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PubMed2003

Hand-assisted laparoscopic nephrectomy for stage T1 and large stage T2 renal tumors.

BACKGROUND AND PURPOSE: Standard laparoscopic nephrectomy (LN) has been shown to be as effective oncologically as open surgery for both stage T1 and stage T2 renal tumors. While much has been published regarding the increasing indications for laparoscopic nephrectomy, there is little in the literature regarding the advantages of hand-assisted laparoscopy (HAL) for the treatment of large (>7-cm) stage T2 renal tumors. To our knowledge, this study is the first to directly compare the results in pathologic stage T1 and stage T2 tumors. Our aim was to assess whether HAL nephrectomy for these larger tumors maintains the same advantages enjoyed by HAL for the smaller ones (<7 cm). PATIENTS AND METHODS: One hundred HAL renal extirpative procedures were performed over a 3-year period. Of these, 60 were radical nephrectomies for malignant disease, of which 50 tumors were stage T1 and 10 stage T2. Standard HAL nephrectomy was performed through a vertical midline or paramedian incision, and the specimen was sent for histologic examination and tumor staging. We retrospectively analyzed our charts to determine if HAL nephrectomy for T2 tumors was as advantageous as for T1 tumors. We collected data on patient age, ASA score, average tumor size, estimated blood loss, operative time, conversion rate, rate of complications, and length of hospital stay. Follow-up ranged from 4 to 26 months with a mean of 11 months. RESULTS: The mean size was 4.68 and 9.22 cm for stage T1 and T2 tumors, respectively. Intraoperatively, stage T2 tumors were associated with less blood loss than were T1 tumors (105 mL v 190 mL). Operative times were equivalent, at 190 and 185 minutes for stage T1 and T2, respectively. No open conversions were required in the T2 group v four (8.7%) in the T1 group. Three of these open conversions were seen in the first 25 HAL cases. No complications or conversions were seen in the stage T2 patients. Of note, the majority of the operations for stage T2 disease were performed after the learning curve had been surpassed. CONCLUSION: The HAL nephrectomy maintains the benefits associated with standard LN. Stage T1 and T2 tumors are equally amenable to HAL nephrectomy, enjoying the same perioperative advantages. The larger size of the higher-stage tumors does not appear to hinder intact organ removal via a 7-cm hand incision. For the novice laparoscopist, we recommend approaching smaller tumors first with HAL nephrectomy, as there is a learning curve. As surgical expertise with HAL nephrectomy increases, larger tumors (stage T2) can be removed safely and expeditiously with little blood loss and a low complication rate. In the short term, patients with stage T2 cancers appear to enjoy the same disease-free survival rate as those with tumors of lower stage. Longer-term follow-up is clearly needed; however, we anticipate the same excellent results as have been demonstrated by others performing conventional radical LN.

Blood Loss, Surgical↗

PubMed2004

Hand-assisted laparoscopic nephrectomy for inflammatory renal conditions.

PURPOSE: Laparoscopic surgery for large renal lesion or kidneys with chronic inflammation has proved to be technically challenging. Hand-assisted laparoscopic surgery might be useful in these complex cases, as it provides surgeons the benefits of tactile feedback, digital retraction, and facilitated dissection of the renal hilar vessels. PATIENTS AND METHODS: Twenty-two patients undergoing hand-assisted laparoscopic (HAL) nephrectomy for benign conditions were compared with patients who underwent HAL radical nephrectomy during the same period. The demographic data, laterality, operative time, estimated blood loss, conversion rate, length of stay, histopathology findings, morbidity, and mortality were reviewed. RESULTS: The main indications for surgery were chronic inflammation and xanthogranulomatous pyelonephritis. Twenty patients had unilateral nephrectomy (10 each on the right and left), and two patients had bilateral nephrectomy. The mean operative times for unilateral and bilateral nephrectomy were 163 minutes (range 55-261 minutes) and 265 minutes (range, 238-291 minutes), respectively. Nine patients (45%) with inflammation had complications (15% major and 30% minor). The mean length of hospitalization for patients undergoing HAL nephrectomy was 7.2 days (range 2-35 days). The patients with inflammatory pathology had longer mean operative times, higher estimated blood loss, longer hospital stay, and higher morbidity than patients undergoing radical nephrectomy. CONCLUSION: Compared with standard laparoscopy, the hand-assisted approach has been reported to reduce operative times and increase safety. The advantages of minimally invasive surgery, such as reduced analgesia, shorter hospital stay, and faster return to normal activity, appear to be similar to those in patients undergoing a pure laparoscopic nephrectomy. Compared with radical nephrectomy for renal tumor, HAL simple nephrectomy can often be more challenging and associated with greater morbidity. For both the community urologist as well as an experienced laparoscopist, this approach is useful in handling these challenging cases.

Adult↗

PubMed2000

Bilateral nephrectomy with concomitant renal graft transplantation for autosomal dominant polycystic kidney disease.

PURPOSE: There has been controversy about pre-transplant nephrectomy in patients with autosomal dominant polycystic kidney disease. Kidneys may be removed in these patients when they cause respiratory compromise, early satiety, increased abdominal girth, pain, hematuria or recurrent infection. We determined whether concomitant bilateral nephrectomy at renal transplantation is safe and efficacious. MATERIALS AND METHODS: Between December 1996 and January 1999, 10 patients with autosomal dominant polycystic kidney disease underwent bilateral nephrectomy with concomitant renal grafting (group 1). We compared these patients to 9 with autosomal dominant polycystic kidney disease matched for age and gender who underwent transplantation only (group 2) and 4 with the same condition who underwent bilateral nephrectomy and renal transplantation as staged procedures (group 3). RESULTS: No patients died perioperatively. There was a lower rate of complications in group 1 than in groups 2 or 3. The only significant differences in intraoperative and perioperative parameters were operative time and intraoperative blood loss, which were greater in group 1 than in group 2. We noted no significant differences in groups 1 and 3. Patient satisfaction analyzed by a survey revealed that the 70% of group 1 patients who responded were satisfied with kidney removal and 7 of the 9 in group 2 desired native kidney removal. All group 3 patients already had a functioning renal graft but were satisfied with native kidney removal, although they would rather have undergone bilateral nephrectomy at transplantation. CONCLUSIONS: Our data imply that there is no higher morbidity or mortality when performing concomitant bilateral nephrectomy at renal transplantation in patients with renal failure due to autosomal dominant polycystic kidney disease. There was a higher rate of satisfaction in patients who underwent nephrectomy and transplantation simultaneously, while those who did not undergo concomitant procedures strongly desired to have had that option. Bilateral nephrectomy may alleviate symptoms while providing greater room for renal graft placement. When done without transplantation, bilateral nephrectomy resulted in the highest number of complications. Our data indicate that if bilateral nephrectomy is performed as an adjunct to transplantation, it should be done at renal grafting.

Adult↗

PubMed2003

Efficacy of nephrectomy for the treatment of nephrogenic hypertension in a pediatric population.

PURPOSE: We evaluated the efficacy of nephrectomy for the management of nephrogenic hypertension in children. MATERIALS AND METHODS: We retrospectively reviewed the records of 320 children who underwent nephrectomy between 1991 and 2001, and 22 underwent nephrectomy for the management of hypertension. Of the 22 patients 16 (73%) had long-term followup, including 8 with end stage renal disease who were dialysis dependent, and 8 with normal renal function and unilateral parenchymal renal disease (UPRD). Within the UPRD group 3 patients had renovascular hypertension, 3 had reflux nephropathy, 1 had renal artery thrombosis and 1 had Page kidney. Age at hypertension onset, age at nephrectomy and elapsed time between diagnosis and intervention were studied. Antihypertensive medication requirements before surgery and after postoperative followup were evaluated to assess treatment efficacy. Complete success was defined as blood pressure normalization without antihypertensive requirements. Partial success was defined as decrease in medication requirements and/or discontinuation of minoxidil. Failure of treatment was defined as persistent hypertension, increased medication requirements or minoxidil dependence. RESULTS: In the end stage renal disease group mean age at diagnosis was 5.9 years (range 15 months to 10 years) and bilateral nephrectomy was performed at a mean age of 8.9 years (19 months to 15 years) with average elapsed time between diagnosis of hypertension and nephrectomy of 3 years. After a mean followup of 4.4 years (range 6 months to 8 years) 7 patients (88%) experienced complete or partial success and nephrectomy management failed in 1. In the UPRD group average elapsed time was 2.2 years (range 1 month to 10 years) between a mean age at diagnosis of 6.7 years (birth to 16 years) and a mean age at nephrectomy of 8.9 years (1 month to 17 years). After a mean followup of 1.6 years (range 1 month to 5 years) complete or partial success was experienced by all 8 patients (100%). All 8 UPRD group patients experienced adequate residual renal function. CONCLUSIONS: The vast majority of patients in both categories experienced complete or partial success from nephrectomy for the management of medication refractory hypertension. Nephrectomy for hypertension control is safe and effective, and obviates the need for morbid medications. We continue to accrue patients in a prospective manner.

Adolescent↗

PubMed1986

Mechanisms by which nephrectomy stimulates adrenal renin.

Renin has been identified in the adrenal gland by several investigators. Nephrectomy is the most potent stimulator of adrenal renin, and in the present study we investigated the mechanism by which nephrectomy stimulates adrenal renin. The pituitary plays a permissive role since hypophysectomy abolished the response of adrenal renin to nephrectomy (from 117.3 +/- 14.55 to 10.37 +/- 1.63 ng angiotensin I/mg protein/hr) and adrenocorticotropic hormone (ACTH) treatment restored the response to nephrectomy in hypophysectomized rats to 120 +/- 20.62 ng angiotensin I/mg protein/hr. However, large doses of ACTH given to intact rats did not increase adrenal renin to the high level observed after nephrectomy. Potassium also plays an important role, since prevention of hyperkalemia after nephrectomy by treatment with a cation exchange resin, sodium polystyrene sulfonate (Kayexalate), significantly reduced the adrenal renin response to nephrectomy. A third factor involved is the lack of negative feedback by plasma angiotensin II. Infusion of angiotensin II intraperitoneally prevented the rise in adrenal renin after nephrectomy (from 65.25 +/- 7.60 to 9.27 +/- 0.99 ng angiotensin I/mg protein/hr) despite an increase in plasma potassium and corticosterone. In conclusion, three factors influence the response of adrenal renin to nephrectomy: 1) the pituitary through the release of ACTH, 2) a direct stimulation by high plasma potassium levels, 3) the lack of angiotensin II feedback inhibition. Whether the high adrenal renin contributes to the high aldosterone observed in rats after nephrectomy remains to be established.

Adrenal Cortex↗

PubMed2001

Laparoscopic live donor nephrectomy: a comparison with the conventional open approach.

PURPOSE: Laparoscopic live donor nephrectomy is an emerging technique that has not yet gained widespread acceptance in the transplant community due to perceived technical difficulties. However, the potential advantages of decreasing donor morbidity, decreasing hospital stay and improving convalescence while producing a functional kidney for the recipient may prove to enhance living related renal transplantation. We report our early experience with laparoscopic live donor nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 50 consecutive laparoscopic nephrectomies performed from October 1998 to May 2000 and compared them with 50 consecutive open donor nephrectomies, which served as historical controls. RESULTS: Donor age, donor sex and number of HLA mismatches did not differ statistically in the 2 groups. In the laparoscopic and open nephrectomy groups mean followup was 109 and 331 days (p = 0.0001), mean operative time was 234 and 208 minutes (p = 0.0068), mean estimated blood loss was 114 and 193 ml (p = 0.0001), and mean hospital stay was 3.5 and 4.7 days (p = 0.0001), respectively. Average renal warm ischemia time was 2.8 minutes in the laparoscopic nephrectomy group. Serum creatinine did not differ statistically in the 2 groups preoperatively or postoperatively at days 1 and 5, and 1 month. The rate of recipient ureteral complications in the laparoscopic and open nephrectomy groups was 2% (1 of 50 cases) and 6% (3 of 50), respectively (not significant). CONCLUSIONS: Laparoscopic live donor nephrectomy is an attractive alternative to open donor nephrectomy. Laparoscopic nephrectomy results in less postoperative discomfort, an improved cosmetic result and more rapid recovery for the donor with equivalent functional results and complications.

Adult↗

PubMed2001

Changing trends in partial nephrectomy at Walter Reed Army Medical Center.

PURPOSE: To evaluate the change in indications, frequency, complications, and outcome in patients undergoing partial nephrectomy at a single institution during a 25-year period. MATERIALS AND METHODS: A retrospective chart review was performed for patients who underwent partial nephrectomy at Walter Reed Army Medical Center from 1970 to 1995. A total of 309 patient records were reviewed for patient age, sex, and primary diagnosis. A more detailed analysis was performed on 47 records of patients who underwent partial nephrectomy from 1986 to 1996. RESULTS: The number of partial nephrectomies declined from the 1970s to the 1990s, demonstrating the trend away from nephron-sparing surgery for benign disease. Partial nephrectomies for renal cell carcinoma increased during the same period. Fifty-seven percent (12 of 21) of patients from 1986 to 1996 underwent partial nephrectomy for incidentally discovered renal tumors. Complications occurred in 25% (11 of 44) of patients, with acute renal insufficiency occurring in 4.5% (2 of 44). Twenty-two of 25 patients who underwent partial nephrectomy for renal cell carcinoma were followed for a mean of 45.6 months. The cancer-specific 5-year survival rate for partial nephrectomy was 88.1%. CONCLUSION: Trends in nephron-sparing surgery showed a movement away from performing ablating surgery for benign disease and toward nephron-sparing surgery for renal masses. Despite a higher complication rate, the curative ability of partial nephrectomy is similar to that of radical nephrectomy.

Adult↗

PubMed2001

Open donor, laparoscopic donor and hand assisted laparoscopic donor nephrectomy: a comparison of outcomes.

PURPOSE: In experienced hands laparoscopic surgery has been shown to be safe for procuring kidneys for transplantation that function identically to open nephrectomy controls. While searching for a safer and easier approach to laparoscopic donor nephrectomy, hand assisted laparoscopic techniques have been added to the surgical armamentarium. We compare allograft function in patients with greater than 1-year followup who underwent open donor (historic series), classic laparoscopic and hand assisted laparoscopic nephrectomy. MATERIALS AND METHODS: The charts of 48 patients who underwent open donor, laparoscopic donor or hand assisted laparoscopic nephrectomy were reviewed. Only patients with greater than 1-year followup and complete charts were included in our study. Of these patients 34 underwent consecutive laparoscopic live donor nephrectomy and 14 underwent open donor nephrectomy. Mean patient age plus or minus standard deviation (SD) was 36.5 +/- 8.4 years for donors and 29 +/- 17 for recipients at transplantation (range 13 months to 69 years). In the laparoscopic group 11 patients underwent the transperitoneal technique, and 23 underwent hand assisted laparoscopic nephrectomy. RESULTS: Total operating time was significantly reduced with the hand assisted laparoscopic technique compared with classic laparoscopy, as was the time from skin incision to kidney removal and warm ischemic time. Average warm ischemic time plus or minus SD was 3.9 +/- 0.3 minutes for laparoscopic nephrectomy and 1.6 +/- 0.2 for hand assisted laparoscopy (p <0.05). Long-term followup of serum creatinine levels revealed no significant differences among the 3 groups. Comparison of those levels for recipients of open nephrectomy versus laparoscopic and hand assisted laparoscopic techniques revealed p values greater than 0.5. No blood transfusions were necessary. Complications included adrenal vein injury in 1 patient, small bowel obstruction in 2, abdominal hernia at the trocar site in 1 and deep venous thrombosis in 1. CONCLUSIONS: Classic laparoscopic donor and hand assisted laparoscopic donor nephrectomies appear to be safe procedures for harvesting kidneys. The recipient graft function is similar in the laparoscopic and open surgery groups.

Adolescent↗

PubMed1996

The effect of nephrectomy on the outcome of renal transplantation in patients with polycystic kidney disease.

Although various forms of polycystic kidney disease (PKD) account for up to 10% of patients requiring renal replacement therapy and severe complications may arise from these kidneys, no clear indications for pretransplant nephrectomy have been defined so far. A total of 104 renal transplants in three pediatric and 96 adult patients suffering from PKD were analysed retrospectively with regard to patient and graft survival in relation to pretransplant or posttransplant nephrectomy and no nephrectomy. Of these 99 patients, 25 had had either unilateral (19) or bilateral (6) nephrectomy sometime before transplantation and 10 patients between 3 and 81 months after transplantation. All patients received Cyclosporine-based immunosuppression. One-year patient and graft survivals for recipients of a first cadaveric renal graft (n = 91) were 94% and 92%, for recipients of second or third graft (n = 13) 89% and 78%. One- and five-year patient survival rates for patients with or without pretransplant nephrectomy were 100% and 100% vs 92% and 84%, respectively. One- and five-year graft survival rates were 100% and 93% for pretransplant nephrectomy patients vs 89% and 74% for the non-nephrectomy group (p < 0.05). Patients not undergoing nephrectomy sometime after transplantation had the same patient but better five-year graft survival when compared to the posttransplant nephrectomy group (89% vs 52%). In patients with early posttransplant urinary tract infection, which is considered in this analysis as a cyst-related complication, graft survival at one year was 77% but 97% in patients without this complication. From these data it is recommended that polycystic kidneys should be removed before transplantation if cyst-related complications occur repeatedly. Posttransplant nephrectomy can be performed with no mortality and should be carried out whenever clinically indicated.

Adolescent↗

PubMed2003

Laparoscopic versus open nephrectomy in 210 consecutive patients: outcomes, cost, and changes in practice patterns.

BACKGROUND: Initially slow to gain widespread acceptance within the urological community, laparoscopic nephrectomy is now becoming the standard of care in many centers. Our institution has seen a dramatic transformation in practice patterns and patient outcomes in the 2 years following the introduction of laparoscopic nephrectomy. We compare the experience with laparoscopic and open nephrectomy within a single medical center. METHODS: Data were collected for all patients undergoing elective nephrectomy (live donor, radical, simple, partial, and nephroureterectomy) between August 1998 and September 2002. Data were analyzed by Wilcoxon rank sum, chi-square, and Fisher's exact test. A p-value <0.05 was considered significant. RESULTS: Of the patients, 92 underwent open nephrectomy, and 118 were treated laparoscopically (87 hand-assisted laparoscopic nephrectomy, 31 totally laparoscopic). There was one conversion (0.8%). Patient demographics and indications for surgery were equivalent for both groups. Mean operative time for laparoscopic nephrectomy (230 min) was longer than for open (187 min, p = 0.0001). Blood loss (97 ml vs 216 ml, p = 0.0001), length of stay (3.9 days vs 5.9 days, p = 0.0001), perioperative morbidity (14% vs 31%, p = 0.01), and wound complications (6.8% vs 27.1%, p = 0.0001) were all significantly less for laparoscopic nephrectomy. For live donors, time to convalescence was less (12 days vs 33 days, p = 0.02), but hospital charges were more for patients treated laparoscopically (19,007 dollars vs 13,581 dollars, p = 0.0001). CONCLUSIONS: Laparoscopic nephrectomy results in less blood loss, fewer hospital days, fewer complications, and more rapid recovery than open surgery. We believe that these benefits outweigh the higher hospital charges associated with the laparoscopic approach.

Adolescent↗

PubMed1994

Transperitoneal nephrectomy for benign disease of the kidney: a comparison of laparoscopic and open surgical techniques.

OBJECTIVE: The objective of this study was to compare the results of laparoscopic nephrectomy for benign disease to open surgical nephrectomy for benign disease. METHODS: Twenty consecutive patients undergoing laparoscopic nephrectomy for benign disease were compared with 23 patients undergoing open surgical nephrectomy for benign disease and with 29 patients undergoing a donor nephrectomy. Data were collected in the following areas: patient age, anesthetic risk, operative time, estimated blood loss, postoperative time to resume oral intake, parenteral analgesics, oral analgesics, hospital stay, complications, and convalescence. Information was obtained through chart review, telephone interviews, and mailed questionnaires. RESULTS: Compared with open surgical nephrectomy, laparoscopic nephrectomy resulted in a statistically significant longer operative time; however, it afforded a statistically significant decrease in postoperative ileus (open group), hospital stay (both groups), oral analgesics (donor group), and convalescence (both groups). The incidence of complications was 15 percent in the laparoscopic group and 0 percent in the two open surgical groups; the majority of complications occurred during the initial seven laparoscopic procedures. CONCLUSIONS: Laparoscopic nephrectomy is a more time-consuming procedure than open surgical nephrectomy. Also, early in one's experience with this technique, the complication rate is higher than with open surgery. However, despite the newness of the technique, it results in significant benefits to the patient: decreased postoperative pain, shorter hospitalization, and more rapid convalescence.

Adult↗

PubMed2006

Adjunctive nephrectomy at post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer.

PURPOSE: Patients with metastatic testicular cancer with residual masses encasing the renal hilum or kidney after platin based chemotherapy may require adjunctive nephrectomy to achieve complete resection at post-chemotherapy retroperitoneal lymph node dissection. We reviewed our experience with adjunctive nephrectomy to assess the impact on cancer control and renal function. MATERIALS AND METHODS: Of 647 post-chemotherapy retroperitoneal lymph node dissection procedures performed at our institution since 1989 adjunctive nephrectomy has been performed in 32 patients (5%). Patient information was obtained from a prospective database. Median followup was 31 months. RESULTS: Of the adjunctive nephrectomy procedures 17 (53%) were performed in high risk settings such as post-salvage chemotherapy, desperation retroperitoneal lymph node dissection, late relapse and reoperative retroperitoneal lymph node dissection. Disease was present in the adjunctive nephrectomy specimen in 21 patients (66%). Following post-chemotherapy retroperitoneal lymph node dissection 7 patients had disease relapse and 5-year disease-free survival was 66%. No case of relapse required substitution for cisplatin due to compromised renal function. Progression to chronic renal insufficiency occurred in 3 patients, 1 of whom required hemodialysis. The calculated creatinine clearance after adjunctive nephrectomy was more than 30% below the age specific norm in 14 patients (50%) and median patient age was 40 years. CONCLUSIONS: Adjunctive nephrectomy at post-chemotherapy retroperitoneal lymph node dissection is most frequently performed in patients with high risk features to ensure the completeness of resection. When indicated, adjunctive nephrectomy should be performed because residual cancer is frequently present and long-term cancer control can be achieved in 66% of patients. Although adjunctive nephrectomy did not interfere with subsequent chemotherapy, the renal reserve in these patients was substantially reduced in 50%, emphasizing the importance of preventative measures to preserve long-term renal function.

Adolescent↗

PubMed2007

Limitations of laparoscopy for bilateral nephrectomy for autosomal dominant polycystic kidney disease.

PURPOSE: We retrospectively studied outcomes following bilateral hand assisted laparoscopic nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the charts of 18 patients with symptomatic autosomal dominant polycystic kidney disease who underwent bilateral hand assisted laparoscopic nephrectomy. Preoperative radiographic imaging was reviewed retrospectively to determine kidney size based on an ellipsoid shape. A visual analog pain scale with scores of 0 to 10 to assess pain related to autosomal dominant polycystic kidney disease was measured preoperatively and postoperatively. RESULTS: Average patient age was 48.2 years (range 30 to 64). Of the patients 14 successfully underwent bilateral hand assisted laparoscopic nephrectomy, while 4 required open conversion. A total of 16 patients underwent nephrectomy for pain and 2 underwent surgery for frequent recurrent symptomatic urinary tract infections. All patients except 1 underwent renal transplantation before bilateral nephrectomy. There was a significant difference in the volume of the right and left kidneys between the hand assisted laparoscopic and open groups (mean +/- SD 1,043 +/- 672 and 1,058 +/- 603.8 vs 4,052 +/- 548 and 3,592 +/- 1,752 cm(3), p <0.001 and 0.06 respectively). There were 5 complications, including wound infection and protracted ileus in 2 patients each, and incisional hernia in 1. In addition, the difference in mean preoperative and postoperative visual analog pain scores was statistically significant (6.9, range 3 to 10 and 0.5, range 0 to 2, p <0.05). CONCLUSIONS: Bilateral laparoscopic hand assisted nephrectomy is a safe and reliable option in patients requiring removal of the 2 kidneys in a single setting. Rather than performing staged nephrectomies, hand assisted laparoscopic nephrectomy allows the single administration of general anesthesia and provides effective relief of bothersome symptoms in patients with symptomatic autosomal dominant polycystic kidney disease. This procedure is safe in patients with renal transplants. Patients with massive polycystic kidneys with a kidney volume of greater than 3,500 cc are at increased risk for open conversion and they may have improved outcomes if open nephrectomy is attempted from the outset.

Adult↗

PubMed2004

Keeping up with the Jones's: open donor nephrectomy in the laparoscopic era.

Several new approaches have been developed to perform donor nephrectomy. These include laparoscopic donor nephrectomy and open donor nephrectomy performed through small incisions, herein referred to as "mini-open donor nephrectomy". In the past, we performed open donor nephrectomy via a standard flank incision. In October 2002, we introduced mini-open donor nephrectomy via an anterior, retroperitoneal approach. Contemporaneously, we offered the option of laparoscopic donor nephrectomy. Herein, we review our single-center experience with these three techniques. Mini-open donor nephrectomy was comparable to the laparoscopic approach for duration of narcotic requirement and donor length of stay. The laparoscopic procedure was more expensive. Both procedures demonstrated improvement over the flank approach by eliminating the risk of pneumothorax, neuropathy, and flank bulge. In addition, length of stay and narcotic requirements were higher with the flank approach. Mini-open donor nephrectomy provides a good alternative to laparoscopic surgery, offering the donor an equivalent convalescence at lower cost and potentially with reduced morbidity.

Adult↗

PubMed2005

Pretransplant nephrectomy in patients with autosomal dominant polycystic kidney disease.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disease and a frequent cause of end-stage renal failure. Transplantation in patients with ADPKD is associated with specific cyst-related problems, especially urinary tract infections (UTI). Although pretransplant nephrectomy has been applied in this group of patients, evidence of the benefits of this strategy is lacking. Therefore, we compared the outcomes and posttransplant complications among patients with or without pretransplant nephrectomy. PATIENTS AND METHODS: ADPKD patients (73) transplanted from cadaveric donors were reviewed retrospectively with regard to posttransplant complications and outcomes. The groups either underwent pretransplant unilateral nephrectomy (n = 30) or were transplanted with native kidneys intact (n = 43). RESULTS: Two patients underwent simultaneous bilateral nephrectomy due to a large size of the polycystic kidneys interfering with the transplant operation. Overall postransplant complications were more frequent in the group without nephrectomy (34% vs 20%); however, the difference was not statistically significant. Most complications were related to cyst infections with 3 deaths (12%) due to lethal septicemia in the group without nephrectomy. No infection-related deaths were noted in the group with pretransplant nephrectomy. CONCLUSIONS: Graft and patient outcomes as well postransplant complications were similar in both groups, independent of previous nephrectomy. It seems that pretransplant unilateral nephrectomy should not be routine and has no advantage over transplantation with both native kidneys intact, although this conclusion is limited by the small number of patients. An Individualized approach should be applied especially when there has been a history of cyst-related infection.

Cadaver↗

PubMed2006

Renal and extrarenal predictors of nephrectomy from the national trauma data bank.

PURPOSE: The kidney is injured in 1.4% to 3.0% of all trauma cases. The management of renal injuries is controversial, as reflected in regional and institutional variations in treatment preferences. Using a national trauma database we identified independent risk factors for nephrectomy. MATERIALS AND METHODS: The population was selected from the National Trauma Data Bank, a voluntary data repository containing all trauma admissions to 268 participating trauma centers. Patients with renal injuries were identified by Abbreviated Injury Scale codes. Patient demographic, associated injuries and facility characteristics were recorded. Univariate and Poisson regression analysis with clustering by facility was performed. RESULTS: Renal injury was present in 8,465 patients. Nephrectomy was performed in 4% of all blunt and 21% of all cases of penetrating renal injuries. Only 0.5% of blunt renal injury cases underwent repair compared with 15% of those of penetrating injuries. On multivariate analysis renal injury severity was the strongest predictor of nephrectomy. The relative risk of nephrectomy for grade V renal injuries was 146 (95% CI 74 to 289) and 33 (95% CI 13 to 89) in the blunt and penetrating models, respectively. The need for laparotomy and surgery on other intra-abdominal organs predicted nephrectomy in patients with blunt and penetrating injuries. Hospital trauma designation did not statistically impact nephrectomy rates. CONCLUSIONS: The severity of renal injury based on the AAST organ injury scale for Renal Trauma is the strongest risk factor for nephrectomy. The need for surgery on other intra-abdominal injuries increases the risk of nephrectomy to a lesser extent. In cases of blunt trauma severe renal injury usually necessitates nephrectomy.

Adult↗

PubMed2006

Robot assisted laparoscopic partial nephrectomy: initial experience.

PURPOSE: Advances in laparoscopy have made laparoscopic partial nephrectomy a technically feasible procedure but it remains challenging to even experienced laparoscopists. We hypothesized that robotic assisted laparoscopic partial nephrectomy may make this procedure more efficacious than the standard laparoscopic approach. MATERIALS AND METHODS: Ten patients with a mean age of 58 years and mean tumor size of 2.0 cm underwent robotic assisted laparoscopic partial nephrectomy and another 10 with a mean age of 61 years and mean tumor size of 2.18 cm underwent laparoscopic partial nephrectomy, as performed by a team of 2 surgeons (MS and ST) between May 2002 and January 2004. Demographic data, intraoperative parameters and postoperative data were compared between the 2 groups. RESULTS: There were no significant differences in patient demographics between the 2 groups. Intraoperative data and postoperative outcomes were statistically similar. In the 10 patients who underwent robotic assisted laparoscopic partial nephrectomy there were 2 intraoperative complications. There was 1 conversion in the laparoscopic partial nephrectomy group. CONCLUSIONS: Robotic assisted laparoscopic partial nephrectomy is a safe and feasible procedure in patients with small exophytic masses. The robotic approach to laparoscopic partial nephrectomy does not offer any clinical advantage over conventional laparoscopic nephrectomy.

Humans↗

PubMedDate not supplied

Complications of contemporary radical nephrectomy: comparison of open vs. laparoscopic approach.

Increasingly, laparoscopy is being employed in the treatment of urologic malignancies. This is most apparent in kidney cancer, where laparoscopic radical nephrectomy is now considered to be a gold standard. Herein, we compared early postoperative morbidity in a contemporary series of open and laparoscopic radical nephrectomies. We reviewed all patients that underwent a radical nephrectomy between October 1999 and May 2001 at our institution. We then compared open radical nephrectomy patients to those undergoing laparoscopic approaches with specific attention to early complications. A total of 74 radical nephrectomies were performed: 41 open, 18 hand-assisted and 15 pure laparoscopic nephrectomies. Overall, complication rates between the open, hand-assist and pure laparoscopic groups were similar (10%, 17% and 12%, respectively, P = 0.133). There was no statistically significant difference in ASA score (P = 0.144), pre-operative hematocrit (P = 0.575) or intra-operative blood loss (P = 0.364). The open nephrectomy group had a statistically larger average tumor size (7.4 cm vs. 4.6 cm; P = 0.005) and younger average age (57 vs. 63; P = 0.019) than the laparoscopic group. Length of hospital stay was significantly shorter in the laparoscopic group (3.6 days vs. 1.7 days; P < 0.0001). Laparoscopic radical nephrectomy has an acceptably low complication rate and compares favorably to open radical nephrectomy. The low rate of complications combined with the advantages of laparoscopic surgery favor a laparoscopic approach for the majority of patients with stage T1 and T2 tumors.

Adult↗