between patients with positive and negative surgical margins (log rank test<0.001), which favored negative surgical margins. Positive surgical margins showed an 18.4-fold higher HR for recurrence when adjusted for multiple tumors, tumor size, tumor growth pattern and pathological stage. Positive surgical margins on final pathological evaluation increase the HR of recurrence and metastasis. In addition to pathological and molecular tumor characteristics, this should be considered to plan appropriate management. Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Chronic Kidney Disease Epidemiology Collaboration versus Modification of Diet in Renal Disease equations for renal function evaluation in patients undergoing partial nephrectomy.

PubMed

Shikanov, Sergey; Clark, Melanie A; Raman, Jay D; Smith, Benjamin; Kaag, Matthew; Russo, Paul; Wheat, Jeffrey C; Wolf, J Stuart; Huang, William C; Shalhav, Arieh L; Eggener, Scott E

2010-11-01

A novel equation, the Chronic Kidney Disease Epidemiology Collaboration, has been proposed to replace the Modification of Diet in Renal Disease for estimated glomerular filtration rate due to higher accuracy, particularly in the setting of normal renal function. We compared these equations in patients with 2 functioning kidneys undergoing partial nephrectomy. We assembled a cohort of 1,158 patients from 5 institutions who underwent partial nephrectomy between 1991 and 2009. Only subjects with 2 functioning kidneys were included in the study. The end points were baseline estimated glomerular filtration rate, last followup estimated glomerular filtration rate (3 to 18 months), absolute and percent change estimated glomerular filtration rate ([absolute change/baseline] × 100%), and proportion of newly developed chronic kidney disease stage III. The agreement between the equations was evaluated using Bland-Altman plots and the McNemar test for paired observations. Mean baseline estimated glomerular filtration rate derived from the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration equations were 73 and 77 ml/minute/1.73 m(2), respectively, and following surgery were 63 and 67 ml/minute/1.73 m(2), respectively. Mean percent change estimated glomerular filtration rate was -12% for both equations (p = 0.2). The proportion of patients with newly developed chronic kidney disease stage III following surgery was 32% and 25%, according to the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration equations, respectively (p = 0.001). For patients with 2 functioning kidneys undergoing partial nephrectomy the Chronic Kidney Disease Epidemiology Collaboration equation provides slightly higher glomerular filtration rate estimates compared to the Modification of Diet in Renal Disease equation, with 7% fewer patients categorized as having chronic kidney disease stage III or worse. Copyright © 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Clinical application of calculated split renal volume using computed tomography-based renal volumetry after partial nephrectomy: Correlation with technetium-99m dimercaptosuccinic acid renal scan data.

PubMed

Lee, Chan Ho; Park, Young Joo; Ku, Ja Yoon; Ha, Hong Koo

2017-06-01

To evaluate the clinical application of computed tomography-based measurement of renal cortical volume and split renal volume as a single tool to assess the anatomy and renal function in patients with renal tumors before and after partial nephrectomy, and to compare the findings with technetium-99m dimercaptosuccinic acid renal scan. The data of 51 patients with a unilateral renal tumor managed by partial nephrectomy were retrospectively analyzed. The renal cortical volume of tumor-bearing and contralateral kidneys was measured using ImageJ software. Split estimated glomerular filtration rate and split renal volume calculated using this renal cortical volume were compared with the split renal function measured with technetium-99m dimercaptosuccinic acid renal scan. A strong correlation between split renal function and split renal volume of the tumor-bearing kidney was observed before and after surgery (r = 0.89, P < 0.001 and r = 0.94, P < 0.001). The preoperative and postoperative split estimated glomerular filtration rate of the operated kidney showed a moderate correlation with split renal function (r = 0.39, P = 0.004 and r = 0.49, P < 0.001). The correlation between reductions in split renal function and split renal volume of the operated kidney (r = 0.87, P < 0.001) was stronger than that between split renal function and percent reduction in split estimated glomerular filtration rate (r = 0.64, P < 0.001). The split renal volume calculated using computed tomography-based renal volumetry had a strong correlation with the split renal function measured using technetium-99m dimercaptosuccinic acid renal scan. Computed tomography-based split renal volume measurement before and after partial nephrectomy can be used as a single modality for anatomical and functional assessment of the tumor-bearing kidney. © 2017 The Japanese Urological Association.

Selective Arterial Clamping Versus Hilar Clamping for Minimally Invasive Partial Nephrectomy.

PubMed

Yezdani, Mona; Yu, Sue-Jean; Lee, David I

2016-05-01

Partial nephrectomy has become an accepted treatment of cT1 renal masses as it provides improved long-term renal function compared to radical nephrectomy (Campbell et al. J Urol. 182:1271-9, 2009). Hilar clamping is utilized to help reduce bleeding and improve visibility during tumor resection. However, concern over risk of kidney injury with hilar clamping has led to new techniques to reduce length of warm ischemia time (WIT) during partial nephrectomy. These techniques have progressed over the years starting with early hilar unclamping, controlled hypotension during tumor resection, selective arterial clamping, minimal margin techniques, and off-clamp procedures. Selective arterial clamping has progressed significantly over the years. The main question is what are the exact short- and long-term renal effects from increasing clamp time. Moreover, does it make sense to perform these more time-consuming or more complex procedures if there is no long-term preservation of kidney function? More recent studies have shown no difference in renal function 6 months from surgery when selective arterial clamping or even hilar clamping is employed, although there is short-term improved decline in estimated glomerular filtration rate (eGFR) with selective clamping and off-clamp techniques (Komninos et al. BJU Int. 115:921-8, 2015; Shah et al. 117:293-9, 2015; Kallingal et al. BJU Int. doi: 10.1111/bju.13192, 2015). This paper reviews the progression of total hilar clamping to selective arterial clamping (SAC) and the possible difference its use makes on long-term renal function. SAC may be attempted based on surgeon's decision-making, but may be best used for more complex, larger, more central or hilar tumors and in patients who have renal insufficiency at baseline or a solitary kidney.

Anatomic features involved in technical complexity of partial nephrectomy.

PubMed

Hou, Weibin; Yan, Weigang; Ji, Zhigang

2015-01-01

Nephrometry score systems, including RENAL nephrometry, preoperative aspects and dimensions used for an anatomical classification system, C-index, diameter-axial-polar nephrometry, contact surface area score, calculating resected and ischemized volume, renal tumor invasion index, surgical approach renal ranking score, zonal NePhRO score, and renal pelvic score, have been reviewed. Moreover, salient anatomic features like the perinephric fat and vascular variants also have been discussed. We then extract 7 anatomic characteristics, namely tumor size, spatial location, adjacency, exophytic/endophytic extension, vascular variants, pelvic anatomy, and perinephric fat as important features for partial nephrectomy. For novice surgeons, comprehensive and adequate anatomic consideration may help them in their early clinical practice. Copyright © 2015 Elsevier Inc. All rights reserved.

Stone formation from nonabsorbable clip migration into the collecting system after robot-assisted partial nephrectomy.

PubMed

Lee, Ziho; Reilly, Christopher E; Moore, Blake W; Mydlo, Jack H; Lee, David I; Eun, Daniel D

2014-01-01

We describe a case in which a Weck Hem-o-lok clip (Teleflex, Research Triangle Park, USA) migrated into the collecting system and acted as a nidus for stone formation in a patient after robot-assisted partial nephrectomy. The patient presented 2 years postoperatively with left-sided renal colic. Abdominal computed tomography scan showed a 10 millimeter renal calculus in the left middle pole. After using laser lithotripsy to fragment the overlying renal stone, a Weck Hem-o-lok clip was found to be embedded in the collecting system. A laser fiber through a flexible ureteroscope was used to successfully dislodge the clip from the renal parenchyma, and a stone basket was used to extract the clip.

Who is at risk of death from nephrectomy? An analysis of thirty-day mortality after 21 380 nephrectomies in 3 years of the British Association of Urological Surgeons (BAUS) National Nephrectomy Audit.

PubMed

Fernando, Archie; Fowler, Sarah; Van Hemelrijck, Mieke; O'Brien, Tim

2017-09-01

To ascertain contemporary overall and differential thirty-day mortality (TDM) rates after all types of nephrectomy in the UK, and to identify potential new risk factors for death. We conducted a retrospective analysis of the 110 deaths that occurred within 30 days of surgery out of the total of 21 380 nephrectomies performed, and calculated the odds ratio (OR) and 95% confidence interval (CI) for TDM based on peri-operative characteristics. The overall TDM rate was 110/21380 (0.5%). The TDM rates after radical, partial, simple nephrectomy and nephro-ureterectomy were 0.6% (63/11057), 0.1% (4/3931), 0.4% (11/2819) and 0.9% (28/3091), respectively. TDM increased with age, stage, estimated blood loss (EBL), operating time and performance status. EBL of 1-2 L was associated with a greater risk of TDM than EBL of 2-5 L (OR 1.38; 95% CI 1.03-2.24). Conversion from minimally invasive surgery was associated with higher risk than non-conversion (OR 2.53; 95% CI 1.14-4.51. Curative surgery was safer than cytoreductive surgery (OR 0.31; 95% CI 0.18-0.54). There was an association between surgical volume and TDM. This study provides contemporary insights into the true risks of all types of nephrectomy. The TDM rate after nephrectomy in the UK appears acceptably low at 0.5%. Established risk factors were confirmed and the following novel risk factors were identified: modest EBL (1-2 L) and conversion from minimally invasive surgery. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

Laparoscopic upper urinary tract surgery for benign and malignant conditions. Does aetiology have an effect on health-related quality of life?

PubMed

Sahai, A; Tang, S; Challacombe, B; Murphy, D; Dasgupta, P

2007-12-01

We present health-related quality of life (HRQoL) data on a cohort of patients undergoing upper urinary tract laparoscopy for a variety of benign and malignant conditions. The Short Form 8 (SF-8) Health Survey is a validated HRQoL questionnaire that calculates scores for physical (PCS8) and mental (MCS8) components of health. It was administered prospectively to 58 patients. Radical nephrectomy or nephroureterectomy was carried out for upper tract malignancy (n = 21). Laparoscopy for benign disease (n = 37) included simple nephrectomy for giant hydronephrosis and small non-functioning kidneys, de-roofing of renal cysts and pyeloplasty. Data were collected before and 6 weeks after surgery. The mean pre- and postsurgery scores were 45.99; 47.43 and 43.93; 51.54 for PCS8 and MCS8 respectively. With regard to the PCS8 score, there was no significant difference before or after surgery (p = 0.585) or when analysing the benign (p = 0.343) or malignant (p = 0.509) groups individually. The MCS8 score, however, showed a significant increase after surgery (p < 0.0001). This remained significant when analysing just the benign (p < 0.0009) or the malignant (p < 0.0003) groups but neither group was more significant than the other (p = 0.750). Laparoscopic upper urinary tract surgery significantly improves mental and does not appear to reduce physical HRQoL in patients regardless of aetiology, 4 weeks following surgery. Interestingly, those operated on for malignant conditions do not have a greater improvement in mental health when compared with benign disease.

Expanding living kidney donor criteria with ex-vivo surgery for renal anomalies

PubMed Central

McGregor, Thomas B.; Rampersad, Christie; Patel, Premal

2016-01-01

Introduction: Renal transplantation remains the gold standard treatment for end-stage renal disease, with living donor kidneys providing the best outcomes in terms of allograft survival. As the number of patients on the waitlist continues to grow, solutions to expand the donor pool are ongoing. A paradigm shift in the eligibility of donors with renal anomalies has been looked at as a potential source to expand the living donor pool. We sought to determine how many patients presented with anatomic renal anomalies at our transplant centre and describe the ex-vivo surgical techniques used to render these kidneys suitable for transplantation. Methods: A retrospective review was performed of all patients referred for surgical suitability to undergo laparoscopic donor nephrectomy between January 2011 and January 2015. Patient charts were analyzed for demographic information, perioperative variables, urological histories, and postoperative outcomes. Results: 96 referrals were identified, of which 81 patients underwent laparoscopic donor nephrectomy. Of these patients, 11 (13.6%) were identified as having a renal anomaly that could potentially exclude them from the donation process. These anomalies included five patients with unilateral nephrolithiasis, four patients with large renal cysts (>4 cm diameter), one patient with an angiomyolipoma (AML) and one patient with a calyceal diverticulum filled with stones. A description of the ex-vivo surgical techniques used to correct these renal anomalies is provided. Conclusions: We have shown here that ex-vivo surgical techniques can safely and effectively help correct some of these renal anomalies to render these kidneys transplantable, helping to expand the living donor pool. PMID:27800047

The effect of kidney morcellation on operative time, incision complications, and postoperative analgesia after laparoscopic nephrectomy.

PubMed

Camargo, Affonso H; Rubenstein, Jonathan N; Ershoff, Brent D; Meng, Maxwell V; Kane, Christopher J; Stoller, Marshall L

2006-01-01

Compare the outcomes between kidney morcellation and two types of open specimen extraction incisions, several covariates need to be taken into consideration that have not yet been studied. We retrospectively reviewed 153 consecutive patients who underwent laparoscopic nephrectomy at our institution, 107 who underwent specimen morcellation and 46 with intact specimen removal, either those with connected port sites with a muscle-cutting incision and those with a remote, muscle-splitting incision. Operative time, postoperative analgesia requirements, and incisional complications were evaluated using univariate and multivariate analysis, comparing variables such as patient age, gender, body mass index (BMI), laterality, benign versus cancerous renal conditions, estimated blood loss, specimen weight, overall complications, and length of stay. There was no significant difference for operative time between the 2 treatment groups (p = 0.65). Incision related complications occurred in 2 patients (4.4%) from the intact specimen group but none in the morcellation group (p = 0.03). Overall narcotic requirement was lower in patients with morcellated (41 mg) compared to intact specimen retrieval (66 mg) on univariate (p = 0.03) and multivariate analysis (p = 0.049). Upon further stratification, however, there was no significant difference in mean narcotic requirement between the morcellation and muscle-splitting incision subgroup (p = 0.14). Morcellation does not extend operative time, and is associated with significantly less postoperative pain compared to intact specimen retrieval overall, although this is not statistically significant if a remote, muscle-splitting incision is made. Morcellation markedly reduces the risk of incisional-related complications.

Impact of body mass index on perioperative outcomes of laparoscopic radical nephrectomy in Japanese patients with clinically localized renal cell carcinoma.

PubMed

Miyake, Hideaki; Muramaki, Mototsugu; Tanaka, Kazushi; Takenaka, Atsushi; Fujisawa, Masato

2010-06-01

The aim of this study was to review the association between body mass index (BMI) and perioperative outcomes of laparoscopic radical nephrectomy (LRN) in Japanese patients with renal cell carcinoma (RCC). This study included 108 consecutive Japanese patients undergoing LRN for RCC between April 2001 and March 2009. These patients were divided into the following two groups according to BMI: the non-obese group (n= 58, BMI 25 kg/m(2) or less) and the obese group (n= 50, BMI greater than 25 kg/m(2)). Perioperative outcomes between these two groups were retrospectively compared. There were no significant differences in clinicopathological parameters other than BMI between the non-obese and obese groups. There were no significant differences in operative time, estimated blood loss during LRN, and the incidences of open conversion and postoperative complications between these two groups. In addition, there were no significant differences in parameters related to postoperative recovery, including time to walk, time to oral intake and time until permission for discharge, between these two groups. However, significant trends toward a prolonged operative time (P= 0.0050) and increased blood loss (P= 0.012) during LRN in relation to BMI were documented by linear regression analyses. Although the degree of obesity in patients included in this study was comparatively slight, these findings suggest that LRN can be safely performed for patients with RCC irrespective of BMI. However, the difficulty of LRN may increase with BMI considering the trends toward longer operative time as well as greater blood loss.

Intravenous Acetaminophen for Postoperative Pain Management in Patients Undergoing Living Laparoscopic Living-Donor Nephrectomy.

PubMed

Vu, Van; Baker, William L; Tencza, Elizabeth M; Rochon, Caroline; Sheiner, Patricia A; Martin, Spencer T

2017-01-01

Postoperative pain is a common complication of laparoscopic living-donor nephrectomies (LLDNs). To determine whether intravenous (IV) acetaminophen administration post-LLDN influenced length of stay (LOS) when used for pain management. This single-center, retrospective study compared patients undergoing LLDN who had received IV acetaminophen for pain control versus those who did not between June 1, 2011, and November 30, 2015. Patient LOS, 30-day readmissions, frequency of pain assessments, patient-reported pain scores, and opioid administration were assessed. A total of 90 patients were included in the analysis (IV acetaminophen, n = 48; non-IV acetaminophen, n = 42). Patients who did not receive IV acetaminophen were more often older (48.8 ± 12.1 vs 39.3 ± 12.1 years; P = 0.012) and female (71.4% vs 47.9%; P < 0.001). The average LOS was similar between the 2 groups (median = 3.0; interquartile range = [3, 4] vs 3.5 [3, 4]; P = 0.737). The 30-day readmissions were higher in the IV acetaminophen group (16.7%) compared with the group not receiving IV acetaminophen (2.4%; P = 0.033). After the first postoperative day, the frequencies of pain assessments performed were similar among the 2 groups. There was no difference in average pain scores between the groups at any time after LLDN. Patients receiving IV acetaminophen were found to have no improvements in hospital LOS, average pain score, or opioid requirements compared with patients not receiving IV acetaminophen. Patients who received IV acetaminophen were also found to have a higher 30-day readmission rate.

Comparison of the short-term efficacy of sequential treatment with intravesical single-port laparoscopic partial cystectomy with bladder preservation or open partial cystectomy in combination with cisplatin plus gemcitabine chemotherapy

PubMed Central

MAI, HAI-XING; LIU, JUN-LE; PEI, SHU-JUN; ZHAO, LI; QU, NAN; DONG, JIN-KAI; CHEN, BIAO; WANG, YA-LIN; HUANG, CHENG; CHEN, LI-JUN

2015-01-01

This study aimed to assess the short-term efficacy of sequential therapy for T2/T3a bladder cancer with intravesical single-port laparoscopic partial cystectomy or open partial cystectomy combined with cisplatin plus gemcitabine (GC) chemotherapy in a prospective randomized controlled study. Thirty patients with bladder cancer who underwent open partial cystectomy (group A) or single-port laparoscopic partial cystectomy (group B) and received standard GC chemotherapy were analyzed. Perioperative functional indicators and tumor recurrence during a 1-year postoperative follow-up were compared between the two groups. The baseline characteristics were comparable between the two groups. The mean operative time, amount of blood loss and duration of hospital stay were 90.3 min, 182.0 ml and 7.3 days, respectively, for group A, and 105.3 min, 49.3 ml and 5.8 days, respectively, for group B. No secondary postoperative bleeding, urine leakage, wound infection or other complications were observed in the two groups. Postoperative scarring was not evident in group B. The overall incidence of surgical complications, tumor recurrence rate and complications during chemotherapy in the postoperative follow-up period of 12 months were similar between the two groups. Single-port laparoscopic partial cystectomy surgery is an idea surgical method for the treatment of invasive bladder cancer, with good surgical effect, minimal invasiveness, rapid recovery and short hospital stay. The data from 1-year postoperative follow-up showed that laparoscopic surgery was superior with regard to perioperative bleeding, postoperative recovery and duration of indwelling urinary catheter use. However, regarding the tumor recurrence rate, long-term comparative details are required to determine the effect of laparoscopic surgery. PMID:26170915

Premalignant lesions in the kidney.

PubMed

Kirkali, Z; Yorukoglu, K

2001-12-07

Renal cell carcinoma (RCC) is the most malignant urologic disease. Different lesions, such as dysplasia in the tubules adjacent to RCC, atypical hyperplasia in the cyst epithelium of von Hippel-Lindau syndrome, and adenoma have been described for a number of years as possible premalignant changes or precursor lesions of RCC. In two recent papers, kidneys adjacent to RCC or removed from other causes were analyzed, and dysplastic lesions were identified and defined in detail. Currently renal intraepithelial neoplasia (RIN) is the proposed term for classification. The criteria for a lesion to be defined as premalignant are (1) morphological similarity; (2) spatial association; (3) development of microinvasive carcinoma; (4) higher frequency, severity, and extent then invasive carcinoma; (5) progression to invasive cancer; and (6) similar genetic alterations. RIN resembles the neoplastic cells of RCC. There is spatial association. Progression to invasive carcinoma is described in experimental cancer models, and in some human renal tumors. Similar molecular alterations are found in some putative premalignant changes. The treatment for RCC is radical or partial nephrectomy. Preneoplastic lesions may remain in the renal remnant in patients treated by partial nephrectomy and may be the source of local recurrences. RIN seems to be a biologic precursor of some RCCs and warrants further investigation. Interpretation and reporting of these lesions would reveal important resources for the biological nature and clinical significance. The management of RIN diagnosed in a renal biopsy and partial nephrectomy needs to be answered.

An Ultrasonic Clamp for Bloodless Partial Nephrectomy

NASA Astrophysics Data System (ADS)

Lafon, Cyril; Bouchoux, Guillaume; Murat, François Joseph; Birer, Alain; Theillère, Yves; Chapelon, Jean Yves; Cathignol, Dominique

2007-05-01

Maximum conservation of the kidney is preferable through partial nephrectomy for patients at risk of disease recurrence of renal cancers. Haemostatic tools are needed in order to achieve bloodless surgery and reduce post surgery morbidity. Two piezo-ceramic transducers operating at a frequency of 4 MHz were mounted on each arm of a clamp. When used for coagulation purposes, two transducers situated on opposite arms of the clamp were driven simultaneously. Heat delivery was optimized as each transducers mirrored back to targeted tissues the wave generated by the opposite transducer. Real-time treatment monitoring with an echo-based technique was also envisaged with this clamp. Therapy was periodically interrupted so one transducer could generate a pulse. The echo returning from the opposite transducer was treated. Coagulation necroses were obtained in vitro on substantial thicknesses (23-38mm) of pig liver over exposure durations ranging from 30s to 130s, and with acoustic intensities of less than 15W/cm2 per transducer. Both kidneys of two pigs were treated in vivo with the clamp (14.5W/cm2 for 90s), and the partial nephrectomies performed proved to be bloodless. In vitro and in vivo, wide transfixing lesions corresponded to an echo energy decrease superior to -10dB and parabolic form of the time of flight versus treatment time. In conclusion, this ultrasound clamp has proven to be an excellent mean for achieving monitored haemostasis in kidney.

Simulation-Based Laparoscopic Surgery Crisis Resource Management Training-Predicting Technical and Nontechnical Skills.

PubMed

Goldenberg, Mitchell G; Fok, Kai H; Ordon, Michael; Pace, Kenneth T; Lee, Jason Y

2017-12-19

To develop a unique simulation-based assessment using a laparoscopic inferior vena cava (IVC) injury scenario that allows for the safe assessment of urology resident's technical and nontechnical skills, and investigate the effect of personality traits performance in a surgical crisis. Urology residents from our institution were recruited to participate in a simulation-based training laparoscopic nephrectomy exercise. Residents completed demographic and multidimensional personality questionnaires and were instructed to play the role of staff urologist. A vasovagal response to pneumoperitoneum and an IVC injury event were scripted into the scenario. Technical and nontechnical skills were assessed by expert laparoscopic surgeons using validated tools (task checklist, GOALS, and NOTSS). Ten junior and five senior urology residents participated. Five residents were unable to complete the exercise safely. Senior residents outperformed juniors on technical (checklist score 15.1 vs 9.9, p < 0.01, GOALS score 18.0 vs 13.3, p < 0.01) and nontechnical performance (NOTSS score 13.8 vs 10.1, p = 0.03). Technical performance scores correlated with NOTSS scores (p < 0.01) and pass/fail rating correlated with technical performance (p < 0.01 for both checklist and GOALS), NOTSS score (p = 0.02), and blood loss (p < 0.01). Only the conscientiousness dimension of the big five inventory correlated with technical score (p = 0.03) and pass/fail rating (p = 0.04). Resident level of training and laparoscopic experience correlated with technical performance during a simulation-based laparoscopic IVC injury crisis management scenario, as well as multiple domains of nontechnical performance. Personality traits of our surgical residents are similar and did not predict technical skill. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Renal Vascular Clamp Placement: A Potential Cause of Incomplete Hilar Control during Partial Nephrectomy.

PubMed

Tryon, David; Myklak, Kristene; Alsyouf, Muhannad; Conceicao, Carol; Peplinski, Brandon; Arenas, Javier L; Faaborg, Daniel; Ruckle, Herbert C; Baldwin, D Duane

2016-03-01

Previous benchtop studies have shown that robotic bulldog clamps provide incomplete vascular control of a Penrose drain. We determined the efficacy of robotic and laparoscopic bulldog clamps to ensure hemostasis on the human renal artery. The effect of clamp position on vascular control was also examined. Fresh human cadaveric renal arteries were used to determine the leak point pressure of 7 bulldog clamps from a total of 3 manufacturers. Five trials were performed per clamp at 4 locations, including the fulcrum, proximal, middle and distal positions. Comparison was done using the Kruskal-Wallis test with p <0.05 considered significant. None of the bulldog clamps leaked at a pressure less than 215 mm Hg when applied at the proximal, middle or distal position. In general leak point pressure decreased as the artery was positioned more distal along the clamp. The exception was when the vessel was placed at the fulcrum position. At that position 80% to 100% of trials with the Klein laparoscopic, 100% with the Klein robotic (Klein Robotic, San Antonio, Texas) and 60% to 80% with the Scanlan robotic (Scanlan International, Saint Paul, Minnesota) clamp leaked at pressure below 215 mm Hg. Each vascular clamp adequately occluded flow at physiological pressure when placed at the proximal, middle or distal position. Furthermore, these results demonstrate that there is leakage at physiological pressure when the artery is placed at the fulcrum of certain clamp types. These results suggest that applying a bulldog clamp at the fulcrum could potentially lead to inadequate vessel occlusion and intraoperative bleeding. Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Impact of Renal Hilar Control on Outcomes of Robotic Partial Nephrectomy: Systematic Review and Cumulative Meta-analysis.

PubMed

Cacciamani, Giovanni E; Medina, Luis G; Gill, Tania S; Mendelsohn, Alec; Husain, Fatima; Bhardwaj, Lokesh; Artibani, Walter; Sotelo, Renè; Gill, Inderbir S

2018-02-05

During robotic partial nephrectomy (RPN), various techniques of hilar control have been described, including on-clamp, early unclamping, selective/super-selective clamping, and completely-unclamped RPN. To evaluate the impact of various hilar control techniques on perioperative, functional, and oncological outcomes of RPN for tumors. We conducted a systematic literature review and meta-analysis of all comparative studies on various hilar control techniques during RPN using PubMed, Scopus, and Web of Science according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement, and Methods and Guide for Effectiveness and Comparative Effectiveness Review of the Agency for Healthcare Research and Quality. Cumulative meta-analysis of comparative studies was conducted using Review Manager 5.3. Of 987 RPN publications in the literature, 19 qualified for this analysis. Comparison of off-clamp versus on-clamp RPN (n=9), selective clamping versus on-clamp RPN (n=3), super selective clamping versus on-clamp RPN (n=5), and early unclamped versus on-clamp (n=3) were reported. Patients undergoing RPN using off-clamp, selective/super selective, or early unclamp techniques had higher estimated blood loss compared with on-clamp RPN (weight mean difference [WMD]: 47.83, p=0.000, WMD: 41.06, p=0.02, and WMD: 37.50, p=0.47); however, this did not seem clinically relevant, since transfusion rates were similar (odds ratio [OR]: 0.98, p=0.95, OR: 0.72, p=0.7, and OR: 1.36, p=0.33, respectively). All groups appeared similar with regards to hospital stay, transfusions, overall and major complications, and positive cancer margin rates. Short- and long-term renal functional outcomes appeared superior in the off-clamp and super selective clamp groups compared with the on-clamp RPN cohort. Off-clamp, selective/super selective clamp, and early unclamp hilar control techniques are safe and feasible approaches for RPN surgery, with similar perioperative and oncological outcomes compared with on-clamp RPN. Minimizing global renal ischemia may provide superior renal function preservation. However, higher quality data are necessary for definitive conclusions in this regard. The objective of partial nephrectomy is to treat the cancer while maximizing renal function preservation. Clamping the main vessels is done primarily to reduce the blood loss during partial nephrectomy; however, vascular clamping can compromise kidney function. In order to avoid clamping, various techniques have been described. Our analysis showed that techniques that avoid main renal artery clamping during RPN are associated with better renal function preservation, yet deliver non-inferior perioperative and oncological outcomes as compared with robotic partial nephrectomy procedures that clamp the main vessels. Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Adjuvant Everolimus for Resected Kidney Cancer

Cancer.gov

In this clinical trial, patients with renal cell cancer who have undergone partial or complete nephrectomy will be randomly assigned to take everolimus tablets or matching placebo tablets daily for 54 weeks.

Surgery Videos: MedlinePlus

MedlinePlus Videos and Cool Tools

... 2009) Mitral Valve Prolapse Minimally Invasive Heart Surgery: Robot Assisted Mitral Valve Repair (Baptist Health South Florida, ... Center, Merriam, KS, 05/04/2012) Kidney Cancer Robot Assisted Partial Nephrectomy Using Fluorescence (Shawnee Mission Medical ...

Positive correlation between motion analysis data on the LapMentor virtual reality laparoscopic surgical simulator and the results from videotape assessment of real laparoscopic surgeries.

PubMed

Matsuda, Tadashi; McDougall, Elspeth M; Ono, Yoshinari; Hattori, Ryohei; Baba, Shiro; Iwamura, Masatsugu; Terachi, Toshiro; Naito, Seiji; Clayman, Ralph V

2012-11-01

We studied the construct validity of the LapMentor, a virtual reality laparoscopic surgical simulator, and the correlation between the data collected on the LapMentor and the results of video assessment of real laparoscopic surgeries. Ninety-two urologists were tested on basic skill tasks No. 3 (SK3) to No. 8 (SK8) on the LapMentor. They were divided into three groups: Group A (n=25) had no experience with laparoscopic surgeries as a chief surgeon; group B (n=33) had <35 experiences; and group C (n=34) had ≥35 experiences. Group scores on the accuracy, efficacy, and time of the tasks were compared. Forty physicians with ≥20 experiences supplied unedited videotapes showing a laparoscopic nephrectomy or an adrenalectomy in its entirety, and the videos were assessed in a blinded fashion by expert referees. Correlations between the videotape score (VS) and the performances on the LapMentor were analyzed. Group C showed significantly better outcomes than group A in the accuracy (SK5) (P=0.013), efficacy (SK8) (P=0.014), or speed (SKs 3 and 8) (P=0.009 and P=0.002, respectively) of the performances of LapMentor. Group B showed significantly better outcomes than group A in the speed and efficacy of the performances in SK8 (P=0.011 and P=0.029, respectively). Analyses of motion analysis data of LapMentor demonstrated that smooth and ideal movement of instruments is more important than speed of the movement of instruments to achieve accurate performances in each task. Multiple linear regression analysis indicated that the average score of the accuracy in SK4, 5, and 8 had significant positive correlation with VS (P=0.01). This study demonstrated the construct and predictive validity of the LapMentor basic skill tasks, supporting their possible usefulness for the preclinical evaluation of laparoscopic skills.

Comparison of Both Sides for Retroperitoneal Laparoscopic Donor Nephrectomy: Experience From a Single Center in China.

PubMed

Qiu, Y; Wang, X; Song, T; Rao, Z; Liu, J; Huang, Z; Lin, T

Laparoscopic donor nephrectomy (LDN) has gradually become the main approach to obtain live donor kidneys. However, the shorter right renal vein limits its wider application. The aim of this study was to compare the outcomes of left- and right-side retroperitoneal LDN. We reviewed the perioperative data of 527 consecutive donors receiving retroperitoneal pure LDN with a new method at our center between April 2009 and April 2014. The patients were divided into group A (the first 100 patients) and group B (the remaining 427 patients). A total of 423 cases of left donor surgery and 104 cases of right donor surgery were compared. The comparison of the laterality of LDN was also performed between group A and group B. This is currently the largest case series of LDN in our country. Although right-side LDN patients had longer operation time and a slightly higher incidence of intraoperative complications compared with left-side LDN patients, the operation time was shorter in both the groups compared with previous reports. In group B, patients undergoing right-side LDN had longer operation time and more frequent complications. Once the learning curve of 100 cases was completed, the incidence of complications and operation time were greatly reduced in both sides for LDN. There was no significant difference in the serum creatinine levels in recipients at 6 months of follow-up. Despite a slightly higher incidence of complications and longer operation time, right-side LDN can achieve equally safe and effective transplantation outcomes. This expands the source of potential donor kidneys. Copyright © 2017. Published by Elsevier Inc.

Surgical team composition has a major impact on effectiveness and costs in laparoscopic donor nephrectomy.

PubMed

Özdemir-van Brunschot, Denise M D; Warlé, Michiel C; van der Jagt, Michel F; Grutters, Janneke P C; van Horne, Sharon B C E; Kloke, Heinrich J; van der Vliet, Johannes A; Langenhuijsen, Johan F; d'Ancona, Frank C

2015-05-01

Limited evidence exists that optimization of surgical team composition may improve effectiveness of laparoscopic donor nephrectomy (LDN). A retrospective cohort study with 541 consecutive LDNs. From 2003 to 2012, surgical team composition was gradually optimized with regard to the surgeons' experience, proficient assistance and the use of fixed teams. Multivariable analysis showed that a surgical team with an experienced surgeon had a significantly shorter operation time (OT) (-18 min, 95% CI -28 to -9), less estimated blood loss (EBL) (-64 mL, 95% CI -108 to -19) and shorter length of stay (LOS) (-1 day, 95% CI -1.6 to 0). Proficient assistance was also independently associated with a shorter OT (-43 min, 95% CI -53 to -33) and reduced EBL (-58 mL, 95% CI -109 to -6), whereas those procedures performed by fixed teams were related to a shorter operation (-50 min, 95% CI -59 to -43) and warm ischemia time (-1.8, 95% CI -2.1 to -1.5), a reduced mean complication grade (-0.14 per patient, 95% CI -0.3 to -0.02) and a shorter LOS (-1.1 day, 95% CI -1.7 to -05). Health care costs for LDN by one staff surgeon with unproficient assistance were 7.707 Euro, whereas costs for LDN by two staff surgeons in fixed teams were 5.614 Euro. Surgical team composition has a major impact on variables that reflect the effectiveness of LDN from the donors' perspective. Health care costs are lower for LDNs performed by two experienced surgeons in fixed team composition. We advocate the use of two experienced surgeons in fixed team composition for LDN.

THE EFFECT OF TOTAL AND PARTIAL NEPHRECTOMY ON THE PHARMACOKINETICS OF INTRAVENOUS PARACETAMOL IN HUMANS.

PubMed

Karbownik, Agnieszka; Polom, Wojciech; Porazka, Joanna; Szalek, Edyta; Grabowski, Tomasz; Wolc, Anna; Matuszewski Marcin; Grzesowiak, Edmund

2017-05-01

Paracetamol is one of the most common analgesic and antipyretic drugs. Recently intravenous paracetamol has been widely used to treat moderate postoperative pain. Surgery is the main method of treatment of renal cancer. Total or partial nephrectomy can be performed, depending on the size and location of the tumor. Pharmacokinetics of drugs may depend on the type of surgery. The aim of the study was to compare the postinfusion pharmacokinetics of paracetamol in patients after total nephrectomy (TN) and nephron sparing surgery (NSS).The research was carried out on two groups of patients after nephrectomy: total (TN n = 37; mean [SD], age, 60.4 [10.9] years; BMI, 26.5 [3.8] kg/m2; creatinine clearance, Cl, 80.9 [37.1] mL/min) and nephron sparing surgery (NSS n = 17; 57.9 [16.5] years; BMI, 29.5 [5.3] kg/m2; Cl, 97.6 [27.8] mL/min). The patients were treated with paracetamol (PerfalganO Bristol-Myers Squibb) at an intravenous dose of 1.000 mg, which was infused for 15 minutes after surgery. The concentrations of paracetamol in the patients' plasma were determined by the HPLC method with UV detection (X = 261 run). The main pharmacokinetic parameters of paracetamol in the TN vs. NSS group were as follows: C.. 29.08 [17.39] vs. 27.54 [15.70] pg/mL (p = 0.6692); AUC5, 29.24 [13.86] vs. 34.85 [14.28] pg.h/mL (p = 0.2896); AUMC5,,,, 47.58 [26.08] vs. 62.02 [27.64] pg-h/mL (p = 0.1345); to. 2.34 [0.96] vs. 1.93 [0.50] h (p = 0.1415), respectively. In both groups the exposure to paracetamol was comparable. The t1/2 after nephron sparing surgery was shorter than after total nephrectomy. Therefore, these patients may demand more frequent drug administration. In the NSS group the C. of the analgesic was considerably reduced in men.

Upper urinary tract laparoendoscopic single-site surgery based on a novel cost-effective reusable platform.

PubMed

Schwentner, Christian; Todenhöfer, Tilman; Seibold, Joerg; Alloussi, Saladin H; Aufderklamm, Stefan; Mischinger, Johannes; Germann, Miriam; Stenzl, Arnulf; Gakis, Georgios

2013-02-01

Several disposable platforms have been introduced for laparoendoscopic single-site (LESS) surgery. Besides technical issues, cost is one of the main limiting factors for their widespread use. We present our experience with LESS surgery for kidney pathologies using the first completely reusable LESS platform. We performed LESS kidney procedures in 29 patients including nephrectomy (18), partial nephrectomy (3), pyeloplasty (4), and renal cyst ablation (4). All procedures were performed using a completely reusable single-port device (X-Cone) with a simplified combination of standard and prebent instruments. We obtained perioperative and demographic data including a visual analog pain scale (VAS); complications were recorded using Clavien grading. Mean patient age was 49.31 years. Conversion to standard laparoscopy was necessary in one and addition of a needlescopic instrument in four cases. No open conversion was necessary. Intra- and postoperative complications occurred in two (Clavien II) cases. Mean operative time was 110, 90, and 89 minutes, and hospital stay was 4.9, 3.1, and 3.6 days for nephrectomy, partial nephrectomy, and pyeloplasty, respectively. Mean VAS was 2.13, 1.67, and 1.5 while blood loss was 81.3 mL, 140 mL, and 17.5 mL, respectively. There were no positive resection margins. LESS with a completely reusable platform is feasible for different upper urinary tract procedures yielding favorable functional and cosmetic results. A simplified combination of standard straight instruments and a single prebent grasper facilitates handling and shortens the learning curve. Reusable materials significantly reduce cost and may help to further adopt LESS surgery in surgical practice.

Damage-control laparoscopic partial cholecystectomy with an endoscopic linear stapler.

PubMed

Özçınar, Beyza; Memişoğlu, Ecem; Gök, Ali Fuat Kaan; Ağcaoğlu, Orhan; Yanar, Fatih; İlhan, Mehmet; Yanar, Hakan Teoman; Günay, Kayıhan

2017-01-01

Several damage-control procedures have been described in the literature in case of severe Calot's triangle inflammation and fibrosis. In this report, we describe patients who underwent laparoscopic partial cholecystectomy using an endoscopic linear stapler. Five patients with acute cholecystitis underwent laparoscopic partial cholecystectomy in our clinic between January - December 2011. All patients had severe fibrosis and inflammation of Calot's triangle. The anterior and posterior walls of the gallbladder were totally resected if possible. The gallbladder was transected at its neck or Hartmann's pouch, leaving a remnant gallbladder pouch behind. Five patients had laparoscopic partial cholecystectomy with an endoscopic linear stapler. The main symptom of all patients on admission to the emergency room was abdominal pain. The mean time for the surgical procedure was 140 minutes (range, 120-180 minutes). Inflammation and fibrosis of Calot's triangle was detected in all patients during surgery and a phlegmonous gallbladder was detected in one patient. Surgical drains were used in all patients and no biliary leakage was detected. Remnant common bile duct calculi were detected in one patient and this patient underwent endoscopic retrograde cholangiopancreatography one month after surgery. When a reliable view of Calot's triangle cannot be obtained due to severe inflammation and fibrosis during laparoscopy, laparoscopic partial cholecystectomy seems to be a safe and feasible alternative to open surgery with an acceptable morbidity rate.

Laparoscopic repair of indirect inguinal hernia in children: does partial resection of the sac make any impact on outcome?

PubMed

Borkar, Nitinkumar B; Pant, Nitin; Ratan, Simmi; Aggarwal, Satish K

2012-04-01

To test the hypothesis that during laparoscopic hernia repair, partial resection of the distal sac along with suture ligation of the neck is better than simple transection and ligation. The following two techniques of laparoscopic hernia repair were compared: Group I, circumferential incision of peritoneum at the deep ring and partial resection of the distal sac and suture ligation at the neck; versus Group II, circumferential incision of the peritoneum at the deep ring and suture ligation at the neck. Twenty-five cases of inguinal hernia were randomly selected in each group between the age group of 6 months to 12 years. The outcome measures were recurrence, intra- or postoperative complications, and time taken for surgery. There were no recurrences in either group. Other parameters for comparison were also not statistically different between the two groups. There was no conversion. Although partial resection of the sac has been an essential step in open hernia repair over five decades, its value has been questioned by our study, because omitting this step during laparoscopic repair has not adversely affected the outcomes. Partial resection of the sac is not a necessary component of hernia repair. It is a technical necessity of the open approach. Therefore, omitting this step in laparoscopic repair does not adversely affect the outcome.

Hand-assisted laparoscopic radical nephrectomy in the treatment of a renal cell carcinoma with a level II vena cava thrombus.

PubMed

Kovac, Jason R; Luke, Patrick P

2010-01-01

Excision of renal cell carcinoma (RCC) with corresponding vena cava thrombus is a technical challenge requiring open resection and vascular clamping. A 58 year old male with a right kidney tumor presented with a thrombus extending 1 cm into the vena cava. Using a hand-assisted transperitoneal approach through a 7 cm gel-port, the right kidney was dissected and the multiple vascular collaterals supplying the tumor were identified and isolated. The inferior vena cava was mobilized 4 cm cephalad and 4 cm caudal to the right renal vein. Lateral manual traction was applied to the right kidney allowing the tumor thrombus to be retracted into the renal vein, clear of the vena cava. After laparoscopic ultrasonographic confirmation of the location of the tip of the tumor thrombus, an articulating laparoscopic vascular stapler was used to staple the vena cava at the ostium of the right renal vein. This allowed removal of the tumor thrombus without the need for a Satinsky clamp. The surgery was completed in 243 minutes with no intra-operative complications. The entire kidney and tumor thrombus was removed with negative surgical margins. Estimated blood loss was 300 cc. We present a laparoscopic resection of a renal mass with associated level II thrombus using a hand-assisted approach. In patients with minimal caval involvement, our surgical approach presents an option to the traditional open resection of a renal mass.

Laparoscopic Heller myotomy with or without partial fundoplication: A matter of debate

PubMed Central

Ramacciato, G; D’Angelo, FA; Aurello, P; Gaudio, M Del; Varotti, G; Mercantini, P; Bellagamba, R; Ercolani, G

2005-01-01

AIM: To present our experience of laparoscopic Heller stretching myotomy followed by His angle reconstruction as surgical approach to esophageal achalasia. METHODS: Thirty-two patients underwent laparoscopic Heller myotomy; an anterior partial fundoplication in 17, and angle of His reconstruction in 15 cases represented the antireflux procedure of choice. RESULTS: There were no morbidity and mortality recorded in both anterior funduplication and angle of His reconstruction groups. No differences were detected in terms of recurrent dysphagia, p.o. reflux or medical therapy. CONCLUSION: To reduce the incidence of recurrent achalasia after laparoscopic Heller myotomy, we believe that His’ angle reconstruction is a safe and effective alternative to the anterior fundoplication. PMID:15770738

Cost-Benefit Performance Simulation of Robot-Assisted Thoracic Surgery As Required for Financial Viability under the 2016 Revised Reimbursement Paradigm of the Japanese National Health Insurance System.

PubMed

Kajiwara, Naohiro; Kato, Yasufumi; Hagiwara, Masaru; Kakihana, Masatoshi; Ohira, Tatsuo; Kawate, Norihiko; Ikeda, Norihiko

2018-04-20

To discuss the cost-benefit performance (CBP) and establish a medical fee system for robotic-assisted thoracic surgery (RATS) under the Japanese National Health Insurance System (JNHIS), which is a system not yet firmly established. All management steps for RATS are identical, such as preoperative and postoperative management. This study examines the CBP based on medical fees of RATS under the JNHIS introduced in 2016. Robotic-assisted laparoscopic prostatectomy (RALP) and robotic-assisted partial nephrectomy (RAPN) now receive insurance reimbursement under the category of use of support devices for endoscopic surgery ($5420 and $3485, respectively). If the same standard amount were to be applied to RATS, institutions would need to perform at least 150 or 300 procedures thoracic operation per year to show a positive CBP ($317 per procedure as same of RALP and $130 per procedure as same of RAPN, respectively). Robotic surgery in some areas receives insurance reimbursement for its "supportive" use for endoscopic surgery as for RALP and RAPN. However, at present, it is necessary to perform da Vinci Surgical System Si (dVSi) surgery at least 150-300 times in a year in a given institution to prevent a deficit in income.

Hilar Parenchymal Oversew: a novel technique for robotic partial nephrectomy hilar tumor renorrhaphy.

PubMed

Chavali, Jaya Sai S; Nelson, Ryan; Maurice, Matthew J; Kara, Onder; Mouracade, Pascal; Dagenais, Julien; Reese, Jeremy; Bayona, Pilar; Haber, Georges-Pascal; Stein, Robert J

2018-01-01

A renorrhaphy technique which is effective for hemostasis but does not place undue tension on the branch vessels of the renal sinus remains one of the challenging steps after hilar tumor resection during robotic partial nephrectomy (RPN). The published V-hilar suture (VHS) technique is one option for reconstruction after an RPN involving the hilum. The objective of this video is to show a novel renorrhaphy technique, Hilar Parenchymal Oversew that has been effective for such cases. We present two cases of RPN for renal hilar tumors. The first case depicts use of the VHS renorrhaphy technique for a tumor that abuts the renal hilum along 20% of its diameter. The second case demonstrates tumor resection and reconstruction for a tumor that has >50% involvement of the hilum along its diameter. After tumor resection, individual sinus vessels can be selectively oversewn with 2-0 Vicryl suture on SH needle. The remaining exposed parenchyma is controlled using the Hilar Parenchymal Oversew technique with a #0 Vicryl on CT-1 needle. For the Hilar Parenchymal Oversew surgery operative time was 225 min, estimated blood loss was 140 ml, warm ischemia time was 19 minutes, and there were no intraoperative complications. Pathology was consistent with clear cell renal cancer with negative margins. Robotic partial nephrectomy with the Hilar Parenchymal Oversew technique is a good alternative to VHS renorrhaphy in the management of renal hilar tumors "bulging" into the renal sinus with >50% of the tumor diameter abutting the hilum. Copyright® by the International Brazilian Journal of Urology.

Integrating robotic partial nephrectomy to an existing robotic surgery program.

PubMed

Yuh, Bertram; Muldrew, Shantel; Menchaca, Anita; Yip, Wesley; Lau, Clayton; Wilson, Timothy; Josephson, David

2012-04-01

As more centers develop robotic proficiency, progressing to a successful robot-assisted partial nephrectomy (RAPN) program depends on a number of factors. We describe our technique, results, and analysis of program setup for RAPN. Between 2005 and 2011, 92 RAPNs were performed following maturation of a robotic prostatectomy program. Operating rooms and supply rooms were outfitted for efficient robotic throughput. Tilepro and intraoperative ultrasound were used for all cases. Training and experiential learning for surgeons, anesthesia and nursing staff was a high priority. An onsite robotic technician helped troubleshoot, prepare the room and staff prior to starting surgery, and provide assistance with different robotic models. Average operative time decreased over time from 235 min to 199 min (p = .03). Warm ischemia time decreased from 26 minutes to 23 minutes (p = .02) despite an increased complexity of tumors and operations on multiple tumors. Median estimated blood loss was 150 mL. Average length of hospital stay was 3 days (range 1-9). Average size of lesions was 2.7 cm (range 0.7-8.6). Final pathology demonstrated 71 (77%) malignant lesions and 21 (23%) benign lesions. The addition of a robot-assisted partial nephrectomy program to an institutional robotic program can be coordinated with several key steps. Outcomes from an operational, oncologic, and renal functional standpoint are acceptable. Despite increased complexity of tumors and treatment of multiple lesions, operative and warm ischemia times showed a decrease over time. An organizational model that involves the surgeons, anesthesia, nursing staff, and possibly a robotic technical specialist helps to overcome the learning curve.

Positive Correlation Between Motion Analysis Data on the LapMentor Virtual Reality Laparoscopic Surgical Simulator and the Results from Videotape Assessment of Real Laparoscopic Surgeries

PubMed Central

McDougall, Elspeth M.; Ono, Yoshinari; Hattori, Ryohei; Baba, Shiro; Iwamura, Masatsugu; Terachi, Toshiro; Naito, Seiji; Clayman, Ralph V.

2012-01-01

Abstract Purpose We studied the construct validity of the LapMentor, a virtual reality laparoscopic surgical simulator, and the correlation between the data collected on the LapMentor and the results of video assessment of real laparoscopic surgeries. Materials and Methods Ninety-two urologists were tested on basic skill tasks No. 3 (SK3) to No. 8 (SK8) on the LapMentor. They were divided into three groups: Group A (n=25) had no experience with laparoscopic surgeries as a chief surgeon; group B (n=33) had <35 experiences; and group C (n=34) had ≥35 experiences. Group scores on the accuracy, efficacy, and time of the tasks were compared. Forty physicians with ≥20 experiences supplied unedited videotapes showing a laparoscopic nephrectomy or an adrenalectomy in its entirety, and the videos were assessed in a blinded fashion by expert referees. Correlations between the videotape score (VS) and the performances on the LapMentor were analyzed. Results Group C showed significantly better outcomes than group A in the accuracy (SK5) (P=0.013), efficacy (SK8) (P=0.014), or speed (SKs 3 and 8) (P=0.009 and P=0.002, respectively) of the performances of LapMentor. Group B showed significantly better outcomes than group A in the speed and efficacy of the performances in SK8 (P=0.011 and P=0.029, respectively). Analyses of motion analysis data of LapMentor demonstrated that smooth and ideal movement of instruments is more important than speed of the movement of instruments to achieve accurate performances in each task. Multiple linear regression analysis indicated that the average score of the accuracy in SK4, 5, and 8 had significant positive correlation with VS (P=0.01). Conclusions This study demonstrated the construct and predictive validity of the LapMentor basic skill tasks, supporting their possible usefulness for the preclinical evaluation of laparoscopic skills. PMID:22642549

Nephron sparing by partial median nephrectomy for treatment of renal hemangioma in a dog.

PubMed

Mott, J C; McAnulty, J F; Darien, D L; Steinberg, H

1996-04-15

A 6-year-old neutered male Golden Retriever was admitted for evaluation of intermittent hematuria of 2 months' duration. A 3-cm heterogeneous mass causing distortion of the caudomedial aspect of the left kidney was detected via ultrasonography. Histologic examination of a renal tissue sample obtained by ultrasound-guided biopsy revealed a telangiectatic vascular plexus of unknown origin. Low glomerular filtration rate was identified by a modified exogenous creatinine clearance test. Excretory urography revealed a filling defect in the medial aspect of the caudal pole of the kidney, near the hilus. Because total renal function was low, a decision was made to perform nephron-sparing surgery involving resection of centrally located renal parenchymal and pelvic tissue by en bloc resection in the median plane, instead of radical nephrectomy. After surgery, the hematuria resolved and further decrease in renal function was not evident. Nephron-sparing surgery is a viable option for dogs with compromised renal function when there is concern that radical nephrectomy may precipitate uremia.

Delayed anastomotic leakage following laparoscopic intersphincteric resection for lower rectal cancer: report of four cases and literature review.

PubMed

Iwamoto, Masayoshi; Kawada, Kenji; Hida, Koya; Hasegawa, Suguru; Sakai, Yoshiharu

2017-08-01

Anastomotic leakage (AL) is one of the most dreadful postoperative complications because it can result in increased morbidity and mortality as well as poorer long-term prognosis. Although most studies of AL limited their investigation time to a period of 30 days postoperatively, only a few studies have shown that AL can occur after that period. Here, we report four patients of rectal cancer with delayed AL following laparoscopic intersphincteric resection (ISR) and conduct a literature review on delayed AL. Case 1 was a 67-year-old male who underwent laparoscopic partial ISR in July 2009. Although the patient was asymptomatic, an anastomotic-urethral fistula was observed 57 months after ISR. Case 2 was a 44-year-old female who underwent laparoscopic partial ISR in July 2008. She presented with discharge of gas and feces from her vagina, and an anastomotic-vaginal fistula was observed 14 months after ISR. Case 3 was a 74-year-old man who underwent laparoscopic partial ISR in August 2007. He presented with pneumaturia and fecaluria, and an anastomotic-urethral fistula was observed 4 months after ISR. Case 4 was a 68-year-old woman who underwent laparoscopic subtotal ISR for rectal cancer in February 2013 and partial hepatic resection for liver metastases in March 2013. She presented with anal pain and purulent perineal discharge, and an anastomotic-perineal fistula was observed 9 months after ISR. All four cases presented with fistula formation and required reoperation (establishment of a diverting ileostomy). Since delayed AL is not a rare postoperative complication, surgeons need to provide long-term follow-up and remain alert to the possible development of delayed AL.

Benign lesions after partial nephrectomy for presumed renal cell carcinoma in masses 4 cm or less: prevalence and predictors in Korean patients.

PubMed

Jeon, Hwang Gyun; Lee, Seung Ryeol; Kim, Kwang Hyun; Oh, Young Taik; Cho, Nam Hoon; Rha, Koon Ho; Yang, Seung Choul; Han, Woong Kyu

2010-09-01

To investigate the prevalence and predictors associated with benign lesions in Korean patients after partial nephrectomy for presumed renal cell carcinoma (RCC) for lesions measuring ≤ 4 cm. We retrospectively investigated the medical records of 376 patients who underwent partial nephrectomy for presumed RCC with renal masses of size ≤ 4 cm between June 1997 and December 2008. Demographic and clinicopathologic parameters were compared between benign lesions and RCC. Logistic regression was done to identify parameters associated with benign lesions. In the 376 patients, 81 tumors (21.5%) were benign, including 35 angiomyolipomas (9.3%), 26 complicated cysts (6.9%), 11 oncocytomas (2.9%), and 9 others (2.4%). Univariate analysis showed that time of surgery, female sex, younger age, and normal body mass index (body mass index (BMI) < 23 kg/m(2)) were associated with benign pathologic findings. On multiple logistic regression analysis, female sex (OR, 4.91; 95% CI, 2.76-08.75; P < .001), age (OR, 0.97; 95% CI, 0.95-0.99; P = .009), and time of surgery (OR, 0.33; 95% CI, 0.11-0.95; P = .040) were independent predictors of benign histologic features. Tumor size, incidental diagnosis, and BMI were not significant predictors (P > .05). Our study with a large cohort of Asian patients showed that the prevalence of benign lesions was similar to previously reported Western studies. However, the most common benign lesion was angiomyolipoma, compared with oncocytoma in Western countries. The results of this study may help clinicians counsel female and younger patients recently diagnosed with small renal masses and decide the most appropriate treatment, including renal biopsies and close observation. Copyright © 2010 Elsevier Inc. All rights reserved.

Anatomic comparison of traditional and enucleation partial nephrectomy specimens.

PubMed

Calaway, Adam C; Gondim, Dibson D; Flack, Chandra K; Jacob, Joseph M; Idrees, Muhammad T; Boris, Ronald S

2017-05-01

To compare pseudocapsule (PC) properties of clear cell renal cell carcinoma tumors removed via both traditional partial nephrectomy (PNx) and enucleative techniques as well as quantify the difference in volume of normal renal parenchyma removed between groups. A retrospective review of clear cell PNx specimens between 2011 and 2014 was performed. All patients undergoing tumor enucleation (TE) were included. A single pathologist reviewed the pathological specimens. This cohort was compared with a previously collected clear cell traditional PNx database. A total of 47 clear cell partial nephrectomies were reviewed (34 PNx and 13 TE). Invasion of tumor completely through the PC and positive surgical margins were seen in 2 (5.8%) and 1 (7.7%) of traditional and TE specimens, respectively (P = 0.82). PC mean (0.63 vs. 0.52mm), maximum (1.39 vs. 1.65mm), and minimum thickness (0.27 vs. 0.19mm) were similar between cohorts (P = 0.29, P = 0.36, and P = 0.44). Gross specimen volume varied considerably between the 2 groups (35.6 vs. 17.9cm 3 , P≤0.05) although tumor volume did not (12 vs. 14.2cm 3 , P = 0.64). The renal tumor consisted of only 37% of the total volume of the traditional PNx specimens compared to 80% of the volume in TEs (P<0.01). Four TE specimens (31%) were "true" TEs (no additional parenchyma identified outside of the PC). PC properties appear independent of surgical technique. True TEs are uncommon. Regardless, there is considerable volume discrepancy of normal renal parenchymal removed between enucleative and nonenucleative PNx groups. Copyright © 2017 Elsevier Inc. All rights reserved.

Early impact of robot-assisted partial nephrectomy on renal function as assessed by renal scintigraphy.

PubMed

Luciani, Lorenzo G; Chiodini, Stefano; Donner, Davide; Cai, Tommaso; Vattovani, Valentino; Tiscione, Daniele; Giusti, Guido; Proietti, Silvia; Chierichetti, Franca; Malossini, Gianni

2016-06-01

To measure the early impact of robot-assisted partial nephrectomy (RAPN) on renal function as assessed by renal scan (Tc 99m-DTPA), addressing the issue of risk factors for ischemic damage to the kidney. All patients undergoing RAPN for cT1 renal masses between June 2013 and May 2014 were included in this prospective study. Renal function as expressed by glomerular filtration rate (GFR) was assessed by Technetium 99m-diethylenetriaminepentaacetic acid (Tc 99m-DTPA) renal scan preoperatively and postoperatively at 1 month in every patient. A multivariable analysis was used for the determination of independent factors predictive of GFR decrease of the operated kidney. Overall, 32 patients underwent RAPN in the time interval. Median tumor size, blood loss, and ischemia time were 4 cm, 200 mL, and 24 min, respectively. Two grade III complications occurred (postoperative bleeding in the renal fossa, urinoma). The GFR of the operated kidney decreased significantly from 51.7 ± 15.1 mL/min per 1.73 m(2) preoperatively to 40, 12 ± 12.4 mL/min per 1.73 m(2) 1 month postoperatively (p = 0.001) with a decrease of 22.4 %. On multivariable analysis, only tumor size (p = 0.05) was a predictor of GFR decrease of the operated kidney. Robotic-assisted partial nephrectomy had a detectable impact on early renal function in a series of relatively large tumors and prevailing intermediate nephrometric risk. A mean decrease of 22 % of GFR as assessed by renal scan in the operated kidney was found at 1 month postoperatively. In multivariable analysis, tumor size only was a significant predictor of renal function loss.

3D-printed soft-tissue physical models of renal malignancies for individualized surgical simulation: a feasibility study.

PubMed

Maddox, Michael M; Feibus, Allison; Liu, James; Wang, Julie; Thomas, Raju; Silberstein, Jonathan L

2018-03-01

To construct patient-specific physical three-dimensional (3D) models of renal units with materials that approximates the properties of renal tissue to allow pre-operative and robotic training surgical simulation, 3D physical kidney models were created (3DSystems, Rock Hill, SC) using computerized tomography to segment structures of interest (parenchyma, vasculature, collection system, and tumor). Images were converted to a 3D surface mesh file for fabrication using a multi-jet 3D printer. A novel construction technique was employed to approximate normal renal tissue texture, printers selectively deposited photopolymer material forming the outer shell of the kidney, and subsequently, an agarose gel solution was injected into the inner cavity recreating the spongier renal parenchyma. We constructed seven models of renal units with suspected malignancies. Partial nephrectomy and renorrhaphy were performed on each of the replicas. Subsequently all patients successfully underwent robotic partial nephrectomy. Average tumor diameter was 4.4 cm, warm ischemia time was 25 min, RENAL nephrometry score was 7.4, and surgical margins were negative. A comparison was made between the seven cases and the Tulane Urology prospectively maintained robotic partial nephrectomy database. Patients with surgical models had larger tumors, higher nephrometry score, longer warm ischemic time, fewer positive surgical margins, shorter hospitalization, and fewer post-operative complications; however, the only significant finding was lower estimated blood loss (186 cc vs 236; p = 0.01). In this feasibility study, pre-operative resectable physical 3D models can be constructed and used as patient-specific surgical simulation tools; further study will need to demonstrate if this results in improvement of surgical outcomes and robotic simulation education.

A New Sliding-Loop Technique in Renorrhaphy for Partial Nephrectomy: A Feasibility Study in a Porcine Model.

PubMed

Lee, Jung Keun; Oh, Jong Jin; Lee, Sangchul; Lee, Seung Bae; Byun, Seok-Soo; Lee, Sang Eun; Jeong, Chang Wook

2016-04-01

We developed a sliding-loop technique that narrowed both sides of the parenchyma in a porcine model and compared it with the conventional sliding-clip technique. Three pigs (30-40 kg) were reused following another experiment conducted by the same researchers. Bilateral kidneys were harvested within 30 minutes after euthanasia. Two partial nephrectomies per kidney were performed on opposite surfaces. All kidney defects were of the same size (diameter of 2.5-3 cm with a depth of 1.0-1.5 cm). The sliding-clip technique and sliding-loop technique were performed separately. In the sliding-loop technique, we created a 1-cm loop at the end of a Vicryl and placed a tetrafluoroethylene polymer pledget in front of the knots passing through the needle. The needle then crossed the loop after passing through the renal parenchyma. A Weck clip was placed and slid on one side to tighten the suture. Tightening was controlled with an equivalent force using a digital push-pull gauge. Three stitches were placed at each renorrhaphy site. The distance between repaired renal surfaces was measured at 5 different points (3 suture sites and 2 middle sites between sutures). The results of the 2 techniques were compared by using the independent t test. The mean distance between renal surfaces was significantly narrower in the sliding-loop technique than in the conventional technique (1.80 ± 1.08 mm vs 5.28 ± 2.46 mm, P < .001). In the porcine model, the sliding-loop technique more effectively closed the partial nephrectomy defects compared with the conventional sliding-clip technique. © The Author(s) 2015.

Randomized clinical trial of 270° posterior versus 180° anterior partial laparoscopic fundoplication for gastro-oesophageal reflux disease.

PubMed

Roks, D J; Koetje, J H; Oor, J E; Broeders, J A; Nieuwenhuijs, V B; Hazebroek, E J

2017-06-01

Partial fundoplications provide similar reflux control with fewer post-fundoplication symptoms compared with Nissen fundoplication for gastro-oesophageal reflux disease (GORD). The best choice of procedure for partial fundoplication remains unclear. The aim of this study was to compare the outcome of two different types of partial fundoplication for GORD. A double-blind RCT was conducted between 2012 and 2015 in two hospitals specializing in antireflux surgery. Patients were randomized to undergo either a laparoscopic 270° posterior fundoplication (Toupet) or a laparoscopic 180° anterior fundoplication. The primary outcome was postoperative dysphagia at 12 months, measured by the Dakkak score. Subjective outcome was analysed at 1, 3, 6 and 12 months after surgery. Objective reflux control was assessed before and 6 months after surgery. Ninety-four patients were randomized to laparoscopic Toupet or laparoscopic 180° anterior fundoplication (47 in each group). At 12 months, 85 patients (90 per cent) were available for follow-up. Objective scores were available for 76 (81 per cent). Postoperative Dakkak dysphagia score at 12 months was similar in the two groups (mean 5·9 for Toupet versus 6·4 for anterior fundoplication; P = 0·773). Subjective outcome at 12 months demonstrated no significant differences in control of reflux or post-fundoplication symptoms. Overall satisfaction and willingness to undergo surgery did not differ between the groups. Postoperative endoscopy and 24-h pH monitoring showed no significant differences in mean oesophageal acid exposure time or recurrent pathological oesophageal acid exposure. Both types of partial fundoplication provided similar control of GORD at 12 months, with no difference in post-fundoplication symptoms. Registration number: NTR5702 (www.trialregister.nl). © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.

Effectiveness of green tea tannin on rats with chronic renal failure.

PubMed

Yokozawa, T; Chung, H Y; He, L Q; Oura, H

1996-06-01

The effects of green tea tannin on nephrectomized rats were examined. There were increases in blood urea nitrogen, serum creatinine, and urinary protein, and a decrease in creatinine clearance in the nephrectomized control rats, whereas better results for these parameters were obtained in rats given green tea tannin after nephrectomy, demonstrating a suppressed progression of the renal failure. When the renal parenchyma was partially resected, the remnant kidney showed a decrease in the activity of radical scavenger enzymes. Green tea tannin, however, was found to lighten the kidney under such oxidative stress. Mesangial proliferation and glomerular sclerotic lesions, which were conspicuous in the rats that were not given green tea tannin after nephrectomy, were also relieved.

Hilar Renal Artery Aneurysm - Ex-vivo Reconstruction and Autotransplantation.

PubMed

Pinto Sousa, Pedro; Veiga, Carlos; Matos, Arlindo; Sá Pinto, Pedro; Almeida, Rui

2017-01-01

Renal artery aneurysm (RAA) is a rare clinical entity with an estimated prevalence of 0.15% to 0.1%in the general population. The majority of patients present asymptomatically and the diagnosis is made incidentally during a hypertension study test, and more rarely, fortuitously after backache. Indications to treat have been subject of intense debate, nevertheless there seems to be some consensus that RAAs greater than 2 cm in diameter, expanding RAA, with thrombus or in pregnant women should be treated. Treatment options vary between surgical or endovascular approach. The complex (hilar) RAA constitute a subset of RAA that present a therapeutic dilemma because of their anatomic location and may require extracorporeal arterial reconstruction and auto-transplantation. We describe a 71-year-old woman with a personal history of hypertension for more than twenty years but normal renal function. Following the study for an abdominal discomfort a complex RAA was incidentally diagnosed. Computed tomographic angiography with three-dimensional reconstruction revealed a 13mm, saccular aneurysm located at the right renal hilum. We performed hand-assisted laparoscopic nephrectomy with ex vivo repair of the RAA. The aneurysm was resected and a polar renal artery was implanted over the resected area with a latero-terminal anastomosis. Complementarily, the renal vein was augmented with a spiral great saphenous vein graft and finally the kidney was implanted into the right iliac fossa. The intervention and postoperative course were uneventful and the patient submitted to ultrasound evaluation on the day after procedure. It revealed normal renal perfusion with normal flow indices. In the last follow-up realized, two months after surgery the patient was alive with a well-functioning auto-transplant. RAA may be nowadays more frequently diagnosed due to the increasing use of imaging techniques. While renal artery trunk aneurysms are most often treated using an endovascular procedure it is not suitable for renal artery branch aneurysms. Hand-assisted laparoscopic nephrectomy with ex vivo repair and auto-transplantation is a challenging but feasible option for treating hilum RAA.

Treatment of patients with metastatic renal cell carcinoma undergoing hemodialysis: case report of two patients and short literature review

PubMed Central

2013-01-01

Background Renal cell carcinoma (RCC) may involve both kidneys. When bilateral nephrectomy is necessary renal replacement therapy is mandatory. Treating such patients with sequential therapy based on cytokines, antiangiogenic factors and mammalian target of rapamycin (mTOR) inhibitors is challenging. Case presentation The first case, a 50-year-old Caucasian female, underwent a radical right nephrectomy for RCC. Twelve years later she underwent a radical left nephrectomy along with total hysterectomy including bilateral salpingo-oophorectomy for RCC involving the right kidney and ovary. Hemodialysis was necessary because of bilateral nephrectomy. She relapsed with pulmonary metastases and enlarged mediastinal lymph nodes and received cytokine based therapy along with bevacizumab. Therapy was discontinued despite the partial response because of hemorrhagic gastritis. Therapy was switched to an antiangiogenic factor but the patient manifested a parietal brain hematoma and stopped therapy. Subsequently disease relapsed with malignant pleural effusion and pulmonary nodules and a mammalian target of rapamycin inhibitor was administered which was withdrawn only at patient’s deteriorating performance status. The patient died of the disease 13 years after the initial diagnosis of RCC. The second case, a 51-year-old, Caucasian male, underwent a radical right nephrectomy for a chromophobe RCC. Six months later he underwent a radical left nephrectomy for RCC that proved to be a clear cell RCC. Due to bilateral nephrectomy hemodialysis was obligatory. Following disease recurrence at the anatomical bed of the right kidney therapy with antiangiogenic factor was administered which led to disease regression. However the patient experienced a left temporal-occipital brain hematoma. A radical excision of the recurrence which histologically proved to be a chromophobe RCC was not achieved and the patient received mTOR inhibitor which led to disease complete response. Nine years after the initial diagnosis of RCC he is disease free and leads an active life. Conclusion Patients with RCC are in significant risk to manifest bilateral disease. Renal insufficiency requiring hemodialysis poses therapeutic challenges. Clinicians must be aware of the antiangiogenic factors’ adverse effects, especially bleeding, that may manifest in higher frequency and more severe in this setting. PMID:23587009

Learning curve of robot-assisted laparoscopic radical prostatectomy for a single experienced surgeon: comparison with simultaneous laparoscopic radical prostatectomy.

PubMed

Ku, Ja Yoon; Ha, Hong Koo

2015-04-01

Despite the large number of analytical reports regarding the learning curve in the transition from open to robot-assisted radical prostatectomy (RARP), few comparative results with laparoscopic radical prostatectomy (LRP) have been reported. Thus, we evaluated operative and postoperative outcomes in RARP versus 100 simultaneously performed LRPs. A single surgeon had performed more than 1,000 laparoscopic operations, including 415 cases of radical nephrectomy, 85 radical cystectomies, 369 radical prostatectomies, and treatment of 212 other urological tumors, since 2009. We evaluated operative (operation time, intraoperative transfusion, complications, hospital stay, margin status, pathological stage, Gleason score) and postoperative (continence and erectile function) parameters in initial cases of RARP without tutoring compared with 100 recently performed LRPs. Mean operation time and length of hospital stay for RARP and LRP were 145.5±43.6 minutes and 118.1±39.1 minutes, and 6.4±0.9 days and 6.6±1.1 days, respectively (p=0.003 and p=0.721). After 17 cases, the mean operation time for RARP was similar to LRP (less than 2 hours). Positive surgical margins in localized cancer were seen in 11.1% and 8.9% of cases in RARP and LRP, respectively (p=0.733). At postoperative 3 months, sexual intercourse was reported in 14.0% and 12.0%, and pad-free continence in 96.0% and 81.0% in patients with RARP and LRP, respectively (p=0.796 and p=0.012). Previous large-volume experience of LRPs may shorten the learning curve for RARP in terms of oncological outcome. Additionally, previous experience with laparoscopy may improve the functional outcomes of RARP.

The Management of Synchronous Bilateral Wilms Tumor: A Report from the National Wilms Tumor Study Group

PubMed Central

Hamilton, Thomas E.; Ritchey, Michael L.; Haase, Gerald M.; Argani, Pedram; Peterson, Susan M.; Anderson, James R.; Green, Daniel M.; Shamberger, Robert C.

2013-01-01

Objective To provide guidelines for future trials, we reviewed the outcomes of children with synchronous bilateral Wilms tumors (BWT) treated on National Wilms Tumor Study-4 (NWTS-4). Methods NWTS-4 enrolled 3,335 patients (pts) including 188 pts with BWT (5.6%). Treatment and outcome data were collected. Results Among 188 BWT pts registered with NWTS-4, 195 kidneys in 123 patients had initial open biopsy, 44 kidneys in 31 pts had needle biopsies. Although pre-resection chemotherapy was recommended, 87 kidneys in 83 pts were managed with primary resection: Complete nephrectomy 48 in 48 pts, 31 partial/wedge nephrectomies in 27 pts, enucleations 8 in 8 pts. No initial surgery was performed in 45 kidneys in 43 pts, 5 kidneys in 3 pts not coded. Anaplasia was diagnosed after completion of the initial course of chemotherapy in 14 pts (initial surgical procedure: 9 open biopsies, 4 needle biopsies, 1 partial nephrectomy). The average number of days from the start of chemotherapy to diagnosis of anaplasia was 390 (range 44–1,925 days). Relapse or progression of disease occurred in 54 children. End stage renal failure occurred in 23 children, 6 of whom had bilateral nephrectomies. The 8 year event free survival (EFS) for BWT with favorable histology was 74%, and overall survival (OS) was 89%; while the EFS for BWT with unfavorable histology was 40%, OS was 45%. Conclusion The current analysis of patients with BWT treated on NWTS-4 shows that preservation of renal parenchyma is possible in many pts following initial preoperative chemotherapy. The incidence of end-stage renal disease remains significantly higher in children with BWT. Future studies are warranted to address the need for earlier biopsy in non-responsive tumors and earlier definitive surgery to recognize unfavorable histology in these high risk patients. PMID:21394016

Robotic Laparoendoscopic Single-site Retroperitioneal Renal Surgery: Initial Investigation of a Purpose-built Single-port Surgical System.

PubMed

Maurice, Matthew J; Ramirez, Daniel; Kaouk, Jihad H

2017-04-01

Robotic single-site retroperitoneal renal surgery has the potential to minimize the morbidity of standard transperitoneal and multiport approaches. Traditionally, technological limitations of non-purpose-built robotic platforms have hindered the application of this approach. To assess the feasibility of retroperitoneal renal surgery using a new purpose-built robotic single-port surgical system. This was a preclinical study using three male cadavers to assess the feasibility of the da Vinci SP1098 surgical system for robotic laparoendoscopic single-site (R-LESS) retroperitoneal renal surgery. We used the SP1098 to perform retroperitoneal R-LESS radical nephrectomy (n=1) and bilateral partial nephrectomy (n=4) on the anterior and posterior surfaces of the kidney. Improvements unique to this system include enhanced optics and intelligent instrument arm control. Access was obtained 2cm anterior and inferior to the tip of the 12th rib using a novel 2.5-cm robotic single-port system that accommodates three double-jointed articulating robotic instruments, an articulating camera, and an assistant port. The primary outcome was the technical feasibility of the procedures, as measured by the need for conversion to standard techniques, intraoperative complications, and operative times. All cases were completed without the need for conversion. There were no intraoperative complications. The operative time was 100min for radical nephrectomy, and the mean operative time was 91.8±18.5min for partial nephrectomy. Limitations include the preclinical model, the small sample size, and the lack of a control group. Single-site retroperitoneal renal surgery is feasible using the latest-generation SP1098 robotic platform. While the potential of the SP1098 appears promising, further study is needed for clinical evaluation of this investigational technology. In an experimental model, we used a new robotic system to successfully perform major surgery on the kidney through a single small incision without entering the abdomen. Copyright © 2016. Published by Elsevier B.V.

Prospective study comparing three-dimensional computed tomography and magnetic resonance imaging for evaluating the renal vascular anatomy in potential living renal donors.

PubMed

Bhatti, Aftab A; Chugtai, Aamir; Haslam, Philip; Talbot, David; Rix, David A; Soomro, Naeem A

2005-11-01

To prospectively compare the accuracy of multislice spiral computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) in evaluating the renal vascular anatomy in potential living renal donors. Thirty-one donors underwent multislice spiral CTA and gadolinium-enhanced MRA. In addition to axial images, multiplanar reconstruction and maximum intensity projections were used to display the renal vascular anatomy. Twenty-four donors had a left laparoscopic donor nephrectomy (LDN), whereas seven had right open donor nephrectomy (ODN); LDN was only considered if the renal vascular anatomy was favourable on the left. CTA and MRA images were analysed by two radiologists independently. The radiological and surgical findings were correlated after the surgery. CTA showed 33 arteries and 32 veins (100% sensitivity) whereas MRA showed 32 arteries and 31 veins (97% sensitivity). CTA detected all five accessory renal arteries whereas MRA only detected one. CTA also identified all three accessory renal veins whereas MRA identified two. CTA had a sensitivity of 97% and 47% for left lumbar and left gonadal veins, whereas MRA had a sensitivity of 74% and 46%, respectively. Multislice spiral CTA with three-dimensional reconstruction was more accurate than MRA for both renal arterial and venous anatomy.

Microlaparoscopic technique for partial salpingectomy using bipolar electrocoagulation.

PubMed

Siegle, J C; Cartmell, L W; Rayburn, W F

2001-07-01

To describe a technique of performing a partial salpingectomy using a small-diameter (2-mm) laparoscope and bipolar electrocoagulation. Sixty consecutive women desiring permanent sterilization underwent laparoscopic partial salpingectomy using a 2-mm transumbilical laparoscope and secondary midline sites suprapubically and midway above the pubis. A midportion of the tube was coagulated using Kleppinger forceps, transected with scissors and removed using grasping forceps. Additional time to remove both coagulated tubal segments averaged 4 minutes (range, 3-10). Each segment (mean, 1.5 cm; range, 0.9-2.4 cm) was confirmed in the operating room, then histologically. The transected tubal edges were separated with no thermal injury to nearby structures and with no mesosalpingeal hemorrhage. No cases required conversion from microlaparoscopy to a traditional method, and recovery time was not prolonged. The puncture sites healed well without sutures. Successful removal of electrocoagulated tubal segments with histologic confirmation was undertaken microlaparoscopically, with minimal additional operative time.

Growth of laparoscopic colectomy in the United States: analysis of regional and socioeconomic factors over time.

PubMed

Bardakcioglu, Ovunc; Khan, Ashraf; Aldridge, Christopher; Chen, Jiajing

2013-08-01

The study was designed to determine the growth pattern and current rate of laparoscopic partial colectomy in the United States and analyze various factors that influence the adaptation rate over time. Laparoscopic colectomy has been shown to have significant short- and long-term benefits compared with the open approach. Despite the evidence from multiple, prospective, randomized trials, the adoption rate in the Unites States is reported to be low. The Nationwide Inpatient Database was used to estimate the rate of laparoscopic partial colectomy in the United States for the years 1996, 2000, 2004, 2008, and 2009 and examine the growth pattern. Multivariate logistic regression analysis was used to determine the impact of the following patient and hospital variables: age, sex, race, payer status, hospital region, and hospital location and teaching status. Significant factors were analyzed for changes over time. Overall, 226,585 partial colectomies were identified. The rate of laparoscopic colectomy was 2.2% (878/38,264) for 1996, 2.7% (1175/42,166) for 2000, 5% (2336/44,817) for 2004, 15% (7548/42,903) for 2008, and 31.4% (14,610/31,888) for 2009. A noticeable change of the growth rate of laparoscopic partial colectomies was noted after 2004, with a significant increase and a possible tipping point after 2008.Urban hospital location [odds ratio (OR = 1.71)], teaching hospital status (OR = 1.21), and private insurance status (OR = 1.46) are significant hospital characteristics predicting the use of laparoscopy overall, but teaching hospital status is not significant after 2008 (OR = 1.51 in 1996 to OR = 1.09 in 2008). Age above 80 years significantly decreases the utilization of laparoscopy (OR = 0.78 for age 80-89 years and 0.69 for >90 years). African American race (OR = 0.84), Medicaid insurance status (OR = 0.52), and self-pay (0.6) are significant socioeconomic characteristics negatively influencing the use of the minimal invasive technique. A marked increase in the rate of laparoscopic colectomy is seen in recent years. The minimal invasive technique seems to be increasingly used in nonteaching hospitals. Significant socioeconomic differences in access to minimal invasive techniques persist.

Automation of a suturing device for minimally invasive surgery.

PubMed

Göpel, Tobias; Härtl, Felix; Schneider, Armin; Buss, Martin; Feussner, Hubertus

2011-07-01

In minimally invasive surgery, hand suturing is categorized as a challenge in technique as well as in its duration. This calls for an easily manageable tool, permitting an all-purpose, cost-efficient, and secure viscerosynthesis. Such a tool for this field already exists: the Autosuture EndoStitch(®). In a series of studies the potential for the EndoStitch to accelerate suturing has been proven. However, its ergonomics still limits its applicability. The goal of this study was twofold: propose an optimized and partially automated EndoStitch and compare the conventional EndoStitch to the optimized and partially automated EndoStitch with respect to the speed and precision of suturing. Based on the EndoStitch, a partially automated suturing tool has been developed. With the aid of a DC motor, triggered by a button, one can suture by one-fingered handling. Using the partially automated suturing manipulator, 20 surgeons with different levels of laparoscopic experience successfully completed a continuous suture with 10 stitches using the conventional and the partially automated suture manipulator. Before that, each participant was given 1 min of instruction and 1 min for training. Absolute suturing time and stitch accuracy were measured. The quality of the automated EndoStitch with respect to manipulation was tested with the aid of a standardized questionnaire. To compare the two instruments, t tests were used for suturing accuracy and time. Of the 20 surgeons with laparoscopic experience (fewer than 5 laparoscopic interventions, n=9; fewer than 20 laparoscopic interventions, n=7; more than 20 laparoscopic interventions, n=4), there was no significant difference between the two tested systems with respect to stitching accuracy. However, the suturing time was significantly shorter with the Autostitch (P=0.01). The difference in accuracy and speed was not statistically significant considering the laparoscopic experience of the surgeons. The weight and size of the Autostitch have been criticized as well as its cable. However, the comfortable handhold, automatic needle change, and ergonomic manipulation have been rated positive. Partially automated suturing in minimally invasive surgery offers advantages with respect to the speed of operation and ergonomics. Ongoing work in this field has to concentrate on minimization, implementation in robotic systems, and development of new operation methods (NOTES).

Robotic renal surgery: The future or a passing curiosity?

PubMed Central

Warren, Jeff; da Silva, Vitor; Caumartin, Yves; Luke, Patrick P.W.

2009-01-01

The development, advancement and clinical integration of robotic technology in surgery continue at a staggering pace. In no other discipline has this rapid evolution occurred to a greater degree than in urology. Although radical prostatectomy has grown to become the prototypical application for the robot, the role of the robot in renal surgery remains controversial. Herein we review the literature on robotic renal surgery. A comprehensive PubMed literature search was performed to identify all published reports relating to robotic renal surgery. All clinically related articles involving human participants were critically appraised in this review. Fifty-one clinical articles were included, encompassing robot-assisted pyeloplasty, nephrectomy, nephroureterectomy, living-donor nephrectomy and partial nephrectomy. Feasibility has been shown for each of these procedures. Robot-assisted techniques have been described for almost all renal-related procedures. However, the intersect between feasibility and necessity as it pertains to robotic renal surgery has yet to be defined. Also, the high cost of surgical robotic technology mandates critical appraisal before adoption, especially in a publicly funded health care system, such as the one present in Canada. PMID:19543471

[A new low-cost webcam-based laparoscopic training model].

PubMed

Langeron, A; Mercier, G; Lima, S; Chauleur, C; Golfier, F; Seffert, P; Chêne, G

2012-01-01

To validate a new laparoscopy home training model (GYN Trainer®) in order to practise and learn basic laparoscopic surgery. Ten junior surgical residents and six experienced operators were timed and assessed during six laparoscopic exercises performed on the home training model. Acquisition of skill was 35%. All the novices significantly improved performance in surgical skills despite an 8% partial loss of acquisition between two training sessions. Qualitative evaluation of the system was good (3.8/5). This low-cost personal laparoscopic model seems to be a useful tool to assist surgical novices in learning basic laparoscopic skills. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Laparoscopic myotomy: technique and efficacy in treating achalasia.

PubMed

Ali, A; Pellegrini, C A

2001-04-01

Esophageal Heller myotomy and a partial antireflux procedure for achalasia are the ideal procedures to benefit from the advances in minimally invasive surgery. The magnified view of the operative field provided by the laparoscope allows precise division of the esophageal muscle fibers with excellent results. Laparoscopic Heller myotomy results in reduced postoperative pain, less morbidity, shorter hospitalization, better resolution of dysphagia, and less postoperative heartburn when compared with the open abdominal and even the thoracoscopic approach. A longer myotomy especially at the distal end, and a loose, well-formed partial fundoplication are the keys to a successful outcome. Superior long-term results after surgical myotomy when compared with nonsurgical interventions argue strongly in favor of surgery in any patient who is fit enough to undergo general anesthesia.

Upper Tract Urological Laparoendoscopic Single-Site Surgery (LESS)

PubMed Central

Tugcu, Volkan; Sahin, Selcuk; Seker, Gokhan; Kargi, Taner; Tasci, Ali Ihsan

2015-01-01

Background and Objectives: Our objective is to report intermediate-term outcomes for patients who have undergone upper tract urologic laparoendoscopic single-site surgery (LESS) at a single institution. Methods: From January 1, 2008, through November 30, 2012, 107 cases treated with LESS were identified, including pyeloplasty (n = 30), ureterolithotomy (n = 32), nephrectomy (n = 35; simple = 31, partial = 4), and cyst decortication (n = 10). Perioperative data were reviewed, and conversion and complication rates were noted. Results: The median follow-up was 21.5 months for pyeloplasty, 20.5 for ureterolithotomy, 28.0 for simple nephrectomy, 14.0 for partial nephrectomy, and 19.0 for cyst decortication. Major complications were encountered in 8 patients, including 3 intraoperative complications (2 bowel injury with serosal tearing and 1 intraoperative bleeding), which were recognized and repaired with LESS or conversion to conventional laparoscopy (CL). During the intermediate postoperative period (30–90 days) major complications occurred in 5 patients: 4 ureteral strictures (Clavien-Dindo grade [CG] IIIb) and 1 urinoma formation (CG IIIa). During the early postoperative period (<30 days), the most common minor complications were flank pain (CG I) in 16 patients and urinary tract infection (CG II) in 11, followed by urinary leakage (CG I) in 8. Conclusions: Intermediate-term functional outcomes of this single-center study confirm that upper tract LESS is a challenging procedure that can be safe and effective when performed by an experienced team. Prospective studies with longer follow-up periods are needed to investigate the safety of LESS in the treatment of various upper urinary tract conditions. PMID:26648679

Asymptomatic Partial Splenic Infarction In Laparoscopic Floppy Nissen Fundoplication And Brief Literature Review

PubMed Central

Odabasi, Mehmet; Abuoglu, Haci Hasan; Arslan, Cem; Gunay, Emre; Yildiz, Mehmet Kamil; Eris, Cengiz; Ozkan, Erkan; Aktekin, Ali; Muftuoglu, Tolga

2014-01-01

Short gastric vessels are divided during the laparoscopic Nissen fundoplication resulting in splenic infarct in some cases. We report a case of laparoscopic floppy Nissen fundoplication with splenic infarct that was recognized during the procedure and provide a brief literature review. The patient underwent a laparoscopic floppy Nissen fundoplication. We observed a partial infarction of the spleen. She reported no pain. A follow-up computed tomography scan showed an infarct, and a 3-month abdominal ultrasound showed complete resolution. Peripheral splenic arterial branches have very little collateral circulation. When these vessels are occluded or injured, an area of infarction will occur immediately. Management strategies included a trial of conservative management and splenectomy for persistent symptoms or complications resulting from splenic infarct. In conclusion, we believe that the real incidence is probably much higher because many cases of SI may have gone undiagnosed during or following an operation, because some patients are asymptomatic. We propose to check spleen carefully for the possibility of splenic infarct. PMID:24833155

[Ambulatory laparoscopic cholecystectomy by minilaparoscopy versus traditional multiport ambulatory laparoscopic cholecystectomy. Prospective randomized trial].

PubMed

Planells Roig, Manuel; Arnal Bertomeu, Consuelo; Garcia Espinosa, Rafael; Cervera Delgado, Maria; Carrau Giner, Miguel

2016-02-01

Difference analysis of ambulatorization rate, pain, analgesic requirements and daily activities recovery in patients undergoing laparoscopic cholecystectomy with standard multiport access (CLMP) versus a minilaparoscopic, 3mm size, technique. Prospective randomized trial of 40 consecutive patients undergoing laparoscopic cholecystectomy. Comparison criteria included predictive ultrasound factors of difficult cholecystectomy, previous history of complicated biliary disease and demographics. Results are analyzed in terms of ambulatorization rate, pain, analgesic requirements, postoperative recovery, technical difficulty, hemorrhage intensity, overnight stay, readmission rate and total or partial conversion. Both procedures were similar in surgery time, technical score and hemorrhage score. MLC was associated with similar ambulatorization rate, 85%, and over-night stay 15%, with only 15% partial conversion rate. MLC showed less postoperative pain (P=.026), less analgesic consumption (P=.006) and similar DAR (P=.879). MLC is similar to CLMP in terms of ambulatorization with less postoperative pain and analgesic requirements without differences in postoperative recovery. Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Using a Harmonic Scalpel "Drilling and Clamping" Method to Implement Zero Ischemic Robotic-assisted Partial Nephrectomy: An Observation Case Report Study.

PubMed

Hou, Chen-Pang; Lin, Yu-Hsiang; Hsu, Yu-Chao; Chen, Chien-Lun; Chang, Phei-Lang; Tsui, Ke-Hung

2016-01-01

Robot-assisted partial nephrectomy (RAPN) has gradually become a popular minimally invasive nephron-sparing surgical option for small renal tumors. Ischemic injury should be minimized because it impacts renal function outcomes following partial nephrectomy. Herein, the authors detail the technique and present initial perioperative outcomes of our novel harmonic scalpel "drilling and clamping" method to implement zero-ischemic RAPN. The authors prospectively collected baseline and perioperative data of patients who underwent zero ischemic RAPN performed by our harmonic scalpel "drilling and clamping" method. From April 2012 to December 2014, a total of 19 consecutive zero ischemic RAPN procedures were performed by a single surgeon. For 18 of the 19 patients, RAPN using our harmonic scalpel "Drilling and Clamping" method was successfully completed without the need for hilar clamping. The median tumor size was 3.4 cm (range: 1.8-6.2); operative time was 3.2 hours (range: 1.9-4.5); blood loss was 100 mL (range: 30-950); and postoperative hospital stay was 4 days (3-26). One patient required intraoperative blood transfusion. Two patients had intra or postoperative complications: 1 was converted to traditional laparotomy because of massive bleeding, whereas another had postoperative stress ulcer. Pathology confirmed renal cell carcinoma in 13 patients (63.2%), angiomyolipoma in 6 patients: (31.5%), and oncocytoma in 1 patient (5.3%). Mean pre- and postoperative serum creatinine (0.82 mg/dL and 0.85 mg/dL, respectively), estimated glomerular filtration rate (84.12 and 82.18, respectively), and hemoglobin (13.27 g/dL and 12.71 g/dL, respectively) were comparable. The authors present a novel zero-ischemic technique for RAPN. They believe that this technique is feasible and reproducible.

Do fibrin sealants impact negative outcomes after robot-assisted partial nephrectomy?

PubMed

Cohen, Jason; Jayram, Gautam; Mullins, Jeffrey K; Ball, Mark W; Allaf, Mohamad E

2013-10-01

Contemporary rates of postoperative hemorrhage after partial nephrectomy (PN) are low. Commercially available hemostatic agents are commonly used during this surgery to reduce this risk despite a paucity of data supporting the practice. We assessed the impact of fibrin sealant hemostatic agents, a costly addition to surgeries, during robot-assisted partial nephrectomy (RAPN). Between 2007 and 2011, 114 consecutive patients underwent RAPN by a single surgeon (MEA). Evicel fibrin sealant was used in the first 74 patients during renorraphy. The last 40 patients had renorraphy performed without the use of any hemostatic agents. Clinicopathologic, operative, and complication data were compared between groups. Multivariate and univariate logistic regression analysis was performed to test the association between the use of fibrin sealants and operative outcomes. Patient demographic data and clinical tumor characteristics were similar between groups. The use of fibrin sealant did not increase operative time (166.3 vs 176.1 minutes, P=0.28), warm ischemia time (WIT) (14.4 vs 16.1 minutes, P=0.18), or length of hospital stay (2.6 vs 2.4 days, P=0.35). The omission of these agents did not increase estimated blood loss (116.6 vs 176.1 mL, P=0.8) or postoperative blood transfusion (0% vs 2.5%, P=0.17). Univariate analysis demonstrated no association between use of fibrin sealants and increased complications (P>0.05). Multivariable logistic regression showed no statistically significant predictive value of omission of hemostatic agents for perioperative outcomes (P>0.05). Perioperative hemorrhage and other major complications after contemporary RAPN are rare in experienced hands. In our study, the use of fibrin sealants during RAPN does not decrease the rate of complications, blood loss, or hospital stay. Furthermore, no impact is seen on operative time, WIT, or other negative outcomes. Omitting these agents during RAPN could be a safe, effective, cost-saving measure.

Internal validation of the renal pelvic score: a novel marker of renal pelvic anatomy that predicts urine leak after partial nephrectomy.

PubMed

Tomaszewski, Jeffrey J; Smaldone, Marc C; Cung, Bic; Li, Tianyu; Mehrazin, Reza; Kutikov, Alexander; Canter, Daniel J; Viterbo, Rosalia; Chen, David Y T; Greenberg, Richard E; Uzzo, Robert G

2014-08-01

To internally validate the renal pelvic score (RPS) in an expanded cohort of patients undergoing partial nephrectomy (PN). Our prospective institutional renal cell carcinoma database was used to identify all patients undergoing PN for localized renal cell carcinoma from 2007 to 2013. Patients were classified by RPS as having an intraparenchymal or extraparenchymal renal pelvis. Multivariate logistic regression models were used to examine the relationship between RPS and urine leak. Eight hundred thirty-one patients (median age, 60 ± 11.6 years; 65.1% male) undergoing PN (57.3% robotic) for low (28.9%), intermediate (56.5%), and high complexity (14.5%) localized renal tumors (median size, 3.0 ± 2.3 cm; median nephrometry score, 7.0 ± 2.6) were included. Fifty-four patients (6.5%) developed a clinically significant or radiographically identified urine leak. Seventy-two of 831 renal pelvises (8.7%) were classified as intraparenchymal. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (43.1% vs 3.0%; P <.001), major urine leak requiring intervention (23.6% vs 1.7%; P <.001), and minor urine leak (19.4% vs 1.2%; P <.001) compared with that in patients with an extrarenal pelvis. After multivariate adjustment, RPS (intraparenchymal renal pelvis; odds ratio [OR], 24.8; confidence interval [CI], 11.5-53.4; P <.001) was the most predictive of urine leak as was tumor endophyticity ("E" score of 3 [OR, 4.5; CI, 1.3-15.5; P = .018]), and intraoperative collecting system entry (OR, 6.1; CI, 2.5-14.9; P <.001). Renal pelvic anatomy as measured by the RPS best predicts urine leak after open and robotic partial nephrectomy. Although external validation of the RPS is required, preoperative identification of patients at increased risk for urine leak should be considered in perioperative management and counseling algorithms. Copyright © 2014 Elsevier Inc. All rights reserved.

The effect of video game "warm-up" on performance of laparoscopic surgery tasks.

PubMed

Rosser, James C; Gentile, Douglas A; Hanigan, Kevin; Danner, Omar K

2012-01-01

Performing laparoscopic procedures requires special training and has been documented as a significant source of surgical errors. "Warming up" before performing a task has been shown to enhance performance. This study investigates whether surgeons benefit from "warming up" using select video games immediately before performing laparoscopic partial tasks and clinical tasks. This study included 303 surgeons (249 men and 54 women). Participants were split into a control (n=180) and an experimental group (n=123). The experimental group played 3 previously validated video games for 6 minutes before task sessions. The Cobra Rope partial task and suturing exercises were performed immediately after the warm-up sessions. Surgeons who played video games prior to the Cobra Rope drill were significantly faster on their first attempt and across all 10 trials. The experimental and control groups were significantly different in their total suturing scores (t=2.28, df=288, P<.05). The overall Top Gun score showed that the experimental group performed marginally better overall. This study demonstrates that subjects completing "warming-up" sessions with select video games prior to performing laparoscopic partial and clinical tasks (intracorporeal suturing) were faster and had fewer errors than participants not engaging in "warm-up." More study is needed to determine whether this translates into superior procedural execution in the clinical setting.

LESS living donor nephrectomy: Surgical technique and results

PubMed Central

Alessimi, Abdullah; Adam, Emilie; Haber, Georges-Pascal; Badet, Lionel; Codas, Ricardo; Fehri, Hakim Fassi; Martin, Xavier; Crouzet, Sébastien

2015-01-01

Purpose: We present the findings of 50 patients undergoing pure trans-umbilical laparo-endoscopic single-site surgery (LESS) living donor nephrectomy (LDN), between February 2010 and May 2014. Materials and Methods: Laparo-endoscopic single-site surgery LDN was performed through an umbilical incision. Different trocars were used, namely Gelpoint (Applied Mιdical, Rancho Santa Margarita, CA) SILS port (Covidien, Hamilton, Bermuda), R-port (Olympus Surgical, Orangeburg, NY) and standard trocars, inserted through the same skin incision but using separate fascial punctures. The standard laparoscopic technique was employed. The kidney was pre-entrapped in a retrieval bag and extracted trans-umbilically. Data were collected prospectively including questionnaires containing patient reported oral pain medication duration and time to recovery. Results: LESS LDN was successful in all patients. Mean warm ischemia time was 6.2 min (3–15), mean procedure time was 233.2 min (172–300), and hospitalization stay was 3.94 days (3–7) with a visual analogue pain score at discharge of 1.32 (0–3). No intraoperative complications occurred. The mean time of oral pain medication was 8.72 days (1–20) and final scar length was 4.06 cm (3–5). Each allograft was functional. Conclusion: Although challenging, trans-umbilical LESS LDN seems to be feasible and safe. Hence, LESS has the potential to improve cosmetic results and decrease morbidity. PMID:26229326

Laparoscopic completion cholecystectomy and common bile duct exploration for retained gallbladder after single-incision cholecystectomy.

PubMed

Kroh, Matthew; Chalikonda, Sricharan; Chand, Bipan; Walsh, R Matthew

2013-01-01

Recent enthusiasm in the surgical community for less invasive surgical approaches has resulted in widespread application of single-incision techniques. This has been most commonly applied in laparoscopic cholecystectomy in general surgery. Cosmesis appears to be improved, but other advantages remain to be seen. Feasibility has been demonstrated, but there is little description in the current literature regarding complications. We report the case of a patient who previously underwent single-incision laparoscopic cholecystectomy for symptomatic gallstone disease. After a brief symptom-free interval, she developed acute pancreatitis. At evaluation, imaging results of ultrasonography and magnetic resonance cholangiopancreatography demonstrated a retained gallbladder with cholelithiasis. The patient was subsequently referred to our hospital, where she underwent further evaluation and surgical intervention. Our patient underwent 4-port laparoscopic remnant cholecystectomy with transcystic common bile duct exploration. Operative exploration demonstrated a large remnant gallbladder and a partially obstructed cystic duct with many stones. Transcystic exploration with balloon extraction resulted in duct clearance. The procedure took 75 minutes, with minimal blood loss. The patient's postoperative course was uneventful. Final pathology results demonstrated a remnant gallbladder with cholelithiasis and cholecystitis. This report is the first in the literature to describe successful laparoscopic remnant cholecystectomy and transcystic common bile duct exploration after previous single-port cholecystectomy. Although inadvertent partial cholecystectomy is not unique to this technique, single-port laparoscopic procedures may result in different and significant complications.

Fertility outcomes after laparoscopic partial bladder resection for deep endometriosis: Retrospective analysis from two expert centres and review of the literature.

PubMed

Nyangoh Timoh, Krystel; Ballester, Marcos; Bendifallah, Sofiane; Fauconnier, Arnaud; Darai, Emile

2018-01-01

To evaluate fertility outcomes after laparoscopic partial bladder resection in women with bladder endometriosis and to review the literature. A retrospective study conducted at two tertiary referral centres -Tenon University Hospital and Poissy University Hospital (Canadian Task Force Classification Level II-2)-from July 2006 to November 2015. Patients with bladder endometriosis who underwent either laparoscopic partial bladder resection (PBR) alone for those without posterior endometriotic lesions (PBR group) or both laparoscopic PBR and associated posterior deep infiltrating endometriosis (DIE) resection (PBR-PDIE group) were included. Pregnancy and live birth rates according to prior infertility, and associated posterior DIE resection were analysed. Thirty-four patients were included; 15 in the PBR group and 19 in the PBR-PDIE group. The median age (range) was 31 years (25-37), Seventeen patients (50%) had prior infertility. The median follow-up after bladder resection was 60.6 months (12-116). Overall, of the 25 (73.5%) patients who wished to conceive, 17 (68%) achieved pregnancies resulting in a live birth rate of 76.4%. Among the 17 patients with prior infertility, nine (52.9%) conceived. Overall, eight patients (53.3%) in the PBR group conceived and nine (47.3%) in the PBR-PDIE group (difference not significant). The present study demonstrates that laparoscopic PBR results in a high pregnancy rate in patients with prior infertility as well as in those with associated posterior DIE suggesting that surgery could be an acceptable alternative to first-line assisted reproductive technology. Copyright © 2017 Elsevier B.V. All rights reserved.

Blood splash injury: an underestimated risk in endourology.

PubMed

Wines, Michael P; Lamb, Alastair; Argyropoulos, Athanasios N; Caviezel, Alessandro; Gannicliffe, C; Tolley, David

2008-06-01

Mucocutaneous and transconjunctival exposure are important portals for the transmission of blood-borne infections to surgeons and health-care workers. Despite this knowledge, few surgeons or their assistants wear protective equipment for procedures perceived to be affiliated with less risk. This study investigates the potential risk of mucocutaneous and transconjunctival blood splash injury during common laparoscopic and endourologic procedures undertaken using standard video endoscopy equipment. Masks combined with eye shields were consecutively collected from the surgeon, surgical assistant, and theater nurse after a variety of endourologic procedures over a 4-month period. These were analyzed macroscopically for visible blood droplets. Modern forensic techniques were then instituted to assess for nonvisible blood exposure. Eye shields from 118 procedures performed by five surgeons were collected. Two hundred and thirty-six masks were examined for visible and visually enhanced evidence of blood contamination. In total, 48.5% of surgeons' masks, 29.5% of assisting surgeons' masks, and 31.8% of scrub nurse masks were positive for either visible or visually enhanced blood contamination. In terms of evidence of blood splash, 84.2% of laparoscopic nephrectomies, 66.7% of pyeloplasties, and 58.3% of flexible ureteroscopies tested positive. Splash injuries remain commonplace, even with the use of video endoscopy equipment. Therefore, all health-care workers should be encouraged to wear eye and face protection when undertaking both endoscopic and laparoscopic urologic procedures. These observations may have broader implications relevant to all minimally invasive surgical procedures, because they demonstrate a much greater potential risk of blood-borne disease transmission during surgery than has been previously appreciated.

Operative technique and early experience for robotic-assisted laparoscopic nephroureterectomy (RALNU) using da Vinci Xi.

PubMed

Darwiche, Fadi; Swain, Sanjaya; Kallingal, George; Punnen, Sanoj; Manoharan, Murugesan; Parekh, Dipen J; Gonzalgo, Mark L

2015-01-01

Robotic-assisted laparoscopic nephroureterectomy (RALNU) has been previously utilized for management of upper tract urothelial carcinoma. The da Vinci Xi surgical system was released in April of 2014. We describe our operative technique and early experience for RALNU using the da Vinci Xi system highlighting unique features of this surgical platform. A total of 10 patients with a diagnosis of upper tract urothelial carcinoma underwent RALNU using the da Vinci Xi system between April and November of 2014. A novel, oblique "in line" robotic trocar configuration was utilized to access the upper abdomen (nephrectomy portion) and pelvis (bladder cuff excision) without undocking. The port hopping feature of da Vinci Xi was utilized to facilitate optimal, multi-quadrant visualization during RALNU. Robotic-assisted laparoscopic nephroureterectomy was successfully completed without open conversion in all 10 patients. Mean operative time was 184 min (range 140-300 min), mean estimated blood loss was 121 cc (range 60-300 cc), and mean hospital stay was 2.4 days. Final pathology demonstrated high grade urothelial carcinoma in all patients. Surgical margins were negative in all patients. No intra-operative complications were encountered. One patient developed a pulmonary embolus after being discharged. No patients required a blood transfusion. Mean patient follow-up was 130 days (range 15-210 days). The use of da Vinci Xi with a novel, oblique "in line" port configuration and camera port hopping technique allows for an efficient and reproducible method for RALNU without the need for repositioning the patient or the robot during surgery.

Kidney and pancreas transplantation at Wake Forest University Baptist Medical Center.

PubMed

Stratta, Robert J; Rohr, Michael S; Adams, Patricia L; Sundberg, Aimee K; Hartmann, Erica L; Armstrong, Greg; Anderson, Teresa K; Farney, Alan C; Roskopf, Julie A; Hairston, Gloria; Kiger, David F; Nagaraj, Shashi K; Iskandar, Samy S; Assimos, Dean G

2003-01-01

More than 1,100 transplants have been performed at WFUBMC, including 60 pediatric transplants and 40 pancreas transplants. The one-year living donor kidney graft survival rate exceeds 90% and the 2 year deceased donor kidney graft survival rate exceeds 80%. The current active waiting list includes more than 300 candidates. Despite more transplants being performed, we continue to under-serve our referral area, which has among the highest rates of hypertension, diabetes, and end stage renal disease in the country. The AOTP has experienced a period of rapid growth over the past 2 years based upon sharing of zero HLA antigen-mismatched kidneys, use of ECD kidneys, liberalization of donor and recipient selection criteria, and the continued development of the pancreas transplant and laparoscopic donor nephrectomy programs. The pancreas transplant program will continue to grow as the waiting list enlarges and matures, with a 200% increase in activity expected within the next few years. The LDKT program will expand as more emphasis is placed on our pretransplant practice, including the more liberal application of laparoscopic donor nephrectomy, which has now become a standard procedure at our WFUBMC is involved in a number of clinical research projects studying new immunosuppressive agents and regimens. In this chapter, we have presented our recent experience with KTX in the elderly, ECD kidneys, alternate day Thymoglobulin administration, valganciclovir prophylaxis, SRL conversion using daclizumab bridge therapy, and pancreas transplantation with portal-enteric drainage. We plan to initiate a number of new protocols in the immediate future, including desensitization of the highly sensitized patient, ABO incompatible transplantation, transplantation of the HIV-positive patient, steroid withdrawal and avoidance regimens, living kidney donation from the anonymous altruistic donor, paired kidney exchanges from living donors, and islet transplantation. WFUBMC remains the most active donor hospital in North Carolina, and a non-heart beating donor protocol has been successfully initiated at our facility. Although much has been accomplished, a number of challenges remain. We look forward to building on our accomplishments, confronting the challenges, and achieving a level of excellence that could only be attained by mutual commitment from a dedicated, multidisciplinary team.

Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula.

PubMed

Melman, Lora; Quinlan, Jessica; Robertson, Brian; Brunt, L M; Halpin, Valerie J; Eagon, J C; Frisella, Margaret M; Matthews, Brent D

2009-06-01

The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter (LES) abnormalities associated with epiphrenic esophageal diverticula and analyze outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication. The endoscopic, radiographic, manometric, and perioperative records for patients undergoing laparoscopic esophageal diverticulectomy, anterior esophageal myotomy, and partial fundoplication from 8/99 until 9/06 were reviewed from an Institutional Review Board (IRB)-approved outcomes database. Data are given as mean +/- standard deviation (SD). An esophageal body motor disorder and/or LES abnormalities were present in 11 patients with epiphrenic diverticula; three patients were characterized as achalasia, one had vigorous achalasia, two had diffuse esophageal spasm, and five had a nonspecific motor disorder. Presenting symptoms included dysphagia (13/13), regurgitation (7/13), and chest pain (4/13). Three patients had previous Botox injections and three patients had esophageal dilatations. Laparoscopic epiphrenic diverticulectomy with an anterior esophageal myotomy was completed in 13 patients (M:F; 3:10) with a mean age of 67.6 +/- 4.2 years, body mass index (BMI) of 28.1 +/- 1.9 kg/m2 and American Society of Anesthesiologists (ASA) 2.2 +/- 0.1. Partial fundoplication was performed in 12/13 patients (Dor, n = 2; Toupet, n = 10). Four patients had a type I and one patient had a type III hiatal hernia requiring repair. Mean operative time was 210 +/- 15.1 min and mean length of stay (LOS) was 2.8 +/- 0.4 days. Two grade II or higher complications occurred, including one patient who was readmitted on postoperative day 4 with a leak requiring a thoracotomy. After a mean follow-up of 13.6 +/- 3.0 months (range 3-36 months), two patients complained of mild solid food dysphagia and one patient required proton pump inhibitor (PPI) for gastroesophageal reflux disease (GERD) symptoms. The majority of patients with epiphrenic esophageal diverticula have esophageal body motor disorders and/or LES abnormalities. Laparoscopic esophageal diverticulectomy and anterior esophageal myotomy with partial fundoplication is an appropriate alternative with acceptable short-term outcomes in symptomatic patients.

A difficult decision: what should we do when malignant tumours are diagnosed in patients supported by left ventricular assist devices?

PubMed

Smail, Hassiba; Pfister, Christian; Baste, Jean-Marc; Nafeh-Bizet, Catherine; Gay, Arnaud; Barbay, Virginie; Bessou, Jean-Paul; Peillon, Christophe; Litzler, Pierre-Yves

2015-09-01

Left ventricular assist devices (LVADs) are used as a bridge to heart transplantation. During the preimplantation or pretransplantation screening, malignant tumours can be discovered. Owing to the lack of guidelines, the management is difficult. We describe our perioperative approach and the patients' outcomes. Between 2006 and 2014, 55 patients underwent implantation of HeartMate II LVAD. Five were diagnosed with malignant tumours: 2 renal, 2 lung and 1 breast tumours. The renal tumours were diagnosed during the preimplantation screening. An LVAD was implanted in both followed by partial nephrectomies 8 and 9 months later. The lung cancers were diagnosed after device implantation, a left pulmonary segmentectomy and a right upper sleeve lobectomy were performed. The breast cancer was diagnosed few months after support and a tumourectomy with lymphadenectomy was performed. Tumour resection was performed successfully in all patients. Prior to surgery haemostasis, device and heart function were evaluated. During surgery, haemodynamics and anticoagulation were monitored. Reoperations were necessary to evacuate haemothorax after lobectomy and an abdominal haematoma post-nephrectomy. After discussion with oncologists, 3 patients were relisted for heart transplantation. Two were successfully transplanted 2 and 3 years after partial nephrectomy with an actual survival of 56 and 59 months after the cancer diagnosis. The follow-up revealed no cancer recurrences. Malignant tumours during support with LVAD can be successfully resected. A multidisciplinary evaluation in these high-risk patients is mandatory. After careful evaluation, regaining the patient's heart transplant candidacy is possible. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Variability of inter-observer agreement on feasibility of partial nephrectomy before and after neoadjuvant axitinib for locally advanced renal cell carcinoma (RCC): independent analysis from a phase II trial.

PubMed

Karam, Jose A; Devine, Catherine E; Fellman, Bryan M; Urbauer, Diana L; Abel, E Jason; Allaf, Mohamad E; Bex, Axel; Lane, Brian R; Thompson, R Houston; Wood, Christopher G

2016-04-01

To evaluate how many patients could have undergone partial nephrectomy (PN) rather than radical nephrectomy (RN) before and after neoadjuvant axitinib therapy, as assessed by five independent urological oncologists, and to study the variability of inter-observer agreement. Pre- and post-systemic treatment computed tomography scans from 22 patients with clear cell renal cell carcinoma in a phase II neoadjuvant axitinib trial were reviewed by five independent urological oncologists. R.E.N.A.L. nephrometry score and κ statistics were calculated. The median R.E.N.A.L. nephrometry score changed from 11 before treatment to 10 after treatment (P = 0.002). Five tumours with moderate complexity before axitinib treatment remained moderate complexity after treatment. Of 17 tumours with high complexity before axitinib treatment, three became moderate complexity after treatment. The overall κ statistic was 0.611. Moderate-complexity κ was 0.611 vs a high-complexity κ of 0.428. Before axitinib treatment the κ was 0.550 vs 0.609 after treatment. After treatment with axitinib, all five reviewers agreed that only five patients required RN (instead of eight before treatment) and that 10 patients could now undergo PN (instead of three before treatment). The odds of PN feasibility were 22.8-times higher after treatment with axitinib. There is considerable variability in inter-observer agreement on the feasibility of PN in patients treated with neoadjuvant targeted therapy. Although more patients were candidates for PN after neoadjuvant axitinib therapy, it remains difficult to identify these patients a priori. © 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.

'Trifecta' outcomes of robot-assisted partial nephrectomy in solitary kidney: a Vattikuti Collective Quality Initiative (VCQI) database analysis.

PubMed

Arora, Sohrab; Abaza, Ronney; Adshead, James M; Ahlawat, Rajesh K; Challacombe, Benjamin J; Dasgupta, Prokar; Gandaglia, Giorgio; Moon, Daniel A; Yuvaraja, Thyavihally B; Capitanio, Umberto; Larcher, Alessandro; Porpiglia, Francesco; Porter, James R; Mottrie, Alexander; Bhandari, Mahendra; Rogers, Craig

2018-01-01

To analyse the outcomes of robot-assisted partial nephrectomy (RAPN) in patients with a solitary kidney in a large multi-institutional database. In all, 2755 patients in the Vattikuti Collective Quality Initiative database underwent RAPN by 22 surgeons at 14 centres in nine countries. Of these patients, 74 underwent RAPN with a solitary kidney between 2007 and 2016. We retrospectively analysed the functional and oncological outcomes of these 74 patients. A 'trifecta' of outcomes was assessed, with trifecta defined as a warm ischaemia time (WIT) of <20 min, negative surgical margins, and no complications intraoperatively or within 3 months of RAPN. All 74 patients underwent RAPN successfully with one conversion to radical nephrectomy. The median (interquartile range [IQR]) operative time was 180 (142-230) min. Early unclamping was used in 11 (14.9%) patients and zero ischaemia was used in 12 (16.2%). Trifecta outcomes were achieved in 38 of 66 patients (57.6%). The median (IQR) WIT was 15.5 (8.75-20.0) min for the entire cohort. The overall complication rate was 24.1% and the rate of Clavien-Dindo grade ≤II complications was 16.3%. Positive surgical margins were present in four cases (5.4%). The median (IQR) follow-up was 10.5 (2.12-24.0) months. The median drop in estimated glomerular filtration rate at 3 months was 7.0 mL/min/1.72 m 2 (11.01%). Our findings suggest that RAPN is a safe and effective treatment option for select renal tumours in solitary kidneys in terms of a trifecta of negative surgical margins, WIT of <20 min, and low operative and perioperative morbidity. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

Osteoprotective effects of osthole in a mouse model of 5/6 nephrectomy through inhibiting osteoclast formation.

PubMed

Li, Xiaofeng; Xue, Chunchun; Wang, Libo; Tang, Dezhi; Huang, Jian; Zhao, Yongjian; Chen, Yan; Zhao, Dongfeng; Shi, Qi; Wang, Yongjun; Shu, Bing

2016-10-01

The present study aimed to investigate the effects of osthole on osteoclast formation and bone loss in a mouse model of 5/6 nephrectomy. The mice in control and osthole groups were treated 1 month following 5/6 nephrectomy with either a placebo or osthole, respectively. At 2 months post‑nephrectomy, the L4 vertebrae were harvested. The bone mineral density (BMD) of cancellous bone was measured using micro‑CT and tartrate‑resistant acid phosphatase (TRAP) staining was performed to evaluate osteoclast formation. Immunohistochemistry staining and reverse transcription‑quantitative polymerase chain reaction were performed to detect the expression of nuclear factor of activated T‑cells, cytoplasmic‑1 (NFATc‑1), c‑Fos, cathepsin K, Trap, matrix metalloproteinase 9 (Mmp9), osteoprotegerin (Opg) and receptor activator for nuclear factor‑κB ligand (Rankl). Bone marrow cells were cultured with osthole, and osteoclast formation was shown by TRAP staining. Primary calvaria osteoblasts were cultured with osthole, and expression levels of Opg and Rankl were detected. Compared with the sham group, the BMD of mice in model group was significantly reduced. The numbers of osteoclasts and the expression levels of NFATc‑1, c‑Fos, cathepsin K and Mmp9 were significantly increased. Compared with the control group, the mice in the osthole group exhibited increased BMD of the L4 vertebrae, a reduction in osteoclast numbers and decreased expression levels of NFATc‑1, c‑Fos, cathepsin K and Mmp9. In vitro experiments also showed that osteoclast formation was decreased following treatment with osthole. Osteoprotegerin (Opg)/receptor activator for nuclear factor‑κB ligand (Rankl) was upregulated by osthole treatment in the L4 vertebrae and in primary cultures of calvarial osteoblasts. Osthole inhibited osteoclast formation and partially reversed the bone loss induced by 5/6 nephrectomy in mice through the upregulation of OPG/RANKL.

Partial nephrectomy for renal tumors: lack of correlation between margin status and local recurrence.

PubMed

Antic, Tatjana; Taxy, Jerome B

2015-05-01

To evaluate the relationship between a positive resection margin in partial nephrectomy (PN) and local recurrence. From January 2005 through December 2012, there were 473 PNs in 466 patients at the University of Chicago. A positive margin was defined as tumor extending to the inked specimen edge, either the parenchymal interface or the peripheral fibroadipose tissue. A local recurrence was defined as an ipsilateral tumor of identical histologic type. Renal cell carcinoma (RCC) accounted for 406 tumors: 243 clear cell RCCs (CRCCs), 77 papillary RCCs (PRCCs), and 47 chromophobe RCCs (CHRCCs). Sixty-one RCCs had positive margins: 43 CRCCs, six PRCCs, nine CHRCCs, and three miscellaneous cell types. Of the 61 positive margins, four CRCCs (all originally multifocal) had a local recurrence, two of which occurred in the same patient. One translocation RCC also recurred. Six cases with negative resection margins had a recurrence. A literature review of 3,803 cases, including our study, shows positive margins in 173, of which 13 recurred; however, 39 with negative margins also recurred. A positive margin in PN seldom correlates with a local recurrence. However, protection from recurrence is not ensured by a negative margin. Copyright© by the American Society for Clinical Pathology.

3.0Tesla magnetic resonance angiography (MRA) for comprehensive renal evaluation of living renal donors: pilot study with computerized tomography angiography (CTA) comparison.

PubMed

Gulati, Mittul; Dermendjian, Harout; Gómez, Ana M; Tan, Nelly; Margolis, Daniel J; Lu, David S; Gritsch, H Albin; Raman, Steven S

2016-01-01

Most living related donor (LRD) kidneys are harvested laparoscopically. Renal vascular anatomy helps determine donor suitability for laparoscopic nephrectomy. Computed tomography angiography (CTA) is the current gold standard for preoperative imaging; magnetic resonance angiography (MRA) offers advantages including lack of ionizing radiation and lower incidence of contrast reactions. We evaluated 3.0T MRA for assessing renal anatomy of LRDs. Thirty consecutive LRDs underwent CTA followed by 3.0T MRA. Data points included number and branching of vessels, incidental findings, and urothelial opacification. Studies were individually evaluated by three readers blinded to patient data. Studies were reevaluated in consensus with discrepancies revealed, and final consensus results were labeled "truth". Compared with consensus "truth", both computed tomography (CT) and magnetic resonance imaging were highly accurate for assessment of arterial and venous anatomy, although CT was superior for detection of late venous confluence as well as detection of renal stones. Both modalities were comparable in opacification of lower ureters and bladder; MRA underperformed CTA for opacification of upper urinary tracts. 3.0T MRA enabled excellent detection of comprehensive renal anatomy compared to CTA in LRDs. Copyright © 2016 Elsevier Inc. All rights reserved.

Money well spent: a comparison of hospital operating margin for laparoscopic and open colectomies.

PubMed

Koopmann, M C; Harms, B A; Heise, C P

2007-10-01

Cost analysis after laparoscopic colectomy has been examined, although reports evaluating the effects of laparoscopy on hospital operating margin are lacking. We compared several cost/revenue measures, including hospital operating margin, between open and laparoscopic colectomies at an academic center. Our cost-accounting database was queried for laparoscopic partial (LPC) and total colectomies (LTC), and open partial (OPC) and total colectomies (OTC) to analyze net revenue, total costs, and total hospital operating margin over a 4-year period. Laparoscopic and open colectomy cases were compared, with mean operating margin as the primary outcome. From July, 2002 through May, 2006, 842 patients were included for analysis with 138 undergoing laparoscopic colectomy. Net revenue was higher in the LTC group compared with open (US dollars 30,300 vs US dollars 26,800 [P = .02]), and lower in the LPC group (US dollars 15,300 vs US dollars 21,300 open [P < .0001]). Total costs were reduced in both the LPC and LTC groups compared with open [US dollars 11,700 vs US dollars 17,600 [P < .0001] and US dollars 18,000 vs US dollars 19,400 [P = .0019], respectively). LPC resulted in a similar HOM (US dollars 3,602) compared with OPC (US dollars 3,647; P = .35). LTC resulted in a higher HOM (US dollars 12,300) compared with OTC (US dollars 7,400; P = .02). LTC generates a significantly higher hospital operating margin than an OTC, although the margins are similar for LPC and OPC.

Laparoscopic Heller Myotomy for Achalasia Technical Aspects.

PubMed

Schlottmann, Francisco; Allaix, Marco E; Patti, Marco G

2018-04-01

Esophageal achalasia is a primary esophageal motility disorder defined by the lack of esophageal peristalsis, and by a lower esophageal sphincter that fails to relax in response to swallowing. Patients' symptoms include dysphagia, regurgitation, aspiration, heartburn, and chest pain. Achalasia is a chronic condition without cure, and treatment options are aimed at providing symptomatic relief, improving esophageal emptying, and preventing the development of megaesophagus. Presently, a laparoscopic Heller myotomy with a partial fundoplication is considered the best treatment modality. A properly executed operation is key for the success of a laparoscopic Heller myotomy.

Routes for virtually guided endoscopic liver resection of subdiaphragmatic liver tumors.

PubMed

Aoki, Takeshi; Murakami, Masahiko; Fujimori, Akira; Koizumi, Tomotake; Enami, Yuta; Kusano, Tomokazu; Matsuda, Kazuhiro; Yamada, Kosuke; Nogaki, Koji; Wada, Yusuke; Hakozaki, Tomoki; Goto, Satoru; Watanabe, Makoto; Otsuka, Koji

2016-03-01

Laparoscopic and thoracoscopic/laparoscopic hepatectomy is a safe procedure that has potential advantages over open surgery. However, deeply positioned liver tumors require expert laparoscopic and thoracoscopic/laparoscopic hepatectomy techniques. Using simulated preoperative three-dimensional virtual endoscopy (P3DVE) guidance, we demonstrate herein that a thoracoscopic approach (TA), thoracoscopic-laparoscopic approach (TLA), and laparoscopic approach (LA) are all feasible and safe routes for performing pure laparoscopic and thoracoscopic/laparoscopic resection of liver tumors located in the 4a, 7, and 8 liver subdiaphragmatic areas. Thirty-eight patients underwent laparoscopic and thoracoscopic/laparoscopic partial liver resection (TA 13 cases, TLA two cases, and LA 23 cases) of the subdiaphragmatic area at Showa University Hospital. All surgical approaches were preoperatively determined based on preoperative 3D virtual endoscopic simulation (P3DVES) visualization and findings using the image processing software SYNAPSE VINCENT(®). Laparoscopic and thoracoscopic/laparoscopic liver resection was successfully performed for all cases under P3DVE instruction. The mean operative times using TA, TLA, and LA approaches were 193, 185, and 190 min, respectively. Mean blood loss during TA, TLA, and LA was 179, 138, and 73 g, respectively. No patients required conversion to open surgery, and there were no deaths, although there were three cases of Clavien-Dindo grade I in TA along with three cases of grade I and one case of grade II in LA. TA, TLA, and LA routes performed under P3DVE instruction are feasible and safe to perform for pure laparoscopic and thoracoscopic/laparoscopic liver resection in selected patients with lesions located in the hepatic subdiaphragmatic area.

Performance comparisons in major uro-oncological surgeries between the USA and Japan.

PubMed

Sugihara, Toru; Yasunaga, Hideo; Horiguchi, Hiromasa; Fushimi, Kiyohide; Dalton, Jarrod E; Schold, Jesse; Kattan, Michael W; Homma, Yukio

2014-11-01

To elucidate the differences in clinical practice between the USA and Japan in major types of uro-oncological surgery by a head-to-head comparison of national databases in the two countries. We compared variations in surgical modality, length of stay, total charges, caseload centralization, transfusion incidence, and in-hospital mortality between the two countries for four major types of uro-oncological surgery (radical prostatectomy, radical cystectomy, nephrectomy and nephroureterectomy) in 2011. Additionally, the chronological changes in surgical modalities were investigated for 2009-11. The national estimates were based on data from the Japanese Diagnosis Procedure Combination database and the US National Inpatient Sample. For radical prostatectomy, radical cystectomy, nephrectomy and nephroureterectomy, minimally-invasive surgery accounted for 24.2% versus 70.2%, 0% versus 14.0%, 50.7% versus 30.7% and 50.2% versus 30.5%, respectively, in Japan versus the USA in 2011. Although minimally-invasive surgery has become increasingly frequent in both countries, the major procedures were robot-assisted surgery in the USA and laparoscopic surgery in Japan. The USA was generally characterized by a slightly younger age at operation, far higher hospital volume, a shorter length of stay, higher charges and less use of transfusion than Japan. The findings suggest substantial differences between the USA and Japan regarding clinical practices in uro-oncological surgery. Standing at the beginning of robotic surgery era in Japan, the precise recognition of these differences will aid a proper understanding of clinical practices. © 2014 The Japanese Urological Association.

The choice of optimal antireflux procedure after laparoscopic cardiomyotomy: two decades of clinical experience in one center

PubMed Central

Kiudelis, Mindaugas; Sakalys, Egidijus; Jonaitis, Laimas; Mickevicius, Antanas; Endzinas, Zilvinas

2017-01-01

Introduction Two types of partial wrap are commonly performed in achalasia patients after Heller myotomy: the posterior 270° fundoplication (Toupet) and the anterior 180° fundoplication (Dor). The optimal type of fundoplication (posterior vs. anterior) is still debated. Aim To compare the long-term rates of dysphagia, reflux symptoms and patient satisfaction with current postoperative condition between two fundoplication groups in achalasia treatment. Material and methods Our retrospective study included 97 consecutive patients with achalasia: 37 patients underwent laparoscopic posterior Toupet (270°) fundoplication followed by Heller myotomy (group I); 60 patients underwent laparoscopic anterior partial Dor fundoplication followed by Heller myotomy (group II). Long-term follow-up results included evaluation of dysphagia symptoms, intensity of heartburn and patient satisfaction with current condition. Results Patients in these two groups did not differ according to age, weight, height, postoperative stay or follow-up period. Laparoscopic myotomy with posterior Toupet fundoplication was effective in 89% of patients, while laparoscopic myotomy with anterior Dor was effective in 93% of patients (p > 0.05). 11% of patients after posterior Toupet fundoplication had clinically significant heartburn vs. 35% of patients after anterior Dor fundoplication (p < 0.05). Overall patient satisfaction with current condition was 88%, with no significant difference between the groups. Conclusions According to our study results, the two laparoscopic techniques were similarly effective in reducing achalasia symptoms, but postoperative clinical manifestation of heartburn is significantly more frequent after anterior Dor fundoplication (35% vs. 11%). The majority of patients (88%) were satisfied with operation outcomes. PMID:29062443

Death during laparoscopy: can 1 gas push out another? Danger of argon electrocoagulation.

PubMed

Sezeur, Alain; Partensky, Christian; Chipponi, Jacques; Duron, Jean-Jacques

2008-08-01

We report the death of a young man during a laparoscopic partial splenectomy performed with an argon plasma coagulator to remove a benign cyst. The report analyzes the very particular mechanism of a gas embolism, which caused death here. This analysis leads us to recommend a close attention on the use of argon coagulators during laparoscopy. The aim of this article is to draw surgeons' attention to the conclusions of a court-ordered expert assessment intended to elucidate the mechanisms responsible for the death of a 20-year-old man during a laparoscopic partial splenectomy performed with an argon plasma coagulator to remove a benign cyst.

Contemporary, age-based trends in the incidence and management of patients with early-stage kidney cancer.

PubMed

Tan, Hung-Jui; Filson, Christopher P; Litwin, Mark S

2015-01-01

Although kidney cancer incidence and nephrectomy rates have risen in tandem, clinical advances have generated new uncertainty regarding the optimal management of patients with small renal tumors, especially the elderly. To clarify existing practice patterns, we assessed contemporary trends in the incidence and management of patients with early-stage kidney cancer. Using Surveillance, Epidemiology, and End Results data, we identified adult patients diagnosed with T1aN0M0 kidney cancer from 2000 to 2010. We determined age-adjusted and age-specific incidence and management rates (i.e., nonoperative, ablation, partial nephrectomy [PN], and radical nephrectomy) per 100,000 adults and determined the average annual percent change (AAPC). Finally, we compared management groups using multinomial logistic regression accounting for patient characteristics, cancer information, and county-level measures for health. From 2000 to 2010, we identified 41,645 adults diagnosed with T1aN0M0 kidney cancer. Overall incidence increased from 3.7 to 7.0 per 100,000 adults (AAPC = 7.0%, P<0.001). Over the study interval, rates of PN (AAPC = 13.1%, P<0.001) increased substantially, becoming the most used treatment by 2010. Among the elderly, rates of nonoperative management and ablation approached nephrectomy rates for those aged 75 to 84 years and became the predominant strategy for patients older than 84 years. Adjusting for clinical, oncological, and environmental factors, older patients less frequently underwent PN and more often received ablative or nonoperative management (P<0.001). As the incidence of early-stage kidney cancer rises, patients are increasingly treated with nonoperative and nephron-sparing strategies, especially among the most elderly. The broader array of treatment options suggests opportunities to better personalize kidney cancer care for seniors. Published by Elsevier Inc.

Nintendo Wii video-gaming ability predicts laparoscopic skill.

PubMed

Badurdeen, Shiraz; Abdul-Samad, Omar; Story, Giles; Wilson, Clare; Down, Sue; Harris, Adrian

2010-08-01

Studies using conventional consoles have suggested a possible link between video-gaming and laparoscopic skill. The authors hypothesized that the Nintendo Wii, with its motion-sensing interface, would provide a better model for laparoscopic tasks. This study investigated the relationship between Nintendo Wii skill, prior gaming experience, and laparoscopic skill. In this study, 20 participants who had minimal experience with either laparoscopic surgery or Nintendo Wii performed three tasks on a Webcam-based laparoscopic simulator and were assessed on three games on the Wii. The participants completed a questionnaire assessing prior gaming experience. The score for each of the three Wii games correlated positively with the laparoscopic score (r = 0.78, 0.63, 0.77; P < 0.001), as did the combined Wii score (r = 0.82; P < 0.001). The participants in the top tertile of Wii performance scored 60.3% higher on the laparoscopic tasks than those in the bottom tertile (P < 0.01). Partial correlation analysis with control for the effect of prior gaming experience showed a significant positive correlation between the Wii score and the laparoscopic score (r = 0.713; P < 0.001). Prior gaming experience also correlated positively with the laparoscopic score (r = 0.578; P < 0.01), but no significant difference in the laparoscopic score was observed when the participants in the top tertile of experience were compared with those in the bottom tertile (P = 0.26). The study findings suggest a skill overlap between the Nintendo Wii and basic laparoscopic tasks. Surgical candidates with advanced Nintendo Wii ability may possess higher baseline laparoscopic ability.

Laparoscopic Harvest of the Rectus Abdominis for Perineal Reconstruction

PubMed Central

Agochukwu, Nneamaka; Bonaroti, Alisha; Beck, Sandra

2017-01-01

Summary: The rectus abdominis is a workhorse flap for perineal reconstruction, in particular after abdominoperineal resection (APR). Laparoscopic and robotic techniques for abdominoperineal surgery are becoming more common. The open harvest of the rectus abdominis negates the advantages of these minimally invasive approaches. (Sentence relating to advantages of laparoscopic rectus deleted here.) We present our early experience with laparoscopic harvest of the rectus muscle for perineal reconstruction. Three laparoscopic unilateral rectus abdominis muscle harvests were performed for perineal reconstruction following minimally invasive colorectal and urological procedures. The 2 patients who underwent APR also had planned external perineal skin reconstruction with local flaps. (Sentence deleted here to shorten abstract.) All rectus muscle harvests were performed laparoscopically. Two were for perineal reconstruction following laparoscopic APR, and 1 was for anterior vaginal wall reconstruction. This was done with 4 ports positioned on the contralateral abdomen. The average laparoscopic harvest time was 60–90 minutes. The rectus muscle remained viable in all cases. One patient developed partial necrosis of a posterior thigh fasciocutaneous flap after cancer recurrence. There were no pelvic abscesses, or abdominal wall hernias. Laparoscopic harvest of the rectus appears to be a cost-effective, reliable, and reproducible procedure for perineal with minimal donor-site morbidity. Larger clinical studies are needed to further establish the efficacy and advantages of the laparoscopic rectus for perineal reconstruction. PMID:29263976

[Robots in general surgery: present and future].

PubMed

Galvani, Carlos; Horgan, Santiago

2005-09-01

Robotic surgery is an emerging technology. We began to use this technique in 2000, after it was approved by the Food and Drug Administration. Our preliminary experience was satisfactory. We report 4 years' experience of using this technique in our institution. Between August 2000 and December 2004, 399 patients underwent robotic surgery using the Da Vinci system. We performed 110 gastric bypass procedures, 30 Lap band, 59 Heller myotomies, 12 Nissen fundoplications, 6 epiphrenic diverticula, 18 total esophagectomies, 3 esophageal leiomyoma resections, 1 pyloroplasty, 2 gastrojejunostomies, 2 transduodenal sphincteroplasties, 10 adrenalectomies and 145 living-related donor nephrectomies. Operating times for fundoplications and Lap band were longer. After the learning curve, the operating times and morbidity of the remaining procedures were considerably reduced. Robot-assisted surgery allows advanced laparoscopic procedures to be performed with enhanced results given that it reduces the learning curve as measured by operating time and morbidity.

Evaluation of FloSeal as a Potential Intracavitary Hemostatic Agent

DTIC Science & Technology

2006-02-01

Laws ER Jr. Use of FloSeal hemostatic sealant in transsphenoidal pituitary surgery : technical note. Neurosurgery. 2002;51:513–516. 14. Kheirabadi BS...of death in com- bat and civilian trauma. When surgery is unavailable, one potential solution to such hemorrhage might be the introduction of an agent...situations, including venous and arterial vascular surgery ,7,9 cardiac valve replacement or cardiopulmonary bypass grafting,6 partial nephrectomies,10

The future of partial nephrectomy.

PubMed

Malthouse, Theo; Kasivisvanathan, Veeru; Raison, Nicholas; Lam, Wayne; Challacombe, Ben

2016-12-01

Innovation in recent times has accelerated due to factors such as the globalization of communication; but there are also more barriers/safeguards in place than ever before as we strive to streamline this process. From the first planned partial nephrectomy completed in 1887, it took over a century to become recommended practice for small renal tumours. At present, identified areas for improvement/innovation are 1) to preserve renal parenchyma, 2) to optimise pre-operative eGFR and 3) to reduce global warm ischaemia time. All 3 of these, are statistically significant predictors of post-operative renal function. Urologists, have a proud history of embracing innovation & have experimented with different clamping techniques of the renal vasculature, image guidance in robotics, renal hypothermia, lasers and new robots under development. The DaVinci model may soon no longer have a monopoly on this market, as it loses its stranglehold with novel technology emerging including added features, such as haptic feedback with reduced costs. As ever, our predictions of the future may well fall wide of the mark, but in order to progress, one must open the mind to the possibilities that already exist, as evolution of existing technology often appears to be a revolution in hindsight. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

[Ablative treatments in localized renal cancer: literature review for 2014].

PubMed

Chodez, M; Fiard, G; Arnoux, V; Descotes, J-L; Long, J-A

2015-07-01

To focus on indications and results of ablative treatments (cyoablation, radiofrequency) for small renal masses, a bibliographic research was conducted in MedLine database using terms of "ablative treatment", "cryotherapy", "radiofrequency", "kidney cancer", "renal cell carcinoma". Sixty-four articles were selected. Carcinologic outcomes seem to be better with cryoablation than with radiofrequency. Available results have to be balanced according to surgical approach, teams' experience and duration of follow-up. Tumour's size and central localization are the main factors of failure. The size of 3cm is the most generally validated. Hospital stay and complications seem to be better with ablative therapies than with surgical approach, especially with percutaneous approach. The renal function preservation appears to be better with ablative therapies. It could be an interesting alternative to partial nephrectomy for small masses, in particular for fragile patients or in particular indications (multifocal tumors, in case of solitary kidney or transplanted kidney). The indications in elderly people must be proposed with care after the comorbidities have been evaluated. Indications of ablative treatment for small renal masses improve, but the gold standard treatment remains partial nephrectomy and indications must be individually discussed. Other ablative treatments are under-development, needing further studies. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Robot-Assisted Laparoendoscopic Single-Site Partial Nephrectomy With the Novel Da Vinci Single-Site Platform: Initial Experience

PubMed Central

Komninos, Christos; Tuliao, Patrick; Kim, Dae Keun; Choi, Young Deuk; Chung, Byung Ha

2014-01-01

Purpose To report our initial clinical cases of robotic laparoendoscopic single-site (R-LESS) partial nephrectomy (PN) performed with the use of the novel Da Vinci R-LESS platform. Materials and Methods Three patients underwent R-LESS PN from November 2013 through February 2014. Perioperative and postoperative outcomes were collected and intraoperative difficulties were noted. Results Operative time and estimated blood loss volume ranged between 100 and 110 minutes and between 50 and 500 mL, respectively. None of the patients was transfused. All cases were completed with the off-clamp technique, whereas one case required conversion to the conventional (multiport) approach because of difficulty in creating the appropriate scope for safe tumor resection. No major postoperative complications occurred, and all tumors were resected in safe margins. Length of hospital stay ranged between 3 and 7 days. The lack of EndoWrist movements, the external collisions, and the bed assistant's limited working space were noticed to be the main drawbacks of this surgical method. Conclusions Our initial experience with R-LESS PN with the novel Da Vinci platform shows that even though the procedure is feasible, it should be applied in only appropriately selected patients. However, further improvement is needed to overcome the existing limitations. PMID:24955221

Robotic retroperitoneal partial nephrectomy: a step-by-step guide.

PubMed

Ghani, Khurshid R; Porter, James; Menon, Mani; Rogers, Craig

2014-08-01

To describe a step-by-step guide for successful implementation of the retroperitoneal approach to robotic partial nephrectomy (RPN) PATIENTS AND METHODS: The patient is placed in the flank position and the table fully flexed to increase the space between the 12th rib and iliac crest. Access to the retroperitoneal space is obtained using a balloon-dilating device. Ports include a 12-mm camera port, two 8-mm robotic ports and a 12-mm assistant port placed in the anterior axillary line cephalad to the anterior superior iliac spine, and 7-8 cm caudal to the ipsilateral robotic port. Positioning and port placement strategies for successful technique include: (i) Docking robot directly over the patient's head parallel to the spine; (ii) incision for camera port ≈1.9 cm (1 fingerbreadth) above the iliac crest, lateral to the triangle of Petit; (iii) Seldinger technique insertion of kidney-shaped balloon dilator into retroperitoneal space; (iv) Maximising distance between all ports; (v) Ensuring camera arm is placed in the outer part of the 'sweet spot'. The retroperitoneal approach to RPN permits direct access to the renal hilum, no need for bowel mobilisation and excellent visualisation of posteriorly located tumours. © 2014 The Authors. BJU International © 2014 BJU International.

Retroperitoneal access for robotic renal surgery.

PubMed

Anderson, Barrett G; Wright, Alec J; Potretzke, Aaron M; Figenshau, R Sherburne

2018-01-01

Retroperitoneal access for robotic renal surgery is an effective alternative to the commonly used transperitoneal approach. We describe our contemporary experience and technique for attaining retroperitoneal access. We outline our institutional approach to retroperitoneal access for the instruction of urologists at the beginning of the learning curve. The patient is placed in the lateral decubitus position. The first incision is made just inferior to the tip of the twelfth rib as described by Hsu, et al. After the lumbodorsal fascia is traversed, the retroperitoneal space is dilated with a round 10 millimeter AutoSutureTM (Covidien, Mansfield, MA) balloon access device. The following trocars are used: A 130 millimeter KiiR balloon trocar (Applied Medical, Rancho Santa Margarita, CA), three robotic, and one assistant. Key landmarks for the access and dissection are detailed. 177 patients underwent a retroperitoneal robotic procedure from 2007 to 2015. Procedures performed include 158 partial nephrectomies, 16 pyeloplasties, and three radical nephrectomies. The robotic fourth arm was utilized in all cases. When compared with the transperitoneal approach, the retroperitoneal approach was associated with shorter operative times and decreased length of stay (1). Selection bias and surgeon preference accounted for the higher proportion of patients who underwent partial nephrectomy off-camp via the retroperitoneal approach. Retroperitoneal robotic surgery may confer several advantages. In patients with previous abdominal surgery or intra-abdominal conditions, the retroperitoneum can be safely accessed while avoiding intraperitoneal injuries. The retroperitoneum also provides a confined space that may minimize the sequelae of potential complications including urine leak. Moreover, at our institution, retroperitoneal robotic surgery is associated with shorter operative times and a decreased length of stay when compared with the transperitoneal approach (2). In selected patients, the retroperitoneal approach is a viable alternative to the transperitoneal approach for a variety of renal procedures. Copyright® by the International Brazilian Journal of Urology.

A comparison of the effects of oral vs. intravenous hydration on subclinical acute kidney injury in living kidney donors: a protocol of a randomised controlled trial.

PubMed

Mackinnon, Shona; Aitken, Emma; Ghita, Ryan; Clancy, Marc

2017-01-19

Optimal treatment for established renal failure is living donor kidney transplantation. However this pathway exposes healthy individuals to significant reduction in nephron mass via major surgical procedure. Laparoscopic donor nephrectomy is now the most common method for live donor transplantation, reducing both donor post-operative pain and recovery time. However this procedure exposes kidneys to additional haemodynamic stresses. It has been suggested that donor hydration-particularly the use of preoperative intravenous fluids-may counteract these stresses, reducing subclinical acute kidney injury and ultimately improving long-term renal function. This may be important in both preservation of donor renal function and recipient graft longevity. A prospective single-centre single-blinded randomized controlled trial will be carried out to determine the effects of donor preoperative intravenous fluids. The primary outcome is donor subclinical acute kidney injury (defined as plasma NGAL, >153 ng/ml) on day 1 postoperatively. Secondary outcomes include intraoperative haemodynamics, recipient subclinical acute kidney injury, perioperative complications and donor sleep quality. Donors will be randomised into two groups: the intervention group will receive active pre-hydration consisting of three litres of intravenous Hartmann's solution between midnight and 8 am before morning kidney donation, while the control group will not receive this. Both groups will receive unlimited oral fluids until midnight, as is routine. Plasma NGAL will be measured at pre-specified perioperative time points, intraoperative haemodynamic data will be collected using non-invasive cardiac output monitoring and clinical notes will be used to obtain demographic and clinical data. The researcher will be blinded to the donor fluid hydration status. Blinded statistical analysis will be performed on an intention-to-treat basis. A prospective power calculation estimates a required sample size of 86 patients. This study will provide important data, as there is currently little evidence about the use of donor preoperative fluids in laparoscopic nephrectomy. It is hoped that the results obtained will guide future clinical practice. This study has been approved by the West of Scotland Research Ethics Committee 3 (reference no. 14/WS/1160, 27 January 2015) and is registered with the International Standard Randomised Controlled Trial Number Register (reference no. ISRCTN10199225 , 20 April 2015).

Gastrectomy

MedlinePlus

... Surgery - stomach removal; Gastrectomy - total; Gastrectomy - partial; Stomach cancer - gastrectomy ... Elsevier; 2017:chap 48. Yang HK, Kwon S. Laparoscopic gastric surgery. In: Cameron JL, Cameron AM, eds. Current ...

Effects of maternal subtotal nephrectomy on the development of the fetal kidney: A morphometric study.

PubMed

Kondo, Tomohiro; Kitano-Amahori, Yoko; Nagai, Hiroaki; Mino, Masaki; Takeshita, Ai; Kusakabe, Ken Takeshi; Okada, Toshiya

2015-11-01

The present study was designed to explore if maternal subtotal (5/6) nephrectomy affects the development of fetal rat kidneys using morphometric methods and examining whether there are any apoptotic changes in the fetal kidney. To generate 5/6 nephrectomized model rats, animals underwent 2/3 left nephrectomy on gestation day (GD) 5 and total right nephrectomy on GD 12. The fetal kidneys were examined on GDs 16 and 22. A significant decrease in fetal body weight resulting from maternal 5/6 nephrectomy was observed on GD 16, and a significant decrease in fetal renal weight and fetal body weight caused by maternal nephrectomy was observed on GD 22. Maternal 5/6 nephrectomy induced a significant increase in glomerular number, proximal tubular length, and total proximal tubular volume of fetuses on GD 22. Maternal 5/6 nephrectomy resulted in an increase in the number of apoptotic cells in the metanephric mesenchyme of the kidney on GD 16, and in the collecting tubules on GD 22. These findings suggest that maternal 5/6 nephrectomy stimulates the development of the fetal kidney while suppressing fetal growth. © 2015 Japanese Teratology Society.

Laparoscopic partial vs total splenectomy in children with hereditary spherocytosis.

PubMed

Morinis, Julia; Dutta, Sanjeev; Blanchette, Victor; Butchart, Sheila; Langer, Jacob C

2008-09-01

Open partial splenectomy provides reversal of anemia and relief of symptomatic splenomegaly while theoretically retaining splenic immune function for hereditary spherocytosis. We recently developed a laparoscopic approach for partial splenectomy. The purpose of the present study is to compare the outcomes in a group of patients undergoing laparoscopic partial splenectomy (LPS) with those in a group of children undergoing laparoscopic total splenectomy (LTS) over the same period. Systematic chart review was conducted of all children with hereditary spherocytosis who had LTS or LPS from 2000 to 2006 at the Hospital for Sick Children, Toronto, Ontario, Canada. T tests were used for continuous data, and chi(2) for proportional data; P value of less than .05 was considered significant. There were 9 patients (14 males) in each group. Groups were similar in sex, age, concomitant cholecystectomy, and preoperative hospitalizations, transfusions, and spleen size. Estimated blood loss was greater in the LPS group (188 + 53 vs 67 + 17 mL; P = .02), but transfusion requirements were similar (1/9 vs 0/9). Complication rate was similar between groups. The LPS group had higher morphine use (4.1 + 0.6 vs 2.4 + 0.2 days; P = .03), greater time to oral intake (4.4 + 0.7 vs 2.0 + 0.2 days; P = .01), and longer hospital stay (6.3 + 1.0 vs 2.7 + 0.3 days; P = .005) than the LTS group. Nuclear scan 6 to 8 weeks postoperatively demonstrated residual perfused splenic tissue in all LPS patients. No completion splenectomy was necessary after a mean follow-up of 25 months. These data suggest that LPS is as effective as LTS for control of symptoms. However, LPS is associated with more pain, longer time to oral intake, and longer hospital stay. These disadvantages may be balanced by retained splenic immune function, but further studies are required to assess long-term splenic function in these patients.

Association between preoperative hydration status and acute kidney injury in patients managed surgically for kidney tumours.

PubMed

Ellis, Robert J; Del Vecchio, Sharon J; Kalma, Benjamin; Ng, Keng Lim; Morais, Christudas; Francis, Ross S; Gobe, Glenda C; Ferris, Rebekah; Wood, Simon T

2018-07-01

The purpose of this study was to investigate whether preoperative dehydration and intraoperative hypotension were associated with postoperative acute kidney injury in patients managed surgically for kidney tumours. A retrospective analysis of 184 patients who underwent nephrectomy at a single centre was performed, investigating associations between acute kidney injury after nephrectomy, and both intraoperative hypotension and preoperative hydration/volume status. Intraoperative hypotension was defined as mean arterial pressure < 60 mmHg for ≥ 5 min. Urine conductivity was evaluated as a surrogate measure of preoperative hydration (euhydrated < 15 mS/cm; mildly dehydrated 15-20 mS/cm; dehydrated > 20 mS/cm). Multivariable logistic regression was used to evaluate associations between exposures and the primary outcome, with adjustment made for potential confounders. Patients who were dehydrated and mildly dehydrated had an increased risk of acute kidney injury (adjusted odds ratio [aOR] 4.1, 95% CI 1.3-13.5; and aOR 2.4, 95% CI 1.1-5.3, respectively) compared with euhydrated patients (p = 0.009). Surgical approach appeared to modify this effect, where dehydrated patients undergoing laparoscopic surgery were most likely to develop acute kidney injury, compared with patients managed using an open approach. Intraoperative hypotension was not associated with acute kidney injury. Preoperative dehydration may be associated with postoperative acute kidney injury. Avoiding dehydration in the preoperative period may be advisable, and adherence to international evidence-based guidelines on preoperative fasting is recommended.

Multi-institutional Experience in Laparoendoscopic Single-site Surgery (LESS): For Major Extirpative and Reconstructive Procedures in Pediatric Urology.

PubMed

Gor, Ronak A; Long, Christopher J; Shukla, Aseem R; Kirsch, Andrew J; Perez-Brayfield, Marcos; Srinivasan, Arun K

2016-02-01

To review peri-procedural outcomes from a large, multi-institutional series of pediatric urology patients treated with laparaendoscopic single-site surgery (LESS) for major extirpative and reconstructive procedures. Consecutive LESS cases between January 2011 and May 2014 from three free-standing pediatric referral centers were reviewed. Data include age, sex, operative time, blood loss, length of stay, and complications according to the modified Clavien-Dindo classification. Hasson technique was used for peritoneal entry, GelPOINT advanced access platform was inserted, and standard 5mm laparoscopic instruments were used. Fifty-nine patients (median age 5 years, 4 months-17 years) met inclusion criteria: 29 nephrectomies, 9 nephroureterectomies, 3 bilateral nephrectomies, 5 heminephrectomies, 5 renal cyst decortications, 3 bilateral gonadectomies, 2 Malone antegrade continence enema, 2 calyceal diverticulectomy, and 1 ovarian detorsion with cystectomy. Median operative times for each case type were comparable to published experiences with traditional laparoscopy. Overall mean and median length of stay was 36.2 hours and 1 day, respectively. There were two complications: port site hernia requiring surgical repair (Clavien IIIb) and a superficial port site infection that resolved with antibiotics (Clavien II). Cosmetic outcomes were subjectively well received by patients and their parents. Operative time was significantly shorter between the first half of the experience and the second half (102 vs 70 minutes, P  <  .05). LESS approach can be broadly applied across many major extirpative and reconstructive procedures within pediatric urology. Our series advances our field's utilization of this technique and its safety. Copyright © 2016 Elsevier Inc. All rights reserved.

Radical robot-assisted laparoscopic nephrectomy with thrombectomy in the vena cava.

PubMed

Estébanez Zarranz, J; Belloso Loidi, J; Gutierrez García, M A; Rubio Calaveras, V; Morales Higelmo, G; Melendo Tercilla, P; Busto Leis, L; Sanz Jaka, J P

2018-04-23

Renal cell carcinoma has a natural tendency to extend through the renal vein. When the thrombus reaches the vena cava, thrombectomy and the necessary reconstruction of the vena cava are typically performed by open pathway. Robot-assisted technology provides advantages for performing this complex technique, using a minimally invasive access. We present the technique we employed in the first case performed in our department. After performing renal artery embolisation, we conducted the surgery with the Vinci S robotic system. The main steps of the surgery are as follows: detachment and Kocher manoeuvre; release of the lower renal pole; clamping and sectioning of the renal artery; endocavitary ultrasound to locate the thrombus; placement of tourniquets in the vena cava below and above the renal veins and in the left renal vein; closure of the 3 tourniquets; opening of the vena cava; resection and extraction of the thrombus; suture of the vena cava; opening of the tourniquets; complete release of the kidney; bagging and extraction of the specimen. The surgery was performed without complications. The patient required a transfusion of 2 units of packed red blood cells and was discharged with modest renal failure (creatinine level of 1.60mg/dl). Radical nephrectomy with thrombectomy in the vena cava is a technique susceptible to severe complications and has, to date, been performed in few centres. We believe that the technique is reproducible and has clear advantages for our patients. Copyright © 2018 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.

Prospective radiographic followup after en bloc ligation of the renal hilum.

PubMed

White, Wesley M; Klein, Frederick A; Gash, Judson; Waters, W Bedford

2007-11-01

We determined the risk of arteriovenous fistula after en bloc ligation of the renal hilum. A prospective evaluation of all patients who underwent en bloc ligation of the renal hilum during nephrectomy for malignant disease was performed. Pertinent operative data were recorded and patients were followed for clinical evidence of arteriovenous fistula formation, including hypertension, abdominal bruit and new onset congestive heart failure. Patients with at least 12 months of followup underwent computerized tomographic arteriography to assess arteriovenous fistula formation. A total of 94 patients underwent en bloc renal hilar ligation during open (43) and laparoscopic (51) nephrectomy using a 45 mm titanium endovascular stapler. Of this cohort 11 patients were lost to followup and 3 died of disease. The remaining 80 patients were followed an average of 35.2 months with no clinical evidence of arteriovenous fistula formation. Specifically there was no statistically significant difference in preoperative and postoperative blood pressure (p = 0.18 and 0.62, respectively), no evidence of abdominal bruit on examination and no new onset congestive heart failure. A total of 32 had increased serum creatinine and, therefore, they were excluded from followup computerized tomographic arteriography. Eight patients had a followup of less than 1 year and they were not yet eligible for evaluation. In the 40 patients who underwent computerized tomographic arteriography no fistulas were noted. Based on clinical followup and prospective radiographic evaluation there appears to be a low risk of arteriovenous fistula formation after en bloc ligation of the renal hilum using a titanium endovascular stapler.

Clinical implications of a rare renal entity: Pleomorphic Hyalinizing Angiectatic Tumor (PHAT).

PubMed

Scalici Gesolfo, Cristina; Serretta, Vincenzo; Di Maida, Fabrizio; Giannone, Giulio; Barresi, Elisabetta; Franco, Vito; Montironi, Rodolfo

2017-02-01

Pleomorphic Hyalinizing Angiectatic Tumor (PHAT) is a rare benign lesion characterized by slow growth, infiltrative behavior and high rate of local recurrences. Only one case has been described in retroperitoneum, at renal hilum, but not involving pelvis or parenchyma. Here we present the first case of PHAT arising in the renal parenchyma. A nodular lesion in right kidney lower pole was diagnosed to a 61 year old woman. The patient underwent right nephrectomy. Microscopically, the lesion showed solid and pseudo-cystic components with hemorrhagic areas characterized by aggregates of ectatic blood vessels. Pleomorphic cells were characterized by large eosinophilic cytoplasm with irregular and hyperchromatic nuclei. Immunohistochemistry was performed and the lesion was classified as a Pleomorphic Hyalinizing Angiectatic Tumor (PHAT). Due to the clinical behavior of this tumor, in spite of its benign nature, review of the surgical margins and close follow up after partial nephrectomy are mandatory. Copyright © 2016. Published by Elsevier GmbH.

Cardiomyotomy.

PubMed

Patti, M G; Tamburini, A; Pellegrini, C A

1999-12-01

During the last decade, minimally invasive surgery has replaced open surgery in the treatment of esophageal achalasia. This new approach, in fact, determines results similar to the open approach, but is associated to a shorter hospital stay, minimal postoperative discomfort, and faster return to regular activity. Between 1991 and 1998, 168 patients underwent a cardiomyotomy by minimally invasive techniques. Good or excellent results were obtained in 85% of patients after thoracoscopic myotomy, and 93% of patients after laparoscopic myotomy and partial fundoplication. The latter procedure was followed by a lower incidence of postoperative gastroesophageal reflux (60% versus 17%). Laparoscopic Heller myotomy and partial fundoplication has emerged as the procedure of choice for esophageal achalasia, and it should be considered today the primary form of treatment for this disease.

The role of laparoscopic surgery for ulcerative colitis: systematic review with meta-analysis.

PubMed

Wu, Xiao-Jian; He, Xiao-Sheng; Zhou, Xu-Yu; Ke, Jia; Lan, Ping

2010-08-01

Crohn's disease is established in laparoscopic surgery due to partial bowel dissection and low postoperative complication rate. However, laparoscopic surgery for ulcerative colitis remains further discussed even if the trend of minimally invasive technique exists. This study is to figure out how laparoscopic surgery works for ulcerative colitis. Sixteen controlled trials were identified through the search strategy mentioned below. There was only one prospective randomized study among the studies selected. A meta-analysis pooled the outcome effects of laparoscopic surgery and open surgery was performed. Fixed effect model or random effect model was respectively used depending on the heterogeneity test of trials. Postoperative fasting time and postoperative hospital stay were shorter in laparoscopic surgery for ulcerative colitis (-1.37 [-2.15, -0.58], -3.22 [-4.20, -2.24], respectively, P < 0.05). Overall complication rate was higher in open surgery, compared with laparoscopic surgery (54.8% versus 39.3%, P = 0.004). However, duration of laparoscopic surgery for ulcerative colitis was extended compared with open surgery (weighted mean difference 69.29 min, P = 0.04). As to recovery of bowel function, peritoneal abscess, anastomotic leakage, postoperative bowel obstruction, wound infection, blood loss, and mortality, laparoscopic surgery did not show any superiority over open surgery. Re-operation rate was almost even (5.2% versus 7.3%). The whole conversion to open surgery was 4.2%. Laparoscopic surgery for ulcerative colitis was at least as safe as open surgery, even better in postoperative fasting time, postoperative hospital stay, and overall complication rate. However, clinical value of laparoscopic surgery for ulcerative colitis needed further evaluation with more well-designed and long-term follow-up studies.

Wound infections after transplant nephrectomy.

PubMed

Kohlberg, W I; Tellis, V A; Bhat, D J; Driscoll, B; Veith, F J

1980-05-01

Wound infections after transplant nephrectomy were analyzed retrospectively. When prophylactic antibiotics were not used, 20% of the closed nephrectomy wounds became infected. Eighty-one percent of the infections were due to staphylococcal organisms. Wounds containing a preexisting focus of infection or those reoperated on more than once within a month prior to nephrectomy are at such high risk for infection that these wounds should be left open for secondary healing. With the use of prophylactic cefazolin sodium, in the immediate preoperative and postoperative period, no wound infections have occurred in 18 closed transplant nephrectomy wounds.

Evolving practice patterns for the management of small renal masses in the USA.

PubMed

Yang, Glen; Villalta, Jacqueline D; Meng, Maxwell V; Whitson, Jared M

2012-10-01

What's known on the subject? and What does the study add? Treatment options for small renal masses include radical nephrectomy (RN), partial nephrectomy (PN), ablation, and surveillance. PN provides equivalent oncological as RN for small tumours, but long-term outcomes for ablation and surveillance are poorly defined. Due to changing techniques and technology, treatment patterns for small renal masses are rapidly developing. Prior studies had analysed utilisation trends for PN and RN to 2006, revealing a relative rise in the rate of PN. However, overall treatment trends including surveillance and ablation had not been studied using a population-based cohort. It has become increasingly clear that RN is associated with greater renal and cardiovascular deterioration than nephron-sparing treatments. Thus, it is important to understand current population-based practice patterns for the treatment of small renal masses to assess whether practitioners are adhering to ever-changing principles in this field. The present study provides up-to-date treatment trends in the USA using a large population-based cohort. To describe the changing practice patterns in the management of small renal masses, including the use of surveillance and ablative techniques. All patients in the Surveillance, Epidemiology and End Results (SEER) registry treated for renal masses of ≤7 cm in diameter, from 1998 to 2008, were included for analysis. Annual trends in the use of surveillance, ablation, partial nephrectomy (PN), and radical nephrectomy (RN) were calculated. Multinomial logistic regression was used to determine the association of demographic and clinical characteristics with treatment method. In all, 48 148 patients from 17 registry sites with a mean age of 63.4 years were included for analysis. Between 1998 and 2008, for masses of <2 cm and 2.1-4 cm, there was a dramatic increase in the proportion of patients undergoing PN (31% vs 50%, 16% vs 33%, respectively) and ablation (1% vs 11%, 2% vs 9%, respectively). In multivariable analysis, later year of diagnosis, male gender, being married, clinically localised disease, and smaller tumours were associated with increased use of PN vs RN. Later year of diagnosis, male gender, being unmarried, smaller tumour, and the presence of bilateral masses were associated with increased use of ablation and surveillance vs RN. PN is now used in half of all patients with the smallest renal masses, and its use continues to increase over time. Ablation and surveillance are less common overall, but there is increased usage over time in select populations. © 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.

Laparoscopic Heller Myotomy and Fundoplication: What Is the Evidence?

PubMed

Rebecchi, Fabrizio; Allaix, Marco E; Schlottmann, Francisco; Patti, Marco G; Morino, Mario

2018-04-01

There is no agreement about the best type of fundoplication to add in patients undergoing laparoscopic Heller myotomy (LHM) for achalasia to reduce the risk of postoperative gastroesophageal reflux. This article reviews the current evidence about the outcomes in achalasia patients undergoing LHM with a partial anterior, a partial posterior, or a total fundoplication. We performed a review of the literature in PubMed/Medline electronic databases, which was evaluated according to the GRADE system. The results of the published randomized controlled trials show with a high level of evidence that the addition of a fundoplication reduces the risk of postoperative abnormal reflux, without impairing the food emptying of the esophagus. LHM with partial fundoplication is considered in most centers worldwide the standard of care for the treatment of patients with achalasia. The current evidence fails to show any significant difference between partial anterior and posterior fundoplication. In the absence of further large randomized controlled trial, the decision of performing an anterior or a posterior wrap is based on the surgeon's experience and preference. The addition of a partial fundoplication to LHM leads to a significantly lower rate of postoperative pathological reflux without impairing the esophageal emptying.

Laparoscopic calibrated total vs partial fundoplication following Heller myotomy for oesophageal achalasia

PubMed Central

Martino, Natale Di; Brillantino, Antonio; Monaco, Luigi; Marano, Luigi; Schettino, Michele; Porfidia, Raffaele; Izzo, Giuseppe; Cosenza, Angelo

2011-01-01

AIM: To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia. METHODS: Fifty-six patients (26 men, 30 women; mean age 42.8 ± 14.7 years) presenting for minimally invasive surgery for oesophageal achalasia, were enrolled. All patients underwent laparoscopic Heller myotomy followed by a 180° anterior partial fundoplication in 30 cases (group 1) and calibrated Nissen-Rossetti fundoplication in 26 (group 2). Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication. A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken. One and two years after surgery, the patients underwent symptom questionnaires, endoscopy, oesophageal manometry and 24 h oesophago-gastric pH monitoring. RESULTS: At the 2-year follow-up, no significant difference in the median symptom score was observed between the 2 groups (P = 0.66; Mann-Whitney U-test). The median percentage time with oesophageal pH < 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group (2; range 0.8-10 vs 0.35; range 0-2) (P < 0.0001; Mann-Whitney U-test). CONCLUSION: Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia. Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure. PMID:21876635

Endoscopic and laparoscopic treatment of gastroesophageal reflux.

PubMed

Watson, David I; Immanuel, Arul

2010-04-01

Gastroesophageal reflux is extremely common in Western countries. For selected patients, there is an established role for the surgical treatment of reflux, and possibly an emerging role for endoscopic antireflux procedures. Randomized trials have compared medical versus surgical management, laparoscopic versus open surgery and partial versus total fundoplications. However, the evidence base for endoscopic procedures is limited to some small sham-controlled studies, and cohort studies with short-term follow-up. Laparoscopic fundoplication has been shown to be an effective antireflux operation. It facilitates quicker convalescence and is associated with fewer complications, but has a similar longer term outcome compared with open antireflux surgery. In most randomized trials, antireflux surgery achieves at least as good control of reflux as medical therapy, and these studies support a wider application of surgery for the treatment of moderate-to-severe reflux. Laparoscopic partial fundoplication is an effective surgical procedure with fewer side effects, and it may achieve high rates of patient satisfaction at late follow-up. Many of the early endoscopic antireflux procedures have failed to achieve effective reflux control, and they have been withdrawn from the market. Newer procedures have the potential to fashion a surgical fundoplication. However, at present there is insufficient evidence to establish the safety and efficacy of endoscopic procedures for the treatment of gastroesophageal reflux, and no endoscopic procedure has achieved equivalent reflux control to that achieved by surgical fundoplication.

Occult Radiographically Evident Port-Site Hernia After Robot-Assisted Urologic Surgery: Incidence and Risk Factors.

PubMed

Christie, Matthew C; Manger, Jules P; Khiyami, Abdulaziz M; Ornan, Afshan A; Wheeler, Karen M; Schenkman, Noah S

2016-01-01

Laparoscopic trocar-site hernias (TSH) are rare, with a reported incidence of 1% or less. The incidence of occult radiographically evident hernias has not been described after robot-assisted urologic surgery. We evaluated the incidence and risk factors of this problem. A single-institution retrospective review of robot-assisted urologic surgery was performed from April 2009 to December 2012. Patients with preoperative and postoperative CT were included for analysis. Imaging was reviewed by two radiologists and one urologist. One hundred four cases were identified, including 60 partial nephrectomy, 38 prostatectomy, and 6 cystectomy. Mean age was 58 years and mean body mass index (BMI) was 29 kg/m(2). The cohort was 77% male. Ten total hernias were identified by CT in 8 patients, 2 of which were clinically evident hernias. Excluding these two hernias, occult port-site hernias were identified radiographically in seven patients. Per-patient incidence of occult TSH was 6.7% (7/104), and per-port incidence was 1.4% (8/564). All hernias were midline and 30% contained bowel. Eight of the 10 occurred at 12 mm sites (p = 0.0065) and 3 of the 10 occurred at extended incisions. Age, gender, BMI, smoking status, diabetes mellitus, immunosuppressive drug therapy, ASA score, procedure, blood loss, prior abdominal surgery, and history of hernia were not significant risk factors. Specimen size >40 g (p = 0.024) and wound infection (p = 0.0052) were significant risk factors. While the incidence of clinically evident port-site hernia remains low in robot-assisted urologic surgery, the incidence of CT-detected occult hernia was 6.7% in this series. These occurred most often in sites extended for specimen extraction and at larger port sites. This suggests more attention should be paid to fascial closure at these sites.

Basic in vitro experiment on the adhesive effects of sheet-type hemostatic agents used in combination with a liquid fibrin sealant.

PubMed

Ishii, Keiichi; Kawashima, Hideki; Hayama, Takuma; Mayabashira, Sumika; Oka, Shiro; Sugimoto, Toshikado

2011-11-01

Various hemostatic agents have been used quite effectively for hemostasis, as well as for providing effective adhesion during laparoscopic partial nephrectomies. In this study, we investigated the adhesiveness to the renal tissue of some sheet-type hemostatic agents used in combination with a liquid fibrin sealant. In Experiment A, component solutions of the fibrin glue (liquid fibrin sealant) were dripped onto a kite string placed annularly on a porcine kidney slice. Then, one of the sheet-type hemostats--namely, the collagen, gelatin, or cellulose hemostat--was placed on the slices, and a string scale was used to measure the force needed to pull the string apart vertically from the kidney slice. Twelve slices were used for each group, and the weight data were analyzed statistically. The tissue adhering to each sheet-type hemostatic agent was fixed in formalin and sliced and then examined by light microscopy after hematoxylin and eosin staining. In Experiment B, the solutions were dripped onto the sheet-type hemostatic agent placed first on the slice, and the force needed for pulling apart the hemostat sheet from the slice was similarly examined. The combination of fibrin glue plus a collagen hemostat was clearly superior in Experiment A, but the hemostat and renal tissue could be pulled apart more easily in Experiment B. These results showed that fibrin glue could not exert its expected adhesive effect unless it is used in combination with another hemostatic agent or is directly applied to renal tissue. It is important to obtain further comparative data among agents and select the appropriate agents, taking into consideration the type of surgery.

Laparoscopic management for spontaneous jejunal perforation caused by nonspecific ulcer: A case report.

PubMed

Sakaguchi, Tatsuma; Tokuhara, Katsuji; Nakatani, Kazuyoshi; Kon, Masanori

2017-01-01

Nonspecific small bowel ulcers are rare and there have been limited reports. We applied laparoscopic surgery successfully for the perforation caused by this disease of jejunum. A 70-year-old man visited to our hospital with complaint of abdominal pain and fever. He was diagnosed abdominal peritonitis with findings of intraperitoneal gas and fluid. Emergency laparoscopic surgery was performed. A perforation 5mm in diameter was recognized in jejunum opposite side of mesentery. Partial resection of jejunum with end-to-end anastomosis and peritoneal lavage were performed. Pathologically, an ulcer was recognized around the blowout perforation without specific inflammation. He was discharged uneventfully 12days after surgery. Laparoscopic surgery has diagnostic and therapeutic advantages because of its lower invasion with a good operation view, and in case of the small bowel, it is easy to shift extra-corporeal maneuver. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Validation of a Postoperative Nomogram Predicting Recurrence in Patients with Conventional Clear Cell Renal Cell Carcinoma.

PubMed

Lee, Byron H; Feifer, Andrew; Feuerstein, Michael A; Benfante, Nicole E; Kou, Lei; Yu, Changhong; Kattan, Michael W; Russo, Paul

2018-01-01

Clear cell renal cell carcinoma (RCC) continues to be the most commonly diagnosed subtype and is associated with more aggressive behavior than papillary and chromophobe RCC. Predicting disease recurrence after surgical extirpation is important for counseling and targeting those at high risk for adjuvant therapy clinical trials. To validate a postoperative nomogram predicting 5-yr recurrence-free probability (RFP) for clinically localized clear cell RCC. We identified all patients who underwent nephrectomy for clinically localized clear cell RCC from 1990 to 2009 at Memorial Sloan Kettering Cancer Center. After excluding patients with bilateral renal masses, familial RCC syndromes, and T3c or T4 tumors due to the limited number, 1642 participants were available for analysis. Partial or radical nephrectomy. Disease recurrence was defined as any new tumor after nephrectomy or kidney cancer-specific mortality, whichever occurred first. A postoperative nomogram was used to calculate the predicted 5-yr RFP, and these values were compared with the actual 5-yr RFP. Nomogram performance was evaluated by concordance index and calibration plot. Median follow-up was 39 mo (interquartile range: 14-79 mo), and disease recurrence was observed in 50 patients. The nomogram concordance index was 0.81. The calibration curve showed that the nomogram underestimated the actual 5-yr RFP. We updated the nomogram by including the entire patient population, which maintained performance and significantly improved calibration. The updated clear cell RCC postoperative nomogram performed well in the combined cohort. Underestimation of actual 5-yr RFP by the original nomogram may be due to increased surgeon experience and other unknown variables. We updated a valuable prediction tool used for assessing the disease recurrence probability after nephrectomy for clear cell renal cell carcinoma. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Global vision system in laparoscopy.

PubMed

Rivas-Blanco, I; Sánchez-de-Badajoz, E; García-Morales, I; Lage-Sánchez, J M; Sánchez-Gallegos, P; Pérez-Del-Pulgar, C J; Muñoz, V F

2017-05-01

The main difficulty in laparoscopic or robot-assisted surgery is the narrow visual field, restricted by the endoscope's access port. This restriction is coupled with the difficulty of handling the instruments, which is due not only to the access port but also to the loss of depth of field and perspective due to the lack of natural lighting. In this article, we describe a global vision system and report on our initial experience in a porcine model. The global vision system consists of a series of intraabdominal devices, which increase the visual field and help recover perspective through the simulation of natural shadows. These devices are a series of high-definition cameras and LED lights, which are inserted and fixed to the wall using magnets. The system's efficacy was assessed in a varicocelectomy and nephrectomy. The various intraabdominal cameras offer a greater number of intuitive points of view of the surgical field compared with the conventional telescope and appear to provide a similar view as that in open surgery. Areas previously inaccessible to the standard telescope can now be reached. The additional light sources create shadows that increase the perspective of the surgical field. This system appears to increase the possibilities for laparoscopic or robot-assisted surgery because it offers an instant view of almost the entire abdomen, enabling more complex procedures, which currently require an open pathway. Copyright © 2016 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.

Impact of transplant nephrectomy on peak PRA levels and outcome after kidney re-transplantation

PubMed Central

Tittelbach-Helmrich, Dietlind; Pisarski, Przemyslaw; Offermann, Gerd; Geyer, Marcel; Thomusch, Oliver; Hopt, Ulrich Theodor; Drognitz, Oliver

2014-01-01

AIM: To determine the impact of transplant nephrectomy on peak panel reactive antibody (PRA) levels, patient and graft survival in kidney re-transplants. METHODS: From 1969 to 2006, a total of 609 kidney re-transplantations were performed at the University of Freiburg and the Campus Benjamin Franklin of the University of Berlin. Patients with PRA levels above (5%) before first kidney transplantation were excluded from further analysis (n = 304). Patients with graft nephrectomy (n = 245, NE+) were retrospectively compared to 60 kidney re-transplants without prior graft nephrectomy (NE-). RESULTS: Peak PRA levels between the first and the second transplantation were higher in patients undergoing graft nephrectomy (P = 0.098), whereas the last PRA levels before the second kidney transplantation did not differ between the groups. Age adjusted survival for the second kidney graft, censored for death with functioning graft, were comparable in both groups. Waiting time between first and second transplantation did not influence the graft survival significantly in the group that underwent nephrectomy. In contrast, patients without nephrectomy experienced better graft survival rates when re-transplantation was performed within one year after graft loss (P = 0.033). Age adjusted patient survival rates at 1 and 5 years were 94.1% and 86.3% vs 83.1% and 75.4% group NE+ and NE-, respectively (P < 0.01). CONCLUSION: Transplant nephrectomy leads to a temporary increase in PRA levels that normalize before kidney re-transplantation. In patients without nephrectomy of a non-viable kidney graft timing of re-transplantation significantly influences graft survival after a second transplantation. Most importantly, transplant nephrectomy is associated with a significantly longer patient survival. PMID:25032103

Declining operative experience for junior level residents: Is this an unintended consequence of minimally invasive surgery?

PubMed Central

Mullen, Matthew G.; Salerno, Elise P.; Michaels, Alex D.; Hedrick, Traci L.; Sohn, Min-Woong; Smith, Philip W.; Schirmer, Bruce D.; Friel, Charles M.

2016-01-01

Introduction Our group has previously demonstrated an upward shift from junior to senior resident participation in common general surgery operations, traditionally performed by junior level residents. The objective of this study was to evaluate if this trend would correct over time. We hypothesized that junior resident case volume would improve. Methods A sample of essential laparoscopic and open general surgery procedures (appendectomy, inguinal herniorrhaphy, cholecystectomy, and partial colectomy) was chosen for analysis. The ACS NSQIP Participant Use Files were queried for these procedures between 2005–2012. Cases were stratified by participating resident post-graduate year (PGY) with ‘junior resident’ defined as PGY1–3. Logistic regression was performed to determine change in junior resident participation for each type of procedure over time. Results 185,335 cases were included in the study. For three of the operations we considered, the prevalence of laparoscopic surgery increased from 2005–2012 (all p<0.001). Cholecystectomy was an exception, which showed an unchanged proportion of cases performed laparoscopically across the study period (p=0.119). Junior resident participation decreased by 4.5%/year (p<0.001) for laparoscopic procedures and by 6.2%/year (p<0.001) for open procedures. The proportion of laparoscopic surgeries performed by junior level residents decreased for appendectomy by 2.6%/year (p<0.001) and cholecystectomy by 6.1%/year (p<0.001), whereas it was unchanged for inguinal herniorrhaphy (p=0.75) and increased for partial colectomy by 3.9%/year (p=0.003). A decline in junior resident participation was seen for all open surgeries, with appendectomy decreasing by 9.4%/year (p<0.001), cholecystectomy by 4.1%/year (p<0.002), inguinal herniorrhaphy by 10%/year (p<0.001) and partial colectomy by 2.9%/year (p<0.004). Conclusions Along with the proliferation of laparoscopy for common general surgical procedures there has been a concomitant reduction in the participation of junior level residents. As previously thought, familiarity with laparoscopy has not translated to redistribution of basic operations from senior to junior residents. This trend has significant implications for general surgery resident education. PMID:27066854

Is simple nephrectomy truly simple? Comparison with the radical alternative.

PubMed

Connolly, S S; O'Brien, M Frank; Kunni, I M; Phelan, E; Conroy, R; Thornhill, J A; Grainger, R

2011-03-01

The Oxford English dictionary defines the term "simple" as "easily done" and "uncomplicated". We tested the validity of this terminology in relation to open nephrectomy surgery. Retrospective review of 215 patients undergoing open, simple (n = 89) or radical (n = 126) nephrectomy in a single university-affiliated institution between 1998 and 2002. Operative time (OT), estimated blood loss (EBL), operative complications (OC) and length of stay in hospital (LOS) were analysed. Statistical analysis employed Fisher's exact test and Stata Release 8.2. Simple nephrectomy was associated with shorter OT (mean 126 vs. 144 min; p = 0.002), reduced EBL (mean 729 vs. 859 cc; p = 0.472), lower OC (9 vs. 17%; 0.087), and more brief LOS (mean 6 vs. 8 days; p < 0.001). All parameters suggest favourable outcome for the simple nephrectomy group, supporting the use of this terminology. This implies "simple" nephrectomies are truly easier to perform with less complication than their radical counterpart.

Robotic-Assisted Procedures in Pediatric Surgery: A Critical Appraisal of the Current Best Evidence in Comparison to Conventional Minimally Invasive Surgery.

PubMed

Friedmacher, Florian; Till, Holger

2015-11-01

In recent years, the use of robotic-assisted surgery (RAS) has expanded within pediatric surgery. Although increasing numbers of pediatric RAS case-series have been published, the level of evidence remains unclear, with authors mainly focusing on the comparison with open surgery rather than the corresponding laparoscopic approach. The aim of this study was to critically appraise the published literature comparing pediatric RAS with conventional minimally invasive surgery (MIS) in order to evaluate the current best level of evidence. A systematic literature-based search for studies comparing pediatric RAS with corresponding MIS procedures was performed using multiple electronic databases and sources. The level of evidence was determined using the Oxford Centre for Evidence-based Medicine (OCEBM) criteria. A total of 20 studies met defined inclusion criteria, reporting on five different procedures: fundoplication (n=8), pyeloplasty (n=8), nephrectomy (n=2), gastric banding (n=1), and sleeve gastrectomy (n=1). Included publications comprised 5 systematic reviews and 15 cohort/case-control studies (OCEBM Level 3 and 4, respectively). No studies of OCEBM Level 1 or 2 were identified. Limited evidence indicated reduced operative time (pyeloplasty) and shorter hospital stay (fundoplication) for pediatric RAS, whereas disadvantages were longer operative time (fundoplication, nephrectomy, gastric banding, and sleeve gastrectomy) and higher total costs (fundoplication and sleeve gastrectomy). There were no differences reported for complications, success rates, or short-term outcomes between pediatric RAS and conventional MIS in these procedures. Inconsistency was found in study design and follow-up with large clinical heterogeneity. The best available evidence for pediatric RAS is currently OCEBM Level 3, relating only to fundoplication and pyeloplasty. Therefore, higher-quality studies and comparative data for other RAS procedures in pediatric surgery are required.

Nephron-sparing surgery across a nation - outcomes from the British Association of Urological Surgeons 2012 national partial nephrectomy audit.

PubMed

Fernando, Archie; Fowler, Sarah; O'Brien, Tim

2016-06-01

To determine the scope and outcomes of nephron-sparing surgery (NSS), i.e. partial nephrectomy, across the UK and in so doing set a realistic benchmark and identify fresh contemporary challenges in NSS. In 2012 reporting of outcomes of all types of nephrectomy became mandatory in the UK. In all, 148 surgeons in 86 centres prospectively entered data on 6 042 nephrectomies undertaken in 2012. This study is a retrospective analysis of the NSS procedures in the dataset. A total of 1 044 NSS procedures were recorded and the median (range) surgical volume was 4 (1-39) per consultant and 8 (1-59) per centre. In all, 36 surgeons and 10 centres reported on only one NSS. The indications for NSS were: elective with a tumour of ≤4.5 cm in 59%, elective with a tumour of >4.5 cm in 10%, relative in 7%, imperative in 12%, Von Hippel-Lindau in 1%, and unknown in 11%. The median (range) tumour size was 3.4 (0.8-30) cm. The technique used was minimally invasive surgery in 42%, open in 58%, with conversions in 4%. The histology results were: malignant in 80%, benign in 18%, and unknown in 2%. In patients aged <40 years 36% (36/101) had benign histology vs 17% (151/874) of those aged ≥40 years (P < 0.01). In patients with tumours of <2.5 cm 29% (69/238) had benign histology vs 14% (57/410) with tumours of 2.5-4 cm vs 8% (16/194) with tumours of ≥4 cm (P = 0.02). In patients aged <40 years with of tumours of <2.5 cm 44% (15/34) were benign. The 30-day mortality was 0.1% (1/1 044). There were major complications (Clavien-Dindo grade of ≥IIIa) in 5% (53/1 044). There was an increased risk of complications after extended elective NSS of 19% (19/101) vs elective at 12% (76/621) (relative risk [RR] 1.54; P < 0.01). Margins were recorded in 68% (709/1 044) of the patients, with positive margins identified in 7% (51/709). Positive surgical margins after NSS for pathological T3 (pT3) tumours were found in 47.8% (11/23) vs 6.1% (32/523) for pT1a, tumours (RR 5.61; P < 0.01). In all, 14% (894/6 042) of the patients underwent surgery for T1a tumours: 55% (488/894) by NSS, 42% (377/894) by radical nephrectomy (RN), and in 3% (29/894) the procedure used was unknown. Major complications after occurred in 4.9% (24/488) of NSS vs 1.3% (5/377) of RN (P < 0.01). Limitations included poor reporting of renal function data and no data on tumour complexity. In its first year, mandatory national reporting has provided several challenging contemporary insights into NSS. © 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.

Effects of a laboratory-based skills curriculum on laparoscopic proficiency: a randomized trial.

PubMed

Coleman, Robert L; Muller, Carolyn Y

2002-04-01

The purpose of this study was to determine the effect and validity of an intensive laboratory-based laparoscopic skills training curriculum on operative proficiency in obstetrics and gynecology residents. This was a prospective, randomized, block-design trial of postgraduate year 3 and 4 residents. The following study schedule was used: week 1 (pre-randomization) included an orientation to study objectives, the administration of a laparoscopic experience questionnaire, timed video-laparoscopic drills (5 total), and the performance of a video-recorded laparoscopic partial salpingectomy; during weeks 2 and 3, the skills group residents repeated the laparoscopic drills 30 minutes daily for 10 days, and the control group residents had no formal practice sessions; during week 4, the week 1 evaluation was repeated. Operative proficiency was quantified by the Global Skills Assessment Tool through blinded, independent scoring of videotapes. Twenty-six residents (skills group, 12; control group, 14) consented to the trial. Patient-related issues excluded 8 residents (30%). At week 1, no significant differences existed in previous laparoscopic experience, timed video skills, or resident operative proficiency (Global Skills Assessment Tool score) between cohorts. At week 4, both groups significantly improved their timed drill test scores. The percent reduction in time from baseline was of greater magnitude in the skills group versus control group (51% vs 18%,P <.0001). Laparoscopic performance also improved in both cohorts (P =.002). However, only the skills group demonstrated significant intra-cohort improvement from baseline (mean, 4.9 points; P =.015; 95% CI, 1-7.5). A core curriculum of intensive video laparoscopic skills training improves not only technical but also operative performance among postgraduate year 3 and 4 residents.

Isolated renal hydatid disease: experience at the queen rania urology center, the king hussein medical center.

PubMed

Abu-Qamar, Adnan A; Aljader, Khalaf M; Habboub, Hazem

2004-01-01

In this retrospective study, we present our experience on the diagnosis and management of isolated Hydatid disease of the kidneys. Between January 1999 and January 2003, eight patients were diagnosed to have Hydatid disease of the kidney and constituted the subjects of this study. Their age ranged between 20 and 63 years age (mean 40); there were five males and three females. Loin pain was the commonest mode of presentation in these patients. Investigations performed included urine analysis, serological tests, eosinophil count and relevant radiological studies. Urine analysis showed hydatiduria in one patient, the Casoni's test was positive in two, Ghedini skin test was positive in three and eosinophilia was noted in two other patients. All patients were treated surgically using loin supracostal extra-peritoneal approach. Total nephrectomy was performed in five patients, partial nephrectomy in one while excision of the cyst was performed in two patients. Our report suggests that a combination of various investigative modalities with a high index of suspicion is necessary in establishing the correct diagnosis. Surgery remains the main option of treatment for renal hydatid disease.

Repair after nephron ablation reveals limitations of neonatal neonephrogenesis

PubMed Central

Tögel, Florian; Freedman, Benjamin S.; Iatrino, Rossella; Grinstein, Mor; Bonventre, Joseph V.

2017-01-01

The neonatal mouse kidney retains nephron progenitor cells in a nephrogenic zone for 3 days after birth. We evaluated whether de novo nephrogenesis can be induced postnatally beyond 3 days. Given the long-term implications of nephron number for kidney health, it would be useful to enhance nephrogenesis in the neonate. We induced nephron reduction by cryoinjury with or without contralateral nephrectomy during the neonatal period or after 1 week of age. There was no detectable compensatory de novo nephrogenesis, as determined by glomerular counting and lineage tracing. Contralateral nephrectomy resulted in additional adaptive healing, with little or no fibrosis, but did not also stimulate de novo nephrogenesis. In contrast, injury initiated at 1 week of age led to healing with fibrosis. Thus, despite the presence of progenitor cells and ongoing nephron maturation in the newborn mouse kidney, de novo nephrogenesis is not inducible by acute nephron reduction. This indicates that additional nephron progenitors cannot be recruited after birth despite partial renal ablation providing a reparative stimulus and suggests that nephron number in the mouse is predetermined at birth. PMID:28138555

Significant impact of R.E.N.A.L. nephrometry score on changes in postoperative renal function early after robot-assisted partial nephrectomy.

PubMed

Miyake, Hideaki; Furukawa, Junya; Hinata, Nobuyuki; Muramaki, Mototsugu; Tanaka, Kazushi; Fujisawa, Masato

2015-06-01

Our objective was to evaluate the significance of the R.E.N.A.L. nephrometry score (RNS)--developed to quantitatively evaluate the complexity of renal tumors in a reproducible manner--in perioperative and renal functional outcomes following robot-assisted partial nephrectomy (RAPN). This study assessed 48 consecutive patients with renal tumors who underwent RAPN. Preoperative RNS for each patient was calculated, and its impact on several parameters associated with perioperative outcomes, including postoperative renal function, was investigated with Spearman's rank correlation test. Mean RNS in the 48 patients was 6.8; of these 48 patients, 21 (43.7%), 24 (50.0%), and three (6.3%) were classified into low-, moderate-, and high-complexity groups, respectively. The RNS was significantly correlated with resected tumor weight and postoperative changes in estimated glomerular filtration rate (eGFR) at both 1 and 4 weeks--but not age, body mass index (BMI), preoperative eGFR, operative time, warm ischemia time, estimated blood loss, postoperative complications, or eGFR-- after RAPN. No component of the RNS (R: radius; E: exophytic/endophytic properties; N: nearness of tumor to the collecting system or sinus; A: anterior/posterior; L: location relative to polar lines) alone had a significant impact on postoperative changes in eGFR at 1 and 4 weeks, whereas resected tumor weight was significantly associated with the R and E subcategories. Measurement of total RNS is useful for predicting renal functional outcomes early after RAPN.

Anatomical Relationship Between the Kidney Collecting System and the Intrarenal Arteries in the Sheep: Contribution for a New Urological Model.

PubMed

Buys-Gonçalves, Gabriela Faria; De Souza, Diogo Benchimol; Sampaio, Francisco José Barcellos; Pereira-Sampaio, Marco Aurélio

2016-04-01

Previous studies have demonstrated that the pig collecting system heals after partial nephrectomy without closure. Recently, a study in sheep showed that partial nephrectomy without closure of the collecting system resulted in urinary leakage and urinoma. The aim of this study was to present detailed anatomical findings on the intrarenal anatomy of the sheep. Forty two kidneys were used to produce tridimensional endocasts of the collecting system together with the intrarenal arteries. A renal pelvis which displayed 11-19 (mean of 16) renal recesses was present. There were no calices present. The renal artery was singular in each kidney and gave two primary branches one to the dorsal surface and one to ventral surface. Dorsal and ventral branches of the renal artery were classified based on the relationship between their branching pattern and the collecting system as: type I (cranial and caudal segmental arteries), type II (cranial, middle and caudal segmental arteries) or type III (cranial, cranial middle, caudal middle, and caudal segmental arteries). Type I was the most common branching pattern for the dorsal and ventral branches of the renal artery. The arterial supply of the caudal pole of the sheep kidney supports its use as an experimental model due to the similarity to the human kidney. However, the lack of a retropelvic artery discourages the use of the cranial pole in experiments in which the arteries are an important aspect to be considered. © 2016 Wiley Periodicals, Inc.

The effects of α-lipoic acid on aortic injury and hypertension in the rat remnant kidney (5/6 nephrectomy) model.

PubMed

Ergür, Bekir Uğur; Çilaker Mıcılı, Serap; Yılmaz, Osman; Akokay, Pınar

2015-06-01

The present study was designed to investigate the effects of α-lipoic acid on the abdominal aorta and hypertension in a remnant kidney model histomorphometrically, immunohistochemically, and ultrastructurally. We surgically reduced the renal tissue mass to 5/6 by applying a remnant kidney model. The rats were divided into 4 groups: Group 1- control group, Group 2- lipoic acid group, Group 3- 5/6 nephrectomy group, and Group IV: 5/6 nephrectomy+lipoic acid-treated group. Lipoic acid solution 100 mg/kg was administered by oral gavage for 8 weeks to Groups II and IV. At the end of the experiment, systemic mean blood pressure was monitored. Then, aortic tissues were removed and fixed. After routine histological procedures, tissue sections were examined histochemically, immunohistochemically (type I angiotensin receptor, vascular endothelial growth factor, alpha-smooth muscle actin), and ultrastructurally. The blood pressure measurements in 5/6 nephrectomy group were significantly higher compared to other groups. In the 5/6 nephrectomy+lipoic acid group, measured blood pressure values and tunica media thickness were significantly lower than in the 5/6 nephrectomy group. In the 5/6 nephrectomy+lipoic acid group, decreased aortic wall thickness, regularity in the structure of elastic fibrils, and more organized elastic lamellae were seen. The expression of type I angiotensin receptor, vascular endothelial growth factor, alpha-smooth muscle actin in the 5/6 nephrectomy+lipoic acid group was decreased compared to the 5/6 nephrectomy group. In the present study, we found that α-lipoic acid could be a favorable agent for the target organ effects of secondary hypertension.

Agenesis of the left hepatic lobe undergoing laparoscopic hepatectomy for hepatocellular carcinoma: a case report.

PubMed

Matsushita, Katsunori; Gotoh, Kunihito; Eguchi, Hidetoshi; Iwagami, Yoshihumi; Yamada, Daisaku; Asaoka, Tadafumi; Noda, Takehiro; Wada, Hiroshi; Kawamoto, Koichi; Doki, Yuichiro; Mori, Masaki

2017-12-01

Agenesis of the left hepatic lobe is a rare anomaly. It is defined as the absence of liver tissue to the left of the gallbladder fossa. Additionally, agenesis of the left hepatic lobe accompanied by hepatocellular carcinoma is quite rare. We experienced the case of a patient with agenesis of the left hepatic lobe, undergoing laparoscopic hepatectomy for HCC. A 79-year-old man was referred to our department with epigastralgia. Abdominal computed tomography revealed agenesis of the left hepatic lobe, accompanied by hepatocellular carcinoma in segments 7 and 8. He underwent laparoscopic partial hepatectomy of segments 7 and 8. The operative findings revealed complete agenesis of the liver to the left of the falciform ligament. The patient had a favorable clinical course without liver dysfunction or any complications. We experienced a case with agenesis of the left hepatic lobe undergoing laparoscopic hepatectomy for HCC. Awareness of such anomaly is important for surgeons to avoid postoperative complications.

Laparoscopic unroofing of splenic cysts results in a high rate of recurrences.

PubMed

Schier, Felix; Waag, Karl-Ludwig; Ure, Benno

2007-11-01

Laparoscopic unroofing is described as an appropriate treatment modality of nonparasitic splenic cysts. However, we repeatedly encountered recurrences with this technique. Because splenic cysts are rare, we analyzed the combined experience of 3 German pediatric surgical departments. Between 1995 and 2005, primary and secondary nonparasitic splenic cysts were unroofed laparoscopically in 14 children (aged 5-12 years; median, 8.5 years). In 3 patients, the inner surface was coagulated with the argon beamer. In most children, the cavity was surfaced with omentum. In addition, in 4 patients the omentum was sutured to the splenic parenchyma. No intraoperative complications occurred, and no inadvertent splenectomy or blood transfusions were necessary. However, in 9 children (64%) the cysts recurred at intervals ranging from 6 to 12 months (median, 12 months). Also, argon laser treatment of the surface resulted in recurrence. Laparoscopic unroofing of true splenic cysts alone proved inadequate in this series. Either removal of the inner layer or partial splenectomy appears to be necessary to prevent recurrences.

Robotic unclamped "minimal-margin" partial nephrectomy: ongoing refinement of the anatomic zero-ischemia concept.

PubMed

Satkunasivam, Raj; Tsai, Sheaumei; Syan, Sumeet; Bernhard, Jean-Christophe; de Castro Abreu, Andre Luis; Chopra, Sameer; Berger, Andre K; Lee, Dennis; Hung, Andrew J; Cai, Jie; Desai, Mihir M; Gill, Inderbir S

2015-10-01

Anatomic partial nephrectomy (PN) techniques aim to decrease or eliminate global renal ischemia. To report the technical feasibility of completely unclamped "minimal-margin" robotic PN. We also illustrate the stepwise evolution of anatomic PN surgery with related outcomes data. This study was a retrospective analysis of 179 contemporary patients undergoing anatomic PN at a tertiary academic institution between October 2009 and February 2013. Consecutive consented patients were grouped into three cohorts: group 1, with superselective clamping and developmental-curve experience (n = 70); group 2, with superselective clamping and mature experience (n = 60); and group 3, which had completely unclamped, minimal-margin PN (n = 49). Patients in groups 1 and 2 underwent superselective tumor-specific devascularization, whereas patients in group 3 underwent completely unclamped minimal-margin PN adjacent to the tumor edge, a technique that takes advantage of the radially oriented intrarenal architecture and anatomy. Primary outcomes assessed the technical feasibility of robotic, completely unclamped, minimal-margin PN; short-term changes in estimated glomerular filtration rate (eGFR); and development of new-onset chronic kidney disease (CKD) stage >3. Secondary outcome measures included perioperative variables, 30-d complications, and histopathologic outcomes. Demographic data were similar among groups. For similarly sized tumors (p = 0.13), percentage of kidney preserved was greater (p = 0.047) and margin width was narrower (p = 0.0004) in group 3. In addition, group 3 had less blood loss (200, 225, and 150ml; p = 0.04), lower transfusion rates (21%, 23%, and 4%; p = 0.008), and shorter hospital stay (p = 0.006), whereas operative time and 30-d complication rates were similar. At 1-mo postoperatively, median percentage reduction in eGFR was similar (7.6%, 0%, and 3.0%; p = 0.53); however, new-onset CKD stage >3 occurred less frequently in group 3 (23%, 10%, and 2%; p = 0.003). Study limitations included retrospective analysis, small sample size, and short follow-up. We developed an anatomically based technique of robotic, unclamped, minimal-margin PN. This evolution from selective clamped to unclamped PN may further optimize functional outcomes but requires external validation and longer follow-up. The technical evolution of partial nephrectomy surgery is aimed at eliminating global renal damage from the cessation of blood flow. An unclamped minimal-margin technique is described and may offer renal functional advantage but requires long-term follow-up and validation at other institutions. Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Safety and hemostatic efficacy of fibrin pad in partial nephrectomy: Results of an open-label Phase I and a randomized, standard-of-care-controlled Phase I/II study

PubMed Central

2012-01-01

Background Bleeding severity, anatomic location, tissue characteristics, and visibility are common challenges encountered while managing intraoperative bleeding, and conventional hemostatic measures (suture, ligature, and cautery) may sometimes be ineffective or impractical. While topical absorbable hemostats (TAH) are useful hemostatic adjuvants, each TAH has associated disadvantages. Methods We evaluated the safety and hemostatic efficacy of a new advanced biologic combination product―fibrin pad―to potentially address some gaps associated with TAHs. Fibrin pad was assessed as adjunctive hemostat in open partial nephrectomy in single-center, open-label, Phase I study (N = 10), and as primary hemostat in multicenter, single-blind, randomized, standard-of-care (SOC)-controlled Phase I/II study (N = 7) in Israel. It was used to control mild-to-moderate bleeding in Phase I and also spurting arterial bleeding in Phase I/II study. Phase I study assessed safety and Phase I/II study, proportion of successes at 10 min following randomization, analyzed by Fisher exact tests at 5% significance level. Results Phase I (N = 10): All patients completed the study. Hemostasis was achieved within 3–4 min (average = 3.1 min) of a single application in all patients. Fibrin pad was found to be safe for human use, with no product-related adverse events reported. Phase I/II (N = 7): Hemostatic success at 10 min (primary endpoint) was achieved in 3/4 patients treated with fibrin pad versus 0/3 patients treated with SOC. No clinically significant change in laboratory or coagulation parameters was recorded, except a case of post-procedural hemorrhage with fibrin pad, which was considered serious and related to the fibrin pad treatment, and required re-operation. Although Data Safety Monitoring Board authorized trial continuation, the sponsor decided against proceeding toward an indication for primary treatment of severe arterial hemorrhage as a replacement for sutures. The study was suspended after 7/30 planned subjects were enrolled. Conclusions The first-in-man trial of fibrin pad demonstrated its safety and efficacy as an adjunctive hemostatic technique for mild-to-moderate bleeding in partial nephrectomy. The study also suggested that the product should not replace sutures or meticulous surgical techniques for the treatment of severe arterial hemorrhage. Trial registration Phase I/II trial, NCT00598130 PMID:23137020

Cost effective laparoendoscopic single-site surgery with a reusable platform.

PubMed

Schwentner, C; Todenhöfer, T; Seibold, J; Alloussi, S; Aufderklamm, S; Mischinger, J; Stenzl, A; Gakis, G

2013-01-01

Many disposable platforms have been applied in laparoendoscopic single-site surgery (LESS). Besides technical issues, cost is one of the limiting factors for its widespread acceptance. The current study describes the first completely reusable LESS-platform. We performed LESS-procedures in 52 patients including nephrectomy (18), adrenalectomy (2), partial nephrectomy (3), pyeloplasty (4), renal cyst ablation (4), pelvic lymphadenectomy (15), and lymphocele ablation (6). All procedures were conducted using a novel reusable single-port device (X-Cone, Karl-Storz) with a simplified set of instruments. We obtained perioperative and demographic data, including a visual analogue pain scale (VAS), and a complication reporting system based on Clavien grading. Mean age was 50.04 y. Conversion to standard laparoscopy was necessary in 3 cases and addition of a needlescopic instrument in 6 cases. There was no open conversion. Intra- and postoperative complications occurred in 3 (Clavien II in 2 and III in 1) cases. Mean operative time was 110, 90, and 89 min, and hospital stay was 4.9, 3.1, and 3.6 d for nephrectomy, pelvic lymphadenectomy, and pyeloplasty, respectively. Mean VAS was 2.13, 1.07, and 1.5 while blood loss was 81.3 mL, 25.67 mL, and 17.5 mL, respectively. Mean lymph node yield was 15 (range, 8 to 21). A completely reusable LESS-platform is applicable to various uses in urology, yielding favorable functional and cosmetic results. Reusable materials are useful to reduce the cost of LESS, further increasing its acceptance. LESS with a completely reusable platform is more cost effective than standard laparoscopy.

Laparoscopic transverse rectus abdominus flap delay for autogenous breast reconstruction.

PubMed

Kaddoura, I L; Khoury, G S

1998-01-01

Laparoscopic ligation of the deep and superficial inferior epigastric vessels was done for ten mastectomized patients who elected to have autogenous reconstruction of their breast. All these patients had at least one indication for the delay which included obesity, smoking, or requirement of a large volume of tissue for their reconstruction. The procedure did not add any morbidity or mortality to our patients and was found to be comparable to the "open" delay in preventing partial tissue loss in all but two patients. We describe the use of a minimally invasive procedure to augment the deep superior epigastric pedicled blood supply for the future transverse rectus abdominus flap. We have found in laparoscopic delay a safe, short procedure that is useful in high risk patients who choose the option of autologous breast reconstruction.

Laparoscopic completion radical cholecystectomy for T2 gallbladder cancer.

PubMed

Gumbs, Andrew A; Hoffman, John P

2010-12-01

The role of minimally invasive surgery in the surgical management of gallbladder cancer is a matter of controversy. Because of the authors' growing experience with laparoscopic liver and pancreatic surgery, they have begun offering patients laparoscopic completion partial hepatectomies of the gallbladder bed with laparoscopic hepatoduodenal lymphadenectomy. The video shows the steps needed to perform laparoscopic resection of the residual gallbladder bed, the hepatoduodenal lymph node nodes, and the residual cystic duct stump in a setting with a positive cystic stump margin. The skin and fascia around the previous extraction site are resected, and this site is used for specimen retrieval during the second operation. To date, three patients have undergone laparoscopic radical cholecystectomy with hepatoduodenal lymph node dissection for gallbladder cancer. The average number of lymph nodes retrieved was 3 (range, 1-6), and the average estimated blood loss was 117 ml (range, 50-200 ml). The average operative time was 227 min (range, 120-360 min), and the average hospital length of stay was 4 days (range, 3-5 days). No morbidity or mortality was observed during 90 days of follow-up for each patient. Although controversy exists as to the best surgical approach for gallbladder cancer diagnosed after routine laparoscopic cholecystectomy, the minimally invasive approach seems feasible and safe, even after previous hepatobiliary surgery. If the previous extraction site cannot be ascertained, all port sites can be excised locally. Larger studies are needed to determine whether the minimally invasive approach to postoperatively diagnosed early-stage gallbladder cancer has any drawbacks.

Laparoscopic lateral pancreaticojejunostomy: a new remedy for an old ailment.

PubMed

Palanivelu, C; Shetty, R; Jani, K; Rajan, P S; Sendhilkumar, K; Parthasarthi, R; Malladi, V

2006-03-01

Lateral pancreaticojejunostomy is considered as the standard surgery for chronic pancreatitis. Yet there are very few reports of this procedure being done laparoscopically. We present our experience with laparoscopic lateral pancreaticojejunostomy till date and describe our technique. Since 1997, we have done 12 laparoscopic lateral pancreatojejunostomies. There were 9 females and 3 males and the average age was 29.3 years. The indication for surgery in all patients was intractable abdominal pain and significant weight loss. Additionally, two patients were also suffering from pancreatic ascites. The average diameter of the pancreatic duct was 14.7 mm. We used a four-port technique. All surgeries were completed without any conversion to open surgery. Post-operatively, there were no major morbidity and nil mortality. The average operating time was 172 minutes. Post-operative stay was short (average 5 days) and on median follow-up of 4.4 years, 83.3% patients had complete pain relief while 16.7% had partial relief. All patients had significant weight gain. Laparoscopic lateral pancreaticojejunostomy is safe, effective and feasible in experience hands. Mastery of intracorporeal knotting and suturing techniques is mandatory before embarking on this surgery.

Systematic review: Laparoscopic fundoplication for gastroesophageal reflux disease in partial responders to proton pump inhibitors

PubMed Central

Lundell, Lars; Bell, Martin; Ruth, Magnus

2014-01-01

AIM: To assess laparoscopic fundoplication (LF) in partial responders to proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD). METHODS: We systematically searched PubMed and Embase (1966-Dec 2011) for articles reporting data on LF efficacy in partial responders. Due to a lack of randomized controlled trials, observational studies were included. Of 558 articles screened, 17 were eligible for inclusion. Prevalence data for individual symptoms were collated across studies according to mutually compatible time points (before and/or after LF). Where suitable, prevalence data were presented as percentage of patients reporting symptoms of any frequency or severity. RESULTS: Due to a lack of standardized reporting of symptoms, the proportion of patients experiencing symptoms was recorded across studies where possible. After LF, the proportion of partial responders with heartburn was reduced from 93.1% (5 studies) to 3.8% (5 studies), with similar results observed for regurgitation [from 78.4% (4 studies) to 1.9% (4 studies)]. However, 10 years after LF, 35.8% (2 studies) of partial responders reported heartburn and 29.1% (1 study) reported regurgitation. The proportion using acid-suppressive medication also increased, from 8.8% (4 studies) in the year after LF to 18.2% (2 studies) at 10 years. In the only study comparing partial responders to PPI therapy with complete responders, higher symptom scores and more frequent acid-suppressive medication use were seen in partial responders after LF. CONCLUSION: GERD symptoms improve after LF, but subsequently recur, and acid-suppressive medication use increases. LF may be less effective in partial responders than in complete responders. PMID:24574753

Renoduodenal Fistula After Transcatheter Embolization of Renal Angiomyolipoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sheth, Rahul A.; Feldman, Adam S.; Walker, T. Gregory, E-mail: tgwalker@partners.org

Transcatheter embolization of renal angiomyolipomas is a routinely performed, nephron-sparing procedure with a favorable safety profile. Complications from this procedure are typically minor in severity, with postembolization syndrome the most common minor complication. Abscess formation is a recognized but uncommon major complication of this procedure and is presumably due to superinfection of the infarcted tissue after arterial embolization. In this case report, we describe the formation of a renoduodenal fistula after embolization of an angiomyolipoma, complicated by intracranial abscess formation and requiring multiple percutaneous drainage procedures and eventual partial nephrectomy.

[Cortico-suprarenal carcinoma].

PubMed

Alecu, L; Costan, I; Viţalariu, Adriana; Lungu, C; Obrocea, F; Gulinescu, L

2002-01-01

The authors show the case of a 69 years old male with a large corticosuprarenalian tumor that was detected on an random abdominal echographic examination. The patient was operated in the General Surgery Department. of Prof. Agrippa Ionescu Hospital, Bucharest. We performed ablation of the large left suprarenalian gland malign tumor with left nephrectomy, splenectomy and partial pancreatectomy. The hystopathological examination reveals a diffuse corticosuprenalian carcinoma. The case is interesting because of low incidence of this kind of malign tumor and also of the unusual tumor evolution in a long time up to its large size (12 cm in diameter).

Declining Operative Experience for Junior-Level Residents: Is This an Unintended Consequence of Minimally Invasive Surgery?

PubMed

Mullen, Matthew G; Salerno, Elise P; Michaels, Alex D; Hedrick, Traci L; Sohn, Min-Woong; Smith, Philip W; Schirmer, Bruce D; Friel, Charles M

2016-01-01

Our group has previously demonstrated an upward shift from junior to senior resident participation in common general surgery operations, traditionally performed by junior-level residents. The objective of this study was to evaluate if this trend would correct over time. We hypothesized that junior resident case volume would improve. A sample of essential laparoscopic and open general surgery procedures (appendectomy, inguinal herniorrhaphy, cholecystectomy, and partial colectomy) was chosen for analysis. The American College of Surgeons National Surgical Quality Improvement Program Participant Use Files were queried for these procedures between 2005 and 2012. Cases were stratified by participating resident post-graduate year with "junior resident" defined as post-graduate year1-3. Logistic regression was performed to determine change in junior resident participation for each type of procedure over time. A total of 185,335 cases were included in the study. For 3 of the operations we considered, the prevalence of laparoscopic surgery increased from 2005-2012 (all p < 0.001). Cholecystectomy was an exception, which showed an unchanged proportion of cases performed laparoscopically across the study period (p = 0.119). Junior resident participation decreased by 4.5%/y (p < 0.001) for laparoscopic procedures and by 6.2%/y (p < 0.001) for open procedures. The proportion of laparoscopic surgeries performed by junior-level residents decreased for appendectomy by 2.6%/y (p < 0.001) and cholecystectomy by 6.1%/y (p < 0.001), whereas it was unchanged for inguinal herniorrhaphy (p = 0.75) and increased for partial colectomy by 3.9%/y (p = 0.003). A decline in junior resident participation was seen for all open surgeries, with appendectomy decreasing by 9.4%/y (p < 0.001), cholecystectomy by 4.1%/y (p < 0.002), inguinal herniorrhaphy by 10%/y (p < 0.001) and partial colectomy by 2.9%/y (p < 0.004). Along with the proliferation of laparoscopy for common general surgical procedures there has been a concomitant reduction in the participation of junior-level residents. As previously thought, familiarity with laparoscopy has not translated to redistribution of basic operations from senior to junior residents. This trend has significant implications for general surgery resident education. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Radical Nephrectomy for Primary Retroperitoneal Liposarcoma Near the Kidney has a Beneficial Effect on Disease-Free Survival.

PubMed

Rhu, Jinsoo; Cho, Chan Woo; Lee, Kyo Won; Park, Hyojun; Park, Jae Berm; Choi, Yoon-La; Kim, Sung Joo

2018-01-01

The purpose of this study is to analyze the clinical impact of radical nephrectomy on retroperitoneal liposarcoma near the kidney. Data of patients who underwent surgery for unilateral primary retroperitoneal liposarcoma near the kidney were retrospectively collected. Patients were divided into four groups according to whether they underwent nephrectomy and combined resection of other organs. Kaplan-Meier survival analysis was used to estimate disease-free survival and overall survival. Multivariable Cox analysis was used to analyze factors related to disease-free survival and overall survival. Nephrectomy (HR = 0.260, CI = 0.078-0.873, p = 0.029) had a beneficial effect on disease-free survival, while interaction model of nephrectomy*other organ resection (HR = 4.655, CI = 1.767-12.263, p = 0.002) showed poor disease-free survival. Other organ resection was not related to disease-free survival (HR = 1.543, CI = 0.146-16.251, p = 0.718). Operation method (p = 0.007) and FNCLCC grade (p < 0.001; G2, HR = 1.833, CI = 0.684-4.915, p = 0.228; G3, HR = 9.190, CI = 3.351-25.199, p < 0.001) were significant factors for disease-free survival. While combined organ resection without nephrectomy group (HR = 1.604, CI = 0.167-15.370, p = 0.682) and radical nephrectomy with combined organ resection group (HR = 1.309, CI = 0.448-3.825, p = 0.622) did not show significant difference in disease-free survival from the mass excision only group, radical nephrectomy without combined organ resection group (HR = 0.279, CI = 0.078-0.991, p = 0.048) showed superior disease-free survival. Radical nephrectomy of unilateral primary retroperitoneal liposarcoma near the kidney has a beneficial effect on disease-free survival.

Saline-filled laparoscopic surgery: A basic study on partial hepatectomy in a rabbit model.

PubMed

Shimada, Masanari; Kawaguchi, Masahiko; Ishikawa, Norihiko; Watanabe, Go

2015-01-01

There is still a poor understanding of the effects of pneumoperitoneum with insufflation of carbon dioxide gas (CO2) on malignant cells, and pneumoperitoneum has a negative impact on cardiopulmonary responses. A novel saline-filled laparoscopic surgery (SAFLS) is proposed, and the technical feasibility of performing saline-filled laparoscopic partial hepatectomy (LPH) was evaluated in a rabbit model. Twelve LPH were performed in rabbits, with six procedures performed using an ultrasonic device with CO2 pneumoperitoneum (CO2 group) and six procedures performed using a bipolar resectoscope (RS) in a saline-filled environment (saline group). Resection time, CO2 and saline consumption, vital signs, blood gas analysis, complications, interleukin-1 beta (IL-1β) and C-reactive protein (CRP) levels were measured. The effectiveness of the resections was evaluated by the pathological findings. LPH was successfully performed with clear observation by irrigation and good control of bleeding by coagulation with RS. There were no significant differences in all perioperative values, IL-1βand CRP levels between the two groups. All pathological specimens of the saline group showed that the resected lesions were coagulated and regenerated as well as in the CO2 group. SAFLS is feasible and provides a good surgical view with irrigation and identification of bleeding sites.

The Impact of Surgeon Volume on Perioperative Outcomes and Cost for Patients Receiving Robotic Partial Nephrectomy.

PubMed

Khandwala, Yash S; Jeong, In Gab; Kim, Jae Heon; Han, Deok Hyun; Li, Shufeng; Wang, Ye; Chang, Steven L; Chung, Benjamin I

2017-09-01

Little is known about the impact of surgeon volume on the success of the robot-assisted partial nephrectomy (RAPN). The objective of this study was to compare the perioperative outcomes and cost related to RAPN by annual surgeon volumes. Using the Premier Hospital Database, we retrospectively analyzed 39,773 patients who underwent RAPN between 2003 and 2015 in the United States. Surgeons for each index case were grouped into quintiles for each respective year. Outcomes were 90-day postoperative complications, operating room time (ORT), blood transfusion, length of stay, and direct hospital costs. Logistic regression and generalized linear models were used to identify factors predicting complications and cost. After accounting for patient and hospital demographics, high- and very high-volume surgeons had 40% and 42% decreased odds of having major complications (p = 0.045 and p = 0.027, respectively). Surgeons with higher volumes were associated with fewer odds of prolonged ORT (0.68 for low, 0.72 for intermediate, 0.56 for high, 0.44 for very high volume, all p < 0.05) and length of hospital stay (0.67 for intermediate, 0.51 for high, 0.45 for very high volume, all p < 0.01) compared with very low-volume surgeons. The 90-day hospital cost was also significantly lower for the surgeons with higher volume, but the statistical significance diminished after consideration of hospital clustering. Surgeons with very high RAPN volumes were found to have superior perioperative outcomes. Although cost of care appeared to correlate with surgeon volume, there may be other more influential factors predicting cost.

Bilateral Wilms' tumor with anaplasia: lessons from the National Wilms' Tumor Study.

PubMed

Hamilton, Thomas E; Green, Daniel M; Perlman, Elizabeth J; Argani, Pedram; Grundy, Paul; Ritchey, Michael L; Shamberger, Robert C

2006-10-01

The purpose of this study was to evaluate whether initial diagnostic technique influenced the ability to identify anaplastic histology, to determine the time interval to diagnosis of anaplasia, and to delineate the incidence of discordant pathology in bilateral Wilms' tumor. We hypothesized that delay in diagnosis of anaplasia could affect time to appropriate surgery and intensive multimodality therapy. One hundred eight-nine children were enrolled in the fourth National Wilms' Tumor Study with synchronous bilateral tumors, 27 of whom were eventually shown to have anaplastic histology. Initial diagnostic technique, time interval to diagnosis of anaplasia, and the incidence of discordant pathology were determined. Anaplasia was identified in 0 of 7 tumors by core needle biopsy, 3 of 9 tumors by open wedge biopsy, and in 7 of 9 cases by partial or complete nephrectomy. The mean duration of first chemotherapy regimen (DD or EE) was 20, 39, and 36 weeks, respectively, before anaplasia was identified at second surgery. Discordant pathology between bilateral tumors was identified on final tissue diagnosis in 20 patients. Only 4 patients had anaplastic tumors in both kidneys. Core needle biopsy did not identify anaplasia in 7 of 7 children. Open biopsy or partial/complete nephrectomy identified anaplasia at initial diagnostic procedure in 10 of 18 children. Twenty of 24 patients at final tissue diagnosis had discordant pathology between the 2 kidneys. Earlier interval incisional biopsy or resection may identify anaplastic histology and limit the duration of chemotherapy targeted to favorable histology for children with bilateral Wilms' tumor and anaplasia.

Simultaneous bilateral robotic partial nephrectomy: Case report and critical evaluation of the technique.

PubMed

Giberti, Claudio; Gallo, Fabrizio; Schenone, Maurizio; Cortese, Pierluigi

2014-06-16

We report our first simultaneous bilateral robot assisted partial nephrectomy (RAPN) in order to show and critically discuss the feasibility of this procedure. Materials and methods A 69-year-old male patient visited our department due to incidental finding of bilateral mesorenal small masses (2.5 cm on the right and 3.5 cm on the left) suspicious for malignancy. We started from the right side with patient in flank position. Port placement: 12-mm periumbilical camera port, two 8-mm robotic ports in wide ''V''configuration, additional 12 mm assistant port on the midline between the umbilicus and symphysis pubis. A right unclamping RAPN with sliding clip renorrhaphy was performed. The trocars were removed and the robot undocked. Without interrupting the anesthesiological procedures, the patient was reported in supine position and, after 180 degrees rotation of the surgical bed, was newly placed in contralateral flank position. Using both the previous periumbilical and midline ports, two other 8-mm robotic trocars were placed. The robot was then redocked and RAPN was also performed on the left side using the same previously reported technique. Results Total time: 285 min. Estimated blood losses: 150 cc. Postoperative period: uneventful. Pathological examination: bilateral renal cell carcinoma, negative surgical margins. Conclusions Our experience was encouraging and confirmed the feasibility and safety of this procedure. The planning of our technique was time and cost effective with cosmetic benefit for the patient. However, we think that an appropriate selection of the patients and a skill in robotic renal surgery are advisable before approaching this type of surgery.

The Impact of Preexisting Chronic Kidney Disease on the Severity and Recovery of Acute Kidney Injury.

PubMed

Lim, Sung Yoon; Ko, Yoon Sook; Lee, Hee Young; Yang, Ji Hyun; Kim, Myung Gyu; Jo, Sang Kyung; Cho, Won Yong

2018-04-12

Recent observational studies have shown that in chronic kidney disease (CKD) patients, a significantly smaller percentage of patients with an episode of acute kidney injury (AKI) have full recovery of renal function compared to those without CKD. However, precise mechanisms involved in the incomplete repair after AKI with preexisting CKD have not been completely ascertained. Here, we assessed the impact of preexisting CKD on the severity and recovery of AKI in a mouse model of 5/6 nephrectomy. Male CD-1 mice underwent 5/6 nephrectomy (Nx). Six weeks post surgery, ischemia reperfusion injury (IRI) or a sham operation was performed and functional, histological, and various molecular parameters were compared between them. Serum creatinine level on day 1 after IRI was comparable between control and Nx mice. However, serum creatinine remained significantly higher throughout the recovery phase in Nx mice compared to control mice. mRNA and protein expression of the cell cycle regulatory proteins were persistently elevated in Nx mice and this was associated with significantly increased levels of the G1 cell cycle arrest markers. Treatment with a p53 inhibitor following IRI resulted in not only decreased expression of G1 arrest markers but also decreased fibrosis, suggesting that prolonged epithelial G1 cell cycle arrest might be partially responsible for impaired recovery from superimposed AKI on CKD. Taken together, reduced nephron mass have a negative effect on the repair process that is partially mediated by the disruption of the cell cycle regulation. © 2018 S. Karger AG, Basel.

National practice patterns and outcomes of pediatric nephrectomy: comparison between urology and general surgery.

PubMed

Suson, Kristina D; Wolfe-Christensen, Cortney; Elder, Jack S; Lakshmanan, Yegappan

2015-05-01

In adults nephrectomy is under the purview of urologists, but pediatric urologists and pediatric general surgeons perform extirpative renal surgery in children. We compared the contemporary performance and outcome of all-cause nephrectomy at pediatric hospitals as performed by pediatric urologists and pediatric general surgeons. We queried the Pediatric Health Information System to identify patients 0 to 18 years old who were treated with nephrectomy between 2004 and 2013 by pediatric urologists and pediatric general surgeons. Data points included age, gender, severity level, mortality risk, complications and length of stay. Patients were compared by APR DRG codes 442 (kidney and urinary tract procedures for malignancy) and 443 (kidney and urinary tract procedures for nonmalignancy). Pediatric urologists performed more all-cause nephrectomies. While pediatric urologists were more likely to operate on patients with benign renal disease, pediatric general surgeons were more likely to operate on children with malignancy. Patients on whom pediatric general surgeons operated had a higher average severity level and were at greater risk for mortality. After controlling for differences patients without malignancy operated on by pediatric urologists had a shorter length of stay, and fewer medical and surgical complications. There was no difference in length of stay, or medical or surgical complications in patients with malignancy. Overall compared to pediatric general surgeons more nephrectomies are performed by pediatric urologists. Short-term outcomes, including length of stay and complication rates, appear better in this data set in patients without malignancy who undergo nephrectomy by pediatric urologists but there is no difference in outcomes when nephrectomy is performed for malignancy. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Pre-bent instruments used in single-port laparoscopic surgery versus conventional laparoscopic surgery: comparative study of performance in a dry lab.

PubMed

Miernik, Arkadiusz; Schoenthaler, Martin; Lilienthal, Kerstin; Frankenschmidt, Alexander; Karcz, Wojciech Konrad; Kuesters, Simon

2012-07-01

Different types of single-incision laparoscopic surgery (SILS) have become increasingly popular. Although SILS is technically even more challenging than conventional laparoscopy, published data of first clinical series seem to demonstrate the feasibility of these approaches. Various attempts have been made to overcome restrictions due to loss of triangulation in SILS by specially designed SILS-specific instruments. This study involving novices in a dry lab compared task performances between conventional laparoscopic surgery (CLS) and single-port laparoscopic surgery (SPLS) using newly designed pre-bent instruments. In this study, 90 medical students without previous experience in laparoscopic techniques were randomly assigned to undergo one of three procedures: CLS, SPLS using two pre-bent instruments (SPLS-pp), or SPLS using one pre-bent and one straight laparoscopic instrument (SPLS-ps). In the dry lab, the participants performed four typical laparoscopic tasks of increasing difficulty. Evaluation included performance times or number of completed tasks within a given time frame. All performances were videotaped and evaluated for unsuccessful attempts and unwanted interactions of instruments. Using subjective questionnaires, the participants rated difficulties with two-dimensional vision and coordination of instruments. Task performances were significantly better in the CLS group than in either SPLS group. The SPLS-ps group showed a tendency toward better performances than the SPLS-pp group, but the difference was not significant. Video sequences and participants` questionnaires showed instrument interaction as the major problem in the single-incision surgery groups. Although SILS is feasible, as shown in clinical series published by laparoscopically experienced experts, SILS techniques are demanding due to restrictions that come with the loss of triangulation. These can be compensated only partially by currently available SILS-designed instruments. The future of SILS depends on further improvements in the available equipment or the development of new approaches such as needlescopically assisted or robotically assisted procedures.

Effect of nephrectomy on the rate and pattern of the disappearance of exogenous gastrin in dogs

PubMed Central

Clendinnen, B. Guy; Reeder, David D.; Brandt, E. N.; Thompson, James C.

1973-01-01

Studies of gastrin metabolism were performed in four dogs before and after nephrectomy. Synthetic human gastrin I was infused for two hours and serum samples were obtained at various times during and after infusion. Serum concentrations of gastrin were measured by radioimmunoassay. A two-compartment model was employed to calculate half-lives under each of four experimental conditions, low and high infusion rates, used both before and after nephrectomy. The model half-life was greatly prolonged after nephrectomy at both infusion rates (from 2·54 min to 5·15 min at the low rate, and from 2·85 min to 7·88 min at the high rate). The metabolic clearance rate, an expression of the rate of catabolism during infusion, decreased significantly after nephrectomy at both infusion rates. These observations indicate that the kidney is an important organ for the catabolism of exogenous gastrin. PMID:4719213

Hilar location is an independent prognostic factor for recurrence in T1 renal cell carcinoma after nephrectomy.

PubMed

Shim, Myungsun; Song, Cheryn; Park, Sejun; Kim, Aram; Choi, Seung-Kwon; Kim, Choung-Soo; Ahn, Hanjong

2015-01-01

We investigated the prognostic significance of tumor location at the renal hilum near the sinus structure on the recurrence in T1 renal cell carcinoma (RCC). A total of 1,818 T1 RCC patients who underwent radical (RN) or partial nephrectomy (PN) from 1997 to 2011 were retrospectively reviewed. A hilar tumor was defined as a tumor abutting the main renal artery and/or vein or its segmental branches, without invasion. We compared the recurrence-free survival (RFS) rates between hilar and nonhilar T1 RCC and analyzed predictors of RFS after nephrectomy. Patients with hilar tumors showed a poorer 5-year RFS compared with nonhilar tumors both in T1a (89.7 vs. 98.5 %, p < 0.001) and T1b (81.6 vs. 95.1 %, p < 0.001) RCCs. Among patients who underwent RN and PN, hilar tumors were associated with lower 5-year RFS (87.6 vs. 97.2 % for RN, 78.1 vs. 98.2 % for PN, both p < 0.001). In T1a hilar tumor, PN was associated with poorer 5-year RFS than RN (79.5 vs. 93.0 %, p < 0.001). In multivariate analysis, a hilar location remained as an independent predictor of recurrence in both T1a and T1b tumors (both p = 0.001). Hilar tumors show a higher recurrence rate than nonhilar counterparts in T1 RCC. In T1a hilar tumors, PN demonstrated poorer RFS than RN. Potential intrinsic renal anatomical or lymphovascular structural differences as well as differences in cancer characteristics need further investigations.

Utility of the RENAL index -Radius; Exophytic/endophytic; Nearness to sinus; Anterior/posterior; Location relative to polar lines- in the management of renal masses.

PubMed

Konstantinidis, C; Trilla, E; Lorente, D; Morote, J

2016-12-01

The growing incidence of renal masses and the wide range of available treatments require predictive tools that support the decision making process. The RENAL index -Radius; Exophytic/endophytic; Nearness to sinus; Anterior/posterior; Location relative to polar lines- helps standardise the anatomy of a renal mass by differentiating 3 groups of complexity. Since the introduction of the index, there have been a growing number of studies, some of which have been conflicting, that have evaluated the clinical utility of its implementation. To analyse the scientific evidence on the relationship between the RENAL index and the main strategies for managing renal masses. A search was conducted in the Medline database, which found 576 references on the RENAL index. In keeping with the PRISM Declaration, we selected 100 abstracts and ultimately reviewed 96 articles. The RENAL index has a high degree of interobserver correlation and has been validated as a predictive nomogram of histological results. In active surveillance, the index has been related to the tumour growth rate and probability of nephrectomy. In ablative therapy, the index has been associated with therapeutic efficacy, complications and tumour recurrence. In partial nephrectomy, the index has been related to the rate of complications, conversion to radical surgery, ischaemia time, function preservation and tumour recurrence, a finding also observed in radical nephrectomy. The RENAL index is an objective, reproducible and useful system as a predictive tool of highly relevant clinical parameters such as the rate of complications, ischaemia time, renal function and oncological results in the various currently accepted treatments for the management of renal masses. Copyright © 2016 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.

[A case of xp11.2 translocation renal cell carcinoma].

PubMed

Horie, Kengo; Kikuchi, Mina; Miwa, Kosei; Minamidate, Yuzuru; Yokoi, Shigeaki; Nakano, Masahiro; Deguchi, Takashi; Ehara, Hidetoshi; Asano, Nami; Hirose, Yoshinobu

2011-03-01

Xp11.2/TFE3 translocation renal cell carcinoma (RCC), a recently classified distinct subtype, is a rare tumor that usually affects children and adolescents. The morphology and biological behavior are not widely recognized, Xp11.2 translocation RCC is suggestive of early metastases despite the small tumor size. The definitive diagnosis requires the evidence of several different reciprocal translocations involving the TFE3 gene located on chromosome Xp11.2. Here, we present a case of Xp11.2 translocation RCC in an 18-yearold male. He was referred to our hospital because of a right renal tumor with macroscopic hematuria and right flank colic. The radiographic evaluation including magnetic resonance imaging (MRI) suggested it to be a typical papillary renal cell carcinoma or benign renal tumor. He underwent laparoscopic nephrectomy against the repeat symptom in spite of small tumor (3.5 cm in diameter). The immunohistochemical study revealed nuclear staining for TFE3 protein in the cancer cells. The urologic and radiologic outcomes were satisfactory after more than 1 year of follow-up.

Randomized clinical trial of laparoscopic anterior 180° partial versus 360° Nissen fundoplication: 5-year results.

PubMed

Cao, Z; Cai, W; Qin, M; Zhao, H; Yue, P; Li, Y

2012-02-01

Anterior partial fundoplication (AF) has been popularized by a lower risk of mechanical side effects. The question then emerges whether anterior partial wrap has a similar antireflux effect with Nissen fundoplication (NF). We therefore conducted a randomized study to compare the long-term outcome of anterior fundoplication with NF. One hundred patients who enrolled in the trial from May 2003 to March 2005 were randomized to laparoscopic AF or laparoscopic NF. Endoscopy, pH monitoring, manometry, a detailed questionnaire, and a visual analog symptom score were completed preoperative at 6, 12, 24, and 60 months after surgical procedures. The postoperative adverse effects such as dysphagia and flatulence were compared between the two groups. Revision surgery or maintenance proton pump inhibitor therapy was defined as failure. Fifty procedures were performed in each group. The outcome at 5 years follow-up was determined for 96 patients (96%; 49 patients in the AF group and 47 in the NF group). Three patients (3%) died of unrelated causes during follow-up, and one patient changed address. Both fundoplications were found to provide good control of reflux-related symptoms in most of the patients. For 96 patients followed up more than 5 years, gastroesophageal reflux symptoms were well controlled in 81 patients (84.38%); the mean DeMeester scores in the AF group decreased from 106.89 ± 14.12 to 12.67 ± 3.14 and in the NF group from 109.51 ± 17.98 to 10.81 ± 2.65, and the esophagitis was ameliorated visibly. Moreover, there were significantly fewer patients in the AF group who complained of flatulence. Compared with NF, anterior 180° partial fundoplication is an effective treatment of gastroesophageal reflux and associates with fewer postoperative adverse effects. © 2011 Copyright the Authors. Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

Postoperative effects of laparoscopic sleeve gastrectomy in morbid obese patients with type 2 diabetes.

PubMed

Mihmanli, Mehmet; Isil, Riza Gurhan; Bozkurt, Emre; Demir, Uygar; Kaya, Cemal; Bostanci, Ozgur; Isil, Canan Tulay; Sayin, Pinar; Oba, Sibel; Ozturk, Feyza Yener; Altuntas, Yuksel

2016-01-01

Laparoscopic Sleeve Gastrectomy has become one of the most popular bariatric surgery types and helps treating not only obesity but also endocrinological diseases related to obesity. Therefore we aimed to evaluate the effects of laparoscopic sleeve gastrectomy on the treatment of type 2 diabetes. All patients, who underwent morbid obesity surgery during 2013-2014 and had a HbA1c >6 % were included in this prospective study. Demographical data, usage of oral antidiabetic drugs or insulin were recorded, and laboratory findings as HbA1c and fasting plasma glucose were evaluated preoperatively and postoperatively at the 6th and 12th months. Diabetes remission criteria were used to assess success of the surgical treatment. Totally 88 patients were included in this study. 55 patients were using oral antidiabetic drugs and 33 patients were using insulin. At the 6th month complete remission was observed in 80 (90.9 %), partial remission in 3 (3.4 %) and persistent diabetes in 5 (5.6 %) patients. At the 12th month complete remission was observed in 84 (95.4 %), partial remission in 1 (1.1 %) and persistent diabetes in 3 (3.4 %) patients. This study indicated that laparoscopic sleeve gastrectomy surgery achieved a complete remission of diabetes in 95.4 % patients having type 2 diabetes during a 1 year fallow up period. However, complete remission of type 2 diabetes has been reported as 80 % during long term fallow up in the literature. In our opinion this rate may change with longer follow up periods and studies involving more patients suffering type 2 diabetes.

[Xanthogranulomatous pyelonephritis in a child with severe malnutrition and recurrent fever].

PubMed

Gramage Tormo, J; Gavilán Martín, C; Atienza Almarcha, T

2015-01-01

Xanthogranulomatous pyelonephritis is a rare inflammatory disease, characterized by replacement of renal parenchyma with granulomatous tissue. Initial clinical presentation includes abdominal pain and constitutional symptoms related to recurrent urinary infections. The microorganisms most commonly involved are Escherichia coli and Proteus mirabilis. Final diagnosis is made by histopathology, and the only curative treatment is total or partial nephrectomy. A recently diagnosed case in our unit is presented, as well as an update on the knowledge of this disease. Copyright © 2014 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.

Squamous cell carcinoma within a horseshoe kidney with associated renal stones detected by computed tomography and magnetic resonance imaging.

PubMed

Imbriaco, Massimo; Iodice, Delfina; Erra, Paola; Terlizzi, Angela; Di Carlo, Rosanna; Di Vito, Concetta; Imbimbo, Ciro

2011-07-01

We describe a 69-year-old man who came to our observation with a history of persistent left flank abdominal pain, fever for several weeks, and a previous history of passing renal stones. Radiological examinations with computed tomography and magnetic resonance imaging revealed a solid mass within the left side of a horseshoe kidney, with associated large renal stones. The patient subsequently underwent partial left nephrectomy. The final diagnosis was consistent with squamous cell carcinoma arising in a horseshoe kidney, with associated renal stones. Copyright © 2011 Elsevier Inc. All rights reserved.

Achalasia-Specific Quality of Life After Pneumatic Dilation or Laparoscopic Heller Myotomy With Partial Fundoplication: A Multicenter, Randomized Clinical Trial.

PubMed

Chrystoja, Caitlin C; Darling, Gail E; Diamant, Nicholas E; Kortan, Paul P; Tomlinson, George A; Deitel, Wayne; Laporte, Audrey; Takata, Julie; Urbach, David R

2016-11-01

Achalasia is a chronic, progressive, and incurable esophageal motility disease. There is clinical uncertainty about which treatment should be recommended as first-line therapy. Our objective was to evaluate the effectiveness of pneumatic dilation compared with laparoscopic Heller myotomy with partial fundoplication in improving achalasia-specific quality of life. This was a prospective, multicenter, randomized trial at five academic hospitals in Canada. Fifty previously untreated adults with a clinical diagnosis of primary achalasia, confirmed by manometric testing, were enrolled between November 2005 and March 2010, and followed for 5 years after treatment. Randomization was stratified by site, in random blocks of size four and with balanced allocation. Patients were treated with pneumatic dilation or laparoscopic Heller myotomy with partial fundoplication. The primary outcome was the difference between the treatments in the mean improvement of the achalasia severity questionnaire (ASQ) score at 1 year from baseline. Prespecified secondary outcomes included general and gastrointestinal quality of life, symptoms, esophageal physiology measures (lower esophageal sphincter relaxation and pressure, esophageal emptying, abnormal esophageal acid exposure), complications, and incidence of retreatment. Functional and imaging studies were performed blinded and all outcome assessors were blinded. There were no significant differences between treatments in the improvement of ASQ score at 1 year from baseline (27.5 points in the Heller myotomy arm vs. 20.2 points in the pneumatic dilation arm; difference 7.3 points, 95% confidence interval -4.7 to 19.3; P=0.23). There were no differences between treatments in improvement of symptoms, general and gastrointestinal quality of life, or measures of esophageal physiology. Improvements in ASQ score diminished over time for both interventions. At 5 years, there were no differences between treatments in improvement of ASQ score, symptoms, and general or gastrointestinal quality of life. There were no serious adverse events. No patient who received Heller myotomy required retreatment, whereas five patients treated initially with pneumatic dilation required retreatment. Treatment with pneumatic dilation or laparoscopic Heller myotomy similarly improves achalasia-specific disease severity at 1 year. Either of the therapeutic approaches can be used as first-line therapy for previously untreated adults with achalasia.

The effect of Mastin® on expression of Nrf2 in the rat heart with subtotally nephrectomy chronic Kidney disease model

NASA Astrophysics Data System (ADS)

Nathania, J.; Soetikno, V.

2017-08-01

Chronic kidney disease (CKD) is increasingly prevalent in Indonesia and worldwide. One of the major causes of morbidity and mortality in CKD is the complication of cardiovascular disease. Mastin® is a supplement that is locally produced in Indonesia and is made from extract of mangosteen pericarp, which is reported to have antioxidative, anti-inflammatory, and antitumor properties. The present study aimed to investigate whether Mastin® could improve antioxidant responses in the rat heart during CKD by measuring the expression of nuclear factor erythroid-2-related factor (Nrf)2, a master regulator of antioxidant response elements. RNA was extracted from the heart tissue of three groups of rats: a normal group, a nephrectomy group, and a nephrectomy with Mastin® group. Two-step real-time RT-PCR was then conducted to calculate the relative expression of the Nrf2 gene. Nrf2 expression was markedly decreased in the nephrectomy group vs the normal group, but slightly increas ed in the nephrectomy with Mastin® group vs the nephrectomy group. CKD resulted in impaired activation of the Nrf2 pathway in the rat heart. Although the administration of Mastin® slightly increased Nrf2 expression, it was not enough to confer cardioprotective effects through the Nrf2 pathway.

Renal blood flow using arterial spin labelling MRI and calculated filtration fraction in healthy adult kidney donors Pre-nephrectomy and post-nephrectomy.

PubMed

Cutajar, Marica; Hilton, Rachel; Olsburgh, Jonathon; Marks, Stephen D; Thomas, David L; Banks, Tina; Clark, Christopher A; Gordon, Isky

2015-08-01

Renal plasma flow (RPF) (derived from renal blood flow, RBF) and glomerular filtration rate (GFR) allow the determination of the filtration fraction (FF), which may have a role as a non-invasive renal biomarker. This is a hypothesis-generating pilot study assessing the effect of nephrectomy on renal function in healthy kidney donors. Eight living kidney donors underwent arterial spin labelling (ASL) magnetic resonance imaging (MRI) and GFR measurement prior to and 1 year after nephrectomy. Chromium-51 labelled ethylenediamine tetraacetic acid ((51)Cr-EDTA) with multi-blood sampling was undertaken and GFR calculated. The RBF and GFR obtained were used to calculate FF. All donors showed an increase in single kidney GFR of 24 - 75 %, and all but two showed an increase in FF (-7 to +52 %) after nephrectomy. The increase in RBF, and hence RPF, post-nephrectomy was not as great as the increase in GFR in seven out of eight donors. As with any pilot study, the small number of donors and their relatively narrow age range are potential limiting factors. The ability to measure RBF, and hence RPF, non-invasively, coupled with GFR measurement, allows calculation of FF, a biomarker that might provide a sensitive indicator of loss of renal reserve in potential donors. • Non-invasive MRI measured renal blood flow and calculated renal plasma flow. • Effect of nephrectomy on blood flow and filtration in donors is presented. • Calculated filtration fraction may be a useful new kidney biomarker.

Activated carbon fiber filters could reduce the risk of surgical smoke exposure during laparoscopic surgery: application of volatile organic compounds.

PubMed

Choi, Seock Hwan; Choi, Dong Hee; Kang, Dong Hwa; Ha, Yun-Sok; Lee, Jun Nyung; Kim, Bum Soo; Kim, Hyun Tae; Yoo, Eun Sang; Kwon, Tae Gyun; Chung, Sung Kwang; Kim, Tae-Hwan

2018-05-16

Generation of smoke is inevitable during surgical procedures. Some volatile organic compounds (VOCs) in surgical smoke are known to be strong carcinogens. We used a prototype of a multi-layered complex filter in an attempt to eliminate VOCs. From June 2015 to July 2015, 20 patients underwent transperitoneal laparoscopic nephrectomy for renal cell carcinoma. Smoke (pre-filter) was collected 20 min after the electrocautery device was first used during the surgery, by the direct collection method, with a 5-L Tedlar® gas-sampling bag. Twenty and 120 min after the filter was applied, smoke (post-filter) was again collected using the same method. The sample was analyzed by gas chromatography and mass spectrography. The cancer risk and hazard quotient were analyzed based on US Environmental Protection Agency guidelines. Twenty patients with a median age of 54.5 (30-80) years were enrolled in the study. Eighteen VOCs were detected using the Japanese indoor air standards mix analysis. The total elimination rate of the VOCs was 86.49 ± 2.83%. The post-filter (120 min) cancer risk (mean ± standard deviation) reduced to a negligible level for benzene, ethylbenzene, and styrene except 1,2-dichloroethane. The post-filter (120 min) hazard quotient for each compound decreased to levels posing a negligible risk for acetone, hexane, benzene, toluene, p-xylene, o-xylene, and styrene. Strong carcinogens, such as 1,2-dichloroethane, benzene, and ethylbenzene, were eliminated by more than 85% by using this activated carbon fiber filter and the risks from these compounds decreased to an almost negligible level. We suggest using every measure, including these filters, to protect the health of operating room personnel.

Improvement in Renal Function and Symptoms of Patients Treated with Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction with Less Than 20% Split Renal Function.

PubMed

Nishi, Morihiro; Matsumoto, Kazumasa; Fujita, Tetsuo; Iwamura, Masatsugu

2016-11-01

To evaluate the efficacy of laparoscopic pyeloplasty (LPP) for lower functioning kidney, we investigated the outcome of this procedure for patients with ureteropelvic junction obstruction with decreased renal function, defined as less than 20% split renal function. Between October 1998 and June 2015, we performed transperitoneal dismembered LPP in 224 patients. Among them, 15 patients with less than 20% split renal function were included in this study. Patient characteristics, perioperative split renal functions, complications, and surgical outcomes were retrospectively investigated. Fourteen of 15 patients had preoperative symptoms, including flank pain in 13 patients and gross hematuria in 1 patient. Preoperative 99mTc-mercaptoacetyltriglycine (MAG3) renogram revealed no response to diuretic injection and median split renal function was 16.5%. Median operative time and blood loss were 170 minutes and 20 mL, respectively. There were no complications during the perioperative period. Postoperative MAG3 renogram at 6 and 12 months after the operation revealed significantly increased split renal function (median: 23.8% and 23.7%, p = 0.001 and 0.008, respectively) and response to diuretic injection in all patients. Preoperative symptoms disappeared and no recurrence was seen during the follow-up period for all patients except for one who experienced flank pain again 4 months after the surgery. He subsequently underwent open pyeloplasty, and flank pain disappeared soon after. LPP for patients with low split renal function and flank pain significantly improved symptoms and split renal functions. Although the long-term clinical effects of LPP are unknown, we recommend performing LPP before considering nephrectomy for patients with lower functioning kidney.

Retroperitoneal laparoscopic nephron sparing surgery for large renal angiomyolipoma: Our technique and experience. A case series of 41 patients.

PubMed

Liu, Xin; Ma, Xin; Liu, Qiming; Huang, Qingbo; Li, Xintao; Wang, Baojun; Li, Hongzhao; Zhang, Xu

2018-06-01

To introduce a 'kidney priority' strategy in treating large renal angiomyolipoma (RAML) with retroperitoneal laparoscopic nephron sparing surgery (RLNSS). From 2010 to 2017, 41 patients with large RAML underwent RLNSS. Distinguished from the standard practice, the kidney was preferentially mobilized and separated from the RAML. Subsequently, it was reconstructed. Finally, the RAML was resected from the perinephric fat. The perioperative variables, surgical technique and complications were reviewed. Patients were followed up with ultrasonography and computed tomography. RLNSS was successfully performed in 35 patients with four conversions to open surgery and two conversions to nephrectomy, respectively. Eight patients required an intraoperative blood transfusion. Seven patients experienced postoperative complications, including one wound infection, one urinary tract infection, one pneumonia, one urinary fistula and three hemorrhage. The median operation time was 167min (range, 95-285min), the median warm ischemia time was 21 min (range, 0-40 min), and the median estimated blood loss was 200 ml (range, 30-2500 ml). The median postoperative stay was 6.5 days (range, 3-11 days). Angiomyolipoma was confirmed pathologically in all patients. Median serum creatine increased after surgery, from 0.7 mg/dl (range, 0.4-1.1 mg/dl) preoperatively to 0.8 mg/dL (range, 0.5-1.4 mg/dl) postoperatively (P = 0.016). No patient required dialysis, and no recurrence was observed after a median follow-up of 35 months (range, 3-85 months). RLNSS is a safe, feasible, effective and minimally invasive procedure to manage large RAML in selected patients. Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Use of the Satinsky clamp for hilar clamping during robotic partial nephrectomy: indications, technique, and multi-center outcomes.

PubMed

Abdullah, Newaj; Rahbar, Haider; Barod, Ravi; Dalela, Deepansh; Larson, Jeff; Johnson, Michael; Mass, Alon; Zargar, Homayoun; Kaouk, Jihad; Allaf, Mohamad; Bhayani, Sam; Stifelman, Michael; Rogers, Craig

2017-03-01

A Satinsky clamp may be a backup option for hilar clamping during robotic partial nephrectomy (RPN) if there are challenges with application of bulldog clamps, but there are potential safety concerns. We evaluate outcomes of RPN using Satinsky vs. bulldog clamps, and provide tips for safe use of the Satinsky as a backup option. Using a multi-center database, we identified 1073 patients who underwent RPN between 2006 and 2013, and had information available about method of hilar clamping (bulldog clamp vs. Satinsky clamp). Patient baseline characteristics, tumor features, and perioperative outcomes were compared between the Satinsky and bulldog clamp groups. A Satinsky clamp was used for hilar clamping in 94 (8.8 %) RPN cases, and bulldog clamps were used in 979 (91.2 %) cases. The use of a Satinsky clamp was associated with greater operative time (198 vs. 175 min, p < 0.001), estimated blood loss (EBL, 200 vs. 100 ml, p < 0.001), warm ischemia time (WIT, 20 vs. 19 min, p = 0.036), transfusion rate (12.8 vs. 4.8 %, p = 0.001), and hospital stay (3 vs. 2 days, p < 0.001). Tumor characteristics and number of renal vessels were similar between groups. There were six intraoperative complications in the Satinsky clamp group, but none were directly related to the Satinsky clamp. On multivariable analysis, the use of the Satinsky clamp was not associated with increase in intraoperative or Clavien ≥3 postoperative complications, positive surgical margin rate or percentage change in estimated glomerular filtration rate. A Satinsky clamp can be a backup option for hilar clamping during challenging RPN cases, but requires careful technique, and was rarely necessary.

Crowdsourcing Assessment of Surgeon Dissection of Renal Artery and Vein During Robotic Partial Nephrectomy: A Novel Approach for Quantitative Assessment of Surgical Performance.

PubMed

Powers, Mary K; Boonjindasup, Aaron; Pinsky, Michael; Dorsey, Philip; Maddox, Michael; Su, Li-Ming; Gettman, Matthew; Sundaram, Chandru P; Castle, Erik P; Lee, Jason Y; Lee, Benjamin R

2016-04-01

We sought to describe a methodology of crowdsourcing for obtaining quantitative performance ratings of surgeons performing renal artery and vein dissection of robotic partial nephrectomy (RPN). We sought to compare assessment of technical performance obtained from the crowdsourcers with that of surgical content experts (CE). Our hypothesis is that the crowd can score performances of renal hilar dissection comparably to surgical CE using the Global Evaluative Assessment of Robotic Skills (GEARS). A group of resident and attending robotic surgeons submitted a total of 14 video clips of RPN during hilar dissection. These videos were rated by both crowd and CE for technical skills performance using GEARS. A minimum of 3 CE and 30 Amazon Mechanical Turk crowdworkers evaluated each video with the GEARS scale. Within 13 days, we received ratings of all videos from all CE, and within 11.5 hours, we received 548 GEARS ratings from crowdworkers. Even though CE were exposed to a training module, internal consistency across videos of CE GEARS ratings remained low (ICC = 0.38). Despite this, we found that crowdworker GEARS ratings of videos were highly correlated with CE ratings at both the video level (R = 0.82, p < 0.001) and surgeon level (R = 0.84, p < 0.001). Similarly, crowdworker ratings of the renal artery dissection were highly correlated with expert assessments (R = 0.83, p < 0.001) for the unique surgery-specific assessment question. We conclude that crowdsourced assessment of qualitative performance ratings may be an alternative and/or adjunct to surgical experts' ratings and would provide a rapid scalable solution to triage technical skills.

Assessment of the relationship between renal volume and renal function after minimally-invasive partial nephrectomy: the role of computed tomography and nuclear renal scan.

PubMed

Bertolo, Riccardo; Fiori, Cristian; Piramide, Federico; Amparore, Daniele; Barrera, Monica; Sardo, Diego; Veltri, Andrea; Porpiglia, Francesco

2018-05-14

To evaluate the correlation between the loss of renal function as assessed by Tc99MAG-3 renal scan and the loss of renal volume as calculated by volumetric assessment on CT-scan in patients who underwent minimally-invasive partial nephrectomy (PN). PN prospectively-maintained database was retrospectively queried for patients who underwent minimally-invasive PN (2012-2017) for renal mass

Is near infrared fluorescence imaging using indocyanine green dye useful in robotic partial nephrectomy: a prospective comparative study of 94 patients.

PubMed

Krane, L Spencer; Manny, Theodore B; Hemal, Ashok K

2012-07-01

To compare a consecutive prospective cohort of patients who underwent robotic partial nephrectomy (RPN) with near infrared fluorescence (NIRF) imaging with indocyanine green dye (ICG) with a previous consecutive patient cohort. A total of 47 consecutive patients with renal masses suspicious for malignancy undergoing RPN were given 5-7.5 mg of ICG before hilar clamping or tumor excision. This cohort of patients was compared with 47 immediate previous consecutive patients who had undergone RPN without NIRF real-time imaging using ICG. The intraoperative, perioperative, and postoperative parameters were collected in an institutional review board-approved prospective database. The preoperative demographics and tumor complexity according to the nephrometry or preoperative aspects and dimensions used for an anatomic (PADUA) scores were similar. The mean warm ischemia time was significantly decreased in the ICG group (15 vs 17 minutes, P = .01). The median hospital stay was 2 days in both groups. No significant difference was seen in the positive margin rate (ICG, 6% vs control, 8.5%; P = .69) or observed Clavien grade III-IV complications in these 2 cohorts (ICG, 4% vs control, 15%; P = .07). No adverse events were associated with ICG dye administration. Differential ICG uptake was observed with selective clamping or in patients with cystic tumors, hypofluorescent tumors with exophytic components, and angiomyelolipomas, but these benefits could not be quantified. NIRF-ICG was transiently helpful to identify the vascular anatomy and not helpful at all for endophytic tumors. RPN using NIRF-ICG can be performed safely and effectively. A decreased warm ischemia time in the ICG cohort was observed without specific measured advantages. Differential ICG uptake by different tumors did not lead to significant differences in the positive margin rate. Copyright © 2012 Elsevier Inc. All rights reserved.

Robotic partial nephrectomy - Evaluation of the impact of case mix on the procedural learning curve.

PubMed

Roman, A; Ahmed, K; Challacombe, B

2016-05-01

Although Robotic partial nephrectomy (RPN) is an emerging technique for the management of small renal masses, this approach is technically demanding. To date, there is limited data on the nature and progression of the learning curve in RPN. To analyse the impact of case mix on the RPN LC and to model the learning curve. The records of the first 100 RPN performed, were analysed at our institution that were carried out by a single surgeon (B.C) (June 2010-December 2013). Cases were split based on their Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score into the following groups: 6-7, 8-9 and >10. Using a split group (20 patients in each group) and incremental analysis, the mean, the curve of best fit and R(2) values were calculated for each group. Of 100 patients (F:28, M:72), the mean age was 56.4 ± 11.9 years. The number of patients in each PADUA score groups: 6-7, 8-9 and >10 were 61, 32 and 7 respectively. An increase in incidence of more complex cases throughout the cohort was evident within the 8-9 group (2010: 1 case, 2013: 16 cases). The learning process did not significantly affect the proxies used to assess surgical proficiency in this study (operative time and warm ischaemia time). Case difficulty is an important parameter that should be considered when evaluating procedural learning curves. There is not one well fitting model that can be used to model the learning curve. With increasing experience, clinicians tend to operate on more difficult cases. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Robotic partial nephrectomy with intracorporeal renal hypothermia using ice slush.

PubMed

Kaouk, Jihad H; Samarasekera, Dinesh; Krishnan, Jayram; Autorino, Riccardo; Acka, Oktay; Brando, Luis Felipe; Laydner, Humberto; Zargar, Homayoun

2014-09-01

To outline our technique for intracorporeal cooling with ice slush during robotic partial nephrectomy (RPN), with real-time parenchymal temperature monitoring. Eleven consecutive patients with enhancing solid renal masses suitable for treatment with RPN between September 2013 and January 2014 were included in the analysis. Institutional review board approval and informed consent were obtained. Preoperative patient characteristics, intraoperative surgical parameters including patient body temperature and ipsilateral kidney temperature with real-time monitoring, and short-term functional outcomes were analyzed. Median age was 55 years (range, 39-75 years) and American Society of Anesthesiologists score was 3 (range, 2-4). Median tumor size was 4 cm (range, 2.3-7.1) and RENAL nephrometry score was 9 (range, 5-11). One patient had a solitary kidney. During cooling, the lowest median renal parenchymal temperature was 17.05°C (range, 11°C-26°C) and cold ischemia time was 27.17 minutes (range, 18-49 minutes). Median time to latest postoperative estimated glomerular filtration rate was 12 days (range, 2-30 days). Median glomerular filtration rate preservation was 81% (range, 47.9%-126%). There was one positive margin. There were no postoperative complications, and no patients experienced a prolonged ileus. The limitations of this study include a small number of patients and short-term follow-up. RPN with renal hypothermia using intracorporeal ice slush is technically feasible. Our simplified method of introducing the ice slush was free of complications and highly reproducible. The use of a needle temperature probe allowed us to monitor in real time cooling of the renal parenchyma. Copyright © 2014 Elsevier Inc. All rights reserved.

Impact of warm ischaemia time on postoperative renal function after partial nephrectomy for clinical T1 renal cell carcinoma: a propensity score-matched study.

PubMed

Lee, Hakmin; Song, Byung D; Byun, Seok-Soo; Lee, Sang E; Hong, Sung K

2018-01-01

To analyse the effect of prolonged warm ischaemia time (WIT) on long-term renal function after partial nephrectomy (PN), as controversy still exists as to whether prolonged WIT adversely affects the incidence of chronic kidney disease (CKD) after PN. We reviewed data from 1816 patients who underwent PN for a clinical T1 renal tumour. The propensity scores for prolonged WIT were calculated with the shorter WIT group (<30 min) matched to the longer WIT group (≥30 min) in a 2:1 ratio. Multivariate analysis was used to determine independent predictors for occurrence of postoperative CKD [defined as an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m 2 ] and major renal function deterioration (MRFD; defined as an eGFR decrease of ≥25% postoperatively). After propensity score matching, there was no significant difference in CKD-free survival between the two WIT groups (P = 0.787). Furthermore, longer WIT did not show any significant associations with postoperative CKD-free survival [hazard ratio (HR) 1.002, 95% confidence interval (CI) 0.989-1.015; P = 0.765) and MRFD-free survival (HR 1.014, 95% CI 1.000-1.028; P = 0.055). From further subgroup analyses using more specific WIT thresholds (≤20, 21-30, 31-40, 41-50, ≥50 min) and status of preoperative CKD, no significant differences were noted in CKD and MRFD-free survival amongst the subgroups (all P > 0.05). Prolonged WIT was not associated with increased incidence of CKD or MRFD after PN. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

Usefulness of the Ice-Cream Cone Pattern in Computed Tomography for Prediction of Angiomyolipoma in Patients With a Small Renal Mass

PubMed Central

Kim, Kwang Ho; Yun, Bu Hyeon; Hwang, In Sang; Hwang, Eu Chang; Kang, Taek Won; Kwon, Dong Deuk; Park, Kwangsung; Kim, Jin Woong

2013-01-01

Purpose A morphologic contour method for assessing an exophytic renal mass as benign versus malignant on the basis of the shape of the interface with the renal parenchyma was recently developed. We investigated the usefulness of this morphologic contour method for predicting angiomyolipoma (AML) in patients who underwent partial nephrectomy for small renal masses (SRMs). Materials and Methods From January 2004 to March 2013, among 197 patients who underwent partial nephrectomy for suspicious renal cell carcinoma (RCC), the medical records of 153 patients with tumors (AML or RCC) ≤3 cm in diameter were retrospectively reviewed. Patient characteristics including age, gender, type of surgery, size and location of tumor, pathologic results, and specific findings of the imaging study ("ice-cream cone" shape) were compared between the AML and RCC groups. Results AML was diagnosed in 18 patients and RCC was diagnosed in 135 patients. Gender (p=0.001), tumor size (p=0.032), and presence of the ice-cream cone shape (p=0.001) showed statistically significant differences between the AML group and the RCC group. In the multivariate logistic regression analysis, female gender (odds ratio [OR], 5.20; 95% confidence interval [CI], 1.45 to 18.57; p=0.011), tumor size (OR, 0.34; 95% CI, 0.12 to 0.92; p=0.034), and presence of the ice-cream cone shape (OR, 18.12; 95% CI, 4.97 to 66.06; p=0.001) were predictors of AML. Conclusions This study confirmed a high incidence of AML in females. Also, the ice-cream cone shape and small tumor size were significant predictors of AML in SRMs. These finding could be beneficial for counseling patients with SRMs. PMID:23956824

Oncologic outcomes of patients with positive surgical margin after partial nephrectomy: a 25-year single institution experience.

PubMed

Petros, Firas G; Metcalfe, Michael J; Yu, Kai-Jie; Keskin, Sarp K; Fellman, Bryan M; Chang, Courtney M; Gu, Cindy; Tamboli, Pheroze; Matin, Surena F; Karam, Jose A; Wood, Christopher G

2018-07-01

To evaluate oncologic outcomes and management of patients with microscopic positive surgical margin (PSM) after partial nephrectomy (PN) for renal cell carcinoma (RCC). We reviewed our database to identify patients who underwent PN between 1990 and 2015 for RCC and had PSM on final pathology. A 1:3 matching was performed to a negative surgical margin (NSM) cohort. Kaplan-Meier method and log-rank test were used to estimate survival and differences in outcomes, respectively. Cox proportional hazards models were conducted to estimate the Hazards ratio. A total of 2297 patients underwent PN at our institution, of which 1863 (81%) had RCC. Microscopic PSM was found in 34 (1.8%) RCC patients who were matched to 100 patients with NSM. Of these 34 patients, local recurrence (n = 4), distant kidney recurrences (n = 4), and metastases (n = 5) developed during a median follow-up of 62 months. Bilateral tumors/tumors in a solitary kidney (n = 12/13, 92%), and multifocal tumors (n = 7/13, 54%) were found in patients who developed recurrence/metastasis. PSM patients were at a higher risk of shorter overall survival (p = 0.001), local recurrence-free survival (p = 0.003), distant recurrence-free survival (p = 0.032) and metastasis-free survival (p = 0.018). There was statistically significant association between PSM and bilateral tumors, prior treated RCC at presentation and higher nephrometry score in multivariable model. There was a low rate of microscopic PSM in our large cohort of patients undergoing PN despite tumor complexity. Higher nephrometry score, bilateral tumors, and prior treated RCC independently predicted PSM which showed worse survival, recurrence and metastasis compared to patients with NSM.

Functional Recovery From Extended Warm Ischemia Associated With Partial Nephrectomy.

PubMed

Zhang, Zhiling; Zhao, Juping; Velet, Lily; Ercole, Cesar E; Remer, Erick M; Mir, Carme M; Li, Jianbo; Takagi, Toshio; Demirjian, Sevag; Campbell, Steven C

2016-01-01

To evaluate the impact of extended warm ischemia on incidence of acute kidney injury (AKI) and ultimate functional recovery after partial nephrectomy (PN), incorporating rigorous control for loss of parenchymal mass, and embedded within comparison to cohorts of patients managed with hypothermia or limited warm ischemia. From 2007 to 2014, 277 patients managed with PN had appropriate studies to evaluate changes in function/mass specifically within the operated kidney. Recovery from ischemia was defined as %function saved/%parenchymal mass saved. AKI was based on global renal function and defined as a ≥1.5-fold increase in serum creatinine above the preoperative level. Hypothermia was utilized in 112 patients (median = 27 minutes) and warm ischemia in 165 (median = 21 minutes). AKI strongly correlated with solitary kidney (P < .001) and duration (P < .001) but not type (P = .49) of ischemia. Median recovery from ischemia in the operated kidney was 100% (interquartile range [IQR] = 88%-109%) for cold ischemia, with 6 (5%) noted to have <80% recovery from ischemia. For the warm ischemia group, median recovery from ischemia was 91% (IQR = 82%-101%, P < .001 compared with hypothermia), and 34 (21%) had recovery from ischemia <80% (P < .001). For warm ischemia subgrouped by duration <25 minutes (n = 114), 25-35 minutes (n = 35), and >35 minutes (n = 16), median recovery from ischemia was 92% (IQR = 86%-100%), 90% (IQR = 78%-104%), and 91% (IQR = 80%-96%), respectively (P = .77). Our results suggest that AKI after PN correlates with duration but not with type of ischemia. However, subsequent recovery, which ultimately defines the new baseline glomerular filtration rate, is most reliable with hypothermia. However, most patients undergoing PN with warm ischemia still recover relatively strongly from ischemia, even if extended to 35-45 minutes. Copyright © 2015 Elsevier Inc. All rights reserved.

Predictors of postoperative decline in estimated glomerular filtration rate in patients undergoing robotic partial nephrectomy.

PubMed

Wiener, Scott; Kiziloz, Halil; Dorin, Ryan P; Finnegan, Kyle; Shichman, Steven S; Meraney, Anoop

2014-07-01

To identify prognostic indicators of estimated glomerular filtration rate (eGFR) following robotic partial nephrectomy (RPN). In a retrospective study of RPN patients, we examined data describing age, gender, eGFR, body mass index (BMI), tumor size (TS), length of stay, and estimated blood loss (EBL). Changes in eGFR (i.e., renal function trajectory [RFT]) and chronic kidney disease (CKD) stage shift were analyzed with mixed model linear and logistic regression analyses, Chi-squared, and t-tests. Changes in eGFR (RFT) were determined in 122 patients at baseline and at 6- and 12-month follow-up visits. Mean age, TS, and Charlson comorbidity index (CCI) were 62±11 years, 3±1.2 cm, and 4.8±1.8, respectively. The pre- and postoperative eGFR was lower in patients >60 years. Preoperative eGFR was unrelated to gender, BMI>30 kg/m(2), histopathology, nuclear grade, and TS. Univariate analyses determined that age, BMI>30, EBL>200 mL, CCI>5, and TS were associated with greater declines in eGFR. Reduced eGFR was also associated with warm ischemia time ≥22 minutes, while age was associated with a ≥1 worsening of British CKD classification. Using multivariate analysis, only age was significantly associated with a decline in eGFR, which was greater in patients with a normal preoperative eGFR. Patient age, BMI>30, EBL>200 mL, CCI>5, and TS were predictors of greater postoperative declines in eGFR. Although a decline in eGFR was proportionally greater in low stage CKD, postoperative changes are associated with advancing age.

Da Vinci Xi and Si platforms have equivalent perioperative outcomes during robot-assisted partial nephrectomy: preliminary experience.

PubMed

Abdel Raheem, Ali; Sheikh, Abulhasan; Kim, Dae Keun; Alatawi, Atalla; Alabdulaali, Ibrahim; Han, Woong Kyu; Choi, Young Deuk; Rha, Koon Ho

2017-03-01

The aims of this study were to compare the perioperative outcomes of da Vinci Xi to Si during robotic-assisted partial nephrectomy (RAPN) and to discuss the feasibility of our novel port placement scheme for the da Vinci Xi platform, to overcome the existing kinetic and technical difficulties we faced with the linear port placement in patients with a small body habitus. A retrospective data analysis of patients who underwent RPN using da Vinci Xi (n = 18) was carried out. The outcomes of the Xi group were compared with the Si group (n = 18) selected using a case-matched methodology. For da Vinci Xi, we applied the universal linear port placement in 12 patients and our modified port placement in the remaining 6 patients. The Xi group had a shorter mean docking time of 17.8 ± 2.6 min compared to the Si group of 20.5 ± 2.1 min (p = 0.002); otherwise, no significant difference was present with regard to the remaining perioperative variables (p > 0.05). The modified Xi port placement had a shorter mean console time of 70.8 ± 9.7 min compared to the universal linear port placement of 89.3 ± 17.2 min (p = 0.03). Moreover, it provided a broader field of vision with excellent robotic arms movement, minimizing collisions and allowing an easier and comfortable surgical assist. Da Vinci Xi appears to be feasible and safe during RPN with similar outcomes to Si. The novel Xi port placement makes surgery easier in patients with low BMI.

The effect of nephrectomy on Klotho, FGF-23 and bone metabolism.

PubMed

Kakareko, Katarzyna; Rydzewska-Rosolowska, Alicja; Brzosko, Szymon; Gozdzikiewicz-Lapinska, Joanna; Koc-Zorawska, Ewa; Samocik, Pawel; Kozlowski, Robert; Mysliwiec, Michal; Naumnik, Beata; Hryszko, Tomasz

2017-04-01

Increased concentration of fibroblast growth factor 23 (FGF-23) and decreased levels of soluble Klotho (sKL) are linked to negative clinical outcomes among patients with chronic kidney disease and acute kidney injury. Therefore, it is reasonable to hypothesize that GFR reduction caused by nephrectomy might alter mineral metabolism and induces adverse consequences. Whether nephrectomy due to urological indications causes derangements in FGF-23 and sKL has not been studied. The aim of the study was to evaluate the effect of acute GFR decline due to unilateral nephrectomy on bone metabolism, FGF-23 and sKL levels. This is a prospective, single-centre observational study of patients undergoing nephrectomy due to urological indications. Levels of C-terminal FGF-23 (c-FGF-23), sKL and bone turnover markers [β-crosslaps (CTX), bone-specific alkaline phosphatase (bALP) and tartrate-resistant acid phosphatase 5b (TRAP 5b)] were measured before and after surgery (5 ± 2 days). Twenty-nine patients were studied (14 females, age 63.0 ± 11.6, eGFR 87.3 ± 19.2 ml/min/1.73 m 2 ). After surgery, eGFR significantly declined (p < 0.0001). Nephrectomy significantly decreased sKL level [709.8 (599.9-831.2) vs. 583.0 (411.7-752.6) pg/ml, p < 0.001] and did not change c-FGF-23 concentration [70.5 (49.8-103.3) vs. 77.1 (60.5-109.1) RU/ml, p = 0.9]. Simultaneously, alterations in bone turnover markers were observed. Serum concentration of CTX increased [0.49 (0.4-0.64) vs. 0.59 (0.46-0.85) ng/ml, p = 0.001], while bALP and TRAP 5b decreased [23.6 (18.8-31.4) vs. 17.9 (15.0-22.0) U/l, p < 0.0001 and 3.3 (3.0-3.7) vs. 2.8 (2.3-3.2) U/l, p < 0.001, respectively]. Nephrectomy among patients with preserved renal function before surgery does not increase c-FGF-23 but reduces sKL. Moreover, nephrectomy results in derangements in bone turnover markers in short-term follow-up. These changes may participate in pathogenesis of bone disease after nephrectomy.

Robotic management of pheochromocytoma of the vesicoureteric junction.

PubMed

Nayyar, Rishi; Singh, Prabhjot; Gupta, Narmada P

2010-01-01

Pheochromocytoma of the urinary bladder is rare, presenting usually with hypertension, hematuria and syncopal attacks. Such cases have usually been managed with open or laparoscopic partial cystectomy. We present a case of bladder pheochromocytoma that had unusual presenting symptoms, a paraneoplastic manifestation and was successfully managed with robotic technique.

Nephrectomy (Kidney Removal)

MedlinePlus

... nephrectomy is needed because of other kidney diseases. Kidney function Most people have two kidneys — fist-sized ... and the disease that prompted the surgery? Monitoring kidney function Most people can function well with only ...

[Renal cell carcinoma producing erythrocytosis due to inappropriate production of erythropoietin].

PubMed

Villanueva-Gimeno, M M; Vicario-Bermúdez, J M; Fonseca-López, Ch; Caballero-Castro, J P; Zabala-López, S I; Sánchez-Elipe, M A; González-Gómez, N

2013-01-01

Erythrocytosis, or polycythaemia, is an increase, in absolute terms, of the erythrocyte mass. The most common solid tumour related to this phenomenon is renal cell carcinoma, which can produce erythrocytosis by increasing erythropoietin production. About 30% of symptomatic renal cell carcinomas are diagnosed due to the appearance of a paraneoplastic syndrome. Polycythaemia is one of these. Surgery, (radical or partial nephrectomy), is the treatment of choice in renal cell carcinoma and helps to keep the erythrocytosis situation under control. Copyright © 2011 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España. All rights reserved.

Laparoscopic vasectomy in African elephants (Loxodonta africana).

PubMed

Rubio-Martínez, Luis M; Hendrickson, Dean A; Stetter, Mark; Zuba, Jeffery R; Marais, Hendrik J

2014-07-01

To describe a surgical technique for, and outcome after, laparoscopic vasectomy of free-ranging elephants. Case series. African elephants (Loxodonta africana; n = 14). Male elephants (12-35 years old) were anesthetized with etorphine and supported in a sling in a modified standing position, and positive pressure ventilated with oxygen. Anesthesia was maintained with IV etorphine. Vasectomy was performed under field conditions by bilateral, open-approach, flank laparoscopy with the abdomen insufflated with filtered ambient air. A 4-cm segment of each ductus deferens was excised. Behavior and incision healing were recorded for 8 months postoperatively. Successful bilateral vasectomy (surgical time, 57-125 minutes) was confirmed by histologic examination of excised tissue. Recovery was uneventful without signs of abnormal behavior. Large intestine lacerations (3 elephants; 1 full and 2 partial thickness) were sutured extracorporeally. One elephant found dead at 6 weeks, had no prior abnormal signs. Skin incisions healed without complication. Laparoscopic vasectomy can be performed in African elephants in their natural environment. © Copyright 2014 by The American College of Veterinary Surgeons.

Robot-assisted partial cystectomy of a bladder pheochromocytoma.

PubMed

Kang, Sung Gu; Kang, Seok Ho; Choi, Hoon; Ko, Young Hwii; Park, Hong Seok; Cheon, Jun

2011-01-01

Pheochromocytoma of the urinary bladder is an unusual tumor that typically presents with hypertensive crises related to micturition. We report here an unusual case of bladder pheochromocytoma that was treated by robotic-assisted laparoscopic partial cystectomy. A 35-year-old male patient presented with headache and hypertension related to micturition. The patient, who had a 3.5 × 4 cm solitary bladder tumor in the bladder dome, underwent robot-assisted partial cystectomy. The whole procedure was successfully performed using the robot without conversion to open surgery. The total operative time was 120 min and the estimated blood loss was 30 ml. Copyright © 2011 S. Karger AG, Basel.

The cost effectiveness of elective laparoscopic sigmoid resection for symptomatic diverticular disease: financial outcome of the randomized control Sigma trial.

PubMed

Klarenbeek, Bastiaan R; Coupé, Veerle M H; van der Peet, Donald L; Cuesta, Miguel A

2011-03-01

Direct healthcare costs of patients with symptomatic diverticular disease randomized for either laparoscopic or open elective sigmoid resection are compared. Cost-effectiveness analysis of the laparoscopic approach compared with open sigmoid resections is presented. An economic evaluation of the randomized control Sigma trial was conducted, comparing elective laparoscopic sigmoid resection (LSR) to open sigmoid resection (OSR) in patients with symptomatic diverticulitis. Prospective registration of detailed intervention units per patient resulted in actual resource use per individual patient. To avoid distributional assumptions, the nonparametric bootstrap was applied. For the cost-effectiveness analysis, differences in total cost between LSR and OSR were compared with the differences in VAS pain score, SF-36 values for general health, and complication rate. The difference in total healthcare costs between the group that received LSR (euro 9969) and the group that received OSR (euro 9366) was not statistically significant. The slight increase in total costs was determined mainly by the significantly higher operation costs of LSR (euro 6663 vs. euro 5306). Lower costs for hospitalization (euro 2983 vs. euro 3598), blood products (euro 87 vs. euro 240), paramedical services (euro 157 vs. euro 278), and emergency attendance (euro 72 vs. euro 115) in the LSR group partially compensated these increased operation costs. The incremental cost-effectiveness ratios (ICER) indicate that improvements in pain, quality of life, and complication rate could be achieved at limited costs. Total healthcare costs of laparoscopic and open elective sigmoid resections for symptomatic diverticular disease are similar. As the clinical outcomes are in favor of the LSR group, candidates for an elective sigmoid resection should preferably be approached laparoscopically.

Acute Hypervolemic Infusion Can Improve Splanchnic Perfusion in Elderly Patients During Laparoscopic Colorectal Surgery

PubMed Central

Zhu, Qian-lin; Deng, Yun-xin; Yu, Bu-wei; Zheng, Min-hua

2018-01-01

Background There is no adequate evidence on how the long duration of laparoscopic surgery affects splanchnic perfusion in elderly patients or the efficacy of acute hypervolemic fluid infusion (AHFI) during the induction of anesthesia. Our aim was to observe the effects of AHFI during the induction of general anesthesia on splanchnic perfusion. Material/Methods Seventy elderly patients receiving laparoscopic colorectal surgery were randomly divided into three groups: lactated Ringer’s solution group (group R), succinylated gelatin group (group G), and hypertonic sodium chloride hydroxyethyl starch 40 injection group (group H). Thirty minutes after the induction of general anesthesia, patients received an infusion of target dose of these three solutions. Corresponding hemodynamic parameters, arterial blood gas analysis, and gastric mucosal carbon dioxide tension were monitored in sequences. Results In all three groups, gastric-arterial partial CO2 pressure gaps (Pg–aCO2) were decreased at several beginning stages and then gradually increased, Pg–aCO2 also varied between groups due to certain time points. The pH values of gastric mucosa (pHi) decreased gradually after the induction of pneumoperitoneum in the three groups. Conclusions The AHFI of succinylated gelatin (12 ml/kg) during the induction of anesthesia can improve splanchnic perfusion in elderly patients undergoing laparoscopic surgery for colorectal cancer and maintain good splanchnic perfusion even after a long period of pneumoperitoneum (60 minutes). AHFI can improve splanchnic perfusion in elderly patients undergoing laparoscopic colorectal surgery. PMID:29382813

A prospective cross-sectional study of laparoscopic subtotal Lind fundoplication for gastro-oesophageal reflux disease--a durable and effective anti-reflux procedure.

PubMed

Shapey, I M; Agrawal, S; Peacock, A; Super, P

2015-01-01

Laparoscopic partial fundoplication for gastro-oesophageal reflux disease (GORD) is reported to have fewer side effects when compared to Nissen fundoplication, but doubts remain over its long term durability in controlling reflux. The aim of this study was to assess outcome of symptoms for all patients presenting with GORD undergoing routine laparoscopic subtotal Lind fundoplication. All patients undergoing laparoscopic fundoplication between August, 1999 and November, 2007 performed by a single surgeon were included in the study. The anti-reflux procedure studied was laparoscopic Lind (300°) fundoplication with crural repair in all cases. Patients completed pre and post-operative questionnaires containing validated scoring systems for heartburn, gas bloat, dysphagia and overall patient satisfaction. Over the 100-month period, 320 consecutive patients underwent laparoscopic subtotal Lind fundoplication. Of these, 256 (80%) replied to the questionnaire at a mean of 31 months (range 3-96 months) following surgery. 91.4% of respondents had an improvement in heartburn symptom score with a significant reduction in score from 7.74 preoperatively to 1.25 postoperatively (p<0.001). There was also a significant reduction of mean modified Visick score for reflux control (heartburn and regurgitation) from 3.49 preoperatively to 1.48 after surgery (p<0.001). In total, 22 patients developed recurrent reflux symptoms with half of these reporting their recurrence within two years following surgery. Because of this all were tested with post-operative pH testing, yet only one had a 24-h pH time outside the normal range. Overall patient satisfaction was high with a visual analogue score of 9 and 88% of the patients claimed they would have the operation again. Laparoscopic Lind fundoplication demonstrates excellent reflux control when performed routinely for all patients presenting with GORD. This technique is both durable and efficacious in controlling reflux symptoms. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Temporary targeted renal blood flow interruption using a reverse thermosensitive polymer to facilitate bloodless partial nephrectomy: a swine survival study.

PubMed

Harty, Niall J; Laskey, Daniel H; Moinzadeh, Alireza; Flacke, Sebastian; Benn, James A; Villani, Rosanna; Kalra, Aarti; Libertino, John A; Madras, Peter N

2012-09-01

What's known on the subject? and What does the study add? Lumagel™ is a reverse thermosensitive polymer (RTP) that has previously been described in the literature as providing temporary vascular occlusion to allow for bloodless partial nephrectomy (PN) while maintaining blood flow to the untargeted portion of the kidney. At body temperature, Lumagel™ has the consistency of a viscous gel but upon cooling rapidly converts to a liquid state and does not reconstitute thereafter. This property has allowed for it to be used in situations requiring temporary vascular occlusion. Previous experience with similar RTPs in coronary arteries proved successful, with no detectable adverse events. We have previously described our technique for temporary vascular occlusion of the main renal artery, as well as segmental and sub-segmental renal branches, to allow for bloodless PN in either an open or minimally invasive approach. These experiments were performed in the acute setting. This study is a two-armed survival trial to assess whether this RTP is as safe as hilar clamping for bloodless PN. Surviving animals showed normal growth after using the RTP, absence of toxicity, no organ dysfunction, and no pathological changes attributable to the RTP. We conclude that Lumagel™ is as safe as conventional PN with hilar clamping, while adding the advantage of uninterrupted perfusion during renal resection. To examine whether randomly selected regions of the kidney could undergo temporary flow interruption with a reverse thermosensitive polymer (RTP), Lumagel™ (Pluromed, Inc., Woburn, MA, USA), followed by partial nephrectomy (PN), without adding risks beyond those encountered in the same procedure with the use of hilar clamping. A two-armed (RTP vs hilar clamp), 6-week swine survival study was performed. Four swine underwent PN using hilar clamps, while six underwent PN with flow interruption using the RTP. The RTP, administered angiographically, was used for intraluminal occlusion of segmental or subsegmental arteries and was compared with main renal artery clamping with hilar clamps. The resection site was randomized for each swine. Laboratory studies were performed preoperatively, and at weeks 1, 3 and 6. Before killing the swine, repeat angiography was performed with emphasis on the site of previous flow interruption. Gross and microscopic examination of kidney, liver, lung, heart, skeletal muscle was later performed, and the vessel that had supported the previous plug was examined. All animals survived. No abnormal chemistry or haematology results were encountered over the 6 weeks. There were no surgical complications in either group. Using angiography we found 100% patency of vessels that had been occluded with the polymer 6 weeks previously for PN. The only gross or microscopic abnormalities were related to the renal resection and scar formation, and were similar in the two groups. Targeted flow interruption with the RTP added no additional risk to PN while allowing bloodless resection and uninterrupted flow to untargeted renal tissue. © 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.

Cranial pole nephrectomy in the pig model: anatomic analysis of arterial injuries in tridimensional endocasts.

PubMed

Pereira-Sampaio, Marco A; Henry, Robert W; Favorito, Luciano A; Sampaio, Francisco J B

2012-06-01

To assess the intrarenal arteries injuries after cranial pole nephrectomy in a pig model to compare these findings with those in humans. Polyester resin was injected through the ureter and the renal artery to make three-dimensional casts of 61 pig kidneys. The cranial pole of the kidneys was sectioned at four different sites before the solidification of the resin, and the casts were examined for arterial damage. Section performed through the hilus (15 kidneys): The cranial division of the renal artery was sectioned in two (13.33%) cases, the ventral branch of the cranial division of the renal artery was sectioned in 13 (86.7%) cases, and the dorsal branch of the cranial division of the renal artery was sectioned in 11 (73.34%) cases. Section at 0.5 cm cranial to the hilus (16 kidneys): The cranial division of the renal artery was sectioned in 1 (6.25%) case, the ventral branch of the cranial division of the renal artery was sectioned in 14 (87.5%) cases, and the dorsal branch of the cranial division of the renal artery was sectioned in 13 (81.25%) cases. Section at 1.0 cm cranial to the hilus (15 kidneys): The ventral branch of the cranial division of the renal artery was sectioned in five (33.33%) cases, and the dorsal branch of the cranial division of the renal artery was injured in five (33.33%) cases. Section at 1.5 cm cranial to the hilus (15 kidneys): No lesions were found in the main arteries, only in the interlobular branches. As previously demonstrated in humans, sections at 1.0 cm or more cranially to the hilus in pigs also showed a significant decrease in damage to the major intrarenal arteries. Therefore, as regards arterial damage, the pig kidney is a useful model for partial nephrectomy in the cranial (upper) pole.

Factors associated with renal function compensation after donor nephrectomy.

PubMed

Burballa, Carla; Crespo, Marta; Redondo-Pachón, Dolores; Pérez-Sáez, María José; Arias-Cabrales, Carlos; Mir, Marisa; Francés, Albert; Fumadó, Lluís; Cecchini, Lluís; Pascual, Julio

2018-05-14

Kidney transplant donors lose 50% of their renal mass after nephrectomy. The remaining kidney compensates for this loss and it is estimated that 70% of the baseline renal function prior to donation is recovered. Factors associated with post-donation renal compensation are not well understood. Retrospective study of 66 consecutive kidney donors (mean age 48.8 years, 74.2% women). We analysed the potential factors associated with the compensatory mechanisms of the remaining kidney by comparing donors according to their renal compensation rate (RCR) (Group A, infra-compensation [<70%]; Group B, normal compensation [>70%]). We compared Group A (n=38) and group B (n=28). Predictors for RCR>70% were higher baseline creatinine (A vs B: 0.73±0.14 vs 0.82±0.11; P=.03) and a lower baseline glomerular filtration rate (GFR), estimated both by MDRD-4 (A vs B: 97.7±18.8 vs 78.6±9.6ml/min; P<.001) and CKD-EPI (A vs B: 101.7±15 vs. 88.3±11.7ml/min; P≤.001). Age, gender, smoking, hypertension and GFR measured by Tc-DTPA did not show any correlation with the RCR. The multivariate analysis confirmed baseline estimated glomerular filtration rate (eGFR) to be a predictor of compensation: the higher the baseline eGFR, the lower the likelihood of >70% compensation (MDRD-4, OR=0.94 [95% CI 0.8-0.9], P=.01). The compensation rate decreased by 0.4% (P<.001) and 0.3% (P=.006) for every ml/min increase in baseline eGFR estimated by MDRD-4 and CKD-EPI, respectively. One year after living donor nephrectomy, the remaining kidney partially compensates baseline renal function. In our experience, baseline eGFR is inversely proportional to the one-year renal compensation rate. Copyright © 2018 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.

Minimally invasive retrieval of a retained Jackson--Pratt drainage tube using the Sachse urethrotome.

PubMed

Fariña-Perez, Luis Angel; Pesqueira-Santiago, Daniel

2012-05-01

A retained postoperative drain tube, trapped by one or more of the sutures of the abdominal wall closure, is a rare complication of frustrating consequences and potential legal repercussions. There are few reports of techniques for minimally invasive removal of an anchored postoperative drain tube, which not infrequently has been treated by reopening the wound. A 75 years-old man with a left T2-T3N0M0 renal carcinoma was treated with transperitoneal laparoscopic nephrectomy and a Jackson-Pratt drain was left in place. Drain removal the day after revealed impossible, as if being caught with fascial suture. With the patient under sedation, we introduced a Sachse urethrotome parallel to the drain, and the abdominal fascia was identified, then the polyglycolic stitch anchoring it to the wall could be severed, freeing the drain. Percutaneous extraction with the Sachse urethrotome of an anchored postoperative drain, should be the first option, before trying a forced traction or using more complex options. This technique is for the first time published in the Spanish bibliography, and we think this possibility should be disclosed to abdominal surgeons.

Laparoscopic cryoablation of angiomyolipomas in adolescents and young adults: A report of four cases associated with tuberous sclerosis and 1 case of sporadic origin.

PubMed

Trelborg, Karina; Nielsen, Tommy Kjærgaard; Østraat, Ernst Øyvind; Olsen, Lars Henning

2016-12-01

Renal angiomyolipomas (AMLs) can be of sporadic origin or associated with tuberous sclerosis (TS). TS-associated AMLs often present in childhood, tend to be bilateral and multiple, and often exhibit a faster growth rate with an increased risk of hemorrhage. Renal cryoablation is well described in adults, whereas experiences with adolescents and young adults are limited. We present here for the first time a series of renal AMLs within adolescents and young adults treated with laparoscopic assisted cryoablation (LCA). The aim was to evaluate whether LCA of AMLs in adolescents and young adults is a safe and feasible treatment modality. From October 2009 to September 2013 a total of five patients at our institution were diagnosed with AMLs requiring treatment. Four patients had TS and one had AML of sporadic origin, all five patients underwent LCA. Data were retrospectively collected by a systematic review of patient material and reassessment of renal imaging. The median age was 16 years (range 13-27 years). Eight AMLs with a median size of 3.9 cm (range 2.1-7.7 cm) were treated in five patients because of tumor size and rapid growth. Follow-up was a median 37 months (range 20-62 months), and all tumors showed a reduction in tumor size, and no regrowth was recognized (see summary table). The procedure was well tolerated, with only few perioperative complications and no postoperative complications. When considering the indication for treating AMLs, the origin (sporadic or TS associated) and size of the tumor are the decisive factors. To preserve renal function and prevent spontaneous hemorrhage caution should be intensified when tumors reach 4 cm, particularly if TS is present. After the diagnosis is established, patients should be monitored with renal imaging at regular intervals to identify rapid-growing tumors. As an alternative to current treatment modalities such as partial nephrectomy and super selective angioembolization, cryoablation is an emerging approach, although experience with pediatric patients is limited. For patients not requiring immediate surgery, pharmacological treatment with mTOR inhibitors is now being evaluated as an alternative treatment option or as neo-adjuvant therapy to ablative techniques. Prophylactic treatment of large or rapid growing AMLs with LCA appears to be a safe and feasible nephron-sparing approach in adolescents and young adults. The low perioperative complication rate and promising effect on outcome might allow treatment of subclinical AMLs in order to minimize the risk of potentially life-threatening complications and preserve renal function. Copyright © 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Exploring for the safer ventilation method in laparoscopic urologic patients? Conventional or low tidal?

PubMed

Ela, Yüksel; Bakı, Elif Doğan; Ateş, Mutlu; Kokulu, Serdar; Keleş, İbrahim; Karalar, Mustafa; Şenay, Hasan; Sıvacı, Remziye Gül

2014-11-01

To study the effects of low tidal volume with positive end-expiratory pressure (PEEP) on arterial blood gases of patients undergoing laparoscopic urologic surgeries. Eighty-six laparoscopic urologic patients were enrolled in this study. Patients were randomized into two groups according to the ventilatory settings. In the conventional group (Group C) (n=43), the tidal volume was 10 mL/kg, and the PEEP was set at 0 cm of H2O. In the low tidal volume with PEEP group (Group LP), the tidal volume was 6 mL/kg, with PEEP of 5 cm of H2O. In both groups total minute volume was 6 L/kg. Peak and plateau airway pressure (PPEAK and PPLAT, respectively) and arterial blood gases were recorded before pneumoperitoneum (PNP) (T1) and the first and third hour (T3) after PNP induction and also after extubation in the intensive care unit. Additionally, heart rate, mean arterial pressure, and peripheral O2 saturation of hemoglobin were recorded. Heart rate, PPEAK, and PPLAT values were similar in both groups. Partial arterial O2 pressure values measured postoperatively were significantly higher in Group LP, whereas those measured before PNP induction were similar (P=.014 and P=.056, respectively). Compared with the baseline, partial arterial CO2 pressure values measured at T1 and at T3 after PNP induction were significantly higher in Group C than in Group LP (P<.001). The pH values of Group C at T1 and at T3 postoperatively were significantly lower than the values of Group LP (P<.001). Extubation times were significantly lower in Group LP. The results of the present study suggest that low tidal volume with PEEP application may be a good alternative for preventing high CO2 levels and yielding better oxygenation and lower extubation times in patients undergoing prolonged laparoscopic urology.

The impact of seat belts and airbags on high grade renal injuries and nephrectomy rate in motor vehicle collisions.

PubMed

Bjurlin, Marc A; Fantus, Richard Jacob; Fantus, Richard Joseph; Mellett, Michele M; Villines, Dana

2014-10-01

Motor vehicle collisions are the most common cause of blunt genitourinary trauma. We compared renal injuries with no protective device to those with seat belts and/or airbags using NTDB. Our primary end point was a decrease in high grade (grades III-V) renal injuries with a secondary end point of a nephrectomy rate reduction. The NTDB research data sets for hospital admission years 2010, 2011 and 2012 were queried for motor vehicle collision occupants with renal injury. Subjects were stratified by protective device and airbag deployment. The AIS was converted to AAST renal injury grade and nephrectomy rates were evaluated. Intergroup comparisons were analyzed for renal injury grades, nephrectomy, length of stay and mortality using the chi-square test or 1-way ANOVA. The relative risk reduction of protective devices was determined. A review of 466,028 motor vehicle collisions revealed a total of 3,846 renal injuries. Injured occupants without a protective device had a higher rate of high grade renal injuries (45.1%) than those with seat belts (39.9%, p = 0.008), airbags (42.3%, p = 0.317) and seat belts plus airbags (34.7%, p <0.001). Seat belts (20.0%), airbags (10.5%) and seat belts plus airbags (13.3%, each p <0.001) decreased the nephrectomy rate compared to no protective device (56.2%). The combination of seatbelts and airbags also decreased total hospital length of stay (p <0.001) and intensive care unit days (p = 0.005). The relative risk reductions of high grade renal injuries (23.1%) and nephrectomy (39.9%) were highest for combined protective devices. Occupants of motor vehicle collisions with protective devices show decreased rates of high grade renal injury and nephrectomy. Reduction appears most pronounced with the combination of seat belts and airbags. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

The Impact of Seat belts and Airbags on High Grade Renal Injuries and Nephrectomy Rates in Motor Vehicle Collisions

PubMed Central

Bjurlin, Marc A; Fantus, Richard J.; Mellett, Michele M.; Fantus, Richard J.; Villines, Dana

2015-01-01

Purpose Motor vehicle collisions (MVCs) are the most common cause of blunt genitourinary trauma. We compared renal injuries with no protective device to those with seat belts and/or airbags utilizing the National Trauma Data Bank (NTDB). Our primary endpoint was a reduction in high-grade renal injuries (grades III-V) with a secondary endpoint of reduction in nephrectomy rate. Materials and Methods The NTDB research datasets, admission year 2010, 2011, and 2012, were queried for MVC occupants with renal injury. Subjects were stratified by protective device and airbag deployment. Abbreviated Injury Score was converted to American Association for the Surgery of Trauma renal injury grade and nephrectomy rates were evaluated. Intergroup comparisons were analyzed for renal injury grades, nephrectomy, length of stay, and mortality with chi-square or one-way ANOVA. Protective device relative risk reduction was determined. Results A review of 466,028 MVCs revealed 3,846 renal injuries. Injured occupants without a protective device had a higher rate of high grade renal injury (45.1%) compared to those with seat belts (39.9%, p=0.008), airbags (42.3%, p=0.317), and seat belts with airbags (34.7%, p<0.001). Seat belts (20.0%, p<0.001), airbags (10.5% p<0.001), and seat belts with airbags (13.3%, p<0.001) reduced the rate of nephrectomy compared to no protective device (56.2%). The combination of seatbelts and airbags also reduced total hospital length of stay (p<0.001) and ICU days (p=0.005). Relative risk reduction of high-grade renal injuries (23.1%) and nephrectomy (39.9%) were highest for combined protective devices. Conclusions Occupants of MVCs with protective devices have reduced rates of high-grade renal injury and nephrectomy. Reduction appears most pronounced with the combination of seat belts and airbags. PMID:24846798

In vitro fertilization surrogate pregnancy in a patient who underwent radical hysterectomy followed by ovarian transposition, lower abdominal wall radiotherapy, and chemotherapy.

PubMed

Steigrad, Stephen; Hacker, Neville F; Kolb, Bradford

2005-05-01

To describe an IVF surrogate pregnancy from a patient who had a radical hysterectomy followed by excision of a laparoscopic port site implantation with ovarian transposition followed by abdominal wall irradiation and chemotherapy, which resulted in premature ovarian failure from which there was partial recovery. Case report. Tertiary referral university women's hospital in Sydney, Australia and private reproductive medicine clinic in California. A 34-year-old woman who underwent laparoscopy for pelvic pain, shortly afterward followed by radical hysterectomy and pelvic lymph node dissection, who subsequently developed a laparoscopic port site recurrence, which was excised in association with ovarian transposition before abdominal wall irradiation and chemotherapy. Modified IVF treatment, transabdominal oocyte retrieval, embryo cryopreservation in Australia, and transfer to a surrogate mother in the United States. Pregnancy. Miscarriage in the second cycle and a twin pregnancy in the fourth cycle. This is the first case report of ovarian stimulation and oocyte retrieval performed on transposed ovaries after a patient developed premature ovarian failure after radiotherapy and chemotherapy with subsequent partial ovarian recovery.

[Bilateral nephrectomy in patients with end-stage renal failure and chronic active pyelonephritis].

PubMed

Lysenko, M A; Vtorenko, V I; Trushkin, R N; Lubennikov, A E; Sysoev, A M; Sokolov, A A

2016-02-01

This study analyzed the results of bilateral nephrectomy in 14 patients with end-stage renal disease (ESRD) and chronic active pyelonephritis. Seven patients had urosepsis, and 10 patients had a purulent form of pyelonephritis, which was one-sided in 7 of them. In the early postoperative period, on average, after 9.3 days, 9 patients died. Statistically significant risk factors for death were: chronic hemodialysis, long-term antibiotic therapy, and existing sepsis. Intraoperative complications and postoperative morbidity were not significantly associated with death. The study results imply the need of differentiated approach to bilateral nephrectomy in patients with ESRD and risk factors for fatal outcome. It must be performed on the strong indications since the intervention does not lead to eradication of sepsis. It is advisable to perform "preventive, sanation" bilateral nephrectomy in the "cold period" in patients at risk for developing urosepsis.

Perioperative Events and Complications in Minimally Invasive Live Donor Nephrectomy: A Systematic Review and Meta-Analysis.

PubMed

Kortram, Kirsten; Ijzermans, Jan N M; Dor, Frank J M F

2016-11-01

Minimally invasive live donor nephrectomy has become a fully implemented and accepted procedure. Donors have to be well educated about all risks and details during the informed consent process. For this to be successful, more information regarding short-term outcome is necessary. A literature search was performed; all studies discussing short-term complications after minimally invasive live donor nephrectomy were included. Outcomes evaluated were intraoperative and postoperative complications, conversions, operative and warm ischemia times, blood loss, length of hospital stay, pain score, convalescence, quality of life, and costs. One hundred ninety articles were included in the systematic review, 41 in the meta-analysis. Conversion rate was 1.1%. Intraoperative complication rate was 2.3%, mainly bleeding (1.5%). Postoperative complications occurred in 7.3% of donors, including infectious complications (2.6%), of which mainly wound infection (1.6%) and bleeding (1.0%). Reported mortality rate was 0.01%. All minimally invasive techniques were comparable with regard to complication or conversion rate. The used techniques for minimally invasive live donor nephrectomy are safe and associated with low complication rates and minimal risk of mortality. These data may be helpful to develop a standardized, donor-tailored informed consent procedure for live donor nephrectomy.

Application of single-image camera calibration for ultrasound augmented laparoscopic visualization

NASA Astrophysics Data System (ADS)

Liu, Xinyang; Su, He; Kang, Sukryool; Kane, Timothy D.; Shekhar, Raj

2015-03-01

Accurate calibration of laparoscopic cameras is essential for enabling many surgical visualization and navigation technologies such as the ultrasound-augmented visualization system that we have developed for laparoscopic surgery. In addition to accuracy and robustness, there is a practical need for a fast and easy camera calibration method that can be performed on demand in the operating room (OR). Conventional camera calibration methods are not suitable for the OR use because they are lengthy and tedious. They require acquisition of multiple images of a target pattern in its entirety to produce satisfactory result. In this work, we evaluated the performance of a single-image camera calibration tool (rdCalib; Percieve3D, Coimbra, Portugal) featuring automatic detection of corner points in the image, whether partial or complete, of a custom target pattern. Intrinsic camera parameters of a 5-mm and a 10-mm standard Stryker® laparoscopes obtained using rdCalib and the well-accepted OpenCV camera calibration method were compared. Target registration error (TRE) as a measure of camera calibration accuracy for our optical tracking-based AR system was also compared between the two calibration methods. Based on our experiments, the single-image camera calibration yields consistent and accurate results (mean TRE = 1.18 ± 0.35 mm for the 5-mm scope and mean TRE = 1.13 ± 0.32 mm for the 10-mm scope), which are comparable to the results obtained using the OpenCV method with 30 images. The new single-image camera calibration method is promising to be applied to our augmented reality visualization system for laparoscopic surgery.

Application of single-image camera calibration for ultrasound augmented laparoscopic visualization

PubMed Central

Liu, Xinyang; Su, He; Kang, Sukryool; Kane, Timothy D.; Shekhar, Raj

2017-01-01

Accurate calibration of laparoscopic cameras is essential for enabling many surgical visualization and navigation technologies such as the ultrasound-augmented visualization system that we have developed for laparoscopic surgery. In addition to accuracy and robustness, there is a practical need for a fast and easy camera calibration method that can be performed on demand in the operating room (OR). Conventional camera calibration methods are not suitable for the OR use because they are lengthy and tedious. They require acquisition of multiple images of a target pattern in its entirety to produce satisfactory result. In this work, we evaluated the performance of a single-image camera calibration tool (rdCalib; Percieve3D, Coimbra, Portugal) featuring automatic detection of corner points in the image, whether partial or complete, of a custom target pattern. Intrinsic camera parameters of a 5-mm and a 10-mm standard Stryker® laparoscopes obtained using rdCalib and the well-accepted OpenCV camera calibration method were compared. Target registration error (TRE) as a measure of camera calibration accuracy for our optical tracking-based AR system was also compared between the two calibration methods. Based on our experiments, the single-image camera calibration yields consistent and accurate results (mean TRE = 1.18 ± 0.35 mm for the 5-mm scope and mean TRE = 1.13 ± 0.32 mm for the 10-mm scope), which are comparable to the results obtained using the OpenCV method with 30 images. The new single-image camera calibration method is promising to be applied to our augmented reality visualization system for laparoscopic surgery. PMID:28943703

Application of single-image camera calibration for ultrasound augmented laparoscopic visualization.

PubMed

Liu, Xinyang; Su, He; Kang, Sukryool; Kane, Timothy D; Shekhar, Raj

2015-03-01

Accurate calibration of laparoscopic cameras is essential for enabling many surgical visualization and navigation technologies such as the ultrasound-augmented visualization system that we have developed for laparoscopic surgery. In addition to accuracy and robustness, there is a practical need for a fast and easy camera calibration method that can be performed on demand in the operating room (OR). Conventional camera calibration methods are not suitable for the OR use because they are lengthy and tedious. They require acquisition of multiple images of a target pattern in its entirety to produce satisfactory result. In this work, we evaluated the performance of a single-image camera calibration tool ( rdCalib ; Percieve3D, Coimbra, Portugal) featuring automatic detection of corner points in the image, whether partial or complete, of a custom target pattern. Intrinsic camera parameters of a 5-mm and a 10-mm standard Stryker ® laparoscopes obtained using rdCalib and the well-accepted OpenCV camera calibration method were compared. Target registration error (TRE) as a measure of camera calibration accuracy for our optical tracking-based AR system was also compared between the two calibration methods. Based on our experiments, the single-image camera calibration yields consistent and accurate results (mean TRE = 1.18 ± 0.35 mm for the 5-mm scope and mean TRE = 1.13 ± 0.32 mm for the 10-mm scope), which are comparable to the results obtained using the OpenCV method with 30 images. The new single-image camera calibration method is promising to be applied to our augmented reality visualization system for laparoscopic surgery.

[Surgical treatment of iatrogenic bile duct injuries following laparoscopic cholecystectomy: analysis of long-term results. Retrospective clinical study in 51 patients operated in the Campania region from 1991 to 2003].

PubMed

Conzo, Giovanni; Amato, Giuseppe; Angrisani, Luigi; Bardi, Ugo; Barone, Giovanni; Belli, Giulio; Brancaccio, Umberto; Calise, Fulvio; Caliendo, Angelo; Celsi, Salvatore; Corcione, Francesco; Cuccurullo, Diego; De Falco, Giuseppe; Delrio, Paolo; De Werra, Carlo; De Sena, Guido; Docimo, Giovanni; Esposito, Maria Grazia; Fantini, Corrado; Giardiello, Cristiano; Musella, Mario; Molino, Carlo; Muto, Crescenzo; Pennetti, Lucio; Puziello, Alessandro; Porcelli, Alberto; Rea, Roberto; Rendano, Franco; Palazzo, Antonietta; Santangelo, Michele; Santaniello, Walter; Santini, Luigi; Sperlongano, Pasquale; Stanzione, Francesco; Tartaglia, Alberto; Tricarico, Annunziato; Vincenti, Rodolfo; Lorenzo, Michele

2005-01-01

An higher incidence rate of iatrogenic bile duct injuries is reported in cholecystectomy performed with the laparoscopy than with the laparotomy approach. The aim of this study was to provide a multicentre report on surgical treatment and the outcome of biliary complications during and following laparoscopic cholecystectomy. A questionnaire was mailed to all surgeons with experience in laparoscopic cholecystectomy in the Campania region. Data were collected from January 1991 to December 2003. Each patient was requested to indicate age, gender, associated diseases, site and type of lesion, surgical experience, diagnosis, treatment and complications. Twenty-six surgeons answered the questionnaire. Fifty-one patients (36 F/15 M; mean age: 42.5 +/- 11.9, range 13-91 years) with bile duct injuries following laparoscopic cholecystectomy were reported. The most frequent lesions were main bile duct partial or total transection. The intraoperative mortality rate was 1/51 (1.9%) due to a complex biliary and vascular injury. The postoperative mortality rate of revision surgery was 5/50 (10%). T-tube positioning (n = 20) and Roux-en-Y hepato-jejunostomy (n = 20) were the procedures most frequently performed. The complication rate in patients treated with the T-tube was significantly higher than in those treated with hepatico-jejunostomy. Surgical treatment of biliary injuries following laparoscopic cholecystectomy was characterized by unusually high mortality and morbidity for a non-neoplastic disease. Roux-en-Y hepato-jejunostomy remains the procedure of choice for these injuries.

[Technical questions of the transrectal specimen extraction].

PubMed

Lukovich, Péter; Csibi, Noémi; Bokor, Attila

2016-03-01

During laparoscopic partial colectomy the specimen can be extracted transrectally. This technique decreases the invasiveness of the surgery, because the abdominal wall incision is avoided. Premises of a new surgical technique are precise technical description as well as a favourable balance of advantages and disadvantages. In this paper the authors review the technique they apply and analyse their first results. 45 laparoscopic bowel resections were performed by a multidisciplinary team between 16th April 2014 and 1st November 2015. Indication of surgery was endometriosis, and the specimen was extracted transrectally in 11 patients. Having ligated both bowel ends proximal and distal to the section infiltrated with endometriosis, and the proximal bowel secured with a laparoscopic bulldog. Then the bowel was resected and the specimen was extracted in a camera bag transrectally. A purse-string suture was placed into the proximal bowel end, and the anvil of the circular stapler--which was introduced transrectally--was inserted into the bowel. After closing the rectal stump, the anastomosis was performed with a circular stapler. We used this technique when the upper third of the rectum or sigmoid colon was infiltrated with endometriosis. The difference between the operation time of the two techniques (transabdominal vs. transrectal specimen extraction: 108 min vs. 118 min) was not significant. There was not difference in the WBC count between the first and second postoperative day, and there was not any anastomosis leakage detected either. By using the above technique, postoperative infections could have been reduced to minimum. Transrectal specimen extraction did not increase postoperative complication The authors believe this is a safe way of specimen extraction after partial colectomy.

Clinically Non-Metastatic Renal Cell Carcinoma With Sarcomatoid Dedifferentiation: Natural History and Outcomes after Surgical Resection with Curative Intent

PubMed Central

Merrill, Megan M.; Wood, Christopher G.; Tannir, Nizar M.; Slack, Rebecca S.; Babaian, Kara N.; Jonasch, Eric; Pagliaro, Lance C.; Compton, Zachary; Tamboli, Pheroze; Sircar, Kanishka; Pisters, Louis L.; Matin, Surena F.; Karam, Jose A.

2015-01-01

Purpose Renal cell carcinoma with sarcomatoid dedifferentiation (sRCC) is an aggressive malignancy associated with a poor prognosis. While existing literature focuses on patients presenting with metastatic disease, characteristics and outcomes for patients with localized disease are not well described. We aimed to evaluate post-nephrectomy characteristics, outcomes, and predictors of survival in patients with sRCC who presented with clinically localized disease. Patients and Methods An IRB-approved review from 1986–2011 identified 77 patients who presented with clinically localized disease, underwent nephrectomy and had sRCC in their primary kidney tumor. Clinical and pathologic variables were captured for each patient. Overall survival (OS) and recurrence-free survival (RFS) were calculated for all patients and those who had no evidence of disease (NED) following nephrectomy, respectively. Comparisons were made with categorical groupings in proportional hazards regression models for univariable and multivariable analyses. Results OS for the entire cohort (N=77) at 2 years was 50%. A total of 56 (77%) patients of the 73 who were NED following nephrectomy experienced a recurrence, with a median time to recurrence of 26.2 months. On multivariable analysis, tumor stage, pathologically positive lymph nodes, and year of nephrectomy were significant predictors of both OS and RFS. Limitations include the retrospective nature of this study and relatively small sample size. Conclusions Long-term survival for patients with sRCC, even in clinically localized disease is poor. Aggressive surveillance of those who are NED following nephrectomy is essential and further prospective studies evaluating the benefit of adjuvant systemic therapies in this cohort are warranted. PMID:25700975

Renal structure and function evaluation of rats from dams that received increased sodium intake during pregnancy and lactation submitted or not to 5/6 nephrectomy.

PubMed

Marin, Evelyn Cristina Santana; Balbi, Ana Paula Coelho; Francescato, Heloísa Della Coletta; Alves da Silva, Cleonice Giovanini; Costa, Roberto Silva; Coimbra, Terezila M

2008-01-01

Adult rats submitted to perinatal salt overload presented renin-angiotensin system (RAS) functional disturbances. The RAS contributes to the renal development and renal damage in a 5/6 nephrectomy model. The aim of the present study was to analyze the renal structure and function of offspring from dams that received a high-salt intake during pregnancy and lactation. We also evaluated the influence of the prenatal high-salt intake on the evolution of 5/6 nephrectomy in adult rats. A total of 111 sixty-day-old rat pups from dams that received saline or water during pregnancy and lactation were submitted to 5/6 nephrectomy (nephrectomized) or to a sham operation (sham). The animals were killed 120 days after surgery, and the kidneys were removed for immunohistochemical and histological analysis. Systolic blood pressure (SBP), albuminuria, and glomerular filtration rate (GFR) were evaluated. Increased SBP, albuminuria, and decreased GFR were observed in the rats from dams submitted to high-sodium intake before surgery. However, there was no difference in these parameters between the groups after the 5/6 nephrectomy. The scores for tubulointerstitial lesions and glomerulosclerosis were higher in the rats from the sham saline group compared to the same age control rats, but there was no difference in the histological findings between the groups of nephrectomized rats. In conclusion, our data showed that the high-salt intake during pregnancy and lactation in rats leads to structural changes in the kidney of adult offspring. However, the progression of the renal lesions after 5/6 nephrectomy was similar in both groups.

Towards a standardized informed consent procedure for live donor nephrectomy: What do surgeons tell their donors?

PubMed

Kortram, Kirsten; Ijzermans, Jan N M; Dor, Frank J M F

2016-08-01

Living kidney donors comprise a unique group of "patients", undergoing an operation for the benefit of others. The informed consent process is therefore valued differently. Although this is a team effort, the surgeon is responsible for performing the donor nephrectomy, and often the one held accountable, should adverse events occur. Although there is some consensus on how the informed consent procedure should be arranged, practices vary. The aim of this study was to evaluate the surgical informed consent procedure for live donor nephrectomy, with special regards to disclosure of complications. A web-based survey was sent to all kidney transplant surgeons (n = 50) in eight transplant centers with questions regarding the local procedure and disclosure of specific details. Response rate was 98% (n = 49), of which 32 (65%) were involved in living donor education; overall, transplant- (50%), vascular- (31%), and abdominal surgeons (13%), and urologists (6%) performed donor nephrectomies in the eight centers. Informed consent procedures varied, ranging from assumed to signed consent. Bleeding was the only complication every surgeon mentioned. Risk of death was always mentioned by 16 surgeons (50%), sometimes by 13 (41%), three surgeons (9%) never disclosed this disastrous complication. Reported mortality rates ranged from 0.003% to 0.1%. Mentioning frequencies for all other complications varied. Important complications are not always disclosed during the surgical informed consent process for live donor nephrectomy. Informed consent procedures vary. To optimally prepare living kidney donors for the procedure, a standardized informed consent procedure for live donor nephrectomy is highly recommended. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Urinary tract injury at the time of laparoscopic and robotic surgery: presentation and management.

PubMed

Evans, Janelle Morgan; Karram, Mickey M; Mahdy, Ayman; Robertshaw, Daniel

2013-01-01

To report a series of urinary tract injuries resultant of laparoscopic or robotic procedures performed for a gynecologic indication. We identified 16 patients with urinary tract fistulas after laparoscopic or robotic gynecologic procedures between 2009 and 2012. We extracted demographic data and prior surgical data as well as reviewed our management of each case. Thirteen subjects had undergone robotic procedures, 2 traditional laparoscopies, and a single-port laparoscopy with time to presentation from 2 days to 9 months postoperatively. Seven patients presented with vesicovaginal fistulas (43%), of which one healed spontaneously. Eight patients had ureterovaginal fistulas. Two patients (25%) were managed with ureteroneocystotomy, 2 patients (25%) were managed with Boari flap, and 4 patients (50%) were managed with double-J stent placement. One patient had a vesicocervical fistula managed via trachelectomy and partial cystectomy. The authors have seen an increase in referrals for urinary tract fistulas in minimally invasive surgery. It is imperative to investigate the effect of a steep learning curve, unfamiliarity with new energy sources, or poor patient selection as contributing factors.

[Critic analysis of a comparative meta-analysis on the morbidity, functional and carcinologic results after radical prostatectomy according to surgical approach. Work of cancerology committee of the French urological association].

PubMed

Bastide, C; Rozet, F; Salomon, L; Mongiat-Artus, P; Beuzeboc, P; Cormier, L; Eiss, D; Gaschignard, N; Peyromaure, M; Richaud, P; Soulié, M

2010-09-01

Surgical approach for radical prostatectomy is even today a subject of debate in the urologic community. Many comparative studies between retropubic and laparoscopic approach (robotic assisted or not) were reported since 10 years without being able to decide between the supporters of retropubic or laparoscopic approach. The committee of cancer research of the French urological association took hold this question after a recent meta-analysis publication on this subject. Although imperfect, this meta-analysis exists and permits to conclude partially on the advantages and the inconveniences supposed for each surgical approach. Regarding morbidity after radical prostatectomy, the only significant difference reported concerns the hemorrhagic risk in favour of the laparoscopic approach. Regarding oncologic results, the only exploitable data concern positive surgical margins rate, which is identical whatever surgical approach. Concerning the functional results, no difference was reported in the literature between different surgical approaches. Copyright © 2010 Elsevier Masson SAS. All rights reserved.

Cytoreductive nephrectomy vs medical therapy as initial treatment: a rational approach to the sequence question in metastatic renal cell carcinoma.

PubMed

Spiess, Philippe E; Fishman, Mayer N

2010-10-01

Renal cell carcinoma (RCC) can be considered as two distinct entities: localized and metastatic disease. We conducted a review of the scientific literature published within the past decade pertaining to cytoreductive nephrectomy for metastatic RCC. Retrospective data and historical prospective series have demonstrated the survival benefit of debulking nephrectomy in well-selected RCC patients. New medical therapies, including vascular endothelial growth factor and mTOR pathway blocking drugs, are active biological agents, with survival improvement and potential regression of metastatic and primary tumors. Our current therapeutic challenge is the optimal integration of multimodal therapy consisting of systemic therapy and surgery including cytoreductive nephrectomy, debulking, and metastasectomy. Empiric data to guide this decision are limited. The decision concerning whether medical or surgical therapy should be the primary treatment approach selected must be made on an individual basis, taking into account patient performance status, clinical parameters, and physician expertise and recommendations, thus making each case a unique therapeutic challenge.

Postoperative elevation in creatine kinase and its impact on renal function in patients undergoing complex partial nephrectomy.

PubMed

Sidana, Abhinav; Walton-Diaz, Annerleim; Truong, Hong; Siddiqui, M Minhaj; Miao, Ning; Shih, Johanna; Mannes, Andrew; Bratslavsky, Gennady; Linehan, W Marston; Metwalli, Adam R

2016-07-01

To identify the risk factors associated with development of postoperative elevation of creatine kinase (CK) and study its effect on renal function in patients who underwent complex multifocal partial nephrectomy (PN). Patients who underwent PN at National Cancer Institute between January 2007 and December 2012 were included in the study. Elevated serum CK was defined as >2000 U/L. Kidney function was assessed using serum creatinine and estimated glomerular filtration rate (eGFR). Changes were reported as percent change from preoperative values and compared using the Wilcoxon test. Regression analysis was performed to identify the predictors of elevation in CK and decline in eGFR. From 407 total cases, 207 had adequate CK data for analysis. Median number of tumors removed was 3 (1-70). Median peak CK was 1458 (82-36,788). Forty-two percent developed CK elevation >2000 U/L. Factors associated with postoperative elevation of CK > 2000 were young age (p = 0.009), high BMI (p = 0.003) and operating room time (p < 0.001). Although CK > 2000 was associated with significantly greater decline in eGFR (37.4 vs. 20.3 %, p < 0.001) in immediate postoperative period, this change largely resolved to a much less clinically relevant (9.2 vs 3.3 %, p = 0.040) change after 3 months. On multivariate analysis, postoperative elevation in CK was not found to be an independent factor determining renal function at 3 months. In our cohort, a significant proportion of patients developed CK elevations >2000 U/L. While patients with elevated CK had more decline in eGFR in immediate postoperative period, postoperative elevations of CK did not appear to impact overall long-term renal function in patients undergoing PN.

Robot-assisted partial nephrectomy for hilar tumors: perioperative outcomes.

PubMed

Eyraud, Rémi; Long, Jean-Alexandre; Snow-Lisy, Devon; Autorino, Riccardo; Hillyer, Shahab; Klink, Joseph; Rizkala, Emad; Stein, Robert J; Kaouk, Jihad H; Haber, Georges-Pascal

2013-06-01

To compare perioperative outcomes of robot-assisted partial nephrectomy (RAPN) for hilar vs nonhilar tumors. The study retrospectively reviewed 364 patients with available computed tomography scans undergoing RAPN. Demographic data and perioperative outcomes results were compared between the hilar (group 1, n = 70) and nonhilar tumors (group 2, n = 294). Multivariate analysis was used to identify predictors of warm ischemia time (WIT), estimated blood loss (EBL), major perioperative complications, and postoperative renal function. There were no differences with respect to demographic variables. Hilar tumors had higher RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) scores (P <.001) and were larger (3.9 vs 2.6 cm, P <.001). Surgeries for hilar tumors were associated with greater operative time (210 vs 180 minutes, P <.001), longer WIT (27 vs 17 minutes, P <.001), and increased EBL (250 vs 200 mL, P = .04). No differences were noted in transfusion rate, length of stay, complications (overall and major) and positive margins. Postoperative estimated glomerular filtration rate showed no significant difference between hilar vs nonhilar patients on postoperative day 3 (70.12 vs 74.71 mL/min/1.73 m(2), P = .31) or at last follow-up (72.62 vs 75.78 mL/min/1.73 m(2), P = .40), respectively. Multivariate analysis found hilar location was independently associated with increased WIT without significant changes in EBL, major complications, or postoperative renal function. RAPN represents a safe and effective procedure for hilar tumors. Hilar location for patients undergoing RAPN in a high-volume institution seems not be associated with an increased risk of transfusions, major complications, or decline of early postoperative renal function. Copyright © 2013 Elsevier Inc. All rights reserved.

Renal pelvic anatomy is associated with incidence, grade, and need for intervention for urine leak following partial nephrectomy.

PubMed

Tomaszewski, Jeffrey J; Cung, Bic; Smaldone, Marc C; Mehrazin, Reza; Kutikov, Alexander; Viterbo, Rosalia; Chen, David Y T; Greenberg, Richard E; Uzzo, Robert G

2014-11-01

Although the effect of tumor complexity on perioperative outcome measures is well established, the impact of renal pelvic anatomy on perioperative outcomes remains poorly defined. To evaluate renal pelvic anatomy as an independent predictor of urine leak in moderate- and high-complexity tumors undergoing nephron-sparing surgery. Patients undergoing open partial nephrectomy (PN) for localized RCC were stratified into intermediate- and high-complexity groups using a nephrometry score (7-9 and 10-12, respectively). A renal pelvic score (RPS) was defined by the percentage of renal pelvis contained inside the volume of the renal parenchyma. On this basis, patients were categorized as having an intraparenchymal (>50%) or extraparenchymal (<50%) renal pelvis. Characteristics of patients with and without an intraparenchymal renal pelvic anatomy were compared. Inclusion criteria were met by 255 patients undergoing PN for intermediate (73.6%) and complex (26.4%) localized renal tumors (mean size: 4.6±2.9cm). Twenty-four (9.6%) renal pelves were classified as completely intraparenchymal. Following stratification by RPS, groups differed with respect to Charlson comorbidity index, body mass index, and largest tumor size, while no differences were observed between hospital length of stay, nephrometry score, estimated blood loss, operative time, and age. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (75% vs 6.5%; p=0.001), secondary intervention (37.5% vs 3.9%; p<0.001), and prolonged duration of urine leak (93±62 d vs 56±29 d; p=0.025). Intraparenchymal renal pelvic anatomy is an uncommon anatomic variant associated with an increased rate of urine leak following PN. Elevated pressures within a small intraparenchymal renal pelvis might explain the increased risk. Preoperative imaging characteristics suggestive of increased risk for urine leak should be considered in perioperative management algorithms. Copyright © 2013. Published by Elsevier B.V.

Anatomical study of renal arterial vasculature and its potential impact on partial nephrectomy.

PubMed

Macchi, Veronica; Crestani, Alessandro; Porzionato, Andrea; Sfriso, Maria Martina; Morra, Aldo; Rossanese, Marta; Novara, Giacomo; De Caro, Raffaele; Ficarra, Vincenzo

2017-07-01

To validate Graves' classification of the intrarenal arteries and to verify the absence of collateral arterial blood supply between different renal segments, in order to maximize peri-operative and functional outcomes of partial nephrectomy. The study was performed on 15 normal kidneys sampled from eight unembalmed cadavers. Kidneys with the surrounding perirenal fat tissue were removed en bloc with the abdominal segment of the aorta. The renal artery was injected with acrylic and radiopaque resins, with the specimen suspended in water. CT examination of the injected kidneys was performed to analyse the branches located deeply. After imaging acquisition, the specimens were treated with sodium hydroxide for removal of the parenchyma to obtain vascular casts. Ten casts (66.6%) showed the classic subdivision of the main artery into single posterior and anterior branches. With regard to the distribution of the segmental or second-order arteries, only two casts (13%) showed a pattern similar to that described by Graves, characterized by four segmental (second-order) branches coming from the anterior renal artery (apical, superior, middle and inferior). In the remaining 13 kidneys (87%) a different arterial vascular network was detected. In 10 casts (80%) a single renal segment was vascularized by two or more different branches coming from an artery leading to another segment (multiple vascularization). Multiple vascularization was observed in three (20%) apical segments, five (33%) superior segments, six (40%) middle segments, seven (47%) inferior segments and two (13%) posterior segments. This study shows that in the human kidneys the arterial vasculature is frequently different from that described by Graves. Moreover, in a significant percentage of cases, a single renal segment receives two or more branches that originate from an artery leading to another segment. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

Robot-assisted partial nephrectomy in 95 consecutive patients: Oncological and functional outcomes at 3 years of follow-up.

PubMed

Castillo, O A; Rodríguez-Carlin, A; Borgna, V

2016-05-01

We present the oncological and functional results from a series of 43 patients with renal tumours, treated consecutively with robot-assisted partial nephrectomy (RPN). Between 2010 and 2014, we performed 95 RPNs. To assess the results, we included only those patients (n=43) who had a minimum follow-up of 2 years. A descriptive analysis was conducted of the demographic characteristics and perioperative variables. We employed Kaplan-Meier curves to assess overall survival, cancer-specific survival and recurrence-free survival. The patients' mean age was 53.1±13.5 years. The mean preoperative tumour size was 3.7±2.3cm. The mean surgical time was 102.2±37.1min. The mean ischemia time was 21.27±7.74minutes, with a median intraoperative bleeding volume of 150mL (IQR, 87.5-425). There was a 7% rate of postoperative complications (Clavien≥III). There was no mortality. The average Fürhman grade was 2.5±0.56. There were no positive surgical margins or local recurrences. The median follow-up was 38±8 months, with an overal survival, recurrence-free survival and cancer-specific survival of 100% at 3 years of follow-up. The recurrence-free survival was 92,3% at 48 months of follow-up. The mean preoperative glomerular filtration rate was 91.04±28.17mL/min/1.73m(2), and the postoperative rate was 89.9±27.69mL/min/1.73m(2), with a nonsignificant reduction (P=.74). The functional and oncological results of our series confirm the safety and efficacy of RPN. RPN offers optimal preservation of renal function and oncological control in the medium term. Copyright © 2015 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.

A Study of Relationship of Atheroembolic Risk Factors with Postoperative Recovery in Renal Function after Partial Nephrectomy in Patients Staged T1-2 Renal Cell Carcinoma during Median 4-Year Follow-up.

PubMed

Kim, Sung Han; Kang, Kyung Min; Yu, Ami; Lee, Jung Hoon; Nam, Byung Ho; Lee, Eun Sik

2016-01-01

The objective of this study is to evaluate the relationship of atheroembolic risk factors with postoperative recovery of renal function after on-clamp partial nephrectomy (PN) with warm ischemia in patients with staged T1-2 renal cell carcinoma (RCC). A total of 234 patients from 2004 to 2012 were included, and their clinicopathologic and operative parameters, including atheroembolic risk factors were reviewed retrospectively. Renal function, as determined by estimated glomerular filtration rate (eGFR) and measurement of serum creatinine level (Cr) at each scheduled follow-up for a median four years, was compared between the high-risk (HR) group (n=49, ≥ five risk factors) and the low-risk (LR) group (n=185, < five risk factors). Except for baseline renal function and number of risk factors for atheroembolism, differences in characteristics between groups were comparatively insignificant. At 3 months after the operation, Cr and eGFR differed significantly between the two groups (p < 0.05), but no differences were observed afterward. Significant deterioration from baseline in Cr and eGFR was observed in both groups at 1 month after the operation, with a greater change in the HR group (p < 0.05). From measurement to measurement, significantly faster deterioration in Cr and eGFR was observed in the HR group than in the LR group until 6 months after the operation (Cr: LR, 0.02 mg/dL and HR, 0.13 mg/dL; eGFR: LR, 1.50 mL/min/1.73 m(2) and HR, 6.38 mL/min/1.73 m(2); p < 0.05). The presence of atheroembolic risk factors may negatively influence postoperative recovery of renal function after PN in patients with localized RCC.

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy

PubMed Central

Klatte, Tobias; Ficarra, Vincenzo; Gratzke, Christian; Kaouk, Jihad; Kutikov, Alexander; Macchi, Veronica; Mottrie, Alexandre; Porpiglia, Francesco; Porter, James; Rogers, Craig G.; Russo, Paul; Thompson, R. Houston; Uzzo, Robert G.; Wood, Christopher G.; Gill, Inderbir S.

2016-01-01

Context A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes. Objective To evaluate the literature regarding pertinent surgical anatomy of the kidney and related structures, nephrometry scoring systems, and current surgical strategies for partial nephrectomy (PN). Evidence acquisition A literature review was conducted. Evidence synthesis Surgical renal anatomy fundamentally impacts PN surgery. The renal artery divides into anterior and posterior divisions, from which approximately five segmental terminal arteries originate. The renal veins are not terminal. Variations in the vascular and lymphatic channels are common; thus, concurrent lymphadenectomy is not routinely indicated during PN for cT1 renal masses in the setting of clinically negative lymph nodes. Renal-protocol contrast-enhanced computed tomography or magnetic resonance imaging is used for standard imaging. Anatomy-based nephrometry scoring systems allow standardized academic reporting of tumor characteristics and predict PN outcomes (complications, remnant function, possibly histology). Anatomy-based novel surgical approaches may reduce ischemic time during PN; these include early unclamping, segmental clamping, tumor-specific clamping (zero ischemia), and unclamped PN. Cancer cure after PN relies on complete resection, which can be achieved by thin margins. Post-PN renal function is impacted by kidney quality, remnant quantity, and ischemia type and duration. Conclusions Surgical renal anatomy underpins imaging, nephrometry scoring systems, and vascular control techniques that reduce global renal ischemia and may impact post-PN function. A contemporary ideal PN excises the tumor with a thin negative margin, delicately secures the tumor bed to maximize vascularized remnant parenchyma, and minimizes global ischemia to the renal remnant with minimal complications. Patient summary In this report we review renal surgical anatomy. Renal mass imaging allows detailed delineation of the anatomy and vasculature and permits nephrometry scoring, and thus precise, patient-specific surgical planning. Novel off-clamp techniques have been developed that may lead to improved outcomes. PMID:25911061

Zonal NePhRO scoring system: a superior renal tumor complexity classification model.

PubMed

Hakky, Tariq S; Baumgarten, Adam S; Allen, Bryan; Lin, Hui-Yi; Ercole, Cesar E; Sexton, Wade J; Spiess, Philippe E

2014-02-01

Since the advent of the first standardized renal tumor complexity system, many subsequent scoring systems have been introduced, many of which are complicated and can make it difficult to accurately measure data end points. In light of these limitations, we introduce the new zonal NePhRO scoring system. The zonal NePhRO score is based on 4 anatomical components that are assigned a score of 1, 2, or 3, and their sum is used to classify renal tumors. The zonal NePhRO scoring system is made up of the (Ne)arness to collecting system, (Ph)ysical location of the tumor in the kidney, (R)adius of the tumor, and (O)rganization of the tumor. In this retrospective study, we evaluated patients exhibiting clinical stage T1a or T1b who underwent open partial nephrectomy performed by 2 genitourinary surgeons. Each renal unit was assigned both a zonal NePhRO score and a RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior, location relative to polar lines) score, and a blinded reviewer used the same preoperative imaging study to obtain both scores. Additional data points gathered included age, clamp time, complication rate, urine leak rate, intraoperative blood loss, and pathologic tumor size. One hundred sixty-six patients underwent open partial nephrectomy. There were 37 perioperative complications quantitated using the validated Clavien-Dindo system; their occurrence was predicted by the NePhRO score on both univariate and multivariate analyses (P = .0008). Clinical stage, intraoperative blood loss, and tumor diameter were all correlated with the zonal NePhRO score on univariate analysis only. The zonal NePhRO scoring system is a simpler tool that accurately predicts the surgical complexity of a renal lesion. Copyright © 2014 Elsevier Inc. All rights reserved.

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy.

PubMed

Klatte, Tobias; Ficarra, Vincenzo; Gratzke, Christian; Kaouk, Jihad; Kutikov, Alexander; Macchi, Veronica; Mottrie, Alexandre; Porpiglia, Francesco; Porter, James; Rogers, Craig G; Russo, Paul; Thompson, R Houston; Uzzo, Robert G; Wood, Christopher G; Gill, Inderbir S

2015-12-01

A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes. To evaluate the literature regarding pertinent surgical anatomy of the kidney and related structures, nephrometry scoring systems, and current surgical strategies for partial nephrectomy (PN). A literature review was conducted. Surgical renal anatomy fundamentally impacts PN surgery. The renal artery divides into anterior and posterior divisions, from which approximately five segmental terminal arteries originate. The renal veins are not terminal. Variations in the vascular and lymphatic channels are common; thus, concurrent lymphadenectomy is not routinely indicated during PN for cT1 renal masses in the setting of clinically negative lymph nodes. Renal-protocol contrast-enhanced computed tomography or magnetic resonance imaging is used for standard imaging. Anatomy-based nephrometry scoring systems allow standardized academic reporting of tumor characteristics and predict PN outcomes (complications, remnant function, possibly histology). Anatomy-based novel surgical approaches may reduce ischemic time during PN; these include early unclamping, segmental clamping, tumor-specific clamping (zero ischemia), and unclamped PN. Cancer cure after PN relies on complete resection, which can be achieved by thin margins. Post-PN renal function is impacted by kidney quality, remnant quantity, and ischemia type and duration. Surgical renal anatomy underpins imaging, nephrometry scoring systems, and vascular control techniques that reduce global renal ischemia and may impact post-PN function. A contemporary ideal PN excises the tumor with a thin negative margin, delicately secures the tumor bed to maximize vascularized remnant parenchyma, and minimizes global ischemia to the renal remnant with minimal complications. In this report we review renal surgical anatomy. Renal mass imaging allows detailed delineation of the anatomy and vasculature and permits nephrometry scoring, and thus precise, patient-specific surgical planning. Novel off-clamp techniques have been developed that may lead to improved outcomes. Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Ipsilateral renal function preservation after robot-assisted partial nephrectomy (RAPN): an objective analysis using mercapto-acetyltriglycine (MAG3) renal scan data and volumetric assessment.

PubMed

Zargar, Homayoun; Akca, Oktay; Autorino, Riccardo; Brandao, Luis Felipe; Laydner, Humberto; Krishnan, Jayram; Samarasekera, Dinesh; Stein, Robert J; Kaouk, Jihad H

2015-05-01

To objectively assess ipsilateral renal function (IRF) preservation and factors influencing it after robot-assisted partial nephrectomy (RAPN). Our database was queried to identify patients who had undergone RAPN from 2007 to 2013 and had complete pre- and postoperative mercapto-acetyltriglycine (MAG3) renal scan assessment. The estimated glomerular filtration rate (eGFR) for the operated kidney was calculated by multiplying the percentage of contribution from the renal scan by the total eGFR. IRF preservation was defined as a ratio of the postoperative eGFR for the operated kidney to the preoperative eGFR for the operated kidney. The percentage of total eGFR preservation was calculated in the same manner (postoperative eGFR/preoperative eGFR × 100). The amount of healthy rim of renal parenchyma removed was assessed by deducting the volume of tumour from the volume of the PN specimen assessed on pathology. Multivariable linear regression was used for analysis. In all, 99 patients were included in the analysis. The overall median (interquartile range) total eGFR preservation and IRF preservation for the operated kidney was 83.83 (75.2-94.1)% and 72 (60.3-81)%, respectively (P < 0.01). On multivariable analysis, volume of healthy rim of renal parenchyma removed, warm ischaemia time (WIT) > 30 min, body mass index (BMI) and operated kidney preoperative eGFR were predictive of IRF preservation. Using total eGFR tends to overestimate the degree of renal function preservation after RAPN. This is particularly relevant when studying factors affecting functional outcomes after nephron-sparing surgery. IRF may be a more precise assessment method in this setting. Operated kidney baseline renal function, BMI, WIT >30 min, and amount of resected healthy renal parenchyma represent the factors with a significant impact on the IRF preservation. RAPN provides significant preservation of renal function as shown by objective assessment criteria. © 2014 The Authors. BJU International © 2014 BJU International.

Renal Autotransplantation - The Solution for Different Pathologies.

PubMed

Pinto Sousa, Pedro; Machado, Rui; Sá Pinto, Pedro; Almeida, Rui

2017-01-01

Renal autotransplantation (RA) is a safe and effective procedure to reconstruct the urinary tract which first successful surgery was performed by Hardy in 1963. The main indications reported for performing RA generally includes renovascular disease, ureteral pathologies and neoplastic disease. RA may be also useful as the last recourse in preventing kidney loss in highly selected patients, especially when conventional methods have failed. The authors pretend to describe four total different situations where the RA was the key solution for the pathology initially presented. 1- 52 years old male with a previous history of right nephrectomy that occurred during an exacerbation of his basal Chron disease so as left ureter cutaneostomie, presented with repetitive urinary tract infections that led to renal function impairment; 2- 57 years old female with the diagnosis of renal artery aneurysm while being studied as a potential renal donor; 3- 49 years old male admitted in the emergency room after a penetrating trauma which conditioned bowel and ureteral lesions with postoperative consecutive and recurrent peritoneal infections that compounded a necessity for a left ureter cutaneostomie, that the patient accurately refused; 4- 24 years old female with the diagnosis of Nutcracker syndrome identified after being studied regarding repetitive urgency admissions with frank hematuria. Every patient was submitted to RA. The intervention and postoperative course were uneventful. We performed an ultrasound evaluation on the day after each procedure to attest normal renal perfusion. The RA were realized in the two patients with ureteral lesions because there was no viable alternative but kidney loss. The other two clinical cases were treated with RA because they concerned a complex renovascular disease (one arterial and the other venous). Despite the existence of an endovascular option for these patients, long term follow up studies are still lacking. The RA is a viable option in specific situations for kidney salvage. The recent development of laparoscopic nephrectomy significantly decreased the surgical hostility to the patient and promoted the RA value on the treatment of complex vascular pathologies, traumatic disease and specific medical situations. It represents a credible alternative with attested results already described in the literature thus requiring a vast Institutional experience with conventional renal transplantation.

Laparoscopic Heller myotomy for achalasia: changing trend toward "true" day-case procedure.

PubMed

Agrawal, Sanjay; Super, Paul

2008-12-01

Laparoscopic Heller myotomy is the most effective therapy for achalasia. All case series have reported a minimum length of stay of more than 1 day. "True" day-case laparoscopic Heller myotomy has not been reported, so far. The aim of this study was to review our results with laparoscopic Heller myotomy with respect to the length of stay following the procedure. All patients undergoing laparoscopic Heller myotomy between August 2000 and July 2007 under the care of one surgeon were included in the study. This was performed by incising 6 cm of distal esophageal musculature, extending to 2 cm below the gastroesophageal junction. The myotomy was covered by an anterior fundoplication. All patients were reviewed in the clinic at a median of 6 weeks after surgery and, thereafter, if necessary. Over the 7-year period, 24 consecutive patients with achalasia were treated in this manner. There were 13 women and 11 men, with an age range of 12-73 years. Intraoperative complications included mucosal perforation in 2 patients (sutured immediately) with no postoperative complications or conversion to open surgery. There were no deaths. The average length of stay was 1.9 days (range, 0-4). The last 2 patients were discharged on the same day, and the 5 previous to this were discharged within 23 hours of surgery. There were no adverse outcomes related to early discharge, and there were no readmissions. All patients reported good to excellent results with a relief of dysphagia on follow-up. Three patients (12%) developed recurrent dysphagia after an initial improvement, requiring dilatation only several months later. Based on our own experience, we believe that laparoscopic Heller myotomy with anterior partial fundoplication is safe and achieves a good outcome in the treatment of achalasia. It is well tolerated and can be considered a true day-case procedure.

High fidelity simulation based team training in urology: a preliminary interdisciplinary study of technical and nontechnical skills in laparoscopic complications management.

PubMed

Lee, Jason Y; Mucksavage, Phillip; Canales, Cecilia; McDougall, Elspeth M; Lin, Sharon

2012-04-01

Simulation based team training provides an opportunity to develop interdisciplinary communication skills and address potential medical errors in a high fidelity, low stakes environment. We evaluated the implementation of a novel simulation based team training scenario and assessed the technical and nontechnical performance of urology and anesthesiology residents. Urology residents were randomly paired with anesthesiology residents to participate in a simulation based team training scenario involving the management of 2 scripted critical events during laparoscopic radical nephrectomy, including the vasovagal response to pneumoperitoneum and renal vein injury during hilar dissection. A novel kidney surgical model and a high fidelity mannequin simulator were used for the simulation. A debriefing session followed each simulation based team training scenario. Assessments of technical and nontechnical performance were made using task specific checklists and global rating scales. A total of 16 residents participated, of whom 94% rated the simulation based team training scenario as useful for communication skill training. Also, 88% of urology residents believed that the kidney surgical model was useful for technical skill training. Urology resident training level correlated with technical performance (p=0.004) and blood loss during renal vein injury management (p=0.022) but not with nontechnical performance. Anesthesia resident training level correlated with nontechnical performance (p=0.036). Urology residents consistently rated themselves higher on nontechnical performance than did faculty (p=0.033). Anesthesia residents did not differ in the self-assessment of nontechnical performance compared to faculty assessments. Residents rated the simulation based team training scenario as useful for interdisciplinary communication skill training. Urology resident training level correlated with technical performance but not with nontechnical performance. Urology residents consistently overestimated their nontechnical performance. Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Renal Cell Carcinoma Associated with Xp11.2 Translocation/TFE3 Gene Fusions: Clinical Features, Treatments and Prognosis.

PubMed

Liu, Ning; Wang, Zhen; Gan, Weidong; Xiong, Lei; Miao, Baolei; Chen, Xiancheng; Guo, Hongqian; Li, Dongmei

2016-01-01

To investigate the clinical characteristics, treatments and prognosis of renal cell carcinoma associated with Xp11.2 translocation/TFE3 gene fusions (Xp11.2 tRCC), the epidemiological features and treatment results of 34 cases of Xp11.2 tRCC, which were diagnosed by immunohistochemistry staining of TFE3 and fluorescence in situ hybridization at our center, were retrospectively reviewed. The 34 patients included 21 females and 13 males aged 3 to 64 years (median age: 27 years). Four patients were children or adolescents (<18 years of age), and 26 patients were young or middle-aged adults (18-45 years). Radical nephrectomy was performed on 25 patients. Laparoscopic nephron-sparing surgery was performed on 9 patients who presented with an isolated mass with a small diameter (<7 cm) and well-defined boundary on computed tomography imaging. Postoperative staging showed that 25 cases (73.53%) were at stage I/II, while 9 cases (26.47%) were at stage III/IV. All stage I/II patients received a favorable prognosis with a three-year overall survival rate of 100%, including the patients who underwent laparoscopic nephron-sparing surgery. With the exception of 2 children, the other 7 stage III/IV patients died or developed recurrence with a median follow-up of 29 months. On univariate analysis, maximum diameter, adjuvant treatment, TNM stage, lymph node metastasis, inferior vena cava tumor thrombosis and tumor boundary were identified as statistically significant factors impacting survival (P<0.05). Multivariate analysis indicated that TNM stage and inferior vena cava tumor thrombosis were independent prognostic factors (P<0.05). In conclusion, Xp11.2 tRCC is a rare subtype of renal cell carcinoma that mainly occurs in young females. Nephron-sparing surgery was confirmed effective preliminarily in the treatment of small Xp11.2 tRCCs with clear rims. Advanced TNM stage and inferior vena cava tumor thrombosis were associated with poor prognosis.

Renal Cell Carcinoma Associated with Xp11.2 Translocation/TFE3 Gene Fusions: Clinical Features, Treatments and Prognosis

PubMed Central

Gan, Weidong; Xiong, Lei; Miao, Baolei; Chen, Xiancheng; Guo, Hongqian; Li, Dongmei

2016-01-01

To investigate the clinical characteristics, treatments and prognosis of renal cell carcinoma associated with Xp11.2 translocation/TFE3 gene fusions (Xp11.2 tRCC), the epidemiological features and treatment results of 34 cases of Xp11.2 tRCC, which were diagnosed by immunohistochemistry staining of TFE3 and fluorescence in situ hybridization at our center, were retrospectively reviewed. The 34 patients included 21 females and 13 males aged 3 to 64 years (median age: 27 years). Four patients were children or adolescents (<18 years of age), and 26 patients were young or middle-aged adults (18–45 years). Radical nephrectomy was performed on 25 patients. Laparoscopic nephron-sparing surgery was performed on 9 patients who presented with an isolated mass with a small diameter (<7 cm) and well-defined boundary on computed tomography imaging. Postoperative staging showed that 25 cases (73.53%) were at stage I/II, while 9 cases (26.47%) were at stage III/IV. All stage I/II patients received a favorable prognosis with a three-year overall survival rate of 100%, including the patients who underwent laparoscopic nephron-sparing surgery. With the exception of 2 children, the other 7 stage III/IV patients died or developed recurrence with a median follow-up of 29 months. On univariate analysis, maximum diameter, adjuvant treatment, TNM stage, lymph node metastasis, inferior vena cava tumor thrombosis and tumor boundary were identified as statistically significant factors impacting survival (P<0.05). Multivariate analysis indicated that TNM stage and inferior vena cava tumor thrombosis were independent prognostic factors (P<0.05). In conclusion, Xp11.2 tRCC is a rare subtype of renal cell carcinoma that mainly occurs in young females. Nephron-sparing surgery was confirmed effective preliminarily in the treatment of small Xp11.2 tRCCs with clear rims. Advanced TNM stage and inferior vena cava tumor thrombosis were associated with poor prognosis. PMID:27893792

Pricing of surgeries for colon cancer: patient severity and market factors.

PubMed

Dor, Avi; Koroukian, Siran; Xu, Fang; Stulberg, Jonah; Delaney, Conor; Cooper, Gregory

2012-12-01

This study examined effects of health maintenance organization (HMO) penetration, hospital competition, and patient severity on the uptake of laparoscopic colectomy and its price relative to open surgery for colon cancer. The MarketScan Database (data from 2002-2007) was used to identify admissions for privately insured colorectal cancer patients undergoing laparoscopic or open partial colectomy (n = 1035 and n = 6389, respectively). Patient and health plan characteristics were retrieved from these data; HMO market penetration rates and an index of hospital market concentration, the Herfindahl-Hirschman index (HHI), were derived from national databases. Logistic and logarithmic regressions were used to examine the odds of having laparoscopic colectomy, effect of covariates on colectomy prices, and the differential price of laparoscopy. Adoption of laparoscopy was highly sensitive to market forces, with a 10% increase in HMO penetration leading to a 10.9% increase in the likelihood of undergoing laparoscopic colectomy (adjusted odds ratio = 1.109; 95% confidence interval [CI] = 1.062, 1.158) and a 10% increase in HHI resulting in 6.6% lower likelihood (adjusted odds ratio = 0.936; 95% CI = 0.880, 0.996). Price models indicated that the price of laparoscopy was 7.6% lower than that of open surgery (transformed coefficient = 0.927; 95% CI = 0.895, 0.960). A 10% increase in HMO penetration was associated with 1.6% lower price (transformed coefficient = 0.985; 95% CI = 0.977, 0.992), whereas a 10% increase in HHI was associated with 1.6% higher price (transformed coefficient = 1.016; 95% CI = 1.006, 1.027; P < .001 for all comparisons). Laparoscopy was significantly associated with lower hospital prices. Moreover, laparoscopic surgery may result in cost savings, while market pressures contribute to its adoption. Copyright © 2012 American Cancer Society.

Long-term symptom control of gastro-oesophageal reflux disease 12 years after laparoscopic Nissen or 180° anterior partial fundoplication in a randomized clinical trial.

PubMed

Roks, D J; Broeders, J A; Baigrie, R J

2017-06-01

Laparoscopic 180° anterior fundoplication has been shown to achieve similar reflux control to Nissen fundoplication, with fewer side-effects, up to 5 years. However, there is a paucity of long-term follow-up data on this technique and antireflux surgery in general. This study reports 12-year outcomes of a double-blind RCT comparing laparoscopic Nissen versus 180° laparoscopic anterior fundoplication for gastro-oesophageal reflux disease (GORD). Patients with proven GORD were randomized to laparoscopic Nissen or 180° anterior fundoplication. The 12-year outcome measures included reflux control, dysphagia, gas-related symptoms and patient satisfaction. Measures included scores on a visual analogue scale, a validated Dakkak score for dysphagia and Visick scores. Of the initial 163 patients randomized (Nissen 84, anterior 79), 90 (55·2 per cent) completed 12-year follow-up (Nissen 52, anterior 38). There were no differences in heartburn, dysphagia, gas-related symptoms, patient satisfaction or surgical reintervention rate. Use of acid-suppressing drugs was less common after Nissen than after 180° anterior fundoplication: four of 52 (8 per cent) and 11 of 38 (29 per cent) respectively (P = 0·008). The proportion of patients with absent or only mild symptoms was slightly higher after Nissen fundoplication: 45 of 50 (90 per cent) versus 28 of 38 (74 per cent) (P = 0·044). The two surgical procedures provided similar control of heartburn and post-fundoplication symptoms, with similar patient satisfaction and reoperation rates on long-term follow-up. © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.

Pricing of Surgeries for Colon Cancer: Patient Severity and Market Factors

PubMed Central

Dor, Avi; Koroukian, Siran; Xu, Fang; Stulberg, Jonah; Delaney, Conor; Cooper, Gregory

2012-01-01

Study Objective Examine effects of HMO penetration, hospital competition, and patient severity on the uptake of laparoscopic colectomy and its price relative to open surgery for colon cancer. Methods We used 2002-2007 the MarketScan Database to identify admissions for privately insured colorectal cancer patients undergoing laparoscopic or open partial colectomy (n=1,035 and n=6,389, respectively). Patient and health plan characteristics were retrieved from these data; HMO market penetration rates and an index of hospital market concentration, Herfindahl-Hirschman Index (HHI), were derived from national databases. Logistic and logarithmic regressions were used to examine the odds of having laparoscopic colectomy, effect of covariates on colectomy prices, and the differential price of laparoscopy. Results Adoption of laparoscopy was highly sensitive to market forces, with a 10% increase in HMO penetration leading to a 10.3% increase in the likelihood of undergoing laparoscopic colectomy (Adjusted Odds Ratio (AOR): 1.109, 95% Confidence Interval: 1.062, 1.158), and a 10% increase in HHI resulting in 6.6% lower likelihood (AOR: 0.936 (0.880, 0.996)). Price models indicated that the price of laparoscopy was 7.6% lower than for open surgery (transformed coefficient (Coeff): 0.927 (0.895, 0.960)). A 10% increase in HMO penetration was associated with 1.6% lower price (Coeff: 0.985 (0.977, 0.992)), while a 10% increase in HHI was associated with 1.6% higher price (Coeff: 1.016 (1.006, 1.027), p < 0.001 for all comparisons). Conclusions Laparoscopy was significantly associated with lower hospital prices. Moreover, Impact Laparoscopic surgery may result in cost savings, while market pressures contribute to its adoption. PMID:22569703

Comparison of Arterial Oxygenation Following Head-Down and Head-Up Laparoscopic Surgery.

PubMed

Imani, Farsad; Shirani Amniyeh, Fatemeh; Bastan Hagh, Ehsan; Khajavi, Mohammad Reza; Samimi, Saghar; Yousefshahi, Fardin

2017-12-01

Regarding the role of gas entry in abdomen and cardiorespiratory effects, the ability of anesthesiologists would be challenged in laparoscopic surgeries. Considering few studies in this area and the relevance of the subject, this study was performed to compare the arterial oxygen alterations before operation in comparison with after surgery between laparoscopic cholecystectomy and ovarian cystectomy. In this prospective cohort, 70 consecutive women aged from 20 to 60 years who were candidate for laparoscopic cholecystectomy (n = 35) and ovarian cystectomy (n = 35) with reverse (20 degrees) and direct (30 degrees) Trendelenburg positions, respectively, with ASA class I or II were enrolled. After intubation and before operation, for the first time, the arterial blood gas from radial artery in supine position was obtained for laboratory assessment. Then, the second blood sample was collected from radial artery in supine position and sent to the lab to be assessed with the same device after 30 minutes from surgery termination. The measured variables from arterial blood gas were arterial partial pressure of oxygen (PaO 2 ) and Oxygen saturation (SpO 2 ) alterations. Total PaO 2 was higher in the first measurement. The higher values of PaO 2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.060) and multivariate analysis (P = 0.654). Furthermore, higher values of SpO 2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.412) and multivariate analysis (P = 0.984). In general, based on the results of this study, the values of PaO 2 in cholecystectomy (upward) were not significantly higher than the values in cystectomy (downward) in laparoscopic surgeries when measured 30 minutes after surgery.

Comparison of Arterial Oxygenation Following Head-Down and Head-Up Laparoscopic Surgery

PubMed Central

Imani, Farsad; Shirani Amniyeh, Fatemeh; Bastan Hagh, Ehsan; Khajavi, Mohammad Reza; Samimi, Saghar; Yousefshahi, Fardin

2017-01-01

Background Regarding the role of gas entry in abdomen and cardiorespiratory effects, the ability of anesthesiologists would be challenged in laparoscopic surgeries. Considering few studies in this area and the relevance of the subject, this study was performed to compare the arterial oxygen alterations before operation in comparison with after surgery between laparoscopic cholecystectomy and ovarian cystectomy. Methods In this prospective cohort, 70 consecutive women aged from 20 to 60 years who were candidate for laparoscopic cholecystectomy (n = 35) and ovarian cystectomy (n = 35) with reverse (20 degrees) and direct (30 degrees) Trendelenburg positions, respectively, with ASA class I or II were enrolled. After intubation and before operation, for the first time, the arterial blood gas from radial artery in supine position was obtained for laboratory assessment. Then, the second blood sample was collected from radial artery in supine position and sent to the lab to be assessed with the same device after 30 minutes from surgery termination. The measured variables from arterial blood gas were arterial partial pressure of oxygen (PaO2) and Oxygen saturation (SpO2) alterations. Results Total PaO2 was higher in the first measurement. The higher values of PaO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.060) and multivariate analysis (P = 0.654). Furthermore, higher values of SpO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.412) and multivariate analysis (P = 0.984). Conclusions In general, based on the results of this study, the values of PaO2 in cholecystectomy (upward) were not significantly higher than the values in cystectomy (downward) in laparoscopic surgeries when measured 30 minutes after surgery. PMID:29696125

Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial.

PubMed

Rawlings, Arthur; Soper, Nathaniel J; Oelschlager, Brant; Swanstrom, Lee; Matthews, Brent D; Pellegrini, Carlos; Pierce, Richard A; Pryor, Aurora; Martin, Valeria; Frisella, Margaret M; Cassera, Maria; Brunt, L Michael

2012-01-01

The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy. A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0-4, five-point Likert scale questionnaire) and 24-h pH testing at 6-12 months after surgery. Data are mean ± SD. Statistical analysis was by Mann-Whitney U test, Wilcoxon signed rank test, and Freidman's test. Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7 years) and gender (52.8 vs. 62.5% male). pH studies at 6-12 months in 43 patients (72%: Dor n = 24 and Toupet n = 19) showed total DeMeester scores and % time pH < 4 were not significant between the two groups. Abnormal acid reflux was present in 10 of 24 Dor group patients (41.7%) and in 4 of 19 Toupet patients (21.0%) (p = 0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups). Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet, the differences were not statistically significant.

Specific esophagogram to assess functional outcomes after Heller's myotomy and Dor's fundoplication for esophageal achalasia.

PubMed

Tsoukali, E; Gouvas, N; Tsiaoussis, J; Pechlivanides, G; Zervakis, N; Mantides, A; Xynos, E

2011-09-01

Esophageal emptying assessed at the 'timed barium' esophagogram correlates well with symptomatic outcomes after pneumatic dilation for esophageal achalasia, although 30% of patients with satisfactory outcome exhibit partial improvement in emptying. The aim of the study was to investigate any correlation of esophageal emptying to symptomatic response after laparoscopic Heller's myotomy and Dor's fundoplication. 'Bread and barium' (transit time of a barium opaque bread bolus) and 'timed barium' (height of esophageal barium column 5 minutes after ingestion of 200-250 mL of barium suspension) esophagogram was used to assess esophageal emptying in 73 patients with esophageal achalasia before 1 and 5 years (31 cases) after laparoscopic myotomy and anterior fundoplication. Symptoms assessment was based to a specific score. At 1-year follow-up, excellent and good symptomatic results were obtained in 95% of the cases. Esophageal maximum diameter, esophageal transit time, and esophageal barium column were significantly correlated to each other and to symptom score postoperatively (P < 0.001). Complete and partial (<90% and 50-90% postoperative reduction in barium column, respectively) emptying was seen in 55% and 31% of patients with excellent result. Patients with a pseudodiverticulum postoperatively had a more delayed esophageal emptying than those without. Symptomatic outcome and esophageal emptying did not deteriorate at 5-year follow-up. Esophageal emptying assessed by 'barium and bread' and 'timed barium' esophagogram correlated well with symptomatic outcome after laparoscopic myotomy for esophageal achalasia. Complete symptomatic relief does not necessarily reflect complete esophageal emptying. Outcomes do not deteriorate by time. Because of wide availability, esophagogram can be applied in follow-up of postmyotomy patients in conjunction with symptomatic evaluation. © 2011 Copyright the Authors. Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

A characterization of factors determining postoperative ileus after laparoscopic colectomy enables the generation of a novel predictive score.

PubMed

Kronberg, Udo; Kiran, Ravi P; Soliman, Mohamed S M; Hammel, Jeff P; Galway, Ursula; Coffey, John Calvin; Fazio, Victor W

2011-01-01

Postoperative ileus (POI) after colorectal surgery is associated with prolonged hospital stay and increased costs. The aim of this study is to investigate pre-, intra-, and postoperative risk factors associated with the development of POI in patients undergoing laparoscopic partial colectomy. Patients operated between 2004 and 2008 were retrospectively identified from a prospectively maintained database, and clinical, metabolic, and pharmacologic data were obtained. Postoperative ileus was defined as the absence of bowel function for 5 or more days or the need for reinsertion of a nasogastric tube after starting oral diet in the absence of mechanical obstruction. Associations between likelihood of POI and study variables were assessed univariably by using χ tests, Fisher exact tests, and logistic regression models. A scoring system for prediction of POI was constructed by using a multivariable logistic regression model based on forward stepwise selection of preoperative factors. A total of 413 patients (mean age, 58 years; 53.5% women) were included, and 42 (10.2%) of them developed POI. Preoperative albumin, postoperative deep-vein thrombosis, and electrolyte levels were associated with POI. Age, previous abdominal surgery, and chronic preoperative use of narcotics were independently correlated with POI on multivariate analysis, which allowed the creation of a predictive score. Patients with a score of 2 or higher had an 18.3% risk of POI (P < 0.001). Postoperative ileus after laparoscopic partial colectomy is associated with specific preoperative and postoperative factors. The likelihood of POI can be predicted by using a preoperative scoring system. Addressing the postoperative factors may be expected to reduce the incidence of this common complication in high-risk patients.

Updates in Mirizzi syndrome

PubMed Central

Valderrama-Treviño, Alan Isaac; Espejel-Deloiza, Mariana; Chernitzky-Camaño, Jonathan; Barrera Mera, Baltazar; Estrada-Mata, Aranza Guadalupe; Ceballos-Villalva, Jesús Carlos; Acuña Campos, Jonathan; Argüero-Sánchez, Rubén

2017-01-01

Mirizzi syndrome, known as extrinsic bile compression syndrome, is a rare complication of cholecystitis and chronic cholelithiasis, secondary to the obliteration of the infundibulum of the gallbladder or cystic duct caused by the impact of one or more calculations in these anatomical structures, which leads to compression of the adjacent bile duct, resulting in partial or complete obstruction of the common hepatic duct, triggering liver dysfunction. Our aim is to identify and describe the current epidemiology, diagnostic methods, and treatment of Mirizzi syndrome. A literature search was performed using different databases, including Medline, Cochrane, Embase, Medscape, PubMed, using keywords: Mirizzi syndrome, epidemiology, markers, pathophysiology, clinical presentation, diagnosis, and treatment. Selected original articles, review articles or case reports from 1997 to 2015 were collected, written in English or Spanish. The endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate diagnostic method. The traditional treatment has been surgery and involves an incision at the bottom of the gallbladder and calculus removal. If fistulas are observed, it is performed a partial cholecystectomy; otherwise, a cholecystocholedochoduodenostomy is an alternative. Endoscopic treatment includes biliary drainage and stone extraction. Many surgeons claim that laparoscopic cholecystectomy is contraindicated in Mirizzi syndrome because of the presence of inflammatory tissue and adhesions in the Calot’s triangle. If dissection is attempt, it can cause unnecessary injury to the bile duct. However, other surgeons consider the laparoscopic approach is feasible, although technically challenging. Currently, laparoscopic cholecystectomy for this condition is considered controversial and technically challenging; however, it has shown that with the right skills and equipment, it is a safe and feasible way to treat some cases of Mirizzi syndrome type I and II. PMID:28653000

Hypernephroma Presenting with Cutaneous Leukocytoclastic Vasculitis and Lupus Anticoagulant: Resolution after Nephrectomy

PubMed Central

Murray, Nigel P.; Ruíz, Amparo; Reyes, Eduardo

2012-01-01

Hypernephroma can present as a variety of paraneoplastic, nonmetastatic conditions, including vasculitis, and rarely a lupus-type anticoagulant. Nephrectomy leads to the resolution of the systemic complaints. Malignancy, in this case hypernephroma, can present as an immune-mediated paraneoplastic syndrome which resolves after removal of the underlying tumor. PMID:22919534

Predictors of new-onset chronic kidney disease in patients managed surgically for T1a renal cell carcinoma: An Australian population-based analysis.

PubMed

Ahn, Thomas; Ellis, Robert J; White, Victoria M; Bolton, Damien M; Coory, Michael D; Davis, Ian D; Francis, Ross S; Giles, Graham G; Gobe, Glenda C; Hawley, Carmel M; Johnson, David W; Marco, David J T; McStea, Megan; Neale, Rachel E; Pascoe, Elaine M; Wood, Simon T; Jordan, Susan J

2018-05-22

New-onset chronic kidney disease (CKD) following surgical management of kidney tumors is common. This study evaluated risk factors for new-onset CKD after nephrectomy for T1a renal cell carcinoma (RCC) in an Australian population-based cohort. There were 551 RCC patients from the Australian states of Queensland and Victoria included in this study. The primary outcome was new-onset CKD (eGFR <60 mL/min per 1.73 m 2 ) and the secondary outcome was new-onset moderate-severe CKD (<45 mL/min per 1.73 m 2 ). Multivariable logistic regression was used to evaluate associations between patient, tumor and health-service characteristics and these outcomes. Forty percent (219/551) of patients developed new-onset CKD, and 12% (68/551) experienced new-onset moderate-severe CKD. Risk factors for new-onset CKD were age, lower preoperative eGFR, tumor size >20 mm, radical nephrectomy, lower hospital caseloads (<20 cases/year), and rural place of residence. The associations between rural place of residence and low center volume were a consequence of higher radical nephrectomy rates. Risk factors for CKD after nephrectomy generally relate to worse baseline health, or likelihood of undergoing radical nephrectomy. Surgeons in rural centres and hospitals with low caseloads may benefit from formalized integration with specialist centers for continued professional development and case-conferencing, to assist in management decisions. © 2018 Wiley Periodicals, Inc.

Percutaneous drainage and/or nephrectomy in the treatment of emphysematous pyelonephritis.

PubMed

Mydlo, Jack H; Maybee, Gabrielle J; Ali-Khan, Mustafa M

2003-01-01

To assess the current and past literature relating to the differential treatment of emphysematous pyelonephritis (EPN). Some of the newer literature suggests percutaneous drainage (PCD), as compared to the standard nephrectomy, as a better modality. Since these two may complement each other, we sought to seek indications when to perform each treatment. Medline and MD Consult were used for our journal review. Ten articles, ranging from 1980 to 2000, were chosen, which covered 162 patients. The criteria for selecting these articles were study size (n < 3 were excluded) and non-overlapping of patient information. Patient data was then used to certain risks of the various treatment modalities. Due to the lack of randomization of the studies, it is difficult to say whether PCD is superior to nephrectomy or not. It appears to be that each treatment may complement each other, and that treatment should be individualized based on the severity of the EPN and the medical condition of the patient. PCD though appears to be acceptable for use in the initial phases of the disease. However, long-term data is lacking to corroborate the overall benefit of PCD compared to nephrectomy. PCD could be utilized initially in some cases of EPN if certain conditions exist. This treatment may complement nephrectomy if the need exists, and therefore, treatment may be staged. Truly randomized studies need to be done to determine if one treatment is better than the other, and provide documented long-term follow-up of these patients.

Oncological outcomes after cytoreductive nephrectomy for patients with metastatic renal cell carcinoma with inferior vena caval tumor thrombus.

PubMed

Miyake, Hideaki; Sugiyama, Takayuki; Aki, Ryota; Matsushita, Yuto; Tamura, Keita; Motoyama, Daisuke; Ito, Toshiki; Otsuka, Atsushi

2018-06-01

To evaluate the oncological outcomes of patients with metastatic renal cell carcinoma (mRCC) involving the inferior vena cava (IVC) who received cytoreductive nephrectomy. This study included 75 consecutive metastatis renal cell carcinoma (mRCC) patients with inferior vena cava (IVC) tumor thrombus undergoing cytoreductive nephrectomy and tumor thrombectomy followed by systemic therapy. Of the 75 patients, 11, 33, 24 and 7 had level I, II, III and IV IVC thrombus, respectively. Following surgical treatment, 25 (group A), 27 (group B) and 23 (group C) received cytokine therapy alone, molecular-targeted therapy alone and both therapies, respectively, as management for metastatic diseases. The median overall survival (OS) of the 75 patients was 16.2 months. No significant differences in OS were noted according to the level of the IVC tumor thrombus. There were no significant differences in OS among groups A, B and C; however, OS in groups B and C was significantly superior to that in group A. Furthermore, multivariate analysis of several parameters identified the following independent predictors of poor OS-elevated C-reactive protein, liver metastasis and postoperative treatment with cytokine therapy alone. The prognosis of mRCC patients with IVC thrombus undergoing cytoreductive nephrectomy may be significantly affected by the type of postoperative systemic therapy rather than the level of the IVC tumor thrombus. Accordingly, cytoreductive nephrectomy should be considered as a major therapeutic option for patients with mRCC involving the IVC, particularly in the era of targeted therapy.

Use of augmented reality in laparoscopic gynecology to visualize myomas.

PubMed

Bourdel, Nicolas; Collins, Toby; Pizarro, Daniel; Debize, Clement; Grémeau, Anne-Sophie; Bartoli, Adrien; Canis, Michel

2017-03-01

To report the use of augmented reality (AR) in gynecology. AR is a surgical guidance technology that enables important hidden surface structures to be visualized in endoscopic images. AR has been used for other organs, but never in gynecology and never with a very mobile organ like the uterus. We have developed a new AR approach specifically for uterine surgery and demonstrated its use for myomectomy. Tertiary university hospital. Three patients with one, two, and multiple myomas, respectively. AR was used during laparoscopy to localize the myomas. Three-dimensional (3D) models of the patient's uterus and myomas were constructed before surgery from T2-weighted magnetic resonance imaging. The intraoperative 3D shape of the uterus was determined. These models were automatically aligned and "fused" with the laparoscopic video in real time. The live fused video made the uterus appear semitransparent, and the surgeon can see the location of the myoma in real time while moving the laparoscope and the uterus. With this information, the surgeon can easily and quickly decide on how best to access the myoma. We developed an AR system for gynecologic surgery and have used it to improve laparoscopic myomectomy. Technically, the software we developed is very different to approaches tried for other organs, and it can handle significant challenges, including image blur, fast motion, and partial views of the organ. Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Laparoscopic management of totally intra-thoracic stomach with chronic volvulus

PubMed Central

Toydemir, Toygar; Çipe, Gökhan; Karatepe, Oğuzhan; Yerdel, Mehmet Ali

2013-01-01

AIM: To evaluate the outcomes of patients who underwent laparoscopic repair of intra-thoracic gastric volvulus (IGV) and to assess the preoperative work-up. METHODS: A retrospective review of a prospectively collected database of patient medical records identified 14 patients who underwent a laparoscopic repair of IGV. The procedure included reduction of the stomach into the abdomen, total sac excision, reinforced hiatoplasty with mesh and construction of a partial fundoplication. All perioperative data, operative details and complications were recorded. All patients had at least 6 mo of follow-up. RESULTS: There were 4 male and 10 female patients. The mean age and the mean body mass index were 66 years and 28.7 kg/m2, respectively. All patients presented with epigastric discomfort and early satiety. There was no mortality, and none of the cases were converted to an open procedure. The mean operative time was 235 min, and the mean length of hospitalization was 2 d. There were no intraoperative complications. Four minor complications occurred in 3 patients including pleural effusion, subcutaneous emphysema, dysphagia and delayed gastric emptying. All minor complications resolved spontaneously without any intervention. During the mean follow-up of 29 mo, one patient had a radiological wrap herniation without volvulus. She remains symptom free with daily medication. CONCLUSION: The laparoscopic management of IGV is a safe but technically demanding procedure. The best outcomes can be achieved in centers with extensive experience in minimally invasive esophageal surgery. PMID:24124329

Radiofrequency Ablation of Renal Tumors with an Expandable Multitined Electrode: Results, Complications, and Pilot Evaluation of Cooled Pyeloperfusion for Collecting System Protection

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rouviere, Olivier; Badet, Lionel; Murat, Francois Joseph

2008-05-15

The objective of this study was to retrospectively evaluate the results of radiofrequency ablation (RFA) of renal tumors with an impedance-based system using an expandable multitined electrode. Twenty-two patients (30 tumors) were treated with RFA over a 7-year period, percutaneously (16 tumors) or intraoperatively (14 tumors). Follow-up imaging was performed at 1-3, 6, and 12 months and yearly thereafter. Twenty-seven of 30 tumors (19/22 patients) showed no residual tumor on the first imaging control. Two residual tumors were successfully ablated by a second RFA procedure. Our mean follow-up period was 35 months (range, 3-84 months). Two tumors that had beenmore » completely ablated based on imaging criteria recurred 11 and 48 months after RFA. One was treated by partial nephrectomy. The other one was not treated because the patient developed bone metastases. One patient had nephrectomy because of an RFA-induced ureteropelvic junction stricture. Nine patients (11 sessions) had a pyeloperfusion of cooled saline during RFA. None developed symptomatic complications, even though in three patients the ablation zone extended to the closest calyx (3-5 mm from the tumor). We conclude that RFA of renal tumors is promising, but serious complications to the collecting system must be taken into consideration. Prophylactic per-procedural cooling of the collecting system is feasible but needs further assessment.« less

Hemostatic agents and instruments in laparoscopic renal surgery.

PubMed

Msezane, Lambda P; Katz, Mark H; Gofrit, Ofer N; Shalhav, Arieh L; Zorn, Kevin C

2008-03-01

Control of bleeding is one of the most technically challenging steps in laparoscopic renal surgery, especially partial nephrectomy. Although there is no consensus on how best to approach hemostasis, the options continue to expand. The original method of sutured renorrhaphy is, perhaps, the most effective; however, great skill is needed to avoid prolonged warm ischemia. Tissue sealants and adhesives serve as a barrier to leakage and as a hemostat. The four classes are fibrin sealants, collagen-based adhesives, hydrogel, and glutaraldehyde-based adhesive. Additionally, oxidized cellulose can be applied to the surface of kidney or used as a bolster. Fibrin sealants are self-activating and work best on a dry field. The gelatin matrix agent consists of human-derived thrombin with a calcium chloride solution and bovine-derived gelatin matrix. The fibrinogen required to form a clot comes from autologous blood. Another product is polyethylene glycol-based hydrogel, which acts as a mechanical sealant. The tissue glue consists of bovine serum albumin and glutaraldehyde, which cross-link to each other, as well as to other tissue proteins. Excessive use or spillage around the renal pelvis and ureter may compromise urinary flow. The methylcellulose products, consisting of oxidized cellulose sheets, usually are positioned within a sutured bolster and act in part by providing direct pressure. A number of energy-based technologies also have been utilized. Monopolar cautery consists of a high-frequency electrical current delivered from a single electrode. Care must be taken to avoid injurious current transfer to surrounding structures. With bipolar cautery, hemostasis occurs only between the electrodes. In the argonbeam coagulator, argon, an inert non-flammable gas that clears from the body rapidly, is coupled with an electrosurgical generator. The gas creates a more even distribution of the energy and better sealing of the tissues. There have been a few reports of serious complications, including gas embolism and tension pneumothorax. The holmium:YAG laser simultaneously dissects and coagulates tissue. However, its use may be limited by smoke and by blood splashing onto the camera lens, and the tissue vaporization and liquid could promote tumor-cell spillage. The potassium-titanyl-phosphate (KTP) and diode lasers have shown promise in animal studies. The saline-coupled radiofrequency tool uses a standard electrosurgical generator to deliver energy through the conductive fluid. The fluid keeps the surface temperature much lower, increases the contact area, and reduces char and eschar formation. One caveat for the use of instruments that coagulate and ablate tissue is that they can damage the collecting system. Furthermore, the char can make it difficult to assess margin status. In practice, a combination of instruments, sealants, or both generally is utilized to obtain hemostasis. These multimodality efforts may be especially useful in the patient with compromised renal function. On the other hand, the cost can rise quickly when multiple agents are employed. Combining suturing and hemostatic technology may be the best strategy.

Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss at 5 Years Among Patients With Morbid Obesity: The SLEEVEPASS Randomized Clinical Trial.

PubMed

Salminen, Paulina; Helmiö, Mika; Ovaska, Jari; Juuti, Anne; Leivonen, Marja; Peromaa-Haavisto, Pipsa; Hurme, Saija; Soinio, Minna; Nuutila, Pirjo; Victorzon, Mikael

2018-01-16

Laparoscopic sleeve gastrectomy for treatment of morbid obesity has increased substantially despite the lack of long-term results compared with laparoscopic Roux-en-Y gastric bypass. To determine whether laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass are equivalent for weight loss at 5 years in patients with morbid obesity. The Sleeve vs Bypass (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial was conducted from March 2008 until June 2010 in Finland. The trial enrolled 240 morbidly obese patients aged 18 to 60 years, who were randomly assigned to sleeve gastrectomy or gastric bypass with a 5-year follow-up period (last follow-up, October 14, 2015). Laparoscopic sleeve gastrectomy (n = 121) or laparoscopic Roux-en-Y gastric bypass (n = 119). The primary end point was weight loss evaluated by percentage excess weight loss. Prespecified equivalence margins for the clinical significance of weight loss differences between gastric bypass and sleeve gastrectomy were -9% to +9% excess weight loss. Secondary end points included resolution of comorbidities, improvement of quality of life (QOL), all adverse events (overall morbidity), and mortality. Among 240 patients randomized (mean age, 48 [SD, 9] years; mean baseline body mass index, 45.9, [SD, 6.0]; 69.6% women), 80.4% completed the 5-year follow-up. At baseline, 42.1% had type 2 diabetes, 34.6% dyslipidemia, and 70.8% hypertension. The estimated mean percentage excess weight loss at 5 years was 49% (95% CI, 45%-52%) after sleeve gastrectomy and 57% (95% CI, 53%-61%) after gastric bypass (difference, 8.2 percentage units [95% CI, 3.2%-13.2%], higher in the gastric bypass group) and did not meet criteria for equivalence. Complete or partial remission of type 2 diabetes was seen in 37% (n = 15/41) after sleeve gastrectomy and in 45% (n = 18/40) after gastric bypass (P > .99). Medication for dyslipidemia was discontinued in 47% (n = 14/30) after sleeve gastrectomy and 60% (n = 24/40) after gastric bypass (P = .15) and for hypertension in 29% (n = 20/68) and 51% (n = 37/73) (P = .02), respectively. There was no statistically significant difference in QOL between groups (P = .85) and no treatment-related mortality. At 5 years the overall morbidity rate was 19% (n = 23) for sleeve gastrectomy and 26% (n = 31) for gastric bypass (P = .19). Among patients with morbid obesity, use of laparoscopic sleeve gastrectomy compared with use of laparoscopic Roux-en-Y gastric bypass did not meet criteria for equivalence in terms of percentage excess weight loss at 5 years. Although gastric bypass compared with sleeve gastrectomy was associated with greater percentage excess weight loss at 5 years, the difference was not statistically significant, based on the prespecified equivalence margins. clinicaltrials.gov Identifier: NCT00793143.

Intravesical ligation as a new technique to manage a refluxing native ureter without simultaneous nephrectomy in renal transplantation.

PubMed

Guzmán, J A

2012-12-01

This article aims to describe an original technique to correct refluxing native ureters observed during a prerenal transplantation study. The correction is performed by intravesical ligation of the native refluxing ureters at the same time as renal transplantation without simultaneous nephrectomy. Between January 2004 and December 2010 we performed intravesical ligation of a refluxing ureter simultaneous with a transplantation procedure without a concomittant native nephrectomy in 12 of 345 subjects (3.47%). The 8 bilateral and 4 unilateral ligations were performed on 11 cadaveric and 1 living-related nonidentical donor transplantations. The implantation of the kidney donor ureter was performed anatomically in the bladder trigone through a transvesical ureteroneocystostomy with a transmural, submucosal antireflux tunnel. Early and late postoperative recovery was satisfactory in all patients. There was no documented kidney area pain, proven urinary tract infection, morbidity or mortality attributed to the procedure. Intravesical ligation is a practical technique to manage vesicoureteral reflux into the native ureters simultaneously with the ureteral implantation of the kidney donor in a single surgical renal transplant procedure without native kidney nephrectomy. Copyright © 2012 Elsevier Inc. All rights reserved.

Routine upper gastrointestinal Gastrografin swallow after laparoscopic Roux-en-Y gastric bypass.

PubMed

Sims, Thomas L; Mullican, Mary A; Hamilton, Elizabeth C; Provost, David A; Jones, Daniel B

2003-02-01

Upper gastrointestinal (UGI) swallow radiographs following laparoscopic Roux-en-Y gastric bypass (LRYGBP) may detect an obstruction or an anastomotic leak. The aim of our study was to determine the efficacy of routine imaging following LRYGBP. Radiograph reports were reviewed for 201 consecutive LRYGBP operations between April 1999 and June 2001. UGI swallow used Gastrografin, static films, fluoroscopic video, and a delayed image at 10 minutes. Mean values with one standard deviation were tested for significance (P < 0.05) using the Mann-Whitney U test statistic. Of 198 available reports, UGI detected jejunal efferent (Roux) limb narrowing (n = 17), partial obstruction (n = 12), anastomotic leak (n = 3), complete bowel obstruction (n = 3), diverticulum (n = 1), hiatal hernia (n = 1), and proximal Roux limb narrowing (n = 1). A normal study was reported in 160 cases (81%). Partial obstruction resolved without intervention. Complete obstruction required re-operation. Compared to 6 patients who developed delayed leaks, early identification of a leak by routine UGI swallow resulted in a shorter hospital stay (mean 7.7 +/- 1.5 days vs 40.2 +/- 12.3 days, P < 0.03). Early intervention after UGI swallow may lessen morbidity. Routine UGI swallow following LRYGBP does not obviate the importance of close clinical follow-up.

IRCAD recommendation on safe laparoscopic cholecystectomy.

PubMed

Conrad, Claudius; Wakabayashi, Go; Asbun, Horacio J; Dallemagne, Bernard; Demartines, Nicolas; Diana, Michele; Fuks, David; Giménez, Mariano Eduardo; Goumard, Claire; Kaneko, Hironori; Memeo, Riccardo; Resende, Alexandre; Scatton, Olivier; Schneck, Anne-Sophie; Soubrane, Olivier; Tanabe, Minoru; van den Bos, Jacqueline; Weiss, Helmut; Yamamoto, Masakazu; Marescaux, Jacques; Pessaux, Patrick

2017-11-01

An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the reduction of biliary and vascular injury. Nineteen hepato-pancreato-biliary (HPB) surgeons from high-volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1-4). Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down (fundus-first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events. © 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.

Results after laparoscopic partial splenectomy for children with hereditary spherocytosis: Are outcomes influenced by genetic mutation?

PubMed

Pugi, Jakob; Carcao, Manuel; Drury, Luke J; Langer, Jacob C

2018-05-01

Laparoscopic partial splenectomy (LPS) theoretically maintains long-term splenic immune function for children with hereditary spherocytosis (HS). Our goal was to review our results after LPS and to determine if specific genetic mutations influence outcome. All children with HS undergoing LPS between 2005 and 2016 were reviewed. Thirty-one children underwent LPS (16 male) at a median age of 9 (range 2-18) years. All experienced an increase in hemoglobin and decrease in reticulocyte count early after LPS and at last follow-up. Twenty-two were sent for genetic analysis. Mutations in α-spectrin, β-spectrin, and Ankyrin were identified in 6, 5, and 11 patients, respectively. Gene mutation was not correlated with complications, perioperative transfusion, length of hospital stay, or median hemoglobin, platelet, or reticulocyte counts. Three children required completion splenectomy at 10.9, 6.9, and 3.2years post-LPS, each with a different gene mutation. LPS is effective in reversing anemia and reducing reticulocytosis. So far less than 10% have required completion splenectomy, and those children did benefit from delaying the risks of asplenia. In this preliminary analysis, genetic mutation did not influence outcome after LPS. A larger multicenter study is necessary to further investigate potential correlations with specific genetic mutations. Prognosis Study. IV. Copyright © 2018. Published by Elsevier Inc.

Effect of renin-angiotensin system on sodium intake.

PubMed Central

Chiaraviglio, E

1976-01-01

1. Water and saline intake was measured in rats depleted of Na by I.P. dialysis. Na intake was prevented 180 min but not 60-90 min after bilateral nephrectomy. Unilateral nephrectomy as well as ureteral ligature had no effect on Na intake. 2. Renin (3u.) injected I.P. re-established the Na appetite abolished by nephrectomy. 3. Angiotensin I (5 ng) or II (5-40 ng) injected into the 3rd ventricle, also restored the Na intake and this effect was dose-dependent. 4. The angiotensin converting-enzyme inhibitor Sq 20,881 (1 mg/kg) inhibited the effect of AI but not that of AII in restoring Na intake. 5. It is concluded that the kidneys might play a role in the regulation of Na intake through the renin-angiotensin system. PMID:1255521

Duplex System with Ectopic Ureter Opens into the Posterior Urethra: Case Report.

PubMed

Milicevic, Snjezana; Bijelic, Radojka; Krivokuca, Vladimir; Jakovljevic, Branislava

2018-04-01

Duplicated ureter or Duplex Collecting System is a congenital condition in which the ureteric bud, the embryological origin of the ureter, arises twice, resulting in two ureters draining a single kidney. This congenital anomaly is rare, and even rarer when the duplex system with ectopic ureter is present. This type of congenital anomaly is even more rarely diagnosed and surgically treated in adulthood. This case report presents a case of a 32-year-old male, who had a duplex collecting system with two ureters on the left side. Ectopic ureter, draining the upper pole of the left kidney, opened into the posterior urethra. In our patient, taking into account the clinical perspective, the renal tissue damaging of the upper pole which was not functional, partial nephrectomy and ureterectomy was successfully performed.

Beware! A simple renal cyst could be a hydatid cyst.

PubMed

Sehgal, Nidhi; Priyadarshi, Vinod

2017-01-01

Kidney is one of the most common sites for the cyst formation in the body, and the management of simple cysts is required entirely for its symptoms and complications. Surgical decortication is an established treatment for a large and symptomatic simple renal cyst. On the other hand, hydatid cysts of the kidney are usually multiloculated complex or calcified cysts and are quite rare. Their surgical treatment also differs and requires complete excision with pericystectomy or partial/complete nephrectomy depending upon residual functional parenchyma, using extreme caution to avoid spillage, recurrence or development of severe anaphylactic shock. A simple cyst harboring a hydatid cyst is highly uncommon and quite dangerous; as if not diagnosed preoperatively, it can create huge trouble for both the patient and the operating surgeon which happened in the present case.

Experience with extracorporeal renal operations and autotransplantation in the management of complicated urologic disorders.

PubMed

Novick, A C; Straffon, R A; Stewart, B H

1981-07-01

Renal autotransplantation with or without an extracorporeal renal operation was performed 45 times upon 43 patients. Twenty-one patients underwent renal autotransplantation as surgical treatment for renovascular hypertension, all of whom are cured or have improved postoperatively. Sixteen renal autotransplants were performed upon 14 patients with extensive ureteral disease, 14 of which were successful. Six patients with carcinoma centrally located in a solitary kidney underwent extracorporeal partial nephrectomy and autotransplantation. Three of these patients are alive with functioning autografts and are tumor-free from one to five years postoperatively. Two patients with multiple recurrent renal calculi were successfully treated by extracorporeal pyelolithotomy and autotransplantation with pyelovesicostomy. An extracorporeal renal operation and autotransplantation can provide the best solution for selected urologic problems not correctable by conventional methods.

Nationwide survey of partial fundoplication in Korea: comparison with total fundoplication.

PubMed

Lee, Chang Min; Park, Joong-Min; Lee, Han Hong; Jun, Kyong Hwa; Kim, Sungsoo; Seo, Kyung Won; Park, Sungsoo; Kim, Jong-Han; Kim, Jin-Jo; Han, Sang-Uk

2018-06-01

Laparoscopic total fundoplication is the standard surgery for gastroesophageal reflux disease. However, partial fundoplication may be a viable alternative. Here, we conducted a nationwide survey of partial fundoplication in Korea. The Korean Anti-Reflux Surgery study group recorded 32 cases of partial fundoplication at eight hospitals between September 2009 and January 2016. The surgical outcomes and postoperative adverse symptoms in these cases were evaluated and compared with 86 cases of total fundoplication. Anterior partial fundoplication was performed in 20 cases (62.5%) and posterior in 12 (37.5%). In most cases, partial fundoplication was a secondary procedure after operations for other conditions. Half of patients who underwent partial fundoplication had typical symptoms at the time of initial diagnosis, and most of them showed excellent (68.8%), good (25.0%), or fair (6.3%) symptom resolution at discharge. Compared to total fundoplication, partial fundoplication showed no difference in the resolution rate of typical and atypical symptoms. However, adverse symptoms such as dysphagia, difficult belching, gas bloating and flatulence were less common after partial fundoplication. Although antireflux surgery is not popular in Korea and total fundoplication is the primary surgical choice for gastroesophageal reflux disease, partial fundoplication may be useful in certain conditions because it has less postoperative adverse symptoms but similar efficacy to total fundoplication.

Contraception Update: Sterilization.

PubMed

Antell, Karen; Deshmukh, Prium; Brown, Elizabeth J

2017-11-01

Female sterilization procedures include postpartum partial salpingectomy via cesarean or minilaparotomy incision, interval laparoscopic procedures, or hysteroscopic placement of microinserts. Rates of failure and serious complications are low and comparable among the various methods. A hysteroscopic procedure requires a 3-month confirmatory hysterosalpingogram before it is considered effective for contraception. Hysteroscopic sterilization has been shown to be associated with a higher reoperation rate than laparoscopic procedures. For male sterilization, vasectomy is a noninvasive and highly effective method. Vasectomy is an outpatient procedure performed under local anesthesia. The procedure requires confirmation of azoospermia with a semen analysis 8 to 16 weeks after the procedure. Patients who are considering sterilization should be counseled about all the available options and the permanent nature of such procedures. Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.

Successful laparoscopic investigation and resection of solitary colonic metastasis from breast cancer (with video).

PubMed

Maekawa, Hisatsugu; Fujikawa, Takahisa; Tanaka, Akira

2012-11-14

Metastasis to gastrointestinal tract from breast cancer is an uncommon situation. We report a case of a 52-year-old woman who had a mastectomy for solid-tubular carcinoma of the breast 16 years ago and bilateral salpingo-oophorectomy for metastatic ovarian tumours 5 years ago, was incidentally found to have colonic metastatic tumour detected by positron emission tomography/CT (PET/CT) during follow-up. After identifying a definite location of the tumour in the ascending colon under laparoscopic investigation, laparoscopy-assisted partial colectomy was successfully performed. Histopathology of the resected specimen showed it to be metastasis from solid-tubular carcinoma of the breast. We should be aware that breast cancer can metastasise to the gastrointestinal tract even after the long interval from initial therapy. An index of high suspicion and detailed assessment is mandatory to make a correct diagnosis and following less invasive surgical treatment.

A laparoscopic approach to treating torsion of a nonpregnant uterus accompanied by a large ovarian cyst in a premenarchal girl.

PubMed

Dutra, Robson Azevedo; Perez-Bóscollo, Adriana Cartafina; Ribeiro, Fernanda Cristina Silva Alves; Vietez, Nádia Bicego

2008-03-01

A 10-year-old premenarchal girl was admitted to our hospital with moderate abdominal pain, although presenting no vomiting or abdominal rebound tenderness. A large abdominal mass was visible and palpable in the periumbilical and epigastric regions. Results of physical examination revealed that the general health status was satisfactory. Computed tomographic scan revealed a large, thin-walled cyst occupying nearly the entire peritoneal cavity. The other viscera were of normal aspect. A laparoscopic approach revealed a left ovarian cystic tumor that was twisted 360 degrees in conjunction with the uterine corpus with hemorrhagic infarction. A partial hysterectomy and a left salpingo-oophorectomy were carried out. The tumor was classified as mature cystic teratoma of the ovary accompanied by hemorrhagic necrosis, not only of the cyst but also of the left uterine tube and the uterine corpus.

Aortic calcification burden predicts deterioration of renal function after radical nephrectomy.

PubMed

Fukushi, Ken; Hatakeyama, Shingo; Yamamoto, Hayato; Tobisawa, Yuki; Yoneyama, Tohru; Soma, Osamu; Matsumoto, Teppei; Hamano, Itsuto; Narita, Takuma; Imai, Atsushi; Yoneyama, Takahiro; Hashimoto, Yasuhiro; Koie, Takuya; Terayama, Yuriko; Funyu, Tomihisa; Ohyama, Chikara

2017-02-06

Radical nephrectomy for renal cell carcinoma (RCC) is a risk factor for the development of chronic kidney disease (CKD), and the possibility of postoperative deterioration of renal function must be considered before surgery. We investigated the contribution of the aortic calcification index (ACI) to the prediction of deterioration of renal function in patients undergoing radical nephrectomy. Between January 1995 and December 2012, we performed 511 consecutive radical nephrectomies for patients with RCC. We retrospectively studied data from 109 patients who had regular postoperative follow-up of renal function for at least five years. The patients were divided into non-CKD and pre-CKD based on a preoperative estimated glomerular filtration rate (eGFR) of ≥60 mL/min/1.73 m 2 or <60 mL/min/1.73 m 2 , respectively. The ACI was quantitatively measured by abdominal computed tomography before surgery. The patients in each group were stratified between low and high ACIs. Variables such as age, sex, comorbidities, and pre- and postoperative renal function were compared between patients with a low or high ACI in each group. Renal function deterioration-free interval rates were evaluated by Kaplan-Meier analysis. Factors independently associated with deterioration of renal function were determined using multivariate analysis. The median age, preoperative eGFR, and ACI in this cohort were 65 years, 68 mL/min/1.73 m 2 , and 8.3%, respectively. Higher ACI (≥8.3%) was significantly associated with eGFR decline in both non-CKD and pre-CKD groups. Renal function deterioration-free interval rates were significantly lower in the ACI-high than ACI-low strata in both of the non-CKD and pre-CKD groups. Multivariate analysis showed that higher ACI was an independent risk factor for deterioration of renal function at 5 years after radical nephrectomy. Aortic calcification burden is a potential predictor of deterioration of renal function after radical nephrectomy. This study was registered as a clinical trial: UMIN000023577.

Prevalence and management of urinary tract endometriosis: a clinical case series.

PubMed

Gabriel, Boris; Nassif, Joseph; Trompoukis, Pantelis; Barata, Sonia; Wattiez, Arnaud

2011-12-01

To report on the prevalence, surgical management, and outcome of urinary tract endometriosis (UTE) in a cohort of 221 patients undergoing laparoscopic surgery for severe endometriosis. UTE can cause significant morbidity, such as silent kidney or progressive renal function loss. Its frequency is underestimated and data on laparoscopic management are scarce. Between 2007 and 2010, 43 patients were eligible for this single-center, retrospective study. The inclusion criterion was the presence of UTE (ie, bladder and/or ureteral endometriosis). All patients were operated laparoscopically. The prevalence of UTE was 19.5% (43/221). There was no correlation between bladder and ureteral endometriosis (P >.05). Ureteral endometriosis was associated with patient's age (P <.01). Patients with bladder, but not ureteral, involvement complained more frequently about dysuria, hematuria, and urinary tract infections. Intraoperative and magnetic resonance imaging (MRI) findings revealed a moderate to good correlation. UTE was not associated with rectovaginal or bowel endometriosis, but rather with involvement of the uterosacral ligaments (P <.01). Twenty-two patients with bladder endometriosis were treated by mucosal skinning and 11 patients underwent partial cystectomy. Superficial ureteral excision was performed in 4 patients, whereas resection with ureteroureterostomy was done in 9 patients. There was no difference regarding the intra- and postoperative complications in patients with or without UTE. In severe pelvic endometriosis, involvement of the urinary tract is quite common. Laparoscopic management is feasible and safe. Because of the lack of specific symptoms, the preoperative diagnosis of ureteral endometriosis still remains a challenge. Pelvic MRI represents a useful preoperative diagnostic tool. Copyright © 2011 Elsevier Inc. All rights reserved.

Irreducible inguinal hernia in children: how serious is it?

PubMed

Houben, Christoph Heinrich; Chan, Kin Wai Edwin; Mou, Jennifer Wai Cheung; Tam, Yuk Huk; Lee, Kim Hung

2015-07-01

We evaluated the experience with irreducible inguinal hernias at our institution. We reviewed patients with an inguinal hernia operation at our institution between 1st January 2004 and 31st December 2013. Individuals with a failed manual reduction of an incarcerated hernia under sedation by the attending surgeon were included into the study group as irreducible hernia. Overall 2184 individuals (426 females) had an inguinal herniotomy with the following distribution: right 1116 (51.1%), left 795 (36.4%) and bilateral 273 (12.5%) cases. A laparoscopic herniotomy was done in 1882 (86.4%). 34 patients (3 females) - just 1.6% of the total - presented at a median age (corrected for gestation) of 12 months (range 2 weeks to 16 years) with an irreducible hernia, of which 24 individuals (70%) were right sided. A laparoscopic approach was attempted in 21 (62%), two required a conversion. The open technique was chosen in 13 (38%) individuals. The content of the hernia sac was distal small bowel in 21 (62%), omentum in four (12%) and an ovary in three (9%) cases. Four patients (12%) required laparoscopic assisted bowel resection and two partial omentectomy (6%). Two gonads (6%) were lost: one intraoperative necrotic ovary and one testis atrophied over time. There was no recurrent hernia. Irreducible inguinal hernias constitute 1.6% of the workload on inguinal hernia repair. The hernia sac contains in males most frequently small bowel and in females exclusively a prolapsed ovary. Significant comorbidity is present in 18%. Laparoscopic and open techniques complement each other in addressing the issue. Copyright © 2015 Elsevier Inc. All rights reserved.

Novel laparoscopic narrow band imaging for real-time detection of bile leak during hepatectomy: proof of the concept in a porcine model.

PubMed

Diana, Michele; Usmaan, Hameed; Legnèr, Andras; Yu-Yin, Liu; D'Urso, Antonio; Halvax, Peter; Nagao, Yoshihiro; Pessaux, Patrick; Marescaux, Jacques

2016-07-01

Bile leakage is a serious complication occurring in up to 10 % of hepatic resections. Intraoperative detection of bile leakage is challenging, and concomitant blood oozing can mask the presence of bile. Intraductal dye injection [methylene blue or indocyanine green (ICG)] is a validated technique to detect bile leakage. However, this method is time-consuming, particularly in the laparoscopic setting. A novel narrow band imaging (NBI) modality (SPECTRA-A; Karl Storz, Tuttlingen, Germany) allows easy discrimination of the presence of bile, which appears in clear orange, by image processing. The aim of this experimental study was to evaluate SPECTRA-A ability to detect bile leakage. Twelve laparoscopic partial hepatectomies were performed in seven pigs. The common bile duct was clipped distally and dissected, and a catheter was inserted and secured with a suture or a clip. Liver dissection was achieved with an ultrasonic cutting device. Dissection surfaces were checked by frequently switching on the SPECTRA filter to identify the presence of bile leakage. Intraductal ICG injection through the catheter was performed to confirm SPECTRA findings. Three active bile leakages were obtained out of 12 hepatectomies and successfully detected intraoperatively by the SPECTRA. There was complete concordance between NBI and ICG fluorescence detection. No active leaks were found in the remaining cases with both techniques. The leaking area identified was sutured, and SPECTRA was used to assess the success of the repair. The SPECTRA laparoscopic image processing system allows for rapid detection of bile leaks following hepatectomy without any contrast injection.

Laparoscopic technique of modified extraperitoneal (retrotransversalis) end colostomy for abdomino-perineal resection.

PubMed

Tulina, I A; Kitsenko, Y E; Ubushiev, M N; Efetov, S K; Wexner, S; Tsarkov, P V

2018-05-19

To describe the technique of a modified extraperitoneal retrotransversalis end colostomy as part of a laparoscopic abdomino-perineal resection (APR). The colostomy site is preoperatively chosen and intraoperatively used for a trocar. After the rectum has been mobilized the descending colon is freed. The peritoneal margin is gently grasped and the parietal peritoneum, extraperitoneal together with the transversalis fascia are separated from the transverse abdominal muscle fibres upwards for 3-4 cm aiming at the trocar site to form the extraperitoneal retrotransversalis canal. The stoma site trocar is partially withdrawn and its head is turned laterally until its tip is positioned in the layer between abdominal wall muscles and underlying transversalis and extraperitoneal fascia together with parietal peritoneum. The CO 2 source can be attached so that the gas helps to separate the layers. After that the colostomy trephine is formed at the site of the trocar, the grasper is inserted to gently deliver the blunt end of the descending colon through the canal and the end colostomy is formed in a usual way. No procedure specific complications were noted in 39 patients who had laparoscopic APR with extraperitoneal retrotransversalis end colostomy from 2009 to 2016. In 23 patients who survived 3.7 ± 1.7 years after surgery there were no clinical or CT signs of parastomal hernia or prolapse. This single institution retrospective case series demonstrate that laparoscopic extraperitoneal retrotransversalis end colostomy is feasible, safe, and effective in preventing parastomal hernias and stomal prolapse This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Validation of Living Donor Nephrectomy Codes

PubMed Central

Lam, Ngan N.; Lentine, Krista L.; Klarenbach, Scott; Sood, Manish M.; Kuwornu, Paul J.; Naylor, Kyla L.; Knoll, Gregory A.; Kim, S. Joseph; Young, Ann; Garg, Amit X.

2018-01-01

Background: Use of administrative data for outcomes assessment in living kidney donors is increasing given the rarity of complications and challenges with loss to follow-up. Objective: To assess the validity of living donor nephrectomy in health care administrative databases compared with the reference standard of manual chart review. Design: Retrospective cohort study. Setting: 5 major transplant centers in Ontario, Canada. Patients: Living kidney donors between 2003 and 2010. Measurements: Sensitivity and positive predictive value (PPV). Methods: Using administrative databases, we conducted a retrospective study to determine the validity of diagnostic and procedural codes for living donor nephrectomies. The reference standard was living donor nephrectomies identified through the province’s tissue and organ procurement agency, with verification by manual chart review. Operating characteristics (sensitivity and PPV) of various algorithms using diagnostic, procedural, and physician billing codes were calculated. Results: During the study period, there were a total of 1199 living donor nephrectomies. Overall, the best algorithm for identifying living kidney donors was the presence of 1 diagnostic code for kidney donor (ICD-10 Z52.4) and 1 procedural code for kidney procurement/excision (1PC58, 1PC89, 1PC91). Compared with the reference standard, this algorithm had a sensitivity of 97% and a PPV of 90%. The diagnostic and procedural codes performed better than the physician billing codes (sensitivity 60%, PPV 78%). Limitations: The donor chart review and validation study was performed in Ontario and may not be generalizable to other regions. Conclusions: An algorithm consisting of 1 diagnostic and 1 procedural code can be reliably used to conduct health services research that requires the accurate determination of living kidney donors at the population level. PMID:29662679