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PubMed2004

Laparoscopic simultaneous bilateral pretransplant nephrectomy for uncontrolled hypertension.

Severe hypertension resistant to multiple antihypertensive drugs represents an indication for bilateral pretransplant renal ablation by surgery or angioembolization. Besides causing severe pain and renal postinfarction syndrome, angioembolization may be ineffective. We present our experience with simultaneous bilateral laparoscopic pretransplant nephrectomies in patients with end-stage renal disease and severe uncontrollable hypertension. Among the three patients considered for bilateral pretransplant laparoscopic nephrectomy between September 2002 and August 2003, the procedure was successfully performed in two patients. Left nephrectomy was performed transperitoneally and right nephrectomy retroperitoneoscopically. In one of the three patients, a prior attempt at angioembolization had produced a dense perirenal reaction, rendering laparoscopic surgery impossible. Total operating time for bilateral laparoscopic nephrectomies was 260 and 280 minutes. Within 1 month following the nephrectomies, all patients became normotensive with minimal or no antihypertensive medications. We conclude that simultaneous bilateral laparoscopic nephrectomy is feasible and less morbid in end-stage renal disease patients. Prior angioembolisation can make laparoscopic surgery difficult or impossible.

Adolescent↗

PubMed2004

Laparoscopic donor nephrectomy for pediatric recipients: outcomes analysis.

OBJECTIVES: To present our outcomes of laparoscopic donor nephrectomy for pediatric recipients. Laparoscopic nephrectomy has become the technique of choice for live donor nephrectomy. However, limited data are available regarding the role of this technique for pediatric recipients, who may pose special challenges and considerations, and whose parents need additional information. METHODS: Since November 1999, we have performed laparoscopic nephrectomy in more than 300 consecutive patients for live donor transplantation. Of these, 20 cases were identified that involved a recipient younger than 18 years of age. The preoperative, intraoperative, and postoperative data were reviewed to analyze the outcomes of these specific cases. The data were compared with a similar group of pediatric recipients receiving kidneys procured using the traditional open technique. RESULTS: The mean donor and recipient age was 40 years (range 26 to 52) and 13 years (range 1.7 to 18), respectively, and 19 cases (95%) involved the left kidney. The mean donor and recipient operative time was 3.3 hours (range 2.5 to 5.2) and 3.9 hours (range 2.4 to 5.1), respectively. The warm and anastomotic time averaged 4 minutes (range 2 to 8) and 30 minutes (range 16 to 41), respectively. Nineteen of the grafts functioned immediately, with a mean creatinine at 24 hours of 2.0 mg/dL (range 0.3 to 6.0). At last follow-up (mean 13.6 months), the mean creatinine was 1.1 mg/dL. Ureteral stricture requiring stent placement occurred in 2 patients (10%). No statistically significant differences were noted in operative parameters, complications, or renal function compared with a contemporary cohort of 26 pediatric patients receiving organs obtained by open donor nephrectomy. CONCLUSIONS: Our early experience with laparoscopic donor nephrectomy for pediatric recipients confirmed that the technique provides quality organs with excellent function. The method yields outcomes comparable to those after traditional open donor nephrectomy and does not require modifications for the recipient operation.

Adult↗

PubMed2004

Laparoscopic versus open cytoreductive nephrectomy for metastatic renal cell carcinoma.

OBJECTIVES: To compare the outcomes of those patients who underwent laparoscopic versus open cytoreductive nephrectomy. Cytoreductive nephrectomy before systemic therapy has been shown to offer a survival advantage compared with systemic therapy alone for metastatic renal cell carcinoma. METHODS: We reviewed the outcomes of all patients who underwent either open or laparoscopic cytoreductive nephrectomy between 2000 and 2003. The inclusion criteria included patients with tumors 15 cm or less without local invasion, venous involvement, or bulky local adenopathy who had concurrent metastatic disease. A total of 64 patients (22 in the laparoscopic group and 42 in the open group) fulfilled these criteria. The parameters measured were age, tumor size, operative time, estimated blood loss, complications, length of hospital stay, percentage of patients receiving systemic therapy, and the interval to the start of systemic therapy. Kaplan-Meier survival estimates were compared. RESULTS: Patients who underwent laparoscopic cytoreductive nephrectomy had a shorter length of stay (2.3 versus 6.1 days) and less operative blood loss (288 versus 1228 mL) than those who underwent open nephrectomy. Patients in the laparoscopic group received systemic therapy sooner after surgery (36 versus 61 days) than those in the open group. The Kaplan-Meier survival estimates were similar for both groups, with a 1-year survival rate of 61% in the laparoscopic group and 65% in the open group. CONCLUSIONS: With judicious patient selection, laparoscopic cytoreductive nephrectomy can be performed safely, with minimal morbidity, and may shorten the interval from nephrectomy to the start of systemic therapy.

Blood Loss, Surgical↗

PubMed2005

Evaluation of surgical models for renal collecting system closure during laparoscopic partial nephrectomy.

OBJECTIVES: To evaluate the utility of the porcine and canine models for collecting system closure after partial nephrectomy involving violation of the renal collecting system. Advanced surgical technologies and novel techniques for performing laparoscopic partial nephrectomy are frequently evaluated in an animal model. METHODS: After evaluation of the upper urinary tract with retrograde pyelography, laparoscopic partial nephrectomy, including violation of the renal collecting system, was performed in 8 domestic pigs (group 1) and 2 dogs (group 2) with documented normal upper urinary tract physiology. No collecting system closure was performed. Subsequently, in an attempt to generate an adequate model for renal collecting system closure, 6 pigs (group 3) underwent partial obstruction of the proximal ureter before laparoscopic partial nephrectomy without collecting system closure. After 3 weeks, the animals underwent evaluation, including retrograde pyelography, and were killed for histopathologic evaluation of the upper urinary tracts. RESULTS: Despite documented transection of major calices in all animals, none with physiologically normal upper urinary tracts developed urinomas. After partial occlusion of the proximal ureter, all pigs had hydronephrosis, but only one of six developed a urinoma. CONCLUSIONS: The porcine and canine models are inadequate for evaluating renal collecting system closure after partial nephrectomy. Our high-pressure partial occlusion model was similarly inadequate. The limitations of these animal models should be considered when reviewing published data regarding technologies for partial nephrectomy. Future data regarding novel technologies for partial nephrectomy should also be carefully considered before clinical application.

Animals↗

PubMed2006

Partial nephrectomy for renal urothelial tumors: clinical update.

OBJECTIVES: To evaluate the contemporary indications and outcome after partial nephrectomy for renal urothelial cancer. Partial nephrectomy is an established treatment for renal cell cancer but its use for renal urothelial tumors has been studied less extensively. METHODS: Records were reviewed for patients undergoing partial nephrectomy for renal urothelial tumors between January 1990 and December 2001. Partial nephrectomy was selected for those with a solitary kidney, chronic renal insufficiency, or bilateral synchronous tumors. Partial nephrectomy was performed according to the principles of partial nephrectomy. Follow-up included ultrasonography, intravenous urography, computed tomography, metastatic workup, and renal function evaluation. RESULTS: This study included 12 patients (12 kidneys, 10 solitary) with a mean age of 68.5 +/- 21 years and a mean follow-up of 40.8 +/- 32 months. The pathologic T stage was Tis in 1 patient, T1 in 3, T2 in 2, and T3 in 6 patients. Of the 12 patients, 6 had negative surgical margins, and 4 of the 12 patients (30%) were tumor free after a mean follow-up of 57.7 months. Of the 6 patients with positive surgical margins (Stage T1 in 2 and T3 in 4), 1 developed recurrence and 3 developed metastasis; 4 died after a mean of 31.3 months. Overall recurrence was seen in 5 (42%) and progression (metastasis) in 6 (50%) patients. Of the 12 patients, 6 were alive, 4 of them were well (mean serum creatinine 1.83 mg/dL) at 62 months of follow-up. Two patients required dialysis. The overall long-term survival rate was 50%. CONCLUSIONS: Partial nephrectomy for renal urothelial tumors is feasible and should be considered in a select population. Dialysis or renal replacement can be delayed or avoided in most of these patients, but strict surveillance remains mandatory.

Aged↗

PubMed1994

The impact of adjuvant nephrectomy on multimodality treatment of metastatic renal cell carcinoma.

Multimodality treatment of metastatic renal cell carcinoma with biological response modifiers and cytoreductive surgery has produced durable responses. The timing and impact of cytoreductive surgery on the success of immunotherapy require further study. We reviewed the treatment of 62 patients with metastatic renal cell carcinoma and primary tumors in place who qualified for multimodality treatment comprising adjuvant nephrectomy and biological response modifier protocols at our institution between 1987 and 1992. Of the patients 37 were scheduled to undergo initial adjuvant nephrectomy followed by biological response modifier therapy. A total of 25 patients underwent initial biological response modifier therapy with planned delayed adjuvant nephrectomy if a response to treatment was demonstrated. Of the 37 patients undergoing initial adjuvant nephrectomy, 8 (22%) were unable to enter induction of immunotherapy because of perioperative complications (1), medical contraindications (2), tumor progression (4) or death (1). Three patients in the initial adjuvant nephrectomy group (8%) had a partial response and the median survival in this group was 12 months (range 1 to 57). In the initial biological response modifier group 3 patients (12%) with an objective response (2 complete and 1 partial) to biological response modifier therapy underwent nephrectomy. The median survival for the initial biological response modifier group was 14 months (range 1 to 48). These results add to our understanding of the impact of adjuvant nephrectomy on patients with metastatic renal cell carcinoma considered for immunotherapy protocols.

Adult↗

PubMed1997

[Renal function after nephrectomy for Wilms' tumor].

BACKGROUND: Most children with Wilms tumour recover after nephrectomy, chemotherapy and sometimes radiotherapy. It is therefore important to assess their long-term renal function. POPULATION AND METHODS: Thirty-three patients with Wilms tumour experienced unilateral nephrectomy between 1986 and 1993: three were excluded; 23 were staged as grade I, one at grade II, two at grade III and four at grade IV. They were treated with SIOP 6 and SIOP 9 protocols. The results were compared to five controls who underwent unilateral nephrectomy including three for renal trauma. The glomerular filtration rate (GFR) was measured by inulin clearance and the renal plasma flow (RPF) by para-amino-hippuric acid clearance. RESULTS: The mean age at nephrectomy was 3.4 +/- 2.5 years (median: 3, range: 0.2-10.6) and the duration of follow-up was 4.6 +/- 3.1 years (median: 4.5, range: 1-8.5), the GFR was 93 +/- 13 mL/min/1.73 m2 (median: 93, range: 73-130), the RPF was 441 +/- 85 mL/min/1.73 m2 (median: 453, range: 236-650) and the filtrated fraction (FF) was 0.21 +/- 0.03 (median: 0.20, range: 0.18-0.31). The difference in renal function between patients and controls was not significant (GRF: 86 +/- 12 mL/min/1.73 m2, RPF: 486 +/- 185 mL/min/1.73 m2, FF: 0.22 +/- 0.03). The electrolyte reabsorption rate was normal and none of the patients suffered from arterial hypertension. Fourteen children had urinary albumin: creatinine ratio > 2 g/mol. When comparing patients according to the duration of follow-up after nephrectomy (< 4 years vs > 4 years), the renal function was not statistically different. The age at nephrectomy (< 2 years vs > 2 years) did not increase the risk of renal impairment. CONCLUSION: Children with Wilms tumour who were treated with nephrectomy and non-nephrotoxic drugs (actinomycin, vincristine, epiadriamycin) have a good long-term renal outcome. It is speculated that systematic renal investigation should be limited to those children with increased microalbuminuria and/or elevated blood pressure.

Analysis of Variance↗

PubMedDate not supplied

A comparison of hospital-based charges following partial and radical nephrectomy.

OBJECTIVE: Recent studies demonstrate similar survival rates in patients treated with either partial or radical nephrectomy for renal tumors less than 4 cm. We retrospectively compared the hospital based charges for these two procedures in a similar cohort of patients treated at Memorial Sloan-Kettering Cancer Center. PATIENTS AND METHODS: A retrospective review of 103 consecutive cases of renal tumors less than 4 cm treated by either radical or partial nephrectomy from 1996 to 1999 was conducted. Overall hospital charges were calculated by analyzing 18 separate departmental charge categories including room and board, pharmacy, radiologic tests, operating room charges, and laboratory services. RESULTS: A total of 66 partial and 37 radical nephrectomies were analyzed. No difference was found in the mean charge per procedure ($16,660, partial and $16,545, radical); (p > .05). The major cost drivers for partial and radical nephrectomy respectively were: 1) room and board, 42% and 44%; 2) operating room charges, 28% and 25%; 3) pathology, 6% and 6%; 4) recovery room, 6% and 7%; and 5) biochemistry, 5% and 5%. Significant increases in charges for partial nephrectomy were noted from the blood bank services and intraoperative surgical supplies. The median length of stay (5 days) was identical for partial and radical nephrectomy. No difference was found in the complication rate for these procedures (p > .05). CONCLUSION: Hospital-based charges for radical and partial nephrectomy are similar at when performed at a tertiary care referral center.

Adult↗

PubMed1989

Unilateral nephrectomy and glomerular solute transport in the dog.

The influence of compensatory hyperfunction that occurs following unilateral nephrectomy on glomerular solute transport was determined in awake, unanesthetized dogs by renal clearance studies. Two groups of dogs were studied using different test solutes: group I (N = 5) using inulin, iothalamate, creatinine and sodium p-aminohippurate; and group II (N = 6) using creatinine, neutral dextran (3000 to 50,000 daltons) and sodium p-aminohippurate. Compensatory hyperfunction, as assessed by the increase in creatinine clearance per kidney, was 43 +/- 7% and 39 +/- 11% in the group I and II dogs, respectively. The inulin to creatinine and iothalamate to creatinine clearance ratios in the group I dogs were 0.93 +/- 0.07 and 1.00 +/- 0.04 before unilateral nephrectomy. The respective values after unilateral nephrectomy of 0.86 +/- 0.04 and 0.89 +/- 0.05 were lower but not statistically different. In the group II dogs, dextran to creatinine clearance ratios (dextran fractional clearance) over the molecular weight range studied also did not change significantly following unilateral nephrectomy. The magnitude of the change in dextran fractional clearance following unilateral nephrectomy was qualitatively consistent with that predicted by previous models of glomerular macromolecular transport based on membrane pore theory. A lack of quantitative agreement with these models, however, precluded a calculation of the changes in glomerular functional parameters following unilateral nephrectomy. Significant alterations in fractional clearance for neutral macromolecules do not occur following unilateral nephrectomy in the dog.

Animals↗

PubMed2000

Comparison of complications after radical and partial nephrectomy: results from the National Veterans Administration Surgical Quality Improvement Program.

OBJECTIVE: To determine whether radical nephrectomy causes less morbidity, less mortality and is associated with a shorter hospital stay than is partial nephrectomy. PATIENTS AND METHODS: A total of 1885 nephrectomies (1373 radical and 512 partial) conducted between 1991 and 1998 in the Department of Veterans Affairs (VA) National Surgical Quality Improvement Program were evaluated. Using multivariate analyses, outcomes were risk-adjusted based on 45 preoperative variables to compare mortality and morbidity rates. RESULTS: The unadjusted 30-day mortality was 2.0% for radical and 1.6% for partial nephrectomy (P = 0.58). Risk-adjusting the two groups did not result in a statistically significant difference in mortality. The 30-day overall morbidity rate was 15% for radical and 16.2% for partial nephrectomy (P = 0.52); risk-adjusted morbidity rates were not statistically different. There were no statistically significant differences in the rates of postoperative progressive renal failure, acute renal failure, urinary tract infection, prolonged ileus, transfusion requirement, deep wound infection, or extended length of stay. CONCLUSIONS: Partial nephrectomy carried out in the VA program has low morbidity and mortality rates, comparable with the complication rates after radical nephrectomy.

Carcinoma, Renal Cell↗

PubMed2001

Hand-assisted laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: The indications for partial nephrectomy are expanding as newer and more complete data come forth. A partial nephrectomy has traditionally required a generous flank incision. We report our experience using hand-assisted laparoscopy (HAL) as a less-invasive approach to partial nephrectomies. PATIENTS AND METHODS: Between October 1999 and May 2000, we performed 11 HAL partial nephrectomies. The average age of the patients was 55.7 years, the average body mass index was 25.6, and the average ASA class was 2.2. The indications for partial nephrectomy were enhancing solid renal lesions (N = 9) and nonfunctioning renal moiety in a duplicated system (N = 2). In the majority of cases, access to the renal pedicle was obtained prior to the partial nephrectomy. However, in no case did the renal artery or vein require occlusion. Several excisional techniques were employed, but all relied heavily on the Harmonic Scalpel in conjunction with the argon beam coagulator. Different hemostatic agents were applied to the renal defect, including Surgicel, Avitene, and fibrin-soaked Gelfoam activated by thrombin. In several instances, pledget reinforced sutures were placed in the renal capsule to aid with hemostasis. RESULTS: The average operative time was 273 minutes, the estimated blood loss 319 mL, and the change in hematocrit 7.3 points. No patient required a transfusion, and there was one conversion to open. Postoperatively patients, required an average of 35.6 mg of morphine sulfate equivalent and 8.2 narcotic tablets, resumed oral intake in 1.7 days, and were discharged home in 3.3 days. There were no major complications and only two minor complications. Postoperatively, five lesions were found to be benign, four lesions were confirmed to be malignant, and two lesions were consistent with a nonfunctioning duplicated renal moiety. Specimen size averaged 180 cc, and the tumor diameter averaged 1.9 cm. There were no positive surgical margins. CONCLUSIONS: Hand-assisted laparoscopic partial nephrectomy is feasible and reproducible. The surgeon's hand in the operative field facilitates dissection, vascular control, hemostasis, and suturing. Further long-term and prospective studies are underway.

Adult↗

PubMed2002

Anatomic landmarks and time management during retroperitoneoscopic radical nephrectomy.

BACKGROUND AND PURPOSE: Retroperitoneoscopy has not been widely considered the preferred approach to laparoscopic radical nephrectomy for cancer, in part because the retroperitoneal anatomic landmarks have not been well defined. The aim of this study is to provide prospective, objective data on retroperitoneoscopic radical nephrectomy with regard to anatomic landmarks and time management of the sequential operative steps. MATERIALS AND METHODS: A uniform database was devised to record predetermined intraoperative parameters prospectively in 18 consecutive retroperitoneoscopic radical nephrectomies. RESULTS: A three- or four-port technique was employed to perform 10 left and 8 right retroperitoneoscopic radical nephrectomies. Initial balloon dilation was routinely performed outside of and posterior to Gerota's fascia. The anatomic landmarks visible immediately on initial insertion of the laparoscope were: psoas muscle in 18 cases (100%), Gerota's fascia in 18 (100%), peritoneal reflection in 15 (83%), ureter and/or gonadal vein in 11 (61%), and renal artery pulsations in 10 (56%). Aortic pulsations were seen in 9 of 10 left (90%) and the inferior vena cava in 2 of 8 right (25%) radical nephrectomies. The mean surgical time was 203 +/- 52.9 minutes (range 105-290 minutes). The sequential operative steps and their individual time breakdowns were: port placement 12 +/- 3.9 minutes, hilar dissection 63 +/- 29.1 minutes, adrenal mobilization 49 +/- 12.1 minutes, specimen mobilization 19 +/- 20.8 minutes, and specimen entrapment and exit 23 +/- 18.2 minutes. When the initial balloon dilation resulted in visibility of four or more anatomic landmarks, the hilar dissection time was significantly shorter (P < 0.001). CONCLUSIONS: Proper development of the retroperitoneal space and identification of adequate anatomic landmarks is important during retroperitoneoscopy. This timed analysis of the sequential operative steps of retroperitoneoscopic radical nephrectomy has served as an important self-assessment tool for us in improving our surgical technique. As a result, our surgical time for retroperitoneoscopic radical nephrectomy has decreased from the earlier 4- to 5-hour range to the current 2- to 3-hour range.

Aged↗

PubMed2003

Laparoscopic radical nephrectomy: financial disincentives by the Health Care Financing Administration.

BACKGROUND AND PURPOSE: Laparoscopic radical nephrectomy is a minimally invasive alternative to open radical nephrectomy. We have noticed that since the beginning of 2001, when the Current Procedural Terminology (CPT) code 50545 became available for laparoscopic nephrectomy, the reimbursement for the laparoscopic operation was significantly lowered. This led us to survey 25 laparoscopic urologic surgeons to assess trends in reimbursement from all over the United States. MATERIALS AND METHODS: During this period, the records of reimbursements for radical nephrectomy were available from a single practice to compare that for the open and laparoscopic techniques. The 19 open and 10 laparoscopic operations were entered in a database for statistical analysis. Endourologists around the country also were polled on the subject. RESULTS: The average reimbursement for an open radical nephrectomy was $1581 +/- 325 (SD), while the average reimbursement for a laparoscopic radical nephrectomy was $1192 +/- 184. Twenty-five polled endourologists had noted similar reductions in reimbursement for laparoscopic procedures. Many of those polled had participated in the Specialty Society Relative Value Unit (RVU) survey for laparoscopic radical nephrectomy and stated that their recommendations were that the value be considered greater than that of the open counterpart. CONCLUSION: The highly significant difference in reimbursement reflects a financial disincentive to surgeons performing laparoscopic procedures. It is obvious that in the U.S., the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) is devaluating all surgical procedures, and financial pressures of this type are disturbing.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed2001

Are concerns over right laparoscopic donor nephrectomy unwarranted?

OBJECTIVE: To examine the ability of several large, experienced transplantation centers to perform right-sided laparoscopic donor nephrectomy safely with equivalent long-term renal allograft function. SUMMARY BACKGROUND DATA: Early reports noted a higher incidence of renal vein thrombosis and eventual graft loss. However, exclusion of right-sided donors would deprive a significant proportion of donors a laparoscopically harvested graft. METHODS: A retrospective review was performed among 97 patients from seven centers performing right-sided laparoscopic donor nephrectomy. Surgical and postoperative demographic factors were evaluated. Complications were identified and long-term renal allograft function was compared with historical left-sided laparoscopic donor nephrectomy cohorts. RESULTS: Right laparoscopic donor nephrectomy was performed for varying reasons, including multiple left renal arteries or veins, smaller right kidney, or cystic right renal mass. Mean surgical time was 235.0 +/- 66.7 minutes, with a mean blood loss of 139 +/- 165.8 mL. Conversion was required in three patients secondary to bleeding or anatomical anomalies. Mean warm ischemic time was limited at 238 +/- 112 seconds. Return to diet was achieved on average after 7.5 +/- 2.3 hours, with mean discharge at 54.6 +/- 22.8 hours. Two grafts were lost during the early experience of these centers to renal vein thrombosis. Both surgical and postoperative complications were limited, with few long-term adverse effects. Mean serum creatinine levels were higher than open and left laparoscopic donor nephrectomy on postoperative day 1, but at all remaining intervals the right laparoscopic donors had equivalent creatinine values. CONCLUSIONS: These results confirm that right laparoscopic donor nephrectomy provides similar patient benefits, including early return to diet and discharge. Long-term creatinine values were no higher than in traditional open donor or left laparoscopic donor cohorts. These results establish that early concerns about high thrombosis rates are not supported by a multiinstitutional review of laparoscopic right donor nephrectomies.

Adolescent↗

PubMed2000

Serum immunosuppressive acidic protein and natural killer cell activity in patients with metastatic renal cell carcinoma before and after nephrectomy.

PURPOSE: To our knowledge the impact of nephrectomy on stage M1 renal cell carcinoma remains to be determined. We previously reported that nephrectomy is beneficial in patients with elevated serum C-reactive protein before treatment, and those in whom nadir C-reactive protein decreases postoperatively to within the normal range may expect longer survival when surgery is combined with postoperative immunotherapy. In this study we determine the effect of nephrectomy on the immune response in patients with metastatic renal cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the records of 40 patients with metastatic renal cell carcinoma diagnosed at our institution between 1986 and 1999. These patients underwent nephrectomy before cytokine therapy with interferon. Before and after nephrectomy we measured serum C-reactive protein, serum immunosuppressive acidic protein and peripheral blood natural killer cell activity. RESULTS: In 15 patients with pretreatment serum C-reactive protein within the normal range (less than 1 ng./ml.) there was no significant difference before and after nephrectomy in the serum immunosuppressive acidic protein level or natural killer cell activity (p = 0.4587 and 0.3892, respectively). On the other hand, in 25 patients with serum C-reactive protein elevated before treatment to 1 ng./ml. or greater serum immunosuppressive acidic protein decreased significantly and natural killer cell activity increased significantly after cytoreductive surgery (p = 0.0002 and 0.0286, respectively). CONCLUSIONS: Our study implies that nephrectomy may be beneficial in patients with elevated serum C-reactive protein before treatment. Further evaluation by a prospective study is needed to make a definitive conclusion.

Adult↗

PubMed2004

Role of nitric oxide in the renal hemodynamic response to unilateral nephrectomy.

Reduction of renal mass by unilateral nephrectomy results in an immediate increase in renal blood flow (RBF) to the remnant kidney, followed by compensatory renal hypertrophy. Whether the increase in RBF after unilateral nephrectomy is mediated by nitric oxide (NO) was tested. It was found that immediately after nephrectomy, blood flow to the remaining kidney increased by 8% (P < 0.01), and inhibition of NO synthesis with Nomega-nitro-L-arginine methyl ester (L-NAME) blocked the increase in RBF. In addition, 2 d after nephrectomy, there was a 49% increase in RBF (corrected per gram of kidney weight), a 25% increase at 7 and 14 d, and a 16% increase after 28 d. Acute inhibition of NO synthesis with L-NAME in uninephrectomized rats caused a greater decrease in RBF on days 2 and 7 compared with controls, whereas by 14 and 28 d, the response to L-NAME was similar to controls. Urinary excretion of cyclic guanosine monophosphate, a marker for renal NO production, increased 2.5-fold by 2 d after uninephrectomy (P < 0.005) and remained at this level through 28 d. Pretreating rats chronically with a subpressor dose of L-NAME beginning 2 d before nephrectomy blocked the increase in RBF seen at 2 and 7 d and retarded the renal hypertrophy that should have developed by 7 d. It is concluded that after unilateral nephrectomy, immediate and sustained increases in RBF are mediated at least in part by NO. The hypertrophic response to unilateral nephrectomy may be partially initiated by the signal of hemodynamic changes.

Animals↗

PubMed2004

Laparoscopic nephrectomy, ex vivo excision and autotransplantation for complex renal tumors.

PURPOSE: In many patients partial nephrectomy is the preferred alternative to radical nephrectomy for upper urinary tract cancers. We describe the use of laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation to expand the realm of minimally invasive, nephron sparing surgery to the most complex renal tumors. MATERIALS AND METHODS: In our cohort undergoing renal surgery 2 patients had a solitary kidney with renal tumors not considered amenable to in situ partial nephrectomy. After transperitoneal laparoscopic nephrectomy ex vivo tumor excision and renorrhaphy were performed. The kidney was transplanted to the ipsilateral iliac vessels through the Gibson extraction incision. RESULTS: Indications for surgery were high grade urothelial carcinoma within a caliceal diverticulum and a central 5 cm renal cell carcinoma. Mean nephrectomy, cold ischemic and transplantation times were 4.5, 2 and 3.7 hours, respectively. No intraoperative or postoperative complications were noted. Hospitalization was 12 and 6 days, respectively. At 20 and 12 months of followup each patient remained off dialysis without evidence of recurrence. CONCLUSIONS: Despite experience with conventional nephron sparing surgery some cases may be more appropriate for ex vivo excision and reconstruction. In these situations the minimally invasive approach provides a kidney suitable for renal autotransplantation, while simultaneously decreasing patient morbidity. This novel approach to complex renal tumors is feasible when one applies principles of laparoscopic donor nephrectomy and possesses experience with renal transplantation.

Aged↗

PubMed2005

Comparison of retroperitoneoscopic nephrectomy versus open approaches to nonfunctioning tuberculous kidneys: a report of 44 cases.

PURPOSE: We retrospectively investigated the advantages of retroperitoneoscopic nephrectomy for nonfunctioning tuberculous kidneys by comparing its clinical results, operative methods and skills with those of open nephrectomy. MATERIALS AND METHODS: Clinical data on 22 patients with nonfunctioning tuberculous kidneys who underwent retroperitoneoscopic nephrectomy, including simple and subcapsular nephrectomy, were compared with those on 22 who underwent open nephrectomy for a similar indication during the same period. Results in the 2 groups were analyzed. RESULTS: There was no statistical difference between the retroperitoneoscopy and open surgery groups with regard to patient age, sex or mean operative time +/- SD (93.0 +/- 12.6 vs 92.6 +/- 35.5 minutes). Mean blood loss was significantly less in the retroperitoneoscopy group than in the open surgery group (78.3 +/- 60.6 vs 160 +/- 120.0 ml). Mean hospital stay after operation was notably shorter in the retroperitoneoscopy group compared with the open surgery group (3.3 +/- 0.9 vs 9.1 +/- 0.8 days). The mean analgesic requirement for opioids and diclofenac sodium was also lower in the retroperitoneoscopy group than in the open surgery group (0 vs 2.1 +/- 0.9 and 5.2 +/- 1.1 vs 5.8 +/- 1.3 doses, respectively). CONCLUSIONS: Retroperitoneoscopic nephrectomy for renal tuberculosis has several advantages over open nephrectomy, namely a smaller wound, less blood loss and more rapid recovery. It may provide a safe and reliable method for treating refractory renal tuberculosis clinically.

Adult↗