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PubMed2005

Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant.

OBJECTIVES: To evaluate whether using a biologic hemostatic sealant facilitates hemostasis during laparoscopic partial nephrectomy. Secure and durable parenchymal hemostasis is a critical requirement during laparoscopic partial nephrectomy. METHODS: Since September 1999, laparoscopic partial nephrectomy has been performed in more than 300 patients by a single surgeon, duplicating open surgical principles. Recently, from patient 225 onward, we modified our technique by incorporating topical application of a gelatin matrix thrombin sealant (FloSeal) to cover the partial nephrectomy bed before sutured renorrhaphy over a Surgicel bolster. The impact of FloSeal on reducing hemorrhagic complications was evaluated by comparing two sequential groups of patients: group 1 consisted of 68 patients in whom FloSeal was not used (patients 156 to 224) and group 2 consisted of 63 patients in whom it was used (patients 225 to 288). RESULTS: Groups 1 (no FloSeal) and 2 (FloSeal) were comparable in tumor size, number of central tumors, and performance of pelvicaliceal suture repair (84% versus 92%; P = 0.16). Intraoperative variables were also comparable in terms of mean warm ischemia time (36.1 versus 37.2 minutes; P = 0.55), blood loss (150 versus 106 mL; P = 0.36), operative time, and hospital stay. However, the FloSeal group had significantly fewer overall complications (37% versus 16%; P = 0.008) and tended toward a lower rate of hemorrhagic complications (12% versus 3%), although this did not achieve statistical significance (P = 0.08). CONCLUSIONS: The results of this study have shown that adjunctive use of gelatin matrix thrombin sealant substantially enhances parenchymal hemostasis and has decreased our procedural and hemorrhagic complications to levels comparable with contemporary open partial nephrectomy series. This gelatin matrix-thrombin tissue sealant is now a routine part of laparoscopic partial nephrectomy at our institution.

Gelatin Sponge, Absorbable↗

PubMed2006

Is laparoscopic nephrectomy the preferred approach in xanthogranulomatous pyelonephritis?

OBJECTIVES: To report our experience with laparoscopic nephrectomy in patients with xanthogranulomatous pyelonephritis (XGP) and compare it with the open approach. XGP is an atypical and severe form of chronic renal infection. Open nephrectomy has been the procedure of choice for XGP. The laparoscopic approach has been used in cases of XGP but with increased complications and operative time. METHODS: A retrospective analysis of all the patients who underwent laparoscopic nephrectomy with a pathologic diagnosis of XGP from January 2001 to August 2005 was done. The demographic profile and data on the operative time, operative technique, blood loss, and complications were obtained. RESULTS: In all, 25 patients underwent nephrectomy with a pathologic diagnosis of XGP, 10 laparoscopically and 15 by the open approach. Laparoscopic nephrectomy for XGP was successful in 80% of the cases. The dissection of the kidney was comparatively difficult in all cases because of dense adhesions in the perirenal region and required modification of the technique. The incidence of major complications was 20% and 10% in the open and laparoscopic groups, respectively. The mean hospital stay in the laparoscopic group was 3.8 days, significantly less than that for the open nephrectomy group (8.2 days). The mean operative time in the laparoscopic group was 3.8 hours compared with 2.5 hours in the open group. CONCLUSIONS: Laparoscopy can be successfully performed in patients with a pathologic diagnosis of XGP. Although a longer operative time is required because of perinephric adhesions, the postoperative recovery is faster and cosmesis superior compared with the open approach. Modifications in the standard laparoscopic technique can be made to complete the procedure successfully and safely.

Adolescent↗

PubMed2006

Right laparoscopic donor nephrectomy: the Washington Hospital Center experience.

OBJECTIVES: To review 167 consecutive laparoscopic living donor nephrectomies performed at the Washington Hospital Center to determine whether the side of extraction, right versus left, affects the operative outcomes. METHODS: From January 2003 to June 2005, 167 consecutive patients (127 left and 40 right) underwent laparoscopic living donor nephrectomy. The right-sided and left-sided procedures were compared in the following categories: operative time, warm ischemia time, length of stay, and complications. RESULTS: The mean operative time for a right donor nephrectomy was 220 minutes versus 228 minutes for a left. The mean estimated blood loss was 115 mL for right donor nephrectomy versus 106 mL for the left. The corresponding mean warm ischemia times were 5.32 minutes and 4.91 minutes. The median length of stay was 3 days in both groups. Five minor and three major complications occurred, including 2 patients with recognized bowel injuries and 1 patient who required reoperation for a bladder injury. CONCLUSIONS: Historically, laparoscopic living donor nephrectomy has been performed solely on the left side because of the increased length of the left renal vein. However, in our experience, the operative parameters and postoperative results were equivalent in the right and left laparoscopic donor nephrectomy groups. Therefore, we recommend removal of the more appropriate kidney, regardless of side.

Adult↗

PubMed1998

Is partial nephrectomy appropriate treatment for unilateral Wilms' tumor?

PURPOSE: After nephrectomy for unilateral Wilms' tumor (WT), two potential hazards threaten the remaining kidney. The development of a metachronous WT (2% to 3%), and decrease in renal function after chemotherapy. Our study aims included: (1) to clarify how many WT patients could benefit from partial nephrectomy (PN) without jeopardizing the high cure rate, (2) to establish the function of the kidney remnant, and (3) to test the radiological criteria for preoperative selection of PN candidates. METHODS: A retrospective analysis of 90 consecutive cases of histologically verified WT (1982 to 1992) was carried out. Data were studied independently by the surgeon, the radiologist, and the pathologist. The preoperative selection criteria for PN were functioning kidney, tumor confined to upper or lower pole leaving two thirds of the kidney tumor free, and no hilar or vascular structures involved. After PN, renal function was estimated by a calculated creatinine clearance (CC) combined with the assessment of the relative function of each kidney by renal scintigraphy. RESULTS: There were 46 boys and 44 girls with median age at diagnosis of 3 years 6 months (range, 3 months to 16 years 7 months). Stage I disease occurred in 40 patients, stage II in 23, stage III in 16, and stage IV occurred in 11 patients. Nearly all patients received preoperative chemotherapy. Radiological analysis of 85 available data sets (5 missing) suggested that PN was possible in 13 patients, and data were inconclusive in two. All 13 patients selected by the radiologist appeared to be in agreement with the pathological criteria for resectability. Of these cases, complete resection by PN was performed in five, could have been possible in retrospect in two, and appeared impossible in six. In two more patients, PN was performed; in both cases the radiologist had predicted PN to be impossible. Median follow-up after PN was 61 months, range, 45 to 167 months. Two patients died of distant metastasis, and no local recurrence occurred. Five are in remission with a median CC level of 110 mL/min, range, 85 to 124. Relative functions of the kidney remnants were 20% to 50%. Contralateral nephrectomy for progressive obstruction was performed in one, but CC level remained normal (85 mL/min). Comparing the preoperative radiological prediction with the combined surgical and pathological findings in a 2 x 2 frequency table, the sensitivity of the radiological findings could be calculated to be 80%, the specificity 97%, and the accuracy 87%. CONCLUSIONS: (1) Partial nephrectomy is safe in approximately 10% of Wilms' tumor patients. (2) The function of the kidney remnant remains well, and even permits contralateral nephrectomy. (3) Preoperative imaging shows an accuracy of 87% to predict the possibility for partial nephrectomy.

Child, Preschool↗

PubMed1998

Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German Urologic Association.

PURPOSE: The centers of the laparoscopy working group of the German Urologic Association collected data to prove the efficacy, safety and reproducibility of laparoscopic nephrectomy. MATERIALS AND METHODS: At 14 centers 482 laparoscopic nephrectomies have been performed until December 1996 via a transperitoneal approach in 344 (71%) and a retroperitoneal approach in 138 (29%). All 482 laparoscopic nephrectomies were performed by a total of 20 surgeons with an average of 24 procedures per surgeon (range 4 to 105). The indications for nephrectomy were benign renal pathology in 444 patients (92%), including renovascular disease in 28%, hydronephrosis in 20%, reflux nephropathy in 15%, chronic pyelonephritis in 12%, end stage nephrolithiasis in 11%, renal dysplasia in 4% and renal tuberculosis in 1%. Of the remaining 38 patients (8%) laparoscopic radical nephrectomy was performed for renal cell carcinoma in 5% and for upper tract transitional cell carcinoma in 3%. RESULTS: Operating time depended mainly on the pathology of the kidney (that is small dysplastic organ versus large hydronephrosis) and the learning curve of the surgeon. However, the average operating time did not vary significantly among the different centers (maximum 277.6 and minimum 81.9 minutes). Intraoperative or perioperative complications were noted in 29 patients (6.0%), including bleeding in 22 (4.6%), bowel injury in 3, hypercarbia in 2 and pleura lesion in 1 and pulmonary embolism in 1. The conversion rate was 10.3% (bleeding, bowel injury, difficult dissection), including 4 patients with renal tuberculosis, 2 with xanthogranulomatous nephritis, and 1 each following renal trauma and embolization. The re-intervention rate was 3.4% due to bleeding in 6 cases, abscess formation in 3, intestinal stenosis in 2 and a pancreatic fistula and port hernia in 1. Mean hospital stay was 5.4 days. CONCLUSIONS: Laparoscopic nephrectomy has become a well established procedure in those urology departments focusing on laparoscopy. The indications and results are reproducible at these centers. However, for patients with severe perinephritis (that is renal tuberculosis, xanthogranulomatous nephritis, posttraumatic atrophy) a higher likelihood of open conversion must be considered.

Adolescent↗

PubMed1995

Partial nephrectomy: technique, complications and pathological findings.

PURPOSE: We evaluate whether partial nephrectomy can be performed safely and efficaciously for renal tumors. MATERIALS AND METHODS: The results of 67 partial nephrectomies performed between 1977 and 1994 for renal cell carcinoma (51), oncocytoma (9), angiomyolipoma (3), transitional cell carcinoma (3) and other nonneoplastic lesions (2) were analyzed retrospectively in detail. RESULTS: Diminished complication rates were noted after 1988, and were attributed to improvements in surgical technique and an increased incidence of smaller, serendipitously discovered tumors. Although 35.5% of the patients had preoperative renal impairment (mean serum creatinine 2.1 mg./dl.), there were minimal changes in renal function and no patient required acute hemodialysis following partial nephrectomy. Among 42 patients with clinical stage T1 to T2 renal cell carcinoma undergoing partial nephrectomy local recurrence was identified in 8.3% of those with primary neoplasms. All 6 patients with local recurrence had negative surgical margins, recurrence often, distant from the operative site and multifocal disease, implicating multicentricity as the etiology of local recurrence. Five patients (83.3%) with local recurrence were alive and asymptomatic at a mean of 138 months after partial nephrectomy. Since capsular penetration was identified in 5 of 27 renal cell carcinomas (18.5%) with a diameter of 3.5 cm. or less, aggressive surgical resection with adequate tumor-free parenchymal and perinephric margins is necessary even for small lesions. CONCLUSIONS: With improved surgical techniques, including regional hypothermia, intraoperative sonography, meticulous dissection and injection of the collecting system with methylene blue, partial nephrectomy is safe and effective in properly selected patients.

Adolescent↗

PubMed2002

Outcome of laparoscopic radical and open partial nephrectomy for the sporadic 4 cm. or less renal tumor with a normal contralateral kidney.

PURPOSE: Nephron sparing surgery provides effective therapy in patients with a solitary sporadic renal tumor 4 cm. or less and a normal contralateral kidney. Laparoscopic radical nephrectomy has been applied as a newer alternative therapy in these patients. These 2 contemporary approaches represent divergent treatment alternatives at centers where laparoscopic nephron sparing surgery is not offered. We compared the short-term and long-term impact of these 2 treatment modalities in patients with a sporadic localized solitary renal tumor 4 cm. or less and a normal opposite kidney. MATERIALS AND METHODS: A retrospective review of a contemporary series of patients (1996 to 2001) who underwent open nephron sparing surgery and met study inclusion criteria was performed and compared with a similar cohort (1997 to 2001) that underwent laparoscopic radical nephrectomy. Only patients with a single renal tumor of 4 cm. or less, normal serum creatinine less than 1.5 mg./dl. and a normal contralateral kidney were included in analysis. The 2 groups were compared in regard to demographic, clinical and pathological variables using parametric and nonparametric tests. Linear regression analysis was done to compare the percent change in serum creatinine, while adjusting for demographic and clinical variables, and followup. RESULTS: A total of 35 patients who underwent laparoscopic radical nephrectomy and 82 who underwent open nephron sparing surgery met study inclusion criteria. Mean patient age in the laparoscopic group was significantly greater (67.3 versus 56.2 years, p <0.001), mean American Society of Anesthesiologists class score was higher (p = 0.04) and mean tumor size was greater (3.1 versus 2.6 cm., p = 0.003) than in the nephron sparing group. The laparoscopic group had significantly decreased mean blood loss (100 versus 200 ml., p <0.001), hospital stay (1 versus 5 days, p <0.001), narcotic use (16.5 versus 224 mg., p <0.001) and operative time (184.4 versus 216.2 minutes, p <0.007) compared with the nephron sparing group. Patients who underwent nephron sparing surgery experienced less postoperative deterioration in renal function, as measured by the percent increase in serum creatinine postoperatively (0% versus 25%, p <0.001). The results of regression analyses at 4 and 6 months of followup indicated that open nephron sparing surgery is associated with significantly lower serum creatinine than laparoscopic radical nephrectomy after adjusting for demographic and clinical variables, and followup. CONCLUSIONS: Open nephron sparing surgery and laparoscopic radical nephrectomy are relatively recent and significant developments for treating patients with renal cell carcinoma and they represent accepted standards of care in those with a small renal mass and normal contralateral kidney. In patients presenting with a sporadic solitary renal tumor of 4 cm. or less and a normal contralateral kidney the significant short-term and intermediate term benefits of the laparoscopic approach must be weighed against the long-term advantage of better renal function associated with open nephron sparing surgery. The distinct advantages of these 2 approaches may ultimately be realized with the standardization of laparoscopic partial nephrectomy.

Aged↗

PubMed2002

Thrombocytosis is associated with a significant increase in the cancer specific death rate after radical nephrectomy.

PURPOSE: We have previously reported that patients with advanced renal cell carcinoma and a normal platelet count of 400,000/mm. have a 64% increase in life expectancy compared with those with thrombocytosis. We determined whether thrombocytosis was predictive of death from renal cell carcinoma after radical nephrectomy was performed with curative intent for early stage disease. MATERIALS AND METHODS: We reviewed the records of 204 patients with renal cell carcinoma who underwent radical nephrectomy with curative intent between June 1993 and January 2000 at Emory University Hospital. Survival, pathological grade and stage were recorded from the Emory Winship Cancer Institute tumor registry. Platelet counts were recorded and any patient with at least 1 platelet count of greater than 400,000/mm. was classified with thrombocytosis. Those with a platelet count of 400,000/mm. were classified with a normal platelet count. RESULTS: There were 26 patients with thrombocytosis and 178 patients with persistently normal platelet counts. The overall and cancer specific death rate in the 26 patients with thrombocytosis was 50% and 42%, respectively. The overall mean time between nephrectomy and death was 12.1 months in this group. The overall and cancer specific death rate in the 178 patients with a normal platelet count was 15.2% and 7.3%, respectively. Mean time to death was 22.6 months in this group. Differences in the overall and cancer specific death rates were highly statistically significant as well as clinically significant. These differences remained significant after controlling for grade, stage and histological type of cancer. CONCLUSIONS: This study documents the association of thrombocytosis with decreased survival in patients with renal cell carcinoma. In those who undergo nephrectomy for early stage renal cell carcinoma with a perioperative platelet count of greater than 400,000/mm. the cancer specific death rate from renal cell carcinoma is greater than 5 times the rate in patients with a persistently normal platelet counts after radical nephrectomy. The platelet count appears to be a new and powerful independent prognosticator in patients with renal cell carcinoma who undergo radical nephrectomy for presumed localized disease.

Aged↗

PubMed2001

Laparoscopic radical nephrectomy: cancer control for renal cell carcinoma.

PURPOSE: We evaluated the clinical efficacy of laparoscopic versus open radical nephrectomy in patients with clinically localized renal cell carcinoma. MATERIALS AND METHODS: Between 1991 and 1999, 67 laparoscopic radical nephrectomies were performed for clinically localized, stages cT1/2 NXMX, pathologically confirmed renal cell carcinoma. During this period 54 patients who underwent open radical nephrectomy with pathologically confirmed stages pT1/2 NXMX disease were also identified. Medical and operative records were retrospectively reviewed and telephone followup was done to assess patient status. RESULTS: In the laparoscopic and open groups average tumor size was 5.1 (range 1 to 13) and 5.4 cm. (range 0.2 to 18), respectively, which was not statistically significant. No patient had laparoscopic port site, wound or renal fossa tumor recurrence in either group. All patients were followed at least 12 months. In the laparoscopic group 2 cancer specific deaths occurred at a mean followup of 35.6 months. In the open group there were 2 cancer specific deaths and 3 cases of disease progression at a mean followup of 44 months. Kaplan-Meier disease-free survival and actuarial survival analysis revealed no significant differences in the laparoscopic and open radical nephrectomy groups. Also, no differences were noted in the complication rate. CONCLUSIONS: Laparoscopic radical nephrectomy is an effective alternative for localized renal cell carcinoma when the principles of surgical oncology are maintained. Initial data show shorter patient hospitalization and effective cancer control with no significant difference in survival compared with open radical nephrectomy.

Adult↗

PubMed2001

Hand assisted laparoscopic donor nephrectomy: a comparison with the open approach.

PURPOSE: Hand assisted laparoscopy combines aspects of open and laparoscopic surgery. A hand in the abdomen may facilitate laparoscopic live donor nephrectomy, allowing more urologists to participate. We report and compare our initial series of hand assisted laparoscopy donor nephrectomy with nephrectomy performed by standard open methods. MATERIALS AND METHODS: In the last 18 months 60 patients at 2 institutions underwent hand assisted laparoscopy donor nephrectomy. This cohort was compared to a contemporary group of 31 patients who underwent open donor nephrectomy via a flank incision at our 2 institutions. Demographic and outcome data were compared retrospectively in a nonrandomized fashion in the 2 groups. RESULTS: Demographic data on patient age, male-to-female ratio and body mass index were similar in the 2 groups. Operative time, transfusion rate, time to oral intake and complications were also similar. However, estimated blood loss, change in hematocrit preoperatively to postoperatively, hospitalization, parenteral and oral narcotic requirement, and donor convalescence were significantly less in the hand assisted laparoscopy versus open groups. In terms of allograft function, nadir creatinine, time to nadir creatinine, creatinine clearance at 6, 12, and 18 months, delayed graft function, episodes of acute rejection and ureteral stricture were similar in the groups. CONCLUSIONS: Hand assisted laparoscopy is safe, efficacious and reproducible for living related donor nephrectomy. Compared with the open technique hand assisted laparoscopy provides the donor with significantly decreased postoperative morbidity, while enabling excellent allograft function. Further randomized prospective studies are warranted.

Adult↗

PubMed1990

Long-term consequence of nephrectomy.

Renal function and blood pressure were assessed in 139 patients after unilateral nephrectomy. Followup ranged from 1 to 57 years, with a mean of 13.0 +/- 1.1 (standard error). Serum creatinine, creatinine clearance, beta 2-microglobulin clearance and blood pressure remained stable during followup. No significant effect of years after unilateral nephrectomy, blood pressure or cause of nephrectomy was observed on creatinine clearance. However, urine excretion of protein (correlation coefficient 0.475, p less than 0.01) and N-acetyl-beta-D-glucosaminidase (correlation coefficient 0.464, p less than 0.01) increased as a function of years after unilateral nephrectomy. Creatinine clearance tended to be low in elderly patients or patients who underwent nephrectomy at an advanced age. Our studies show that despite the late development of proteinuria and tubular injury, unilateral nephrectomy is not associated with deterioration in kidney function or elevation of blood pressure during long-term followup.

Acetylglucosaminidase↗

PubMed1978

Bilateral nephrectomy for hypertension in patients with chronic renal failure on a dialysis program.

During the last 6 years 33 bilateral nephrectomies have been performed for severe hypertension in patients with chronic renal failure on a dialysis program. Nephrectomy resulted in a prompt and sustained reduction in blood pressure, an improved sense of well-being and a gain of weight. Despite the fact that the mean hematocrit decreased from 25 to 18 per cent all patients thrived. The nephrectomy group showed an 85 per cent 5-year cumulative survival rate compared to 55 per cent in the non-nephrectomy group. There was 1 mortality and low morbidity. Simultaneous nephrectomy by 2 teams, using a posterior approach, proved more satisfactory than an anterior or bilateral flank apprach. The indications for and arguments against bilateral nephrectomy are discussed.

Adult↗

PubMed1977

The role of adjunctive nephrectomy in patients with metastatic renal cell carcinoma.

The results of therapy for 78 patients with disseminated renal cell carcinoma are evaluated. Symptoms related to the primary tumor were noted in only 28 per cent of the patients and were not difficult to manage in those patients not undergoing nephrectomy. Adjuctive nephrectomy, therefore, is a more appropriate term than palliative nephrectomy when referring to removal of the primary tumor as part of an aggresive combined therapeutic approach. Of patients receiving an adjunctive nephrectomy those with osseous metastases only had a better 1-year survival rate (36 per cent) than those with metastases to other sites (18 per cent). Complete regression of metastases was noted in 12 per cent of patients treated with medroxyprogesterone acetate and adjunctive nephrectomy. The role of adjunctive nephrectomy combined with embolic infarction, hormonal therapy, chemotherapy and/or immunotherapy is discussed.

Adenocarcinoma↗

PubMed2000

Retroperitoneal minilaparoscopic nephrectomy in the rat model.

OBJECTIVES: Development of small animal models for laparoscopic surgery is important for basic pathophysiologic and oncologic studies, instrument development, and surgical training. Although transperitoneal laparoscopy has been described in the rat, the technical feasibility of the retroperitoneoscopic approach for major renal surgery has not been reported previously. Herein, we describe the development of a rat model for retroperitoneal minilaparoscopic nephrectomy. METHODS: Sixteen male Sprague-Dawley rats underwent a three-port bilateral retroperitoneoscopic nephrectomy using 2 and 3-mm instruments and optics exclusively. After developing the technique in 10 animals, the study was conducted in 6 animals. Following retroperitoneal balloon dilation and CO(2) pneumoretroperitoneum (mean 4.5 mm Hg), nephrectomy was accomplished by intracorporeal en bloc ligation of the renal pedicle. To prevent peritoneal entry, the anterior surface of the kidney was mobilized subcapsularly. Volume of the created retroperitoneal space and peritoneal integrity were confirmed by a contrast x-ray study. Intraperitoneal pressure was monitored constantly during the procedure. RESULTS: Mean surgical time was 74.5 minutes (range 60 to 95) and estimated blood loss was less than 1 mL. Mean volume of the retroperitoneal space was 8.4 mL after initial balloon dilation, and 11.5 mL after nephrectomy. Mean weight of the excised kidneys was 1. 4 g. Inadvertent peritoneotomy occurred during 3 of 12 study nephrectomies. Complications included renal artery hemorrhage leading to death in 1 animal and renal vein injury in 1 animal. CONCLUSIONS: Laparoscopic retroperitoneal nephrectomy in the rat model is technically feasible. This novel small animal model can be used for further studies of the retroperitoneal laparoscopic approach.

Animals↗

PubMed2001

Hand-assisted laparoscopic donor nephrectomy minimizes warm ischemia.

OBJECTIVES: Traditional open donor nephrectomy is associated with good donor outcomes and excellent allograft function. Laparoscopic donor nephrectomy may accomplish these same goals with less morbidity. We report our initial experience with hand-assisted laparoscopic living donor nephrectomy using a commercially available hand-assist device. METHODS: Donor and allograft outcomes for the first 30 patients undergoing hand-assisted laparoscopic live donor nephrectomy in our institution were prospectively analyzed. RESULTS: Hand-assisted laparoscopic donor nephrectomy was successfully completed in 29 (97%) of 30 donors. Organ dissection was carried out purely laparoscopically. Vessel division and allograft extraction were performed using a hand-assisted technique. The average operative time was 275 minutes (range 193 to 360), with an estimated blood loss of 99 mL (range 50 to 300). Pneumoperitoneum was consistently maintained during the hand-assisted portion of the procedure. The mean warm ischemic time was 72.5 seconds (range 30 to 165). On average, the regular diet was resumed after 2.2 days (range 1 to 3), and patients were discharged home 3.4 days (range 2 to 5) after surgery. Eight minor complications occurred in the donor group. Immediate graft function occurred in all 30 cases. No ureteral complications occurred. The recipient creatinine levels ranged from 0.6 to 2.4 mg/dL at an average follow-up of 11.5 months (range 1 to 23). CONCLUSIONS: Laparoscopic donor nephrectomy is technically feasible and can be performed with minimal morbidity. Hand-assisted kidney extraction may help to facilitate immediate allograft function by minimizing the warm ischemic time.

Adult↗

PubMed2002

Coloepiploic mobilization during left radical nephrectomy for renal cell carcinoma is indicated to reduce the risk of iatrogenic splenectomy.

OBJECTIVES: To determine whether coloepiploic mobilization (CEM) is indicated to reduce the incidence of iatrogenic splenectomy during left radical nephrectomy for renal cell carcinoma. The incidence of iatrogenic splenectomy during a left nephrectomy is estimated to be between 1.4% and 24%. In a recent study, we reported that the incidence of iatrogenic splenectomy was 8% during a left nephrectomy performed for renal cell carcinoma through a transperitoneal anterior subcostal incision. METHODS: A left radical nephrectomy was performed in 233 consecutive patients for renal cell carcinoma through a transperitoneal anterior subcostal incision with a CEM procedure in which the left colonic flexure was completely detached from the epiploa. Perioperative and postoperative complications, including splenic injury, were noted in a database. The mean patient age was 51.3 years (range 21.3 to 90.2). The mean tumor size was 58 mm (range 15 to 230). RESULTS: An iatrogenic splenectomy was required in 3 patients, and in 1 patient, a splenic injury was treated conservatively. The incidence of iatrogenic splenectomy accompanying left radical nephrectomy was 1.3%. The mean operative time was 120 minutes (range 80 to 240). The mean time to normal gut motility was 3.4 days (range 2 to 11) and to discharge from the hospital it was 9.3 days (range 6 to 19). Regarding CEM, we did not observe any significant abdominal complications. CONCLUSIONS: The incidence of iatrogenic splenectomy during a left radical nephrectomy through a transperitoneal anterior subcostal incision may be reduced by performing the technique of CEM.

Adult↗

PubMed2002

Transvaginal laparoscopic nephrectomy: development and feasibility in the porcine model.

OBJECTIVES: To assess feasibility of laparoscopic nephrectomy completed entirely by way of the vagina in the porcine model. METHODS: Six transvaginal laparoscopic nephrectomies were performed in female farm pigs. Two acute and two 1-week survival animals were used for the study. Before killing the survival animals, a second transvaginal laparoscopic nephrectomy was performed on the remaining renal unit. For one renal unit, the laparoscopic nephrectomy was completed entirely by way of the vagina. In five renal units, a single, 5-mm transabdominal trocar for the laparoscope was required to facilitate visualization. RESULTS: The operative time for the procedure completed entirely by way of the vagina was 360 minutes, and the mean operative time for the procedures requiring placement of a single 5-mm transabdominal trocar was 210 minutes. In 5 cases, dissection, control of the renal pedicle, and extraction of the kidney were successfully completed using a transvaginal approach. In 1 acute case, an uncontrollable vascular injury occurred during placement of the Endo-GIA stapler, resulting in exsanguination. In all other cases, the mean blood loss was less than 30 mL, and no significant perioperative complications were noted. Both survival pigs had normal bowel and bladder function before being killed. CONCLUSIONS: Complete transvaginal laparoscopic dissection and nephrectomy is feasible in the porcine model using a single, 5-mm abdominal trocar for visualization. A completely transvaginal laparoscopic nephrectomy was performed once, but limitations imposed by the porcine anatomy and by the currently available instrumentation made the procedure very cumbersome. Additional development of this technique in animal models and improved instrumentation is needed before clinical assessment is warranted.

Animals↗

PubMed2002

Minimal incision living donor nephrectomy: improvement in patient outcome.

OBJECTIVES: To analyze the minimal incision living donor (MILD) nephrectomy and compare it with the standard open donor (SOD) nephrectomy with respect to incision size, operative time, complication rate, length of hospital stay, and recipient creatinine. METHODS: Forty-five consecutive patients who underwent MILD nephrectomy were compared with 13 patients who had previously undergone SOD nephrectomy. The MILD nephrectomy was performed through a minimally invasive incision using a modified, anterolateral, retroperitoneal approach without a rib resection. The incision length, operative time, complication rates, length of hospital stay, and recipient creatinine were analyzed. RESULTS: The average incision length in the MILD group was 8.6 cm compared with 21.8 cm in the SOD group (P >0.005.) The operative times (209 minutes in the MILD group versus 191 minutes in the SOD group) were not significantly different. Four postoperative complications were encountered in the SOD group and seven in the MILD group. The average hospital stay for the MILD patients was 2.5 days compared with 4.6 days in the SOD group, and as the procedure was refined, the length of stay was reduced to 1 day in 3 patients. The recipient creatinine at 1 and 6 months was 1.39 and 1.4 mg/dL in the MILD group, respectively. CONCLUSIONS: The MILD nephrectomy allows the patient to undergo a less morbid procedure with a more aesthetic incision. Patients have fewer complications, minimal anesthesia exposure, and short hospital stays.

Adult↗