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PubMed1996

Retroperitoneal laparoscopic nephrectomy in children: preliminary report of six cases.

Laparoscopic nephrectomy is a new procedure that must be evaluated in adults and children. This technique allows a reduction in complications and sequelae. The majority of indications, such as renal dysplasia and destroyed kidneys due to obstructive or refluxing uropathy, are suitable for laparoscopic nephrectomy. Contraindications are Wilms' tumor and trauma, which represent only 20 percent of nephrectomies in our experience. As in open surgery, to perform nephroureterectomy for benign disease, a retroperitoneal approach seems more logical than transperitoneal approach, which is the usual approach for laparoscopic surgeons. We have attempted six retroperitoneal laparoscopic nephrectomies in children from 3 months to 14 years old. The patient is positioned in a lateral position after creation of a retropneumoperitoneum under visual control; three or four ports are needed and renal vessels are dissected then clipped, or coagulated if small. Destroyed kidneys are generally of small size, so they can be extracted via a 10- or 12-mm cannula site without morcellation. Operative time ranges from 35 to 210 mm (median 120 mm). We have had no complications or conversions. Retroperitoneal laparoscopic nephrectomy in children is a feasible and safe procedure in well-trained hands.

Adolescent↗

PubMed1997

Hand-assisted laparoscopic nephrectomy: technical considerations.

PURPOSE: Laparoscopic nephrectomy can be technically difficult and associated with lengthy operative times because of the limitations imposed by working with long instruments rotating about a fixed site on the abdominal wall, and without direct manual contact with the tissue. Hand-assisted laparoscopy is an option that addresses these problems. Herein we report our initial technique for hand-assisted laparoscopic nephrectomy. TECHNIQUE: After obtaining pneumoperitoneum and placing a 12-mm cannula lateral to the rectus muscle, a 7- to 8-cm incision is made in the upper midline. A commercially available wound protector and occlusive sleeve are inserted. Once an arm strap has been secured, the surgeon can operate with one hand in the abdomen while maintaining pneumoperitoneum. Using instruments placed through one or two additional laparoscopic ports, the nephrectomy is completed and the specimen is removed through the upper midline incision. Our continued experience with 10 hand-assisted laparoscopic nephrectomies to date has been favorable. CONCLUSION: Hand-assisted laparoscopic nephrectomy may facilitate the laparoscopic management of demanding pathologies, such as severely inflamed kidneys and larger tumors. It is particularly advantageous when intact specimens are required. Although more experience is required to define the role of hand-assisted urologic laparoscopy, we are encouraged by our initial technique and results.

Humans↗

PubMed1985

Urinary albumin excretion after donor nephrectomy.

Surgical ablation of renal tissue in animals leads to compensatory hyperfiltration, hypertension, and focal glomerular sclerosis in remnant nephrons, in association with albuminuria; the detection of slightly elevated urinary albumin (microalbuminuria) has been shown to predict later, more severe renal disease in diabetics. To determine whether unilateral nephrectomy in humans initiates a similar pathogenetic sequence, we measured urinary albumin excretion (UalbV), total protein excretion (UprotV), creatinine clearance (Ccreat) and blood pressure in 22 transplant donors before and at intervals up to 3 years after donor nephrectomy. Urinary albumin was determined using a sensitive enzyme immunoassay (ELISA). Mean Ccreat fell on average to 68% of prenephrectomy values at all times after nephrectomy, indicating a rise of 33% in average single nephron filtration rate. Mean absolute and fractional albumin excretion rates and UprotV values were transiently elevated one week postnephrectomy, but returned thereafter to values not significantly different from prenephrectomy values. Blood pressure rose slightly, but significantly, with time after nephrectomy. Average increases of 10 mm and 5 mm in systolic and diastolic pressures, respectively, were noted by 2 years after surgery. In this study, there was no evidence of glomerular injury from hyperfiltration in the 3 years following donor nephrectomy.

Adult↗

PubMed1999

Current Status of Partial Nephrectomy in the Management of Kidney Cancer.

BACKGROUND: The technique of partial nephrectomy for managing renal cancers is well recognized, but guidelines regarding indications for its use are not generally accepted. METHODS: The authors review the indications for partial nephrectomy in various clinical situations, and they include their own experience to clarify the utility of the technique. RESULTS: Intraoperative renal ultrasound and helical computed tomography can assist the surgeon in technical decisions. Partial nephrectomy is considered when nephrectomy would render the patient anephric and dependent on dialysis. CONCLUSIONS: The technical and operative advances in partial nephrectomy make the approach increasingly attractive for patients with kidney cancer in a variety of clinical circumstances.

Journal Article↗

PubMedDate not supplied

Hand-assisted laparoscopic nephrectomy in living donor.

OBJECTIVE: Report the authors' initial experience with hand-assisted laparoscopic nephrectomy technique in renal donors for transplantation. MATERIALS AND METHODS: Twenty-seven donors submitted to hand-assisted laparoscopic nephrectomy were retrospectively analyzed from February 2001 to June 2002. Technical aspects of the donor surgery, results, and complications, are discussed, as well as recipient's complications and outcomes. RESULTS: Among 27 hand-assisted laparoscopic nephrectomies, left kidney was withdrew in 18 donors (66.6%), and right kidney in 9 (33.3%). The operative time ranged from 55 to 210 minutes (mean 132.7 + 37.6 min), and the time of hot ischemia ranged from 2 to 11 minutes (mean 4.7 + 2.5 min), with an estimated mean blood loss during the intraoperative period of 133.3 mL. Conversion to open surgery was necessary for 1 (3.7%) patient due to vascular lesion. In graft evaluation, immediate diuresis was observed in 26 (96.3%) cases, and mean serum creatinine in PO day 7 was 1.5 + 1.1 mg/dL. Renal vein thrombosis occurred in 1 (3.7%) patient requiring graft removal. Lymphocele was observed in 3 recipients (11.1%), and urinary leakage due to ureteral necrosis in 1 case (3.7%). CONCLUSION: Hand-assisted laparoscopic nephrectomy in living donors is a safe procedure and an effective alternative to open nephrectomy. In this series, the procedure presented low morbidity after surgery providing to the recipient a good morphological and functional quality of the graft.

Journal Article↗

PubMed2001

Increased transplantation of kidneys with multiple renal arteries in the laparoscopic live donor nephrectomy era: surgical technique and surgical and nonsurgical donor and recipient outcomes.

BACKGROUND: For anatomical and technical reasons, many transplant centers restrict laparoscopic live donor nephrectomy (in contrast with open live donor nephrectomy) to left kidneys. HYPOTHESIS: This change in surgical practice increases procurement and transplantation rates of live donor kidneys with multiple renal arteries (RAs), without affecting donor and recipient outcomes. DESIGN AND SETTING: Retrospective review at an academic tertiary care referral center comparing laparoscopically procured single vs multiple-RA kidney grafts (April 1997 to October 2000). PATIENTS: Seventy-nine consecutive left laparoscopic live kidney donors and 78 transplant recipients. MAIN OUTCOME MEASURES: Donor and recipient complications and postoperative length of stay; cold and warm ischemia time; operating time; short-term and long-term graft function; and survival. RESULTS: We noted multiple RAs in 21 (27%) of all kidneys. The proportion of donors with 1 or more perioperative complications was 19% in the single-RA group vs 10% in the multiple-RA group (P was not significant). For the recipients, we noted no significant differences between groups with respect to surgical complications, quality of early and late graft function, rejection rates, graft losses (all immunologic), and graft survival. Cold and warm ischemia time and length of stay were similar for donors and recipients in both groups. Median operating times were significantly longer for the multiple-RA vs single-RA group (difference, 41 minutes for donors and 45 minutes for recipients; P<.02). CONCLUSIONS: While the introduction of laparoscopic live donor nephrectomy has significantly increased the number of grafts with multiple RAs (compared with historical open controls), this change in practice is safe for both donors and recipients from a patient outcome-based perspective. However, from an economic perspective, the longer operating time associated with multiple-RA grafts provides strong added rationale for optimization of surgical instruments and techniques to make right-sided laparoscopic nephrectomy a routine intervention.

Adult↗

PubMed2002

Learning laparoscopic donor nephrectomy safely: a report on 100 cases.

HYPOTHESIS: There is concern that learning laparoscopic live donor nephrectomy (LLDN) is associated with increased morbidity. We propose that with a team approach LLDN can be learned safely, without increased donor morbidity or graft failure, even during the early portion of a learning curve. DESIGN: Case series with cohort comparison. SETTING: Tertiary referral center. PATIENTS: The laparoscopic group consisted of 100 donors and 100 recipients; the open group, 50 donors and 50 recipients. INTERVENTIONS: A team approach that combines laparoscopic and urologic expertise was used to perform 100 cases of LLDN. MAIN OUTCOME MEASURES: Donor morbidity and graft function in the laparoscopic group were compared with those in the open group. RESULTS: Laparoscopic live donor nephrectomy was completed in 99 patients. One patient required conversion to open donor nephrectomy because of intraoperative hemorrhage. Minor complications occurred in 6 laparoscopic group donors (6%) and 3 open group donors (6%). Laparoscopic and open group donors were of similar age. Operative times were longer for laparoscopic group donors (231 vs 209 minutes). Mean hospital stay was shorter for laparoscopic group donors (3.3 vs 4.7 days). Graft function was comparable between the laparoscopic and open groups, with equivalent postoperative creatinine levels. Graft survival was comparable. Recipient ureteral complications occurred with less frequency (2% vs 6%) in the laparoscopic group. CONCLUSIONS: By forming an operative team that combines expertise in laparoscopy with expertise in live donor nephrectomy, surgeons can learn LLDN safely. Adoption of the techniques developed by those who pioneered the procedure can further minimize the morbidity associated with a learning curve.

Adult↗

PubMed1980

Wound infections after transplant nephrectomy.

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.

Cefazolin↗

PubMed1983

Selective posttransplantation bilateral native nephrectomy. Indications and results.

Twenty-five patients underwent bilateral native nephrectomy one to 68 months (mean, 15.6 months) following renal transplantation. The indications were erythrocytosis in two patients, recurrent urinary tract infection in three, medically uncontrolled hypertension in 18, and hypertension and urinary tract infection in two. One patient died two months after the nephrectomy, and one allograft was lost because of acute tubular necrosis. Both patients with erythrocytosis had prompt return of the hematocrit level and RBC mass to normal. Native nephrectomy eradicated the infection in each of the five patients with recurrent urinary tract infections. Results of nephrectomy for hypertension were classified as excellent in six patients, good in nine, and poor in four. Native renal-vein renin ratios of patients with excellent or good responses were not statistically different when compared with those of poor responders.

Adult↗

PubMed1991

Bilateral nephrectomy before transplantation: indications, surgical approach, morbidity and mortality.

Forty patients with end-stage renal failure, who had undergone simultaneous bilateral native nephrectomy before a subsequent renal transplant operation, were reviewed with particular reference to the indications and surgical approach for bilateral nephrectomy and to the complications of the procedure. The main indications for bilateral nephrectomy are hypertension resistant to medical therapy, persistent symptomatic renal infection, severe renal protein loss and occasionally polycystic kidneys or bilateral renal tumours. In this consecutive series of 40 patients both kidneys were removed because of chronic pyelonephritis with reflux (n = 28), glomerulonephritis with reflux (n = 9) and uncontrolled hypertension (n = 3). Surgical morbidity was less in patients who had bilateral nephrectomy performed through bilateral vertical lumbotomy incisions. There was no surgical mortality.

Bacterial Infections↗

PubMed2003

Prediction of progression after radical nephrectomy for patients with clear cell renal cell carcinoma: a stratification tool for prospective clinical trials.

BACKGROUND: The objective of the current study was to develop an algorithm to predict progression to metastases after radical nephrectomy for patients with clinically localized renal cell carcinoma (RCC) to allow stratification of patients for potential adjuvant therapy trials. METHODS: The authors identified 1671 sporadic patients with clinically localized, unilateral clear cell RCC who underwent radical nephrectomy between 1970 and 2000. The clinical features examined included age, gender, smoking history, recent onset hypertension, performance status, and presenting symptoms. The pathologic features examined included surgical margins, tumor stage, regional lymph node status, tumor size, nuclear grade, histologic tumor necrosis, sarcomatoid component, cystic architecture, and multifocality. Metastases free survival was estimated using the Kaplan-Meier method. A multivariate Cox proportional hazards regression model was fit to determine associations between the clinical and pathologic features and distant metastases. RESULTS: The median follow-up was 5.4 years (range, 0-31 years). Metastases occurred in 479 patients at a median of 1.3 years (range, 0-25 years) after nephrectomy. The estimated metastases free survival rates were 86.9% at 1 year, 77.8% at 3 years, 74.1% at 5 years, 70.8% at 7 years, and 67.1% at 10 years. Multivariate analysis showed that the following features were associated with progression to metastases: tumor stage, regional lymph node status, tumor size, nuclear grade, and histologic tumor necrosis (P < 0.001 for all). CONCLUSIONS: In patients with clear cell RCC, tumor stage, regional lymph node status, tumor size, nuclear grade, and histologic tumor necrosis showed statistically significant associations with progression to metastatic RCC. The authors present a scoring algorithm based on these features that can be used to predict disease progression after patients undergo radical nephrectomy for clinically localized clear cell RCC. Cancer 2003;97:1663-71.

Adenocarcinoma, Clear Cell↗

PubMed2003

Scoring algorithm to predict survival after nephrectomy and immunotherapy in patients with metastatic renal cell carcinoma: a stratification tool for prospective clinical trials.

BACKGROUND: The objective of this study was to develop an algorithm capable of stratifying the survival of patients with metastatic renal cell carcinoma (RCC) after nephrectomy and immunotherapy. METHODS: The medical records of 173 patients who underwent radical nephrectomy for metastatic RCC and received recombinant interleukin-2 (IL-2)-based immunotherapy between 1989 and 2000 were evaluated. Survival was the primary endpoint and was assessed based on clinical, surgical, and pathologic parameters. The clinical parameters included age, gender, performance status, existing hypertension, thyroid-stimulating hormone (TSH) levels, location of metastases, and presenting symptomatology. The surgical features included the requirement for blood transfusion or adrenalectomy. The pathologic factors involved tumor stage, tumor size, nuclear grade, lymph node status, and histologic subtype. Disease-specific survival was estimated using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards models were used to determine associations between clinical and pathologic features and survival. RESULTS: The median follow-up was 3.2 years (range, 0.2-9.3 years). Death due to RCC occurred in 123 patients (71%) at a median of 13 months (range, from 0.1 months to 8.4 years) after nephrectomy. Multivariate analysis revealed that the following features were associated with survival: lymph node status (P = 0.002), constitutional symptoms (P = 0.005), location of metastases (P < 0.001), sarcomatoid histology (P = 0.003), and TSH level (P = 0.038). A scoring system based on the features in the multivariate model was created to stratify patients into low-risk, intermediate-risk, and high-risk groups. Estimated survival rates at 1 years, 3 years, and 5 years were 92%, 61%, and 41%, respectively, for the low-risk group and 66%, 31%, and 19%, respectively, for the intermediate risk group. The high-risk group had 1% survival at 1 year and no survivors at 3 years. CONCLUSIONS: In patients with metastatic RCC who were treated with nephrectomy and IL-2 immunotherapy, regional lymph node status, constitutional symptoms, location of metastases, sarcomatoid histology, and TSH levels were associated with survival. The authors present a scoring algorithm based on these features that can be used to predict survival in patients who present with metastatic RCC and to stratify such patients for prospective clinical trials.

Adult↗

PubMed1995

Comparison of nephrectomy and/or doxorubicin treatment in rabbit renal VX-2 carcinoma.

To compare survival after local intra-arterial and intravenous administration of doxorubicin, VX-2 carcinoma was implanted in one kidney of 48 rabbits. Treatments were given 9-14 days after tumor implantation. Survival after doxorubicin was significantly longer than the controls, whereas no difference was established between intra-arterial or intravenous treatment. Overall only 9 of 32 doxorubicin-treated rabbits were cured at autopsy after 18 months. It was assumed that circulating tumor cells from tumor implantation resulted in "primary" lung metastases. To kill circulating tumor cells intravenous doxorubicin was given immediately before implantation in 40 rabbits, followed by combinations of nephrectomy and doxorubicin. Doxorubicin without nephrectomy cured 8 of 16 rabbits, whereas doxorubicin combined with nephrectomy cured 4 of 16. Doxorubicin improved survival in responders, but likelihood of response was limited. Nephrectomy did not improve survival, most likely due to metastatic seeding at implantation. Intravenous doxorubicin immediately before did not prevent metastatic spread in connection with tumor implantation.

Animals↗

PubMed1985

Preliminary study of the Nd:YAG laser in canine partial nephrectomy.

Partial nephrectomy is effective in the treatment of segmental renal disease but hemostasis remains a challenge. In this preliminary investigation the Nd:YAG laser was used alone or as an adjunct to the scalpel in partial nephrectomies to determine if hemostasis could be improved. A technique of 100-W laser transection with occlusion of the renal artery was effective for partial nephrectomy and achieved complete hemostasis. Conditions of patent renal artery flow or renal cooling were associated with a reduction in necrosis depth with 100-W laser partial nephrectomies. All techniques were compatible with survival over the 5-day study period.

Animals↗

PubMed1988

Electrophysiology of rat distal colon after partial nephrectomy. Implications for K transport.

Previous in vivo studies in rat and man indicate that chronic renal insufficiency leads to an increase in the capacity of the large intestine for K secretion. The present studies were performed in isolated rat distal colon with conventional and K-sensitive microelectrodes to determine the cellular basis for enhanced colonic K secretion after 70% nephrectomy. The data revealed that in animals fed a regular diet, nephrectomy had no effect on the Na or K conductance of the apical membrane, or the kinetics of the basolateral membrane Na-K pump, but intracellular K activity decreased from 70 +/- 4 mmol/l to 58 +/- 4 mmol/l (P less than 0.005). In control (non-nephrectomised) animals, feeding a diet modestly (4-fold) enriched with K resulted in small but significant increases in the Na and K conductance of the apical membrane, no change in the kinetics of the basolateral membrane Na-K pump, and a rise in intracellular K activity from 70 +/- 4 mmol/l to 94 +/- 7 mmol/l (P less than 0.005). In contrast, in animals fed the K enriched diet, nephrectomy resulted in (i) large, amiloride-sensitive increases in transepithelial voltage and total tissue conductance (consistent with an appreciable degree of secondary hyperaldosteronism), (ii) marked increases in the Na and K conductance of the apical membrane, (iii) significant hyperpolarization of the basolateral membrane, (iv) a 100% increase (P less than 0.02) in the maximum activity of the basolateral membrane Na-K pump, and (v) a rise in intracellular K activity from 94 +/- 7 mmol/l to 129 +/- 7 mmol/l (P less than 0.0025). These data suggest that the combination of modest dietary K enrichment and 70% nephrectomy stimulated an active K secretory process which reflected an increase in the K excretory load applied to the colonic mucosa, and the effects of aldosterone. In this model of renal insufficiency, enhanced K secretion by the transcellular and paracellular (potential-dependent) pathways results in a marked rise in the K excretory capacity of the colon.

Animals↗

PubMed1989

Management of Finnish congenital nephrotic syndrome by unilateral nephrectomy.

Finnish congenital nephrotic syndrome is fatal unless managed aggressively; treatment in hospital with albumin infusions and subsequent bilateral nephrectomy allows survival. However, it consistently results in protein malnutrition which may lead to serious infections and severe physical and developmental retardation, as well as the subsequent burden of dialysing an anephric child. We treated a boy by unilateral nephrectomy at 3 months. The reduced protein loss allowed home management with albumin infusions and resulted in a substantial rise in his plasma IgG levels. The glomerular filtration rate declined fairly rapidly after unilateral nephrectomy, so he needed peritoneal dialysis by 16 months, which was straightforward as he still maintained a good urine output. Management by unilateral nephrectomy has allowed this boy to grow and develop normally. The time spent in hospital was minimal and the very high cost of providing albumin preparations was reduced considerably.

Albumins↗

PubMed1993

Protein and lipid metabolism in nephrotic infants on peritoneal dialysis after nephrectomy.

Congenital nephrotic syndrome of the Finnish type (CNF) is associated with protein deficiency despite substantial protein supplementation in the nephrotic state before nephrectomy. Different protein intakes (2.5 vs. 3.7 g/kg per day) in hypoproteinaemic children on continuous cycling peritoneal dialysis (CCPD) were studied. Lipids were also measured to determine whether severe atherogenic abnormalities seen during nephrosis improved after nephrectomy. Growth was normal or became normal with both protein intakes. Serum pre-albumin and transferrin concentrations became normal. Total protein (57 +/- 3.0 vs. reference limits 60-75 g/l) and albumin (28 +/- 5.0 vs. reference limits 30-50 g/l) concentrations improved but remained below normal, even with the higher protein intake. Muscle mass determined by measuring femoral quadriceps muscle thickness using ultrasound was markedly reduced in all patients at nephrectomy. It improved (P < 0.05) in all but 2 patients who had several bacterial infections, but reached normal level in only 3 patients within 6 months. Plasma total, very low-density lipoprotein (VLDL) and low-density lipoprotein (LDL) triglyceride concentrations decreased (P < 0.05, P < 0.05 and P < 0.01, respectively) and VLDL, LDL and high-density lipoprotein (HDL) particles contained less triglyceride than in the nephrotic state. HDL cholesterol concentrations increased by 28% [0.58 +/- 0.22 mmol/l during nephrosis, 0.81 +/- 0.21 mmol/l on CCPD after nephrectomy (P < 0.05)] but remained below the level of 1.38 +/- 0.75 mmol/l in normal controls (P < 0.001). If compared with controls there were still significant abnormalities in lipoprotein concentrations on CCPD.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Proteins↗

PubMed2003

[Improvement of hemostasis in laparoscopic and open partial nephrectomy with gelatin thrombin matrix (FloSeal)].

Long-term follow-up studies have demonstrated that effective local tumor control and long-term tumor-free progression rates can be achieved by nephron-sparing surgery. However, hemostasis is a major issue and the lack of effective means of hemostasis has limited a wider use of the laparoscopic approach to nephron-sparing surgery. Between January 2001 and August 2002, a total of 36 patients with renal cell carcinomas were treated by partial nephrectomies using a two-component tissue sealant (FloSeal). The median age was 55.2 years (range: 34-71 years). Follow-up time was 1-18 months (median: 5.5 months). The tumor diameter ranged from 2 to 5 cm (median: 2.9 cm). Open retroperitoneal surgery was performed in 17 cases and laparoscopic partial nephrectomy in 19 cases. The two-component tissue sealant (consisting of a gelatin matrix with granular and thrombin components) was applied after resection of the tumor and before perfusion of the kidney. The following parameters were recorded: (1) time until complete hemostasis was achieved, (2) decrease in postoperative hemoglobin level, (3) postoperative bleeding, and (4) presence or absence of a perirenal hematoma 24 h and 10 days postoperatively by ultrasound. After application of the tissue sealant for 1-2 min to the moist resection site, hemostasis was immediate in all cases. During the laparoscopic partial nephrectomies, a laparoscopic applicator was used that avoided wasting the tissue sealant within the dead space of the instrument. When reperfusion of the kidney was established, hemostasis was maintained. The decrease in postoperative hemoglobin level ranged from 0.3 to 1.2 points (median: 0.8 points). None of the patients required blood transfusions. There were no cases of postoperative bleeding. An ultrasound examination 24 h and 10 days postoperatively demonstrated the absence of a significant perirenal hematoma. The two-component tissue sealant FloSeal provided immediate and durable hemostasis in open and laparoscopic partial nephrectomies. The tissue sealant may provide a tool to expand the possibilities of laparoscopic nephron-sparing surgery.

Adult↗