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At least 631 records · Page 35Linked to original sources

PubMed2001

Retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys: a single-center experience.

OBJECTIVES: To report our experience of 185 cases of retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys with various modified techniques for differing etiologies. The feasibility, complications, and long-term outcomes are discussed. METHODS: The present study comprised 185 patients who underwent retroperitoneoscopic nephrectomy or nephroureterectomy during a 57-month period beginning July 1995. All procedures were done using the retroperitoneoscopic approach. Thirty-two patients had a history of previous surgery, 20 patients had a percutaneous nephrostomy, and 12 patients had mild renal impairment. RESULTS: Retroperitoneoscopic nephrectomy and nephroureterectomy were completed successfully in 167 patients. Eighteen patients required conversion to open surgery, 4 on an emergent basis and 14 electively. The mean operating time was 100 minutes (range 45 to 240), mean blood loss was 133 mL (range 30 to 1200), and mean hospital stay was 3 days (range 2 to 8). A total of 37 complications (16.2% were minor and 3.78% were major) occurred. Re-intervention was needed in 1 patient. No mortality resulted. Previous surgery, percutaneous nephrostomy, and chronic renal impairment did not affect the outcome. Apart from one incisional hernia, no long-term complications occurred. CONCLUSIONS: Retroperitoneoscopic nephrectomy and nephroureterectomy can be performed safely and successfully with obvious advantages for benign nonfunctioning kidneys regardless of the etiology or pathogenesis, with modifications in the approach in very difficult cases. Patients with conditions often considered to be contraindications (ie, genitourinary tuberculosis, pyonephrosis, history of previous surgery, percutaneous nephrostomy, stone disease, chronic renal failure, and horseshoe kidney) can also be successfully treated by skillful dissection and modifications in the surgical technique.

Adolescent↗

PubMed2001

Transperitoneal laparoscopic nephrectomy for giant polycystic kidneys: a case control study.

OBJECTIVES: To describe the technique and compare the surgical outcomes of patients with autosomal dominant polycystic kidney disease (ADPKD) undergoing laparoscopic or open nephrectomy for giant kidneys. METHODS: The surgical outcome of our first 10 consecutive patients with ADPKD who underwent laparoscopic nephrectomy was analyzed from a large prospective computer database. The results were compared with the 10 most recent open nephrectomy procedures performed for ADPKD at the same institution. To facilitate safe laparoscopic hilar dissection, the kidneys were made manageable by volume reduction, accomplished through diligent cyst puncture and aspiration using a novel prototype suction device with a beveled tip. RESULTS: No statistically significant differences were found between the laparoscopic and open surgical groups relative to patient sex, age, or median preoperative kidney size (24.0 versus 21.5 cm, respectively). The laparoscopic patients were significantly heavier than their open counterparts (94 versus 78 kg, P = 0.0095) and had a longer operative time (247 versus 205 minutes, P = 0.04). One conversion to open surgery occurred in the laparoscopic group because cysts were adherent to the spleen and colonic mesentery. No intraoperative complications or deaths occurred in either group and the postoperative complications were similar. The mean length of the postoperative hospitalization was markedly reduced with the laparoscopic compared with the open approach (2.6 versus 6.6 days, P = 0.00002). At a median of 12 months after surgery, none of the laparoscopic patients had recurrent pain, bleeding, or infection. CONCLUSIONS: Laparoscopic nephrectomy is technically safe and feasible in patients with ADPKD. Progressive cyst aspiration is a critical step, facilitating the identification of vital structures and the creation of enough abdominal cavity space to operate. The advantages of this minimally invasive technique include a short hospital stay, minimal pain, low morbidity, and superior cosmesis.

Adult↗

PubMed2001

Radiographic versus pathologic size of renal tumors: implications for partial nephrectomy.

OBJECTIVES: To compare the radiographic size with the pathologic size of renal tumors to determine whether these two measurements vary significantly and to evaluate whether any differences in tumor size could have an impact on the decisions regarding partial nephrectomy. METHODS: In 87 renal tumors excised by partial nephrectomy, the maximum transaxial tumor size on computed tomography (CT) was compared with its corresponding pathologic transverse size. Tumors were locally excised after vascular occlusion and hypothermia. The average size of the tumors selected for partial nephrectomy by preoperative CT scan was 3.4 cm (range 1.9 to 9.3). The difference between the CT size and pathologic size was correlated with the histologic type of the renal tumors. RESULTS: Of the 87 tumors, 52 (60%) were classified as clear cell carcinoma and 35 (40%) as other histologic types (papillary, chromophobe, oncocytoma, and angiomyolipoma). Clear cell carcinomas decreased an average of 0.97 cm versus 0.39 cm for the other tumor types. Of 62 tumors greater than 3 cm on CT, 43 averaged 0.87 cm smaller at pathologic evaluation (36 clear cell and 7 other types) and 19 showed no significant (less than 0.5 cm) decrease in size (2 clear cell and 17 other histologic types). Of 30 tumors greater than 4 cm on CT, 22 clear cell carcinomas shrank more than 1 cm and 8 tumors displaying other histologic features showed no decrease in size. CONCLUSIONS: For renal tumors measuring greater than 4 cm, a decrease in tumor size may help facilitate partial nephrectomy, especially for clear cell carcinomas that do not extensively involve major vascular structures or the collecting system.

Adenocarcinoma, Clear Cell↗

PubMed2001

Use of hydro-jet cutting for laparoscopic partial nephrectomy in a porcine model.

OBJECTIVES: To evaluate whether a laparoscopic hydro-jet device can provide a safe and effective partial nephrectomy. Partial nephrectomy is still one of the most challenging operations in urologic laparoscopy. The control of hemorrhage is very difficult to achieve with laparoscopic techniques. In open surgery, hydro-jet resection is used to cut the renal parenchyma selectively, avoiding damage to the vascular structures or collecting system.Methods. Laparoscopic wedge, as well as pole, resections of the kidney were performed in 5 pigs under general anesthesia. After exposure of the kidney, the renal capsule was incised using electrocautery. The hydro-jet was then used to dissect the renal parenchyma. In pole resections, the collecting system and central vessels were divided using an Endo-GIA. Hemostasis was achieved by electrocoagulation or clips. The dissection time and intraoperative complications were evaluated.Results. The operations were performed successfully in all animals without temporary ischemia. The hydro-jet generator allowed precise and effective tissue dissection without significant hemorrhage. The parenchymal vessels were selectively coagulated. The collecting system and central vessels remained intact and could be divided after application of the Endo-GIA. The mean dissection time was 42 +/- 6 minutes for the wedge resections and 54 +/- 8 minutes for the pole resections. CONCLUSIONS: These experimental results demonstrate the suitability of hydro-jet dissection for safe laparoscopic partial nephrectomy without temporary ischemia and with reduction of the operative trauma to the kidney. On the basis of our own experiences with other techniques, including electrocautery and laser technology for partial nephrectomy, we conclude that laparoscopic hydro-jet resection represents an interesting alternative to other techniques.

Animals↗

PubMed2002

Laparoscopic donor nephrectomy in the elderly patient.

OBJECTIVES: To evaluate retrospectively the outcome of laparoscopic donor nephrectomy in patients aged 65 years or older, because data regarding tolerance profile and renal allograft outcome of laparoscopic donor nephrectomy in the elderly patient are lacking. METHODS: Since February 1995, 6 patients aged 65 years or older underwent laparoscopic donor nephrectomy for living-related renal transplantation. Patient demographic, intraoperative, and postoperative parameters, as well as renal allograft outcome, were evaluated. RESULTS: The median donor age was 69.5 years (range 65 to 74), and the median American Society of Anesthesiologists score was 2 (range 2 to 3). The median operative time was 240 minutes (range 183 to 298), with a median blood loss of 300 mL (range 150 to 400). No intraoperative complications or open conversions occurred. Postoperatively, the median time to resumption of oral intake was 1 day (range 1 to 3), and the median hospital stay was 3 days (range 2 to 4). The median narcotic analgesic requirement was 17 mg (range 11 to 27) morphine sulfate equivalent, and the median convalescence was 2 weeks (range 1 to 4). The 1-year renal allograft survival was 100% (n = 6). CONCLUSIONS: Laparoscopic donor nephrectomy is well tolerated by the elderly patient and provides satisfactory patient and renal allograft outcome. Although our sample size was small, it appears that laparoscopy is an acceptable modality for renal donation in the elderly population.

Adult↗

PubMed2002

Renovascular complications of laparoscopic donor nephrectomy.

OBJECTIVES: To review the operative renovascular injuries related to our laparoscopic donor nephrectomy experience, since management of intraoperative renovascular complications during laparoscopic nephrectomy can present a serious challenge. METHODS: During a 6-year period, 353 patients underwent laparoscopic donor nephrectomy. A retrospective chart review was performed to identify and evaluate the renovascular complications associated with the procedure. RESULTS: Eight cases (2.3%) of renovascular complications were identified. Vascular injury involved the renal artery in 6 cases and the renal vein in 2 cases. The etiologies included endovascular GIA stapling failure (n = 2), surgical clip dislodgment (n = 2), and vessel laceration during dissection or stapling (n = 4). Open conversion was necessary in 6 cases (75%). No patient mortality or allograft loss occurred. CONCLUSIONS: Laparoscopic donor nephrectomy is associated with a low incidence of renovascular complications. Laparoscopic or open surgical management may be required when problems arise to optimize donor safety and allograft survival.

Female↗

PubMed2002

Novel modification of partial nephrectomy technique using porcine small intestine submucosa.

INTRODUCTION: To describe a novel partial nephrectomy technique that uses small intestine submucosa (SIS) to ensure a watertight closure of the collecting system and minimize parenchymal bleeding. The indications for nephron-sparing surgery have increased in recent years. The most prevalent complications after partial nephrectomy include urinary leakage/fistula and parenchymal bleeding. Porcine SIS has been used in animal models to reconstruct portions of the urinary tract successfully. TECHNICAL CONSIDERATIONS: Twenty-two consecutive patients underwent 24 partial nephrectomies that required entry into the collecting system for presumed renal cell carcinoma. After temporary occlusion of the renal vessels and renal hypothermia, the tumor and a margin of normal parenchyma were excised. The cut surface was cauterized with an argon beam coagulator, and visible vessels were suture ligated. The collecting system was reapproximated with interrupted, absorbable sutures. A multilayer piece of hydrated SIS was sutured in place over the exposed collecting system and parenchymal defect with several figure-of-eight chromic sutures. With a mean follow-up of 18.4 months, none of the 22 patients experienced postoperative urinary leaks/fistulas or postoperative hemorrhage requiring transfusion. The serum creatinine returned to within 0.2 mg/dL of baseline in all patients after surgery. CONCLUSIONS: We describe a novel technique of partial nephrectomy using SIS, which, we believe, aids in closure of the collecting system and decreases parenchymal bleeding.

Adult↗

PubMed2003

Pretransplant native nephrectomy in patients with end-stage renal failure: assessment of the role of laparoscopy.

OBJECTIVES: To evaluate the outcome and morbidity of laparoscopic nephrectomy in patients with end-stage renal disease. METHODS: Between August 1991 and September 2001, 64 laparoscopic nephrectomies were carried out for the native kidneys of 62 patients with end-stage renal failure. The procedures were performed in preparation for renal transplantation. The indications were vesicoureteral reflux with persistent or recurrent urinary tract infection in 26 renal units, uncontrolled hypertension in 15, chronic pyelonephritis or hydronephrosis with urinary tract infection in 8, renal calculi in 13, heavy proteinuria in 1, and small renal tumor in 1. The left side was removed in 52 procedures and the right side was removed in 12. Forty-eight and 16 renal units were removed through the retroperitoneal and transperitoneal approach, respectively. RESULTS: Sixty procedures were successfully performed (94%). Four patients required open exploration (6%). Four major complications were recorded: pneumothorax in 1, large hematoma in 1, colonic injury in 1, and bleeding in 1. No mortality related to the procedures or their complications occurred. The patients received allograft transplantation shortly after the procedure, with a mean of 26 days. Both transperitoneal and retroperitoneal approaches were effectively used with satisfactory outcome. CONCLUSIONS: Laparoscopy should be considered as the procedure of choice for pretransplant nephrectomy. The high success rate, low morbidity, early recovery, and short duration between nephrectomy and transplantation all are considered as real advantages for this patient population.

Adolescent↗

PubMed2003

Laparoscopic radical nephrectomy for suspected renal cell carcinoma in dialysis-dependent patients.

OBJECTIVES: To characterize the treatment and outcomes of laparoscopic nephrectomy for suspected renal cancer in patients with dialysis-dependent renal failure. Laparoscopic nephrectomy is currently an accepted modality in the treatment of renal cell carcinoma in many patients. However, the indications for the minimally invasive approach in patients with renal dysfunction are unclear. End-stage renal disease has multiple manifestations associated with increased operative morbidity that are potentially amplified during laparoscopy. METHODS: We reviewed our single-center experience for performing laparoscopic nephrectomy in patients with renal failure. Of patients receiving dialysis and having a kidney removed laparoscopically, 7 underwent the operation for suspected renal carcinoma because of a solid mass on imaging. The preoperative, intraoperative, and postoperative considerations were reviewed. RESULTS: Of the 7 patients, 5 (71%) underwent successful removal of the kidney by laparoscopy. The amount of blood loss (120 mL) and the median time to discharge after surgery (3 days) were comparable to published data and our experience in patients with normal renal function; however, the operative time (mean 294 minutes) was longer. No recurrences had been detected at the last follow-up examination (median 21 months, range 18 to 51). Despite meticulous attention to perioperative and anesthetic considerations, two complications were observed-ileus and necrotizing fasciitis of the flank. CONCLUSIONS: Pure laparoscopic nephrectomy for renal malignancy is feasible in patients with end-stage renal failure. However, this population is at increased risk of complications, despite maintaining the advantages of reduced blood loss and shorter hospitalization. The decision to proceed with laparoscopy and the selection of the specific surgical approach (transperitoneal or retroperitoneal) should be based on both surgeon experience and patient factors. In addition, careful preoperative preparation and intraoperative anesthetic management are crucial.

Adult↗

PubMed2003

Nephrectomy for metastatic renal cell carcinoma: Indiana University experience.

OBJECTIVES: To report on the short-term morbidity of radical nephrectomy in 32 patients with poorer performance status and more advanced primary renal cell carcinoma (RCC). Nephrectomy followed by immunotherapy has been shown to improve survival in selected, good performance status patients with metastatic RCC. METHODS: We report on 32 patients who underwent radical nephrectomy (20 open procedures and 12 laparoscopic) in the setting of metastatic RCC at Indiana University between 1999 and 2002. The study group included patients with advanced primary tumors (inferior vena cava involvement, large size, and involvement of adjacent structures). The patients' performance status score ranged from 0 to 2. RESULTS: The average hospital stay was 5.1 days. No significant intraoperative complications were encountered, and postoperative complications occurred in 6 patients, including one perioperative death. At 4 weeks postoperatively, 21 (72.4%) of 29 assessable patients had a performance status equal to, or better than, their preoperative status, including 4 patients who converted from a preoperative performance status of 2 to 0 or 1 postoperatively. Eleven patients (34.4%) went on to receive postoperative immunotherapy. CONCLUSIONS: The results of our study demonstrated that radical nephrectomy in the setting of metastatic RCC has a low morbidity and acceptable recovery in these patients with advanced primary tumors and poorer performance status.

Adult↗

PubMed2003

Quality of life after surgery for localized renal cell carcinoma: comparison between radical nephrectomy and nephron-sparing surgery.

OBJECTIVES: To compare the impact of radical nephrectomy and nephron-sparing surgery (NSS) for localized renal cell carcinoma on quality of life (QOL). METHODS: Retrospectively, 357 patients who had undergone NSS (n = 158) or radical nephrectomy (n = 199) for localized renal cell carcinoma completed postal questionnaires, including measures of QOL with validated instruments (SF-36, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 [EORTC QLQ-C30]), the impact of the stress of cancer, fear of recurrence, and worry about having fewer than two normal kidneys. A subset of 51 patients diagnosed after 2000 were followed up prospectively for at least 1 year. RESULTS: The mental and physical health composite scores were not significantly different from the validated norms for an age and sex-matched community sample. Although the type of operation had no influence on patients' overall QOL, all patients who underwent elective NSS showed a significantly greater score on physical function than patients treated with radical nephrectomy (P <0.001). Predictors for higher scores included elective NSS, comorbidity (assessed with standardized checklist), tumor size, and time since nephrectomy. The overall QOL scores and recovery of stress from cancer in patients treated with NSS for tumor less than 4 cm with a normal contralateral kidney were significantly superior to those who underwent NSS for tumor greater than 4 cm (P <0.05). Patients questioned after mandatory NSS were significantly more concerned about cancer recurrence. CONCLUSIONS: Patients without evidence of disease have relatively normal physical and mental health after operative treatment for localized renal cell carcinoma, independent of the kind of surgery. The QOL correlates proportionally with the size of tumor and is significantly better for patients undergoing NSS for tumor less than 4 cm with a normal contralateral kidney.

Aged↗

PubMed2003

Bipolar needle electrocautery for laparoscopic partial nephrectomy without renal vascular occlusion in a porcine model.

OBJECTIVES: To report a novel method of accomplishing laparoscopic lower pole partial nephrectomy in an acute porcine model using a bipolar needle electrode without the need for renal arterial occlusion. METHODS: Six animals (12 renal units) underwent laparoscopic polar nephrectomy using the bipolar needle electrode. After complete laparoscopic mobilization of the lower pole of the kidney, the bipolar needle electrode was repeatedly inserted full-thickness into the renal parenchyma and applied transversely, creating regional ischemia to the entire lower pole without renal vascular occlusion. The specimen was then amputated using laparoscopic scissors. RESULTS: For the 12 laparoscopic partial nephrectomies, the mean operative time was 39 +/- 30 minutes, and the mean blood loss was 90 +/- 112 mL. Of the 12 cases, 10 (83%) were performed successfully with the bipolar needle electrocautery as the only source of hemostasis and without the need for ancillary hemostatic measures. Two of the procedures (17%) required temporary arterial control for hemostasis. For the successful procedures, the mean operative time was 29 +/- 4 minutes, and the mean blood loss was 48 +/- 11 mL. Histologic analysis of the specimens demonstrated coagulative necrosis between 2 and 4 mm from the line of the surgical incision. CONCLUSIONS: Bipolar needle electrocautery is a promising device that can be used to facilitate laparoscopic partial nephrectomy with minimal blood loss and without the need for renal arterial occlusion and warm ischemia. Additional studies are required to optimize the delivery parameters of this device.

Animals↗

PubMed1996

Simultaneous radical nephrectomy and repair of abdominal aortic aneurysm.

OBJECTIVES: The combination of abdominal aortic aneurysm repair with other intra-abdominal surgery is controversial. Most studies have shown that a variety of procedures can be performed at the same time as an aneurysm repair with little change in mortality or complication rates. We conducted a retrospective study to determine if aneurysm repair could be safely and effectively combined with radical nephrectomy. METHODS: We studied 10 patients who underwent combined abdominal aortic aneurysm repair and radical nephrectomy during a 4-year period. Results from this group were compared to a separate control group of 10 patients who underwent radical nephrectomy alone and another of 12 patients underwent abdominal aortic aneurysm repair alone, during the same time period. RESULTS: The overall mortality was 10% and significant complications occurred in an additional 10% of patients. Minor, self-limiting complications occurred in 30% of patients. There were no aortic graft infections that occurred in the entire series of patients at 18 months of mean follow-up. There were no remarkable differences in the entire series of patients and the combined values in a separate group of control patients who had undergone either procedure alone. CONCLUSIONS: Simultaneous radical nephrectomy for presumed renal cell carcinoma can be safely combined with repair of abdominal aortic aneurysm in selected patients.

Aged↗

PubMed1995

Reconsidering the necessity of ipsilateral adrenalectomy during radical nephrectomy for renal cell carcinoma.

OBJECTIVES: Ipsilateral adrenalectomy is traditionally advocated as part of radical nephrectomy performed for renal cell carcinoma. The current study addresses the controversy of whether ipsilateral adrenalectomy should be performed routinely during radical nephrectomy. METHODS: A total of 225 patients were treated surgically for renal cell carcinoma over an 18-year period. Of these patients, 158 underwent nephrectomy and simultaneous ipsilateral adrenalectomy and the other 67 had sparing of the ipsilateral adrenal gland. A retrospective analysis of the medical records and assessment of the clinical and the pathologic data were performed. Rates of survival and progression were evaluated in a subgroup of 109 patients, further subdivided into 54 patients who underwent concomitant adrenalectomy and 55 patients with the ipsilateral adrenal preserved during surgery. RESULTS: Histopathologic abnormalities were detected in seven adrenal specimens (4.4%); however, only 3 patients (1.9%) had involvement of the adrenal by renal cell carcinoma. All cases of adrenal involvement were detected by the preoperative imaging modalities. Ipsilateral adrenalectomy did not improve the outcome in comparison to adrenal preservation. CONCLUSIONS: In view of the rarity of ipsilateral adrenal metastasis, the questionable prognostic merits of concomitant adrenalectomy, and the availability of accurate imaging modalities, we conclude that ipsilateral adrenalectomy is not necessary in the majority of the patients undergoing radical nephrectomy for renal cell carcinoma.

Adenoma↗

PubMed2000

Laparoscopic radical nephrectomy for cancer.

Laparoscopic radical nephrectomy is a rapidly emerging technique for the treatment of renal cell carcinoma. Surgeons at multiple institutions have reported excellent technical results with this procedure, with encouraging safety and efficacy data and low complication rates comparable with the rates in open radical nephrectomy. Although debate continues regarding the pros and cons of the transperitoneal versus retroperitoneal approach and regarding morcellation versus intact specimen extraction, laparoscopic radical nephrectomy is beginning to approach standard-of-care status at select institutions for tumors less than 8 cm in size. Although generally accepted indications for laparoscopic radical nephrectomy include T1-T2N0M0 tumors, increasing experience and operator confidence have allowed expansion of these indications to include select patients with nodal disease, preoperatively staged level I renal vein thrombus, cytoreductive surgery before immunotherapy protocols, and the rare patient with a laterally directed locally invasive (pT4N0M0) renal cell carcinoma.

Carcinoma, Renal Cell↗

PubMed2004

Adjuvant autologous renal tumour cell vaccine and risk of tumour progression in patients with renal-cell carcinoma after radical nephrectomy: phase III, randomised controlled trial.

BACKGROUND: Organ-confined renal-cell carcinoma is associated with tumour progression in up to 50% of patients after radical nephrectomy. At present, no effective adjuvant treatment is established. We aimed to investigate the effect of an autologous renal tumour cell vaccine on risk of tumour progression in patients with stage pT2-3b pN0-3 M0 renal-cell carcinoma. METHODS: Between January, 1997, and September, 1998, 558 patients with a renal tumour scheduled for radical nephrectomy were enrolled at 55 institutions in Germany. Before surgery, all patients were centrally randomised to receive autologous renal tumour cell vaccine (six intradermal applications at 4-week intervals postoperatively; vaccine group) or no adjuvant treatment (control group). The primary endpoint of the trial was to reduce the risk of tumour progression, defined as progression or death. All patients were assessed after standardised diagnostic investigations at 6-month intervals for a minimum of 4.5 years. FINDINGS: By preoperative and postoperative inclusion criteria, 379 patients were assessable for the intention-to-treat analysis. At 5-year and 70-month follow-up, the hazard ratios for tumour progression were 1.58 (95% CI 1.05-2.37) and 1.59 (1.07-2.36), respectively, in favour of the vaccine group (p=0.0204, log-rank test). 5-year and 70-month progression-free survival rates were 77.4% and 72%, respectively, in the vaccine group and 67.8% and 59.3%, respectively, in the control group. The vaccine was well tolerated, with only 12 adverse events associated with the treatment. INTERPRETATION: Adjuvant treatment with autologous renal tumour cell vaccine in patients with renal-cell carcinoma after radical nephrectomy seems to be beneficial and can be considered in patients undergoing radical nephrectomy due to organ-confined renal-cell carcinoma of more than 2.5 cm in diameter.

Cancer Vaccines↗

PubMed1998

Bilateral nephrectomy: the best, but often overlooked, treatment for refractory hypertension in hemodialysis patients.

Bilateral nephrectomy for treatment of refractory hypertension in chronic hemodialyzed patients has been infrequently carried out. We analyzed the benefits of this operation on blood pressure, clinical state, drug treatment, and quality of life. In 10 hemodialyzed patients with refractory hypertension, systolic (SBP) and diastolic (DBP) blood pressure were measured 1 month before nephrectomy bilateral and 3, 6, 9, and 12 months after. In addition, the use of antihypertensive drugs before and after surgery was evaluated. Four patients had SBP and DBP values characteristic of malignant hypertension. In all 10 patients hypertension responded neither to reduction of plasma volume by ultrafiltration nor to multiple antihypertensive drug therapy. Hypertensive crises were associated with cerebral hemorrhage in two patients, severe encephalopathy with persistent neural dysfunction in one patient, and encephalopathy and diplopia in another. Three months after bilateral nephrectomy blood pressure decreased significantly (P < .005) and was normal in nine patients. In one noncompliant patient with intradialytic body weight increases of nearly 10%, blood pressure was still elevated. Malignant or drug-resistant hypertension with hypertensive crises is an indication for bilateral nephrectomy. The clinical state and quality of life improved in all patients in the present study and antihypertensive treatment is no longer necessary.

Adult↗

PubMed1998

Effects of split torso positioning and laparoscopic surgery for donor nephrectomy on respiratory mechanics.

STUDY OBJECTIVE: To test whether split torso positioning, abdominal insufflation, and other procedures performed during laparoscopic nephrectomy would affect mechanical impedances to inflation [i.e., elastance (E) and resistance (R) of the total respiratory system (Ers, and Rrs), lungs (EL and RL), and chest wall (Ecw and Rcw)] differently from previously studied laparoscopic procedures. DESIGN: Unblinded study, each patient serving as own control. SETTING: University hospital. PATIENTS: 12 ASA physical status I and II patients scheduled for laparoscopic donor nephrectomy, all without cardiopulmonary disease. INTERVENTIONS: Patients were anesthetized and paralyzed, tracheally intubated and mechanically ventilated at 10, 20, and 30 breaths/minute and at tidal volumes of 250, 500, and 800 ml. Measurements were made in the following positions: supine, split torso, abdominal insufflation (Pab = 15 mmHg), and supine after deflation. MEASUREMENTS AND MAIN RESULTS: Airway flow and pressure and esophageal pressure were measured. Discrete Fourier transformation was used to calculate E and R. These were analyzed with repeated measures, linear multiple regression with accepted level of significance at p < 0.05. Ers, Ecw, and Rcw increased (p < 0.05) while EL decreased (p < 0.05) when patients changed from supine to split torso. During Pab = 15 mmHg, Ers, Ecw, and Rcw increased further and Rrs and RL increased (p < 0.05). Following abdominal deflation, Ecw and Ers remained elevated (p < 0.05). The changes in Ecw caused by laparoscopy and surgery were greater than we have previously measured in other laparoscopic procedures, while the changes in EL were less. CONCLUSIONS: Laparoscopic nephrectomy affects lung and chest wall mechanical properties differently from other laparoscopic procedures. This finding could be due to the split torso positioning, and the effects of abdominal swelling on the chest wall caused by administration of more perioperative fluids with laparoscopic nephrectomy.

Adult↗