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PubMed2006

The indications for partial nephrectomy in the treatment of renal cell carcinoma.

Partial nephrectomy is performed more frequently for small, incidentally discovered, low-stage renal tumors. Importantly, one should distinguish the imperative indications for such surgery from the relative and elective indications, while taking contraindications to nephron-sparing surgery into account. The main advantage of partial nephrectomy over radical nephrectomy is the avoidance of renal insufficiency; the major disadvantages include the possibility of local recurrence and perioperative complications. In this article, the literature on nephron-sparing surgery was reviewed in order to put the management of renal cancer into a modern perspective.

Carcinoma, Renal Cell↗

PubMed1975

Urinary concentration and dilution after unilateral nephrectomy in the rat.

1. The effects of unilateral nephrectomy on urinary concentration and dilution were studied in Sprague-Dawley rats. To exclude incomplete suppression of antidiuretic hormone, free water formation was also sutdied in rats with congenital diabetes insipidus (Brattleboro strain). 2. Urinary solute-free water formation was similar in Sprague-Dawley and Brattleboro rats. Uninephrectomized animals excreted a water load promptly and diluted their urine to the same degree as control rats. Maximal values for Cwater and TCwater per kidney were higher after nephrectomy, but were similar to those of control rats at comparable rates of fluid delivery to the distal nephron. Renal tissue osmolaity was similar in uninephrectomized and sham-operated animals, indicating that nonantidiuretic hormone-dependent backflux of filtrate was the same in the two groups. The only defect observed in uninephrectomized animals was a small reduction in maximal urine osmolaity. 3. These results demonstrate that free water formation and reabsorption are unaffected by unilateral nephrectomy and suggest that, in the remaining kidney, filtrate reabsorption along the entire nephron increases in proportion to the increment in glomerular filtration.

Animals↗

PubMed1977

Effect of nephrectomy and enterectomy on plasma clearance of intravenously administered dipeptides in rats.

1. Sham-operated and bilaterally nephrectomized rats were injected intravenously with glycyl-L-leucine, glycylglycine and glycylsarcosine, and the concentrations of these dipeptides in plasma and muscle, liver, renal cortex (in the sham-operated rats) and intestinal mucosa at various intervals were determined. 2. Initially the plasma concentrations of glycyl-leucine and glycylglycine were higher in nephrectomized than in control rats but later the concentrations were similar in both groups of rats. The disappearance of these two dipeptides from plasma was almost complete within 20 min, and their plasma half-lives were not changed remarkably by nephrectomy. In contrast, nephrectomy markedly impaired disappearance of glycylsarcosine from plasma and prolonged its half-life from 7-6 min to 52-0 min. 3. Glycyl-leucine and glycylglycine were not detected in tissues of control rats injected with these dipeptides, but glycylsarcosine was recovered from all four tissues examined. Nephrectomy resulted in greater accumulations of glycylsarcosine in tissues and the appearance of glycylglycine in the remaining three tissues and glycyl-leucine in muscle. 4. Enterectomy did not have a remarkable effect on plasma half-life of glycylglycine but it allowed recovery of this dipeptide from renal cortex, liver and muscle. 5. It is concluded that kidneys amd small intestine are involved in the disposition of circulating dipeptides, but in their absence other tissues may assume a greater role in this regard. However, renal clearance appears to be an important route for the disposition of dipeptides which are poorly hydrolysed by body tissues.

Animals↗

PubMed1978

Role of persistent vascular renin after bilateral nephrectomy in Goldblatt-two kidney hypertension.

1. Aorta homogenate contains renin-like activity which on incubation generates angiotensin I over a wide pH range. 2. Rat aortic renin measured at an incubation pH of 6.5 rose and fell in parallel to plasma renin with salt depletion and salt-loading respectively. Renin little relationship with plasma renin. 3. Aortic renin (pH 6.5) was elevated in Goldblatt-two kidney hypertension and slowly fell for 24h after bilateral nephrectomy whereas the fall in plasma renin was complete by the first hour. Aortic renin (pH 5.3) was also high, but did not fall after bilateral nephrectomy. 4. Aortic renin (pH 6.5) is probably derived from plasma renin whereas renin measured at pH 5.3 is probably a tissue renin. 5. The prolonged half-life of aortic renin (pH 6.5) explains the observation that the renin-angiotensin system appears to be active in maintaining blood pressure for several hours after bilateral nephrectomy whereas the decline in plasma renin is rapid and does not continue significantly beyond 1 h.

Angiotensin I↗

PubMed1983

Effect of dietary protein restriction on the development of renal failure after subtotal nephrectomy in rats.

We have examined the effect of a low protein diet on the development of glomerular sclerosis and progressive renal failure after subtotal nephrectomies in rats. Two groups of male Sprague-Dawley rats were studied after five-sixths nephrectomy; group 1 were maintained on a normal diet (13.5 g day-1 kg-1 body weight) and group 2 were fed with a low protein diet (6 g day-1 kg-1 body weight). Rats maintained on a low protein diet survived for longer, and had significantly less glomerular sclerosis and significantly greater glomerular filtration rates when the experiment ended after 7 months. We conclude that dietary protein influences favourably the development of glomerular scarring and renal failure after subtotal nephrectomy in rats.

Animals↗

PubMed2001

Prediction of post-operative glomerular filtration rate after nephrectomy for renal malignancy.

The importance of a correct estimation of contralateral renal function in cases of renal malignancy is obvious, necessitating a conservative approach to tumour resection when function of the contralateral kidney is markedly reduced. The aim of the present study was to determine the accuracy of preoperative gamma camera renography and (51)Cr-EDTA clearance to predict the glomerular filtration rate (GFR) early and up to 6 months after nephrectomy for renal malignancy. Patients (n=40) underwent both gamma camera renography ((99m)TC-DTPA) and (51)Cr-EDTA clearance preoperatively, whereas (51)Cr-EDTA clearance was measured within 1 week and up to 6 months after nephrectomy. The single kidney GFR values of the contralateral kidneys were estimated preoperatively and then compared with the post-operative (51)Cr-EDTA clearance values. The predicted GFR values were lower compared with the measured post-operative (51)Cr-EDTA clearance values (45 +/- 2 vs. 54 +/- 3 ml min(-1) 1 week after nephrectomy and 53 +/- 3 ml min(-1) 6 months later, P<0.01, respectively). The difference between the measured and predicted GFR was larger in patients below the median age of 60 years (P<0.05) and confined to patients with a relative uptake of >30% by the tumour affected kidney. Prediction of post-operative GFR by non-invasive renal function tests performed prior to surgery for renal malignancy underestimate post-operative GFR when the function of the tumour affected kidney is preserved, indicating an adaptive GFR increase in these cases.

Aged↗

PubMed1999

Follow-up guidelines for nonmetastatic renal cell carcinoma based on the occurrence of metastases after radical nephrectomy.

OBJECTIVE: To define guidelines for the follow-up management of nonmetastatic renal cell carcinoma (RCC), by assessing tumour recurrences and the clinical course in patients who had undergone radical nephrectomy. PATIENTS AND METHODS: The records of 187 patients with pT1-3, N0-X, M0 RCC who underwent radical nephrectomy between 1982 and 1997 were reviewed prospectively. Clinicopathological variables were compared with the time of first recurrence, site of metastasis and reason for diagnosis. RESULTS: Metastases were diagnosed in 98 sites in 56 of the 187 patients (30%). The risk for developing metastases increased with stage; 80% of the patients had their metastases diagnosed within 3 years (median 14.5 months) after nephrectomy. The time to first diagnosis was longer for patients with pT1 tumours and for those with skeletal metastases. The cause-specific 5-year survival rate for pT1 tumours was 95%, for pT2 87% and for pT3 tumours 37%. All patients with diploid pT1-2 RCC survived, having a survival advantage over those with aneuploid pT1-2 tumours (P=0.018). Also, pT1-2 tumours of < 5 cm were associated with better survival rates. Among 74 patients with pT3 tumours, 45 got metastases; DNA ploidy in these tumours did not influence survival. Of 30 patients with lung metastases, 28 were diagnosed during follow-up, while 25 of 26 other metastatic sites were diagnosed because of symptoms. CONCLUSIONS: The risk for tumour progression depends mainly on stage; these results indicate no need for follow-up in patients with diploid pT1-2 tumours or with aneuploid pT1 tumours of < 5 cm. For patients with aneuploid pT1-2 tumours of > 5 cm and pT3 tumours, follow-up is indicated.

Adult↗

PubMed2000

Preoperative simulation of partial nephrectomy with three-dimensional computed tomography.

OBJECTIVE: To evaluate prospectively the accuracy of computer-aided three-dimensional (3D) volume-rendered computed tomography (CT) in determining the appropriate anatomical limits (tumour size, tumour location, multifocality and vascular supply) and as a potential tool in the preoperative simulation of nephron-sparing surgery (NSS) in patients with small-volume renal cell carcinoma (RCC). PATIENTS AND METHODS: The study included 36 patients who underwent transperitoneal radical nephrectomy for RCC of < 4 cm diameter. Helical CT was undertaken before surgery and the extent of the tumour, the course of major renal arteries and veins, and the relationship of the tumour to the collecting system were shown by 3D volume-rendered CT. The CT findings were compared with the pathological results of all kidney specimens, obtained using 3-mm step-sections. RESULTS: Before nephrectomy, 39 renal tumours were identified in the 36 patients; three renal lesions of < 4 mm were not detected. All main venous branches and 42 of 43 arteries were identified by 3D volume-rendered CT. Knowing these features, a partial nephrectomy was simulated; a surgical lesion to the pelvicalyceal or vascular system which would have been produced by the simulated surgery was displayed in colour on the simulated surface of the section. CONCLUSION: Computer simulation provided an excellent 3D reconstruction of all kidneys, including the tumour, vasculature and renal hilum, allowing a significantly better preoperative evaluation of the renal mass. Visualizing possible resection margins and predicting the operative risks seem to be major advantages of this new method, especially when preparing for complex surgery. Reconstructed 3D CT appears to be a useful tool for defining the indications for and limitations of NSS.

Adult↗

PubMed2003

Hand-assisted laparoscopic vs the open (flank incision) approach to radical nephrectomy.

OBJECTIVE: To compare the outcome in contemporaneous groups of patients undergoing hand-assisted laparoscopic radical nephrectomy (HALRN) or open (flank) radical nephrectomy (ORN), as many series worldwide have confirmed the feasibility and advantages of LRN in managing renal cell carcinoma (RCC). PATIENTS AND METHODS: We retrospectively evaluated 44 patients who underwent radical nephrectomy for RCC from 1999 to 2001, 22 by HALRN and 22 by ORN, through an extraperitoneal 11th or 12th rib flank incision. Standard perioperative variables were assessed; a validated questionnaire was also sent to each patient after surgery, allowing them to report their overall satisfaction and the period needed for them to return to both routine and full activities. The outcomes of HALRN and ORN were compared using Wilcoxon rank-sum analysis. RESULTS: There was a statistically significant difference between HALRN and ORN in operative duration, length of hospital stay, total narcotic requirement, pain scores at 1 week and 1 month after surgery, and the time to resume routine and full activity, with all variables (except operative duration) lower in the HALRN group. There were no significant differences between the groups in pain at 1-3 days, estimated blood loss or overall satisfaction. CONCLUSION: Compared with ORN, HALRN is associated with lower narcotic requirement, pain scores, a shorter hospital stay and earlier resumption of routine and full activities. However, several obstacles remain, including increased operative duration and the increased equipment costs.

Age Factors↗

PubMed2003

Hand-assisted laparoscopic radical nephrectomy-associated rhabdomyolysis with ARF.

Intraoperative rhabdomyolysis with resultant acute renal failure is a rare complication seen, most commonly, with urologic surgical procedures. Since the early 1990s, the refinement of laparoscopic techniques has permitted their application more broadly. Among the procedures to benefit from these less invasive surgical methods has been radical nephrectomy. In general, this has resulted in less postoperative pain and shorter convalescence. Nonetheless, laparoscopic radical nephrectomy still represents major surgery and is not free from operative risks. To highlight one of these risks, we present a case of a young, obese man with renal cell carcinoma who underwent a hand-assisted laparoscopic radical nephrectomy that was complicated by rhabdomyolsis resulting in acute renal failure (ARF). We discuss the clinical insults that contributed to the development of azotemia with particular attention paid to our current understanding of the pathogenesis of myoglobinuric ARF. In addition, we review the literature concerning surgery-associated, rhabdomyolytic ARF with the aim of providing clinicians guidance for the avoidance and early recognition of this rare, but very serious, surgical complication.

Acute Kidney Injury↗

PubMed1976

[Complications after thoraco-retroperitoneal nephrectomy (author's transl)].

We are of the opinion that for large kidney tumors in the upper region as the afflicted venous portions, the most advantageous incision is a thoraco-retro- peritoneal one. It allows the surgeon total freedom of movement and ensures reliable radical tumor-nephrectomy, as well as reconstruction possibilities in the large vessels. Of course, use of this incision is not without complications. They appear, however, not as often as opponents of this method would suppose. There are other statistics to support our convictions (4). From the check-ups of our thoraco-retroperitoneal nephrectomy patients, we are able to surmise the following: - The post operative mortality rate is not increased with this method. The cause for the mortalities are, as far as one can tell, old age and/or a generally poor condition piror to nephrectomy. - Post operative complications due to access though the thorax are very few. Not one patient had to be re-operated, punctured, or treated using suction drainage. No respiratory difficulties were observed. - Post operative complications from the wound were naturally relative to the extent of the incision. It was also here unnecessary to perform a second operation except in one case of a retroperitoneal hematoma from heparinization. This complication was not the result of this particular incision.

Follow-Up Studies↗

PubMed1975

[Treatment of renal hypertension by nephrectomy in persons over 40 years of age].

42 patients aged over 40 years at the time of nephrectomy (between 1961 and 1972) for unilateral renal disease and arterial hypertension were re-investigated. The WHO criteria for normotensive and hypertensive blood pressure levels were used. Systolic and diastolic pressures returned to normal after nephrectomy in 15 patients, systolic pressure alone in nine. Systolic and diastolic pressures remained unchanged in twelve. When grouped by histological criteria, only patients with small pyelonephritis kidney improved significantly, while those with pyelonephritis, arteriolosclerosis and renal-artery stenosis did not. It is concluded that patients aged over 40 years who have hypertension associated with unilateral renal disease may benefit from nephrectomy, especially if they have a small pyelonephritic kidney.

Adult↗

PubMed2001

Primary nephrectomy for emergency: a rare event in the International Society of Paediatric Oncology Nephroblastoma Trial and Study no. 9.

Experience of the International Society of Paediatric Oncology (SIOP) Trials and Studies indicates that the preoperative chemotherapy in Wilms' tumour improves stage distribution, decreases complication rate and reduces postoperative treatment. However, some situations may lead to prompt primary surgery. The aim of the study is to assess reasons leading to primary emergency nephrectomy. Records of 720 patients with non-metastatic unilateral nephroblastoma who were registered in the SIOP Trial and Study 9 were reviewed. Twenty-four (3%) cases of primary emergency nephrectomy were identified. Reasons leading to emergency nephrectomy were massive bleedings from ruptured tumours in 13 patients, suspicion of an "acute abdomen" in 7, bowel occlusion in 2 and other in 2. Postoperative treatment included radiotherapy in 71% of cases and anthracyclines in 92%. Complications were frequent and happened in 25% of patients, the outcome however, was favourable and 22 of 24 patients are alive (from 9 to 79 months). The 7 patients with a suspicion of an "acute abdomen" probably constitute the group which could have been markedly reduced if adequately diagnosed and observed prior to surgery.

Child↗

PubMed2002

In hydronephrosis less than 10 % kidney function is not an indication for nephrectomy in children.

PURPOSE: To reduce the incidence of nephrectomy or hydronephrosis in children. MATERIALS AND METHODS: From September 1998 to October 2000, we treated 58 patients with hydronephrosis; their ages ranged from 35 days to 11 years (mean age 4 years 7 months). All patients were subjected to a DTPA renogram with split function. In 12 patients (study group), kidney function was less than 10 % (range 0 - 10 %). Initially, nephrostomy was carried out in all 12 patients followed by Anderson-Hyne's pyeloplasty after 4 - 6 weeks. Postoperatively renal USG, urine r/m/e & c/s (routine and microscopic examination and culture and sensitivity test), blood urea, serum creatinine were assessed and DMSA scan and DTPA renogram with split functions were carried out in all patients. RESULTS: In the study group, all 12 patients showed improvement of renal function (more than 10 %) after nephrostomy and in all of them pyeloplasty was subsequently carried out within 4 - 6 weeks. There were no significant pre-, peri- or postoperative complications. CONCLUSIONS: Contrary to common practice we do not recommend nephrectomy for hydronephrotic kidneys which show < 10 % of renal function on renogram. The renal functional status improves significantly after a preliminary nephrostomy, thus avoiding the need for a straightforward nephrectomy in children along with all the possible long-term effects of a single kidney.

Child↗

PubMed2003

Laparoscopic radical nephrectomy for renal cell carcinoma.

PURPOSE: To estimate the efficacy of the laparoscopic radical nephrectomy we analyzed the clinical data of our series. PATIENTS AND METHODS: One hundred eighty five patients were enrolled in our laparoscopic radical nephrectomy program between July, 1992 and July, 2001. Of the 185 patients, 146 had small renal tumors (smaller than 5 cm in diameter) and 39 had large tumors (equal to or more than, 5 cm in diameter). Under a laparoscope the kidney, adrenal gland, and perirenal fatty tissue were dissected in an en bloc fashion. In case of taking out a small tumor, the specimen was fractionated within the sack to avoid an additional skin incision after entrapping in the laparoscopy sack in the working space. In case of a large tumor, regional lymph nodes dissection was done and the specimen was taken out intact in the sack through an enlarged incision. RESULTS: Our laparoscopic procedure was successful in 171 of the 185 cases; 14 patients required open surgery because of bleeding from an injured vessels or treatment for other injured organs. The mean operative time was 4.7 hours for both small and large tumors. Estimated blood loss was between 237 and 380 ml on average for small and large tumors, respectively. Full convalescence was achieved around 3 weeks after operation in both groups. Only one patient who had large tumor was found to have micrometastasis in 1 of 5 regional lymph nodes. Recurrences were observed in 4 cases of the small tumor group and in 2 cases of the large tumor group during 1 to 108 months of follow-up. CONCLUSION: Laparoscopic radical nephrectomy is a very useful and safe surgical procedure for renal cell carcinoma.

Carcinoma, Renal Cell↗

PubMed1992

Long-term results after partial and unilateral nephrectomy in childhood.

In a clinical follow-up, 47 patients after unilateral or partial nephrectomy were examined. The average age at operation was 5.8 years (range 3 days-17.1 years), the average follow-up period after surgery was 11.9 years (range 8.2-18.3 years). Main indications for surgery were hydronephrosis (n = 27), other congenital malformations (n = 6) and neoplasia (n = 9). In one patient, we found hypertension, two patients presented with moderately diminished creatinine clearance, two further patients suffered from unilateral hydronephrosis after partial nephrectomy. We found by ultrasonography marked compensatory hypertrophy in cases of solitary kidneys (225.6 +/- 49.3%) as well as contralateral kidneys after partial nephrectomy (158.7 +/- 55.6%).

Adolescent↗

PubMed1998

Rarity of surgical complications after postchemotherapy nephrectomy for nephroblastoma. Experience of the International Society of Paediatric Oncology-Trial and Study "SIOP-9". International Society of Paediatric Oncology Nephroblastoma Trial and Study Committee.

The aim of the study was to assess rates and types of nephrectomy-related complications in children nephrectomized for nephroblastoma after preoperative chemotherapy. Records of 598 Wilms' tumour patients registered in the International Society of Paediatric Oncology Trial & Study No. 9 (SIOP-9), and pretreated correctly according to the protocol with vincristine + actinomycin D +/- epirubicine or adriamycin prior to nephrectomy, were retrospectively reviewed. Forty-nine patients (8%), who suffered from 54 complications, were identified. Most frequent events were small-bowel occlusions (3.7%) and tumour ruptures (2.8%). Other complications were registered in 2.0% of cases. The low rate of nephrectomy complications and no deaths related to registered ones, are another argument for preoperative chemotherapy in Wilms' tumour patients.

Adolescent↗

PubMed2006

Outcome of nephrectomy and kidney-preserving procedures for the treatment of emphysematous pyelonephritis.

OBJECTIVE: Emphysematous pyelonephritis (EPN) is an acute necrotizing infection of the kidney characterized by gas formation. In order to compare the outcome of nephrectomy and kidney-preserving procedures for the treatment of EPN we reviewed our experiences of EPN over the past 18 years. MATERIAL AND METHODS: The medical records of 17 patients with EPN treated between October 1986 and September 2004 were retrospectively reviewed. Abdominal X-ray and/or CT were used as diagnostic methods. RESULTS: Women outnumbered men (12 vs five), and all patients had diabetes. Obstruction of the corresponding reno-ureteral unit was found in one patient. Thirteen of the 17 patients (76%) had poorly controlled diabetes (hemoglobin A1c>7%). The diagnosis of EPN was confirmed by gas in the parenchymal or perinephric space as detected by abdominal X-ray or CT. Escherichia coli was the commonest organism present in urine cultures (52%), followed by Klebsiella pneumoniae (24%). Prompt efforts were made to control diabetes, and i.v. antibiotics were given. Nephrectomy was performed in 10 patients and nine patients survived (90% success rate). The success rate among those who received medical therapy only was 50% (2/4 patients). Percutaneous drainage was performed in three patients, two of whom survived (67% success rate). The overall mortality rate was 17.6% (3/17 patients). CONCLUSIONS: Immediate nephrectomy with glycemic control measures and antibiotic administration is crucial for the successful treatment of EPN. However, in inoperable cases, percutaneous drainage can be an effective treatment option.

Adult↗