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PubMed2004

Prophylactic bilateral nephrectomies in two paediatric patients with missense mutations in the WT1 gene.

BACKGROUND: Denys-Drash syndrome (DDS) is associated with mutations of the Wilms' tumour 1 (WT1) gene, and is characterized by pseudohermaphroditism, a progressive glomerulopathy, and the development of Wilms' tumour. More than 90% of patients with DDS who carry constitutional intragenic WT1 mutations are at high risk (90%) for the development of Wilms' tumour. WT1 is a signalling protein with 90% of WT1 mutations occurring in the WT1 zinc finger region as single nucleotide polymorphisms, the majority of which are missense mutations. METHODS: Constitutional DNA was extracted from peripheral blood. Direct sequencing and restriction enzymes were employed to analyse mutations. RESULTS: Two children, 46XY males who had evidence of pseudohermaphroditism, hypogonadism and renal failure with a glomerulopathy atypical for DDS, but no Wilms' tumour or nephroblastomatosis, on investigation, prior to transplant, were identified with missense mutations in the WT1 gene, in exons 8 and 9, respectively. The decision to do prophylactic nephrectomies was based on the genetic identification of WT1 mutations supporting a diagnosis of incomplete DDS, with the potential for increased risk of malignancy with the development of Wilms' tumour. The nephrectomy specimens demonstrated nephrogenic rests (nephroblastomatosis), which have a potential for malignant transformation. CONCLUSIONS: WT1 missense mutations in exons 8 and 9 can be regarded as having the potential for malignant change supporting prophylactic nephrectomy in apparent incomplete DDS patients with end-stage renal disease.

Child↗

PubMed2006

Mini-incision for strictly retroperitoneal nephrectomy in living kidney donation vs flank incision.

BACKGROUND: Mini-incision donor nephrectomies (MIDNs) were established during the last decade, as an alternative to traditional open donor nephrectomy (ODN) via flank incision. In this study, we investigated intra-operative and post-operative data on outcome following MIDN in comparison with ODN data. METHODS: Data of 70 living kidney donations, performed at the University of Regensburg Medical Center since 1996, were evaluated. Donor operation was performed as either strictly retroperitoneal MIDN (n = 34) or as traditional ODN (n = 36) via flank incision. Total operation time, warm ischaemia time (WIT), perioperative pain-medication usage and creatinine levels as well as length of hospital stay, return to complete enteral nutrition and regular digestion were evaluated retrospectively. RESULTS: Total operation times were similar in MIDN, n = 34 (132 +/- 26 min) and in ODN, n = 36 (140 +/- 37 min) (P = 0.424). WIT was also similar in both: MIDN (0.9 +/- 0.4 min) and ODN (0.9 +/- 0.4 min) (P = 0.568). The requirement for post-operative opioids in morphine equivalent doses was significantly lower in MIDN (8.4 +/- 16 mg) compared with ODN (44 +/- 57 mg) (P = 0.001). Additional application of non-opioids (metamizole) (MIDN: 4.8 +/- 6.3 g, ODN: 3.4 +/- 3.9 g) and non-steroidal antirheumatic (NSAR) (diclofenac) (MIDN: 322 +/- 361 mg, ODN: 247 +/- 474 mg) revealed no significant differences between the groups. The hospital stay was 4.9 +/- 1.4 days in MIDN which was significantly shorter than that in ODN (9.3 +/- 3.3 days) (P = 0.001). Patients achieved fully independent mobility earlier in MIDN than in ODN (P = 0.934). Start of enteral nutrition with fluids was significantly quicker in MIDN (1.9 +/- 7 h) compared with ODN (12 +/- 13 h) (P = 0.05). Full enteral nutrition was accomplished significantly earlier in MIDN (1.6 +/- 0.8 days) (P = 0.023). Return to normal digestion revealed no significant differences between groups. Serum creatinine levels of all kidney donors were in the normal range (66 +/- 18 micromol/l) one day before nephrectomy, increased on day 1 after surgery (119 micromol/l +/- 31 micromol/l) and were stable on day 3 (115 micromol/l +/- 30 micromol/l) without significant differences. CONCLUSION: Strictly, retroperitoneal MIDN in living kidney donation is a fast and safe method for the procurement of a living donor graft, giving the patient a significantly shorter period of recovery, and thus is an attractive and recommendable alternative to traditional ODN procedures.

Adult↗

PubMed2000

Increased rates of donation with laparoscopic donor nephrectomy.

OBJECTIVE: To examine the impact of laparoscopic nephrectomy and recipient education on the proportion of kidney recipients who could identify a potential live donor, and on the live donor (LD) transplantation rate. SUMMARY BACKGROUND DATA: Laparoscopic donor nephrectomy (LDN) results in less postoperative surgical pain, a shorter hospital stay, and quicker recovery than the standard open donor nephrectomy (ODN). The authors hypothesized that the availability of this less invasive surgical technique would enhance the willingness of family and friends to donate. METHODS: The study population consisted of 3,298 end-stage renal disease patients referred for kidney transplant evaluation between November 1991 and February 2000, divided into three groups. The first group received no formal LD education and had only ODN available. The second group received formal education about the LD process and had only ODN available. The third group had both formal LD education and LDN available. Records were examined to determine what proportion of each group had any potential donors tissue-typed, and the rate at which they received an LD transplant. RESULTS: Before LDN availability and formal LD education, only 35.1% of referrals found a potential donor, and only 12.2% received an LD transplant within 3 years. Institution of a formal education program increased the volunteer rate to 39.0%, and 16.5% received an LD transplant. When LDN became available, 50% of patients were able to find at least one potential donor, and within 3 years 24.7% received an LD transplant. Regression analysis indicated that availability of LDN was independently associated with a 1.9 relative risk of receiving an LD transplant. Kaplan-Meier death-censored 1- and 3-year graft survival rates for ODN transplants were 95.8% and 90.6%, versus 97.5% and 94. 8% for LDN. CONCLUSIONS: The availability of LDN and an LD family education program has doubled the live donor transplantation rate, and outcomes remain excellent.

Adolescent↗

PubMed1989

Solution of methodological problems in measurement of inactive renin in rat plasma using trypsin activation, and the effect of nephrectomy and sialo-adenectomy on inactive plasma renin.

Trypsin activation of rat plasma destroys angiotensinogen and generates a tetradecapeptide-like material, verified by high performance liquid chromatography, which interferes with the measurement of inactive renin. Using an assay based on removal of the material by a cation-exchange resin and the addition of exogenous angiotensinogen, the plasma concentration of inactive renin in intact conscious male rat was 0.48 GU/l (range 0.28-0.67 GU/l, n = 20). Inactive renin comprised about 70% of the total plasma renin. The level of inactive renin was unchanged 24 h after bilateral nephrectomy and 7 days after submandibular sialo-adenectomy. Bilateral nephrectomy of previously sialo-adenectomized rats decreased the level of inactive renin significantly. Our findings are in contrast to the marked increase, reported by several other investigators, in inactive plasma renin in rats following bilateral nephrectomy, and do not support the previously suggested, mainly extrarenal, origin of inactive plasma renin.

Animals↗

PubMed1993

The effect of enalapril on glomerular growth and glomerular lesions after subtotal nephrectomy in the rat: a stereological analysis.

INTRODUCTION: Angiotensin converting enzyme (ACE) inhibitors have a beneficial effect on glomerular injury in different models of renal damage. Their presumed nephroprotective action has been related partly to actions on glomerular growth. We examined the effect of prophylactic administration of a moderate dose of enalapril (50 mg/l in drinking water) in male Sprague-Dawley rats on a diet containing 40% protein and moderate NaCl. METHODS: The rats were followed for 8 weeks after subtotal nephrectomy and compared with sham-operated matched controls. RESULTS: The number of glomeruli per kidney was reduced significantly in both the enalapril-treated and control groups. The median glomerulosclerosis index was significantly lower in the enalapril-treated than in the untreated subtotally nephrectomized rats. The mean absolute glomerular volume was significantly higher after subtotal nephrectomy, but was significantly lower in the enalapril-treated than in the untreated subtotally nephrectomized rats. The total numbers of cells per glomerulus and of mesangial or endothelial cells, as well as nuclear volumes of mesangial cells and the total capillary length per glomerulus, were all significantly higher after subtotal nephrectomy. These parameters were significantly lower in the enalapril-treated than in the untreated nephrectomized rats. The rise in systemic blood pressure was modest in the nephrectomized rats and the arteriolar volume: length ratio was unchanged by treatment with enalapril. CONCLUSIONS: In subtotally nephrectomized rats enalapril inhibits (but fails to reverse completely) the compensatory glomerular enlargement and the increase in mesangial cell number and activation, with a concomitant reduction in the development of glomerulosclerosis. The results is compatible with antiproliferative, and possibly antiangiogenic, actions of ACE inhibitors.

Animals↗

PubMed1995

Complications of laparoscopic nephrectomy in 185 patients: a multi-institutional review.

PURPOSE: We document the incidence of complications associated with laparoscopic nephrectomy in a multi-institutional study. MATERIALS AND METHODS: The study included the initial 185 patients undergoing laparoscopic nephrectomy at 5 centers in the United States between June 1990 and July 1993. RESULTS: A total of 30 patients (16%) had 34 complications. There was no mortality. Access-related complications included 2 cases of hernia formation at the trocar site, 1 abdominal wall hematoma and 1 trocar injury to a hydronephrotic kidney. Intraoperative complications included 5 cases of vascular injury, 1 splenic laceration and 1 pneumothorax. Postoperative complications involved the gastrointestinal tract in 6 cases, cardiovascular system in 6, genitourinary tract in 4, respiratory system in 4 and musculoskeletal system in 2. Miscellaneous complications occurred in 3 patients. Open surgical intervention was required electively in 8 patients and on an emergency basis in 2. The incidence of complications decreased with experience: 71% occurred during the initial 20 cases at each institution. CONCLUSIONS: In our early experience the complication rate for laparoscopic nephrectomy was 12% in patients with benign renal disease and 34% in those with renal cancer. Based on this collective experience, recommendations for prevention, recognition and treatment of complications are made.

Adult↗

PubMed1997

The effect of Wilms tumor chemotherapy on contralateral renal growth after nephrectomy.

PURPOSE: Our aim was to evaluate the effect of current Wilms tumor chemotherapy on renal growth and function after unilateral nephrectomy. MATERIALS AND METHODS: Yorkshire piglets were enrolled in 2 study groups: group 1--6 underwent unilateral nephrectomy and placebo infusion, and group 2--10 underwent nephrectomy, and infusion of 7.5 mcg/kg. actinomycin D and 0.75 mcg/m2 vincristine according to the National Wilms Tumor Study 4 protocol. Weekly measurements of renal size by ultrasound and gross specimens at sacrifice at age 11 weeks were examined and weekly laboratory studies were recorded. Growth rates of renal length and volume were evaluated by linear regression analysis. Terminal renal length and volume were compared between groups. RESULTS: Mean slope plus or minus standard deviation of the rate of growth in length in the control and chemotherapy groups was 0.067 +/- 0.004 and 0.074 +/- 0.011, respectively (p < or = 0.148, not statistically significant). Mean slope of growth in volume was 1.401 +/- 0.240 versus 1.642 +/- 0.456 (p < or = 0.252), average terminal renal length was 10.71 +/- 1.02 versus 11.58 +/- 1.03 cm (p < or = 0.13, not significant) and mean final volume was 128.67 +/- 32.41 versus 137 +/- 32.52 cc (p < or = 0.65). No differences in final serum creatinine levels were noted. CONCLUSIONS: Chemotherapy for Wilms tumor did not adversely affect contralateral renal growth or function in a nephrectomized piglet model.

Animals↗

PubMed1998

Natural history of refluxing distal ureteral stumps after nephrectomy and partial ureterectomy for vesicoureteral reflux.

PURPOSE: We evaluated the natural history of refluxing distal ureteral stumps after nephrectomy and partial ureterectomy. MATERIALS AND METHODS: Between 1985 to 1996, 38 patients a mean age of 37 months underwent nephrectomy and partial ureterectomy for reflux into a nonfunctioning kidney. The diagnosis included primary reflux in 23 patients, reflux associated with posterior urethral valves in 10 and ipsilateral ureterocele in 5. Mean followup was 45 months. RESULTS: Only 1 patient with an ipsilateral ureterocele and 1 with contralateral reflux (5%) had symptomatic infections during postoperative followup, and each underwent a secondary procedure to remove the ureteral stump. No patient with only primary unilateral reflux required surgery for the refluxing stump. CONCLUSIONS: Because of the low risk of morbidity associated with a refluxing ureteral stump, we recommend nephrectomy and proximal ureterectomy in patients with reflux into a nonfunctioning kidney.

Adolescent↗

PubMed1999

Transperitoneal and retroperitoneal laparoscopic nephrectomy for giant hydronephrosis.

PURPOSE: We evaluate laparoscopic nephrectomy for giant hydronephrosis with an emphasis on the operative technique of retroperitoneoscopic surgery. MATERIALS AND METHODS: During the last 2 years 13 men and 5 women underwent laparoscopic nephrectomy for giant hydronephrosis via a transperitoneal (6) or retroperitoneal (12) approach. The etiology was congenital ureteropelvic junction obstruction in 17 patients and hydronephrosis caused by stone disease in 1. Three patients had a contralateral obstructed kidney. Renal parameters were normal in all patients. RESULTS: All procedures were successfully completed without the need for conversion to open surgery. Mean operating time was 113.8 minutes (range 70 to 165) and average blood loss was 260 ml. (range 40 to 600). No patient required a blood transfusion. Postoperative recovery was uneventful with an average postoperative hospital stay of only 3.2 days (range 2 to 5). CONCLUSIONS: Laparoscopic nephrectomy is a good alternative to open surgery for giant hydronephrosis and significantly reduced the morbidity of surgery. A retroperitoneal approach is feasible, despite the large amount of retroperitoneal space occupied by these hugely dilated kidneys. Modifications of our technique have been invaluable to the successful outcome in this series.

Adolescent↗

PubMed1996

Pregnancy after donor nephrectomy.

Potential female donors frequently ask whether unilateral nephrectomy will impair future childbearing capabilities. To address this question, we surveyed 220 women who underwent donor nephrectomy between 1985 and 1992. Of the 144 women who responded, 33 became pregnant after donation for a total of 45 pregnancies. Seventy-five percent of the pregnancies were carried to term without difficulty. Complications incurred during gestation included miscarriage (13.3%), preeclampsia (4.4%), gestational hypertension (4.4%), proteinuria (4.4%), and tubal pregnancy (2.2%). Four of the 45 pregnancies (excluding miscarriages) required preterm hospitalization, resulting in an overall morbidity of 8.8%. There were no pregnancy-related deaths, and no fetal abnormalities were reported. Problems with persistent hypertension, proteinuria, or changes in renal function were not noted. None of the above complications exceeded what has been noted for the general population. Infertility was a problem in 8.3% (3/36) of our respondents, compared with a worldwide incidence of 16.7%. Based on these results, we conclude that donor nephrectomy is not detrimental to the prenatal course or outcome of future pregnancies.

Female↗

PubMed1997

Laparoscopic assisted live donor nephrectomy--a comparison with the open approach.

Live donor renal transplantation provides significant advantages when compared with cadaveric donor renal transplantation in terms of improved patient and graft survival, a lower incidence of delayed function, and a shorter waiting time. Yet despite these advantages, live donors continue to be an under utilized source of kidneys for transplantation. Disincentives to live donation include the length of hospitalization, postoperative pain, cosmetic concerns, and the prolonged convalescence associated with the donor operation. In many instances minimally invasive video-assisted techniques have proven more efficacious than standard open procedures in terms of patient discomfort, length of hospital stay, cost, and length of time until the patient can return to full activity. Laparoscopic live donor nephrectomies are being performed at our institution in an attempt to make live donation more attractive to the potential donor. The purpose of this study was to retrospectively review the results of laparoscopic live donor nephrectomy (LapNx) and to compare them with those obtained using the standard open approach (OpenNx). Ten consecutive LapNx were performed from February 1995 through April 1996. The control group consisted of the 20 consecutive OpenNx performed at the same institution from January 1991 through January 1995 immediately before the initiation of the LapNx program. Live donors were considered candidates for LapNx if they possessed at least one kidney with normal renal anatomy with single renal vessels and a single ureter. LapNx was safely performed in all cases. No patients required open conversion or blood transfusions. The allograft warm ischemic time for the laparoscopic cases was 4.2+/-1.3 min. All kidneys harvested laparoscopically produced urine on the table immediately upon revascularization. Presently nine of the ten recipients have functioning allografts. At three months posttransplant the calculated recipient creatinine clearances were 67.0+/-11.5 ml/min and 64.8+/-21.4 ml/min for the LapNx and OpenNx groups, respectively (P=NS). The LapNx donors had a significantly decreased estimated blood loss, shorter time until resumption of oral intake, decreased postoperative pain (in terms of decreased analgesic requirements), shorter hospitalization, and a shorter interval until the resumption of full activities (P<0.05 for all). In addition, the LapNx group donors returned to work sooner than the OpenNx group (3.9+/-1.6 wk vs. 6.4+/-3.1 wk, respectively) (P=0.024). Four individuals agreed to donate a kidney only after learning of the availability of the laparoscopic approach. We conclude that laparoscopic live donor nephrectomy is technically feasible. In addition, it may offer significant advantages over the standard open approach in terms of patient comfort and convenience. These advantages may make live donor renal transplantation more attractive to prospective donors. The potential decrease in hospitalization and convalescence may also prove to be financially advantageous. We believe that further careful study of this procedure is warranted.

Adult↗

PubMed1998

Treatment of posttransplant hypertension by laparoscopic bilateral nephrectomy?

BACKGROUND: Hypertension is an important risk factor for the development of chronic graft failure and decreased graft and patient survival after renal transplantation. METHODS: Between September 1994 and August 1996, 14 patients underwent laparoscopic bilateral nephrectomy for treatment of drug-resistant hypertension after successful renal transplantation. Common causes of hypertension were largely excluded before bilateral nephrectomy. A scoring system was developed for comparison of different antihypertensive regimes. In this system, points were given according to type and dosage of each antihypertensive drug. RESULTS: At 6-month follow-up, all patients showed well-controlled blood pressure (median of mean arterial pressure: 104 vs. 130 mmHg preoperatively, P<0.001, n=14), and significantly fewer antihypertensive drugs were needed according to the scoring system (48.9+/-20.9 points vs. 105.9+/-23.5 points preoperatively, P<0.001, n=14). During laparoscopy, three conversions to open surgery were necessary. Postoperatively, four complications occurred. After laparoscopy, immunosuppression and other oral medication were given continuously. The hospital stay ranged between 3 and 6 days (median: 5 days). CONCLUSIONS: The results indicate that bilateral nephrectomy using the laparoscopic technique can be an effective alternative method for a selected group of patients with severe hypertension, which is unresponsive to conservative management after successful renal transplantation with regard to improving the long-term graft survival.

Adult↗

PubMed2000

Laparoscopic live donor nephrectomy: the recipient.

BACKGROUND: Laparoscopic live donor nephrectomy offers advantages to the donor in terms of decreased pain and shorter recuperation. Heretofore no detailed analysis of the recipient of laparoscopically procured kidneys has been performed. The purpose of this study was to determine whether laparoscopic donor nephrectomy had any deleterious effect on the recipient. METHODS: A retrospective review was conducted of all live donor renal transplantations performed from January 1995 through April 1998. The control group received kidneys procured via a standard flank approach (Open). Rejection was diagnosed histologically. Creatinine clearance was calculated using the Cockroft-Gault formula. RESULTS: A total of 110 patients received kidneys from laparoscopic (Lap) and 48 from open donors. One-year recipient (100% vs. 97.0%) and graft (93.5% vs. 91.1%) survival rates were similar for the Open and Lap groups, respectively. A similar incidence of vascular thrombosis (3.4% vs. 2.1%, P=NS) and ureteral complications (9.1% vs. 6.3%, P=NS) were seen in the Lap and Open groups, respectively. The incidence of acute rejection for the first month was 30.1% for the Lap group and 31.9% for the Open group (P=NS). The rate of decline of serum creatinine level in the early posttransplantation period was initially greater in the Open group, but by postoperative day 4 no significant difference existed. No difference was observed in allograft function long-term. The median length of hospital stay was 7.0 days for both groups. CONCLUSIONS: Laparoscopic live donor nephrectomy does not adversely effect recipient outcome. The previously demonstrated benefits to the donor, and the increased willingness of individuals to undergo live kidney donation, coupled with the acceptable outcomes experienced by recipients of laparoscopically procured kidneys justifies the continued development and adoption of this operation.

Acute Disease↗

PubMed2002

Hand-assisted retroperitoneoscopic living-donor nephrectomy: initial 10 cases.

BACKGROUND: Most living-donor nephrectomies are performed either by transperitoneal laparoscopy, with or without hand assistance, or by retroperitoneal open surgery, with or without video assistance. We therefore started to combine the benefits of these techniques: hand assistance to increase safety and control of the laparoscopic technique, and the retroperitoneal approach to minimize the risk of complications associated with the transabdominal approach. Herein, we report on our first 10 donors nephrectomized with hand-assisted retroperitoneoscopy. RESULTS: Only left nephrectomies were performed. One donor had two renal arteries and two donors had retroaortic renal veins. There were no intra- or postoperative complications. Mean operating time was 155 min (110-230 min). CONCLUSIONS: Hand-assisted retroperitoneoscopy in living-donor nephrectomy is a promising new method that could reduce the risks of traditional transperitoneal laparoscopy and should be further evaluated.

Adult↗

PubMed1999

Laparoscopic donor nephrectomy: standard of care or unnecessary risk of organ loss?

Laparoscopic donor nephrectomy was developed to remove disincentives to live donation. It has been demonstrated to decrease the length of hospitalization, postoperative pain, time to convalescence and activity, while providing an optimal cosmetic result. Initial reports suggest that laparoscopic donor nephrectomy is feasible and equivalent to open donor nephrectomy.

Humans↗

PubMed1999

Renal cell carcinoma: should radical nephrectomy be performed in the presence of metastatic disease?

Metastatic renal cell carcinoma is associated with an unfavorable prognosis and the treatment options are limited. Adjunctive radical nephrectomy, performed either before or after the administration of systemic immunotherapy, has been proposed as a means of improving outcome. The role of nephrectomy for patients with metastatic disease remains controversial. This article reviews the role of nephrectomy in metastatic renal cell carcinoma and the optimal timing for surgery relative to immunotherapy.

Carcinoma, Renal Cell↗

PubMed2003

The role of partial nephrectomy in the treatment of pediatric renal hypertension.

PURPOSE: From 5% to 25% of hypertension in children is renovascular compared with only 1% in adults. Although much attention is given to renovascular disease involving the main renal arteries, renin producing renal disease may also be intrarenal, involving abnormalities of the segmental vessels or renal parenchyma. We present our results of partial nephrectomy in this unique group of pediatric patients with hypertension in whom renin dependent hypertension involved only a segment of the kidney. MATERIALS AND METHODS: Six patients 10 months to 16 years old were referred for the evaluation of hypertension. Initial evaluations included computerized tomography, ultrasound, voiding cystourethrography and radionuclide renal scan. Renal arteriography with renal vein renin sampling was performed in 5 patients, of whom 4 underwent selective segmental renal vein sampling. Diagnoses included segmental hypoplasia (Ask-Upmark kidney), reflux associated scarring and renal arteriovenous malformation. RESULTS: In patients who underwent selective segmental renal vein sampling an increased renin level was present in the area of the renal lesion (mean 24.9 ng./ml. per hour, range 9.2 to 40.6) compared to the ipsilateral renal vein (15.6, 114 to 29.8). Three patients had evidence of contralateral suppression of renin secretion. All 6 patients underwent upper, lower or mid segment partial nephrectomy. All patients became immediately normotensive and remained so at a mean 10 years of followup. CONCLUSIONS: Partial nephrectomy provides an excellent nephron sparing cure for segmental renal hypertension. In the pediatric population selective segmental renal vein renin sampling is invaluable for locating the renin producing lesion. As in adults, contralateral renin suppression is predictive of surgical cure.

Adolescent↗

PubMed2003

Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients.

PURPOSE: Laparoscopic partial nephrectomy is an emerging minimally invasive, nephron sparing approach for renal cell carcinoma. We compared perioperative outcomes after laparoscopic and open nephron sparing surgery (NSS) for patients with a solitary renal tumor of 7 cm or less at a single institution. MATERIALS AND METHODS: Since September 1999, 100 consecutive patients have undergone laparoscopic partial nephrectomy for a sporadic single renal tumor of 7 cm or less at our institution. A contemporary cohort of 100 consecutive patients with similar inclusion criteria have undergone open NSS since April 1998. Since our laparoscopic technique was based on our established open surgical principles, the 2 approaches were similar, including transient renal vascular control, sharp tumor excision in a bloodless field, pelvicaliceal repair when necessary, suture ligation of transected intrarenal blood vessels and suture repair of the renal parenchymal defect over a bolster. Demographic, intraoperative, postoperative and short-term followup data were retrospectively compared between the 2 groups. RESULTS: Median tumor size was 2.8 cm in the laparoscopic group and 3.3 cm in the open group (p = 0.005). There were significantly more tumors greater than 4 cm in the open group (p <0.001). There were more patients with a solitary kidney in the open surgical group (p = 0.002). More patients in the open group underwent NSS for a malignant tumor (p = 002). Comparing the laparoscopic versus open groups, median surgical time was 3 vs 3.9 hours (p <0.001), blood loss was 125 vs 250 ml (p <0.001) and mean warm ischemia time was 27.8 vs 17.5 minutes (p <0.001), respectively. In the laparoscopic and open groups median analgesic requirement was 20.2 vs 252.5 mg morphine sulfate equivalents (p <0.001), hospital stay was 2 vs 5 days (p <0.001) and average convalescence was 4 vs 6 weeks (p <0.001). Median preoperative serum creatinine (1.0 vs 1.0 mg/dl, p = 0.52) and postoperative serum creatinine (1.1 vs 1.2 mg/dl, p = 0.65) were similar in the 2 groups. No kidney was lost due to warm ischemic injury. Three patients in the laparoscopic group had a positive surgical margin compared to none in the open groups (3% vs 0%, p = 0.1). Laparoscopic NSS was associated with a higher rate of major intraoperative complications (5% vs 0%, p = 0.02). There were no significant differences in overall postoperative complications, although renal/urological complications were more common in the laparoscopic group (11% vs 2%, p = 0.01). CONCLUSIONS: Open surgical partial nephrectomy remains the established standard for nephron sparing treatment of renal tumors. When applied to small renal tumors, the laparoscopic approach is associated with longer warm renal ischemia time, more major intraoperative complications and more postoperative urological complications. Our data also suggest that more deliberate efforts to achieve a wider surgical margin are necessary with the laparoscopic approach. Nevertheless, our data suggest that laparoscopic NSS is emerging as an effective, minimally invasive therapeutic approach with respect to renal functional outcome with the additional advantages of decreased postoperative narcotic use, earlier hospital discharge and a more rapid convalescence. Continued efforts are required to develop laparoscopic renal hypothermia techniques and facilitate intrarenal suturing, while minimizing warm ischemia time.

Aged↗