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PubMed1999

[Laparoscopic living-donor nephrectomy. A small study shows positive results, but the procedure still lacks satisfactory evaluation].

Retrospective analysis and comparison of a small series of 12 laparoscopic live donor nephrectomy (LapLDN) procedures with 15 open live donor nephrectomies, all 27 performed in 1998, showed operating time to be significantly longer but sick leave shorter and hospital stay somewhat shorter in the LapLDN subgroup. One patient in the open procedure subgroup developed herniation and scar discomfort, and in one LapLDN procedure severe bleeding necessitated conversion to open nephrectomy. All kidneys in both subgroups manifested immediate resumption of function after transplantation. Though the LapLDN procedure has yet to be satisfactorily evaluated, the present findings were predominantly in its favour.

Evaluation Studies as Topic↗

PubMed2000

Complete radical nephrectomy and vena caval thrombectomy during circulatory arrest.

PURPOSE: A modification of radical nephrectomy for renal carcinoma and vena caval tumor thrombectomy for supradiaphragmatic tumor extension under hypothermic circulatory arrest is presented. MATERIALS AND METHODS: Nephrectomy was performed during the circulatory arrest time in 16 consecutive patients during the last 4 years. RESULTS: Average hypothermic circulatory arrest time increased by 6 minutes. By elimination of manipulation of tumor and thrombus before circulatory arrest potential thrombus fragmentation and embolization were minimized. There were no significant differences in blood loss or complications compared to a prior series of 10 patients undergoing the procedure using conventional techniques. CONCLUSIONS: Performance of complete radical nephrectomy along with venal caval embolectomy during circulatory arrest increases the safety of the procedure without significant morbidity.

Humans↗

PubMed1999

[Transperitoneal laparoscopic nephrectomy].

OBJECTIVES: To evaluate the feasibility and complications of transperitoneal laparoscopic nephrectomy. MATERIAL AND METHODS: 30 transperitoneal laparoscopic nephrectomies were performed between November 1992 and October 1998: 17 for malignant lesions (10 renal cell carcinomas, 7 urothelial tumours) and 13 for benign lesions. RESULTS: The operation was performed entirely by laparoscopy in 25 cases, with 4 conversions: 3 for technical problems (difficulties of dissection: 1, haemorrhage: 2). One patient underwent laparotomy on the same day and three patients were transfused. The mean operating time was 116 minutes. No laparoscopy-specific complications were observed. CONCLUSION: A standard technique must be performed regardless of the disease: systematic open laparoscopy, wide colonic dissection, exposure of the vessels and resection in the plane of the radical nephrectomy. The risk of cancer dissemination with laparoscopy appears to be non-existent for renal cell carcinomas and controversial for urothelial tumours. Complications were always benign, although there is always a risk of bleeding, regardless of the operator's experience. The current technical conditions of laparoscopic surgery and its extension to all forms of visceral surgery should encourage the use of this technique by urologists, particularly for renal surgery.

Adult↗

PubMedDate not supplied

The role of adjuvant immunotherapy after radical nephrectomy and prognostic factors in pT3N0M0 renal cell carcinoma.

Five-year overall survival after radical nephrectomy in pT3N0M0 renal cell carcinoma is 35-50%. In light of immunotherapy, which has shown some activity in advanced diseases with increasing efficacy in limited metastatic invasion, we decided to explore the theoretical advantage of adjuvant immunotherapy in radically resected stage pT3N0M0 renal cell carcinoma. We studied several factors including tumor size, nuclear grade, mean nuclear area and expression of p53 protein to find out which factor is concerned with disease progression. A total of 10 patients with pT3N0M0 RCC who received radical nephrectomy from February 1992 to April 1999 were randomly assigned to receive treatment with either interferon-alpha alone or interferon-alpha plus vinblastine. Eight patients with pT3N0M0 RCC who received only radical nephrectomy from January 1984 to February 1993 were analyzed and the results were compared with the first group. Six out of 10 (60%) patients in the adjuvant immunotherapy group are alive with no evidence of disease. Metastases were documented in 4 patients (40%) with a median interval to progression of 17.5 months. All of them died of tumor. In the surgery only group, 5 out of 8 patients (62.5%) are still alive with no evidence of disease. Two patients (25%) developed distant metastases and both of them died of tumor. The median progression interval was 11 months. There were no statistical differences in time to progression and survival rate between the two groups. In the univariate analysis using a log-rank test, the expression of p53 protein seemed to be associated with shorter survival (p = 0.0591). However, in the multivariate analysis using Cox's proportional hazard model, no parameter had significant independent prognostic value. We concluded that adjuvant immunotherapy did not improve the survival of patients with pT3N0M0 RCC. Furthermore, we failed to find significant prognostic factors in patients with pT3N0M0 RCC.

Adult↗

PubMed2000

A clinical series of laparoscopic nephrectomy, nephroureterectomy and heminephroureterectomy in the pediatric population.

PURPOSE: Laparoscopic techniques have enabled less invasive surgery in pediatric urology. We report our experience with laparoscopic nephrectomy, nephroureterectomy and heminephroureterectomy in 26 children, and evaluate our series to establish the safety and efficacy of such procedures for benign disease. MATERIALS AND METHODS: Laparoscopic procedures were done in 15 girls and 11 boys 4 months to 11 years old (mean age 37) during a 23-month period. Laparascopic surgery consisted of nephrectomy in 14 (1 horseshoe kidney), nephroureterectomy in 6 and laparoscopic heminephroureterectomy in 6 cases. RESULTS: Mean overall operative time for the laparoscopic procedures was 165 minutes (range 43 to 355). Blood loss was less than 5 cc in all cases and there were no intraoperative complications in our series. Overall postoperative analgesic administration during hospitalization was 0.20 mg./kg. morphine sulfate and 19 mg./kg. acetaminophen as well as 0.9 mg./kg. codeine in 6 patients who did not receive morphine. Three children were discharged home on the day of surgery, while 17, 3, 1 and 2 were discharged home on postoperative days 1, 2, 4 and 5, respectively. Cosmetic results were excellent in all cases. CONCLUSIONS: Nephrectomy, nephroureterectomy and heminephroureterectomy may be performed for benign disease in children using laparoscopy with minimal morbidity, minimal postoperative discomfort, improved cosmesis and a short hospital stay. It may even be done as an outpatient procedure.

Adolescent↗

PubMed1999

[Laparoscopic donor nephrectomy: initial experience in Israel].

We present our initial experience in laparoscopic nephrectomy. 6 patients were operated for a kidney donation and 2 for treatment of a benign disease. All procedures were completed successfully, with no conversion to laparotomy or intraoperative complications. Mean operating time was 210 minutes, and in the donor kidneys the mean warm-ischemic time was 165 seconds. There were 3 postoperative complications, and mean hospitalization was 3.5 days. The transplanted kidneys are all functioning. From our initial experience, laparoscopic nephrectomy appears to be both feasible and safe. Its implementation requires a combined team with experience in donor surgery and advanced laparoscopic skills. The procedure may increase the availability of living donor kidneys, due to the smaller impact on the donor compared to conventional donor nephrectomy.

Adolescent↗

PubMed2000

Fibrin sealant treatment of splenic injury during open and laparoscopic left radical nephrectomy.

PURPOSE: We describe the use of fibrin sealant for rapid and definitive hemostasis of splenic injuries incurred during open and laparoscopic left nephrectomy. MATERIALS AND METHODS: In 2 patients undergoing left nephrectomy for a suspicious renal mass splenic laceration occurred during mobilization of the colonic splenic flexure at open nephrectomy and laparoscopic upper pole dissection, respectively. Fibrin sealant was applied topically in each case. RESULTS: In each patient fibrin sealant achieved immediate hemostasis and each recovered without further splenic bleeding. CONCLUSIONS: The topical application of fibrin sealant safely, rapidly and reliably achieves definitive hemostasis of splenic injuries. It is simple to use in the open and laparoscopic approaches.

Administration, Topical↗

PubMed1999

[The most common complications associated with nephrectomy].

Access to the kidney and technical performance of nephrectomy should be related to the stage of the disease and degree of pathological process development (I. Viktorov 1983, S. Lambrev and T. Andreev 1961, T. Patrashkov 1982, F. S. Judy et al 1995). Advanced pathoanatomical changes in the kidney and pararenal space greatly interfere with the operation, especially in the event of adhesions to peritoneum and contiguous tissues (N. A. Lopatkina et al 1986, N. Minkov 1987, T. Patrashkov and H. Kumanov 1988). In the authors' reports presented are analyzed 388 patients nephrectomized in the University Hospital "Alexandrovska", covering the period 1990 through 1995. All updated methods are used in diagnosing. The commonest intraoperative complications recorded in a series of 188 nephrectomies (48.45%) include: 1. Pus collections in the kidney--88 cases (46.80%). 2. Opening of peritoneum--64 (34.04%). 3. Decompressive puncture of the kidney--15 (7.97%). 4. Neoplastic masses escaping from the renal parenchyma into the operative field--7 (3.72%). 5. Opening of pleura--5 (2.66%). 6. Purposeful opening of the tumor itself for decompression--3 (1.95%). 7. Kidney removal gives rise to diffuse bleeding necessitating inserting a tampon for hemorrhage control--2 (1.06%). 8. Splenectomy--1 (0.53%). 9. Because of advanced neoplastic process only biopsy is taken--1 (0.53%). 10. Hemicolectomy--1 (0.53%). 11. Injury to v cava inferior--1 (0.53%). As shown by the experience gained, nephrectomy is a technically difficult operation, particularly in case of altered topoanatomical interrelations during secondary interventions on the kidney and ureter, or in case of concomitant pyelonephritis. Intraoperative complications are not life endangering provided treatment is undertaken in opportune time.

Adult↗

PubMed1999

[Methods most frequently used in the diagnosis of renal diseases leading to nephrectomy].

In the past few years, the progress of science and technology, and introduction of new diagnostic and treatment methods (echography, isotope study, computerized axial tomography, renovasography, magnetic resonance imaging and others) have contributed greatly to early detection and timely treatment of pathological processes involving the kidney (ZK El-Zein, 1995). After practical implementation of new clinical methods of examination it becomes possible to gain better insight into the undelying causes and character of renal diseases (T. Patrashkov, 1982). The study covers 388 patients subjected to nephrectomy for various diseases of the kidneys and urether, diagnosed and treated in the Department of Urology-University Hospital "Alexandrovska", over the period 1990 through 1995. The commonest diagnostic methods used to make diagnosis prior to nephrectomy include: 1. Survey roentgenography of kidneys, urethers and urinary bladder (KUB)--364 (93.81%). 2. Venous urography--320 (82.47%). 3. Echography--302 (77.83%). (Antegrade pyelography--2 (0.51%). 4. Isotope nephrogram (ING)--212 (54.63%). 5. Scintography of kidneys--126 (32.47%). 6. Computerized axial tomography (CAT)--82 (21.13%)/(70.68%) among 116 renal tumor nephrectomies. 7. Renovasography--82 (21.13%). 8. Retrograde pyelography--48 (12.37%). 9. Gamma-camera--10 (2.57%). 10. Cystoscopy--6 (1.54%). 11. Ureterorenoscopy--2 (0.51%). Presumably, apart from the new "noninvasive" methods of study (computerized axial tomography--CAT and echography), the conventional venous urography has by no means lost its popularity.

Adult↗

PubMed2001

Robot assisted laparoscopic nephrectomy.

PURPOSE: The feasibility and safety of remote laparoscopic surgery using a surgical telemanipulator have been demonstrated in laboratory experience and recently in clinical practice. To our knowledge we report the first robot assisted, laparoscopic nephrectomy in a human. MATERIALS AND METHODS: A 77-year-old woman was diagnosed with a nonfunctioning hydronephrotic right kidney due to ureteropelvic junction obstruction. Robot assisted, transperitoneal right laparoscopic nephrectomy was performed. RESULTS: Complete dissection was successfully performed with the robot. The renal pedicle was dissected without any problem, and the artery and vein were individually ligated. Operative time was 200 minutes, anesthesia time was 245 minutes and blood loss was less than 100 ml. Convalescence was uneventful. Histological examination confirmed the preoperative diagnosis. CONCLUSIONS: We report the technical feasibility of robot assisted laparoscopic nephrectomy in humans. Current technology needs further improvement and its actual usefulness for patient treatment must be established by large clinical trials. Technological improvements and future telecommunication networks should open new avenues in surgery, namely remote telesurgery.

Aged↗

PubMed1998

[Effect of Shenmai injection on morphological structure of kidney and peritoneum in rats with 5/6 nephrectomy].

OBJECTIVE: To study the protective effect of Shenmai injection (SMI) on kidney and peritoneum in rats with 5/6 nephrectomy. METHODS: By using cell morphological quantification, light microscopy and scanning electron microscopy, the morphological structure changes of peritoneum and kidney in rats with 5/6 nephrectomy caused chronic renal failure model after the intramuscular or intraperitoneal injection of SMI were observed. RESULTS: The SMI injection could relieve glomerular sclerosis, promote the recovery and proliferation of injured peritoneal mesothelial cell. The effect of the SMI intraperitoneal injection is better than that intramuscular of injection. CONCLUSION: The SMI has the protective effect on kidney and peritoneum in rats with 5/6 nephrectomy.

Animals↗

PubMedDate not supplied

Pre-transplant bilateral native nephrectomy for medically refractory hypertension.

Hypertension arising from retained native kidneys can compromise both the patient and graft survival. Bilateral nephrectomy should be considered in a select group of patients, whom have refractory hypertension, prior to renal transplantation. Between January 1991 and July 1998 we performed 10 bilateral nephrectomies where hypertension was the indication. The mean age was 23 yrs (range 11-45) at the time of surgery. Nine patients were on dialysis pre-operatively (6-H/D, 3-CAPD). All 10 patients witnessed a reduction in the number of antihypertensive medications they were obliged to take daily. We also found less surgical morbidity associated with performing surgery through bilateral dorsal lumbotomy incisions as opposed to through a midline incision. Also the post-operative hospital stay was less in the patient group who under went bilateral dorsal lumbotomy. Seven patients at a mean follow up period of 46.43+/-26.06 months have functioning grafts with a mean serum creatinine of 164.14+/-42.83 micromol/dl. We have shown in our patient group how bilateral nephrectomy can be successfully used for refractory hypertension in patients prior to renal transplantation. We also believe that where possible these kidneys should be removed through a bilateral dorsal lumbotomy incision rather than a midline one.

Adolescent↗

PubMed2002

The effect of dopamine on renal function in solitary partial nephrectomy surgery.

PURPOSE: Dopamine continues to be used for preventing and treating acute renal failure. We determined the effects of dopamine on postoperative renal function in patients with a solitary kidney undergoing partial nephrectomy. MATERIALS AND METHODS: We performed a prospective randomized controlled study at a tertiary care referral center involving 24 patients with a solitary kidney undergoing partial nephrectomy secondary to malignancy. Patients were randomized to receive dopamine (11) [corrected] or no dopamine (13) [corrected]. Intraoperatively those assigned to the dopamine group received a 3 microg./kg. per minute dopamine infusion. Patients in each group received an adequate amount of fluid to maintain good urine production, systemic blood pressure and central venous pressure. Serum electrolytes, blood urea nitrogen, creatinine, serum and urine osmolality, and urine output were measured at baseline, intraoperatively and through postoperative day 4. Preoperatively and postoperatively renal blood flow and the glomerular filtration rate were measured. RESULTS: In the 2 groups blood urea nitrogen and serum creatinine increased postoperatively. Although the degree of this increase showed a trend to be lower in the dopamine group, the difference did not reach statistical significance. There was no difference in renal blood flow or the glomerular filtration rate in the treatment groups. CONCLUSIONS: Administering dopamine to patients with a solitary kidney undergoing partial nephrectomy provided no renoprotective effect.

Blood Pressure↗

PubMed2002

Partial nephrectomy using a vascular sealing system.

PURPOSE: The margin resected at partial nephrectomy is so fragile that it is not easy to control bleeding. To control bleeding we developed a new technique using a vascular sealing system for hemostasis. MATERIALS AND METHODS: A 38-year-old woman with renal cell carcinoma underwent partial nephrectomy. A tumor was identified in the lower pole of the left kidney. The kidney was exposed with the perinephric fat and the main renal artery was identified and clamped. Along the incision line the renal cortex was cut sharply to 10 to 15 mm. deep. A jaw of the vascular sealing system was carefully inserted into the sinus space between the renal pelvis and medulla. The jaws were gradually clamped together, and the renal medulla and vasculature were compressed and then sealed completely by computer controlled current. Because the renal pelvis was involved by tumor, the pelvis was removed partially with the tumor and approximated with absorbable sutures. RESULTS: Before reperfusion only a few additional sutures were needed for hemostasis. Warm ischemia time was 19 minutes. CONCLUSIONS: Our technique seems to be a promising method of rapidly achieving reliable hemostasis for partial nephrectomy.

Adult↗

PubMed2002

The uncertainty of radio frequency treatment of renal cell carcinoma: findings at immediate and delayed nephrectomy.

PURPOSE: Radio frequency thermal therapy for the ablation of renal cell carcinoma has been reported. Outcomes are usually measured by imaging alone. We have performed ex vivo and in vivo experiments using radio frequency in porcine models in our laboratory. We now report our early experience in the treatment of renal cell carcinoma in patients who underwent post-radio frequency radical or partial nephrectomy. MATERIALS AND METHODS: We treated 10 patients diagnosed with small renal masses with radio frequency. All masses were biopsied before treatment. In 4 patients 5 renal cell carcinomas were treated with radio frequency after surgical exposure of the tumor followed immediately by partial or radical nephrectomy (acute group). Six other patients were treated percutaneously with ultrasound or computerized tomography guided radio frequency under local anesthesia and intravenous sedation 7 days before partial or radical nephrectomy (delayed group). A median of 2 radio frequency cycles was applied. Mean total heating time was 17 minutes 15 seconds. Specimens were analyzed grossly and histologically. Triphasic contrast-enhanced computerized tomography and/or magnetic resonance imaging was performed before and 7 days after radio frequency treatment in the delayed group. RESULTS: Mean radiological largest diameter of all 11 masses was 2.4 cm. and mean gross diameter was 2.2 cm. Pathological examination demonstrated residual viable tumor in approximately 5% of the volume in 4 of the 5 tumors in the acute group and in 3 of the 6 masses of the delayed group. In 1 delayed case the viable tumor appeared to be in contact with the renal vein. No significant complications were observed in 9 of the 10 patients. In 1 delayed case, a subcapsular hepatic hematoma, biliary fistula and pneumonia developed and resolved. CONCLUSIONS: Based on our experience, we continue to consider percutaneous radio frequency for the treatment of small renal cell carcinomas as a potentially curative therapy. However, complete tumor cell death appears to be difficult to achieve with our current treatment protocol. More phase II testing is indicated to ensure that this technique is an effective and reproducible treatment alternative.

Carcinoma, Renal Cell↗

PubMed2002

Outcome of surgical treatment of isolated local recurrence after radical nephrectomy for renal cell carcinoma.

PURPOSE: Isolated local recurrences after radical nephrectomy for renal cell carcinoma occur in 2% to 3% of cases. Today local recurrences can be detected at an early stage due to modern imaging techniques. It remains controversial whether an aggressive surgical approach to this problem can prolong survival. MATERIALS AND METHODS: We retrospectively analyzed 16 patients who were treated surgically at our institution for suspected isolated local renal cell carcinoma recurrence during the last 10 years. All patients had undergone extensive staging and had no evidence of distant metastases with the local recurrence. Surgical exploration confirmed carcinoma recurrence in 13 of the 16 cases and all 13 patients underwent complete resection of the local recurrence. Three patients were found to have had false-positive computerized tomography findings on surgical exploration. RESULTS: Mean time to recurrence was 45.5 months (range 7 to 224). Only 2 patients were symptomatic, while in 11 disease had been detected at routine followup. Mean size of the recurrent tumor was 5.92 cm. (range 2 to 10). All patients survived surgery without major complications. Of the patients 7 died of metastatic disease after a mean survival of 23.1 months (range 4 to 68) following recurrence removal and 6 are alive with a mean survival of 53.0 months (range 18 to 101) (p = 0.09). Time to recurrence after nephrectomy was significantly longer (p <0.05) and size of recurrence significantly smaller (p <0.04) in the patients still alive. In 1 surviving patient evidence of metastatic disease developed 9 months after surgery for recurrence. CONCLUSIONS: Careful followup after radical nephrectomy for renal cell carcinoma allows the diagnosis of small local recurrences before they become symptomatic in the majority of cases. Although most of these patients will eventually have and die of metastatic disease, an aggressive surgical approach is justified and can result in prolonged survival.

Aged↗

PubMed2002

Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus.

PURPOSE: To our knowledge we present the initial clinical report of hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with tumor thrombus extending into the inferior vena cava. MATERIALS AND METHODS: A 76-year-old man was referred to our medical center with a 12.5 x 10 cm. stage T3b right renal tumor extending into the inferior vena cava. The caval thrombus was limited and completely below the level of the hepatic veins. After preoperative renal embolization via the hand assisted transperitoneal approach the right kidney was completely dissected with the renal hilum. Proximal and distal control of the inferior vena cava was obtained with vessel loops and a single lumbar vein was divided between clips. An endoscopic Satinsky vascular clamp was placed on the inferior vena cava just beyond its juncture with the right renal vein, thereby, encompassing the caval thrombus. The inferior vena cava was opened above the Satinsky clamp and a cuff of the inferior vena cava was removed contiguous with the renal vein. The inferior vena cava was repaired with continuous 4-zero vascular polypropylene suture and the Satinsky clamp was then removed. A literature search failed to reveal any similar reports of laparoscopic radical nephrectomy for stage T3b renal cell cancer. RESULTS: Surgery was completed without complication with an estimated 500 cc blood loss. Pathological testing confirmed stage T3b grade 3 renal adenocarcinoma with negative inferior vena caval and soft tissue margins. CONCLUSIONS: The introduction of vascular laparoscopic instrumentation and the hand assisted approach enabled us to extend the indications for laparoscopic radical nephrectomy to patients with minimal inferior venal caval involvement.

Aged↗

PubMedDate not supplied

Incarcerated Spigelian hernia following laparoscopic living-donor nephrectomy.

We present the case of an incarcerated Spigelian hernia that manifested 24 hours after a laparoscopic living-donor nephrectomy. The differential diagnosis, proposed management, and a review of the literature is presented. Bowel obstruction occurring within a few days following laparoscopic surgery is most often attributed to a hernia at a trocar site. In the case of living-donor nephrectomy. the hernia could also occur at the incision made for removal of the kidney. Spigelian hernia has not been reported as a complication of laparoscopic surgery in the past and, therefore, would not normally be considered in the differential diagnosis of any complications following laparoscopic surgery. With the increasing use of laparoscopy, unsuspected intraabdominal conditions may be diagnosed during the procedure or become manifest because of increased intraabdominal pressure created by the pneumoperitoneum. Here we report the diagnosis and repair of a Spigelian hernia that became manifest 1 day after laparoscopic nephrectomy.

Female↗